Hermiston Herald
December 6, 2002

Report: Army needs attitude adjustment: Investigation says violations resulted from the lack of'questioning attitude'

By Frank Lockwood
Staff writer

HERMISTON - Safe incineration of chemical weapons requires a new work
culture of more questioning attitudes, an Army investigation reveals. Permit
violations during surrogate trial burns were due, in part, to a lack of
"questioning attitudes" says an Army investigation of Umatilla Chemical
Agent Disposal Facility's operations in late September.

No danger to workers or the environment resulted, but in spite of Washington
Demilitarization Company's open door safety policy, mistakes made during
UMCDF's Surrogate Trial Burns indicated an "immature" conduct of operations
mentality. The findings were reported by the Liquid Incinerator I Shakedown

Incident Operating Without Permit Required Instrumentation, September 26,
2002, Incident Investigation Final Report October 10.

Surrogate Trial Burns do not involve the burning of actual agent, and depot
officials say neither humans nor the environment were put at risk, but an
alarm-equipped system known to the experts as the Rolling One-Hour Average
(ROHA) Automatic Waste Feed Cutoffs (AWFCO) was inadvertently bi-passed
during off-and-on testing for several days, when a jumper was left in place
after it was supposed to have been removed.

The combined ROHA/AWFCO system is configured to automatically shut down if
something goes wrong. The way testing was performed at UMCDF was not legal
in Oregon, though it would have been allowable in other states according to

Rick Kelly, spokesperson for Washington Demilitarization Company.
Oregon has more restrictive laws. Unlike at other demilitarization sites,
UMCDF surrogate materials are classified as hazardous wastes. Other data,
recovered following the incident, showed that the Oregon permit limits were
not exceeded during the tests despite of the error. UMCDF is the
country'sfirst chemical demilitarization facility to implement new Clean Air
Act requirements for ROHAs to stop calculating when the Resource

Conservation Recovery Act alarms and certain other alarms are initiated.
"Instruments were not disabled intentionally," Kelly said, "It was human
error." The company has already implemented corrective actions, he said.

A similar situation would not happen during actual agent incineration, Kelly
said, because the only occasion for bi-passing the safety systems occurs
during the testing phase. Certain bi-pass cables were left in place after
they should have been removed.

Sequence of Events

• The problem was detected by the trial burn manager half way through the
  test sequence, at about 12:45 p.m. on Sept. 27, but, an incorrect decision
  was made to continue testing. The incorrect decision was due to "poor
  communications" between the DEQ and the incinerator personnel. The DEQ
  representative's recollection of what was decided in the discussions differs
  from what the incineration folk thought was said or implied. It was never
  his understanding that all the ROHA generated AWFCOs were disabled, only
  specific ones.
  
• On Sept. 30, the environmental shift engineer notified the environmental
  manager of information not printing out on the data report. He was informed
  that the DEQ had authorized the surrogate trial burns to continue anyway.
  
• Oct. 1, the Washington Demilitarization Environmental Manager discovered
  that the ROHAs were not counting, held information gathering discussion with
  personnel, and informed the WDC project manager, who immediately suspended
  surrogate trial burn activities.

As the Army's investigation concluded, the liquid incinerator had
"intermittently processed surrogate material as part of the shakedown test
without permit required rolling one-hour average instrumentation." The
conclusion went on to say, "A calculation of the instantaneous data for the
ROHAs was performed and no Permit required automatic waste feed cutoff
values were exceeded."

Problems Noted

The report noted shortcomings in the company's procedures and work culture.
Among them were these and others:

• The shift superintendent had been only peripherally involved with
  discussions relating to the inoperable ROHAs, and relied on the test
  director to decide if testing should continue. "This separation of
  responsibilities removed the shift superintendent from the decision making
  process and placed complete responsibility with the test director," the
  report said.
  
• Procedures did not specify the proper use/removal of software jumper
  control cables, the jumpers which created the violation.
  
• A basic tenant was violated: Equipment must be properly controlled and it
  status must be known. "The shift superintendent was not aware that ... he
  was outside of the Limited Conditions of Operations and the Permit."
  
• There was a lack of a necessary questioning attitude. "Personnel ... did
  not sufficiently display a questioning attitude when faced with uncertainty.
  Despite schedule pressure and a perceived validation by the ODEQ to proceed
  with operations, none of the involved individuals appear to have challenged
  the decision to proceed with testing. "

The report also indicated "poor communications and a general weakness in
knowledge," and noted that the Surrogate Trial Burn manager solicited
feedback but did not receive any objections to continued operations.

Recommendations were made in the report as to how to address the problems.
In addition, Kelly said the company has an absolute open door policy when it
comes to safety concerns and that workers can even go over the supervisor's
head with those concerns, without reprisal.

Depot spokesperson Mary Binder said the public should expect that unexpected
problems will continue to show up during testing, that such hitches are
normal and to be expected when bringing a large, complicated system such as
the incinerator on line, and that this is one reason for the test phase
prior to going hot.

More information about the incineration project is always available at the
PMCD Outreach Office in Hermiston. The telephone number is (541) 564-9339.
n Frank Lockwood may be reached at 567-6457 or by e-mail at
flockwood@hermistonherald.com.