Testimony from the Federal Trial held in
Salt Lake City, Utah June 7-June 18
in front of Judge Tena Campbell
(The following was transcribed from notes taken at the trial.)
Timothy Thomas testified June 7, 1999.
He is the Army TOCDF Site Project Manager, and Assistance Manager for
CAMDS. He is the highest Army authority over TOCDF and is responsible
for compliance with federal and state laws and safe operation of TOCDF.
He gets reports from staff and contractors about malfunctions and gives
briefings to management and officials (local, state, Congress and Army)
The metal parts furnace (MPF) and deactivation furnace (DFS) as
originally permitted at TOCDF were intended to process munitions
drained at least 95% of agent (5% or less residual agent when burned in
these furnaces).
The Brine Reduction Area (BRA) was intended to remove water from
pollution abatement systems brines The Dunnage incinerator (DUN) was
intended to incinerate all dunnage from unpack operations including
wooden pallets, charcoal from ventilation system, DPE suits and
miscellaneous waste materials.
The TOCDF HVAC system was intended to prevent agent migration
within the facility by drawing air from C category areas intended to be
free of agent (adjacent to outside environment) into B category areas and
then into the routinely hot (contaminated) A category areas from where
the contaminated air should be drawn through the HVAC carbon
filtration system to remove agent before its release into the environment.
Contrary to the design and intention, however, contaminated air
sometimes migrates from category A to category B and category C areas,
and from category B to category C areas.
The Dunnage Incinerator (DUN) has not been used and the Army has no
intention to use it. The DUN is a known source of dioxin emissions
based on JACADS testing (no trial burn has been performed on the DUN
at TOCDF). The DUN will be removed from the TOCDF permit.
The Brine Reduction Area (BRA) is not operational at TOCDF, has been
shut down for some time and is expected to remain in shut down for an
extended period.
The MPF is being used to burn contaminated wood dunnage.
During June 4th 1999 power outage, TOCDF lost power and the HVAC
system went down. Backup generator system did not come on
automatically as it is designed to do. It took some time to manually
start it up. TOCDF experienced agent migration because of the HVAC
being down. Without the negative air pressure created by the HVAC
fans, agent migrates. In this case, agent migrated into observation
corridors (Level C). The doors to the outside environment in level C
areas do not have air tight seals. This was not the first time for a power
outage. It was not the first time the emergency power system had malfunctioned.
On May 21, 1999, another incident occurred at TOCDF. Agent migration
occurred from a category A area where workers were performing
maintenance on contaminated DFS waste strainers to a category C area
where workers were simultaneously working with ton containers with
respirators only slung at their sides. The employees put on their masks
only after the ACAMS agent monitor alarm had sounded in the room
they were in. This incident was not a breach of procedure but was a
design and system failure. TOCDF is having to replace filters more than
anticipated because of clogging of strainers.
Also in the third week of May, 1999, another incident occurred at TOCDF
during the processing of agent filled projectiles. Each projectile has a
burster well and nose closure. On this occasion employees were
manually separating these two components during processing. A high
agent reading came from one or more projectiles during this operation
resulting in very high agent readings (1900 TWA). Workers were wearing
only Level B clothing to remove the projectile nose closures at the time.
Level B gear is not designed to protect workers from such high levels of
agent. Above 40 TWA workers should be wearing a higher level of
protection -- the DPE Level A. The 1900 TWA Reading was approximately
50 times higher than the max allowed for Level B clothing. The burster
well is press fit into the throat of the projectile but the press fit was not
as tight as the Army expected. This incident with the high agent
readings occurred in the unpack area which was categorized as a level B
area at the time but which is actually adjacent to the outside
environment. These locations are normally classified level C. The 1 TWA
is a standard intended to protect workers. The General Population Level
(GPL) is a standard intended to protect the general public. The 1900
TWA when converted to GPL would be greater than 1900 GPL.
In December 1998, there was an incident at TOCDF involving a large
spill of 140 gallons of nerve agent GB (sarin). The spill occurred while
replacing filter bags in agent strainers in agent storage tank room. The
sump alarm did not give warning in time to mitigate the size of the spill.
The spill resulted from one employee who was changing the filters failing
to notice a washer that was put in place prior by another employee. Both
filter bags in a two filter system were being replaced simultaneously.
The Army has asked for permission from Utah to begin burning agent
heels in munitions of greater than 5%. Agent has gelled or crystallized
and doesn't flow easily. The plan is to feed 1 full rocket per hour instead
of feeding 40 rockets per hour presuming a 5% heel. There has been no
trial burn demo for this new full rocket plan, and none is planned.
The new process of burning only one rocket per hour slows down the
destruction process (by a factor of forty) and thereby increases storage
risk. The Army does not know when the agent gelling and crystallization
occurred in the rockets. It could have been there in August 96 when
agent processing at TOCDF began. Waste characterization testing was
not adequate to determine the extent of this problem.
Hot Cut-Outs occur at TOCDF and involve employees removing their
protective suits in the presence of nerve agent in the air as indicated by
an ACAMS alarm and reading. The Army wouldn't use the term hot cut
out unless an ACAMS alarm is indicating agent present above 40 TWA.
Above 0 but below 40 TWA, the Army considers the employee removing
their protective suit not a hot cut-out, but a routine procedure. Mr.
Thomas has not seen a report saying hot cut-outs are safe with agent in
the air. The 40 TWA is deemed acceptable by the Army based on this
having been the Army's method for a long period of time and because the
Army routinely checks for and relies on cholinesterase depression in
employees as the means of confirming exposure. In some cases at
TOCDF some agent is found in monitoring close to employees'
underclothing and skin after removal of protective suits.
An incident occurred at TOCDF on March 30, 1998 that involved a
violation of the agent feed limit for the MPF which led to a furnace
shutdown and a maximum agent monitor (ACAMS) alarm in the MPF
duct leading to the stack.
The TOCDF had operated from August 1996 (agent operations startup) to
March 30, 1998 (when the incident occurred) without a system to
continuously monitor each furnaces emissions (separately) for agent.
TOCDF also violated the requirement to continuously monitor the
common stack for agent emissions by failing to keep the two on-line
ACAMS in the common stack properly staggered.
During the March 30, 1998 incident, the stack ACAMS did register a
chemical release. The Army does not know the quantity or identity of
the chemical released. The DAAMS tubes, the backup and confirmatory agent
monitoring system for the ACAMS were not fully trackable prior to the March 30,
1998 incident and chain of custody for possession of DAAMS tubes was
not maintained.
EG&G has requested approval of new procedure involving draining
agent from ton containers (TCs) having highly acidic contents (low pH) into
clean tons (a portion at a time) and feeding clean tons to MPF rather
than sending liquid to Liquid Incinerators (LICs) as per original design.
TOCDF only checks pH if there is possible problem and are not testing
each TC as it comes thru. The finding of low pH TCs was a surprise C
i.e. not discovered until after agent operations had begun.
The Army has not updated its agent exposure standards notwithstanding
the 1997 NRC Report .
The Army has made no decision on the ultimate disposition of
contaminated dunnage that is stored at TOCDF. The Army intends to do
trial burns burning dunnage in the MPF.
Martin del mar Gray testified June 8, 1999
He is Section Manager of Chem. Demil Section of Utah DEQ DSHW .
His responsibilities are: Supervises 10 scientists and engineers, makes
site visits, receives reports from staff visits, must ensure compliance with
state delegated version of RCRA, writes NOVs, involved in preparation of
NOV/proposed Consent of Decree.
A recent power failure occurred at TOCDF. Lightning knocked power out,
took at least 15 minutes for back-up generator to come on-line. There
have been 13 instances of failing to test back-up generators. Back up
generator should come on line instantaneously. Agent migration
occurred into Level C area. More than one alarm indicating agent
migration. There were seven separate alarms. There was a global power
loss and HVAC system went out. DEQ got a verbal report on voice mail.
Army is investigating. It is a cause of some concern that it took so long
for generator to come on because when HVAC goes down agent can
migrate through facility. There are some plexiglass barriers but there are
not air tight closures.
It's impossible to continuously monitor furnace emissions using only one
ACAMS and no DAAMS. EPA never approved use of ACAMS for agent
monitoring in stack environment. State has not validated ACAMS for
use in stack gas agent monitoring.
Utah DEQ expects Army to assume ACAMS alarm indicates agent
present until alarm is shown as not confirmed by DAAMS analysis.
The Utah DEQ and the Army have no emissions data for burning greater
than 5% heels.
Employees in protective suits might get holes in suits when exposed to
agent material from low pH (acidic) ton containers . There is a
requirement for Haz Waste operators to characterize waste. Low pH was
a surprise to Utah. It would be a failure to characterize waste if they had
processed any TCs. They do not check for low pH before they burn
routinely.
Gray didn't know about use of TCs with history of previously containing
Lewisite and Mustard until after agent operations began. Understands
that no one at TOCDF knew of re-use policy. They began agent
operations without being aware of previous uses of TCs now filled with
GB. It was discovered by previous haz waste manager that there was
arsenic in brine--Trina Allen. Lewisite has high arsenic content. State
required testing after this disclosure.
Marty Gray testified again on June 15, 1999.
In the original permit there is language that requires that there be
continuous monitoring and controlling of emissions from each furnace.
This language was an error. It was never intended to be in the permit
although it took the state 2 years to clarify the language, which was
done in May 1999. In response to a request from the permittee for
clarification of language a paragraph was added to the permit that says a
single ACAMS monitor shall be maintained in the duct, with staggered
monitors in the common stack. The request was made in 1997 and the
paragraph was added in 1999. The original language has not been
removed from permit although it was never intended to have continuous
monitoring in the duct. It was in the draft version of the permit but it
was supposed to have been removed. The language requiring continuous
monitoring in the duct was in the version put out for public comment
and approved by the state.
Marty Gray testified again on June 16, 1999.
He affirmed that he received the message from Kori Holmes on his
answering machine and that the copy provided to him to look at was
consistent with the message he remembered. The message said that the
June 4th power outage lasted 25 minutes and there were three site
masking alarms during the event.
Colonel Joseph E. Huber testified June 8, 1999.
He is the Commander of the Deseret Chemical Depot.
He is responsible for everything that does and does not happen at
TOCDF and the rest of the Depot. He receives briefings on activities
at the depot in a timely manner and briefs others.
He had a recent meeting with General Doesberg. During their
conversation the May 26 incident in the Toxic Maintenance Area ( TMA)
was discussed. The nature of the incident was that some workers were
removing plastic bags of waste when an alarm sounded causing them to
exit. The agent reading of 1985 TWA was caused by a torn bag
containing the nerve agent GB . The workers were dressed in Level B
clothing.
The Utah incinerator facility is presently in a stand down where there is
a cessation of processing. The reason for the stand down is to ensure
that procedures are in place. The Stand Down was issued after a series
of discussions between the contractor and Project Manager for Chemical
Demilitarization ( PMCD) staff at Edgewood.
A Technical Review Team from Aberdeen is looking at the TMA incident
and may look at others.
In the power outage event that happened June 4, agent alarms were
simultaneous. It was characterized as a "chemical event" with a report
and press release. Nerve agent GB migrated into a C area--observation
corridors. The system is not designed to allow for this. The a alternative
generator power did not automatically start. There was an 8-10 minute
delay. They don't intend to allow the facility to run until they find the
cause and fix it.
Richard A. Sutherland testified on June 9, 1999.
He was the Control Room Operator on March 30, 1998 with control of
the primary utilities including some 20 support systems. Sutherland was
never told the results of the DAAMS tubes that were pulled at 3:46, the
time of the incident.
Clayton R. Hall testified June 8, 1999.
He was the Control Room Supervisor during the March 30, 1998
incident. The Carbon monoxide level during the incident was at 3000
parts per million (ppm) which indicates rapid volatilization. The bomb
was quenched with atomized water during the burn. The quench was
stopped before it was complete. The Automatic Continuous Alarm
Monitoring System (ACAMS) was operating properly. It saw something
when it alarmed.
Ronald Weyland testified June 9, 1999.
He was a Bulk Drain System (BDS) operator during the March 30, 1998
incident. There had been previous difficulty draining MC-1 bombs.
There is no method that he knows that could identify solid heels in a
bomb. He found out later that the BDS probe might have been out of
position. It was a mistake not to have passed that information on to
him.
Jeffery L. Harris testified June 9, 1999.
He is a Plant Shift Manager. On May 21st, nerve agent GB migrated into
the Unpack Area (UPA) where it is not intended to be. The negative
pressure air system isn't supposed to work that way. It came as a
surprise to him. There were 7 workers in the UPA when the alarm went
off. None of the workers were in appropriate protective clothing. After
the alarm sounded, workers donned their masks. There was no
protection from skin contact to the nerve agent present in the room.
Larry A. Davis testified June 9, 1999.
He is a Control Room Operator. He as on duty May 21st when agent
migrated in the Unpack Area. There was no alarm in the Explosive
Containment Vestibule (ECV) so he was in the presence of nerve agent
GB and he wasn't aware of it.
Gilbert Richard Moreno testified June 9, 1999.
He is a Container Handling Building Operator. His gas mask was at his
hip when the alarm sounded for nerve agent presence on May 21st in the
Unpack Area. He was not dressed in protective clothing appropriate for
being exposed to nerve agent.
Brenda Mohr Meyer testified June 9, 1999.
While Ms. Meyer worked in Hazardous Waste Management at the Utah
incinerator facility, she was asked to search for missing vials of nerve
agent while she was dressed in protective clothing inappropriate for
handling liquid nerve agent.
Ray William Bills testified June 9, 1999.
Mr. Bills is in charge of compliance issues. During the March 30, 1998
incident, the Tooele Chemical Demilitarization Facility (TOCDF) had a
waste feed violation in the Metal Parts Furnace (MPF). There was also a
permit violation when the carbon monoxide (CO) level reached 3000
parts per million (ppm). The CO limit in the TOCDF permit is 100 ppm.
The Brine Reduction Area (BRA) is not currently functioning at TOCDF
and hasn't functioned for approximately one year. It is in an extended
shutdown. The Waste Management Plan has been amended to reflect the
non-use of the BRA in the spring of 1999. The 1998 Plan included the
use of the BRA. The Dunnage Incinerator (DUN) has never been used. It
also is in extended shut down. It was never intended to use the DUN.
Dunnage is characterized HazWaste or industrial waste. Contaminated
waste is being stored at TOCDF. TOCDF is generating 45 million pounds
of hazardous waste while destroying three million pounds of nerve agent.
There are violations being considered beyond those that have been self-
reported. Some categories are repeated: improper storage; inspection
failures. Arsenic was found in Brine in one sample above the RCRA limit .
He saw a document identifying arsenic sometime in 1979-1981, before
his assignment to TOCDF. He knew arsenic may very well be a
component but he didn't label ton containers based on his knowledge of
the possibility of arsenic. More than 100 ton containers previously
contained Lewisite. He informed the Utah State regulators affirmatively
regarding: arsenic in brine in April of 97, 3-4 months after finding it .
Subsequently they started labeling incoming ton containers as
containing arsenic. There was no sampling prior to burning that
identified source of arsenic. He did not disclose to the State that ton
containers could possibly have previously contained Lewisite, Mustard
Gas, Chlorine, etc.
Some of these ton containers have very low pH value. Liquid agent has
been taken out of pressurized ton containers and put in clean ton
containers to burn in the metal parts furnace (MPF). It is an unusual
procedure. The normal procedure is to drain and run the liquid agent
into the liquid incinerator but it was changed due to refractory
degrading in the liquid incinerator . There is a temporary permit just for
pressurized tons. There are 17. If the agent in the ton containers is
above 4 pH then they are processed normally. Basically TOCDF
stumbled over the problem because one of them leaked. Low pH agent
creates damage to the system and if it comes in contact with protective
clothing it does damage. Low pH agent is too corrosive to process in the
liquid incinerator.
Usually the masking alarm is turned off after the agent alarms stop
ringing off.
There is an obligation to identify waste leaving the TOCDF facility, also
to identify waste going out of stack. There was no effort to quantify or
qualify chemical that was recorded going out of stack on March 30th,
1998. Windrose was attached to unusual occurrence report as an effort
to help track direction of plume that was emitted.
When there is a single ACAMS and it is being challenged or serviced
there cannot be continuous monitoring. TOCDF has been in violation
for failing to stagger ACAMS numerous times--it is a recurring problem
keeping ACAMS staggered. When they are not staggered there is some
period when there's no sampling.
William Ray Bills testified again on June 16, 1999.
He testified that he had received a copy of the memo by Kori Holmes, an
environmental inspector, that said that the June 4th power outage
lasted 25 minutes and that there had been three site masking alarms
during the event.
Richard Myron Sisson testified June 9, 1999.
He is Analytical Branch Chief , ensuring the laboratory operates in
compliance with government regulations. He doesn't know if DAAMS
tubes pulled at 3:46 am on March 30, 1998 were analyzed. He doesn't
know for a fact that DAAMS tubes were in place at 3:46 am.
Steve Jones testified June 9, 1999.
He is Safety Security Manager for EG&G. He has recently been
reinstated at TOCDF after being fired illegally for raising safety concerns.
He has been on training path and learned in the training that in a
recent incident, a worker exposed to agent had still been ringing off
positive on the agent sensor after being stripped out of his protective
suit.
He has learned that the DUN is shut down and has been pulled from the
permit and that the BRA is secured and has not been in operation for
some time. The MPF is feeding charcoal, GB ton containers, and liquid
GB other than in heels. He also has learned that burning low pH agent
in the liquid incinerators is deteriorating the piping. Low pH agent is
either being put into ton containers and being burned in the MPF or it is
being directly piped into the MPF from the punch and drain station.
Sam Guello testified June 9, 1999.
He is the present Safety and Surety Manager at TOCDF. He acts as
advisor to the General Manger and Risk Manager.
>
In the June 4 Power Outage Event, nerve agent GB was where it
shouldn't be. It shouldn't be in Level C areas.
Miscellaneous waste is being processed in the MPF. but munitions are
not being processed during the present stand down.
In Hot Cut-outs, protective clothing is removed from employees while
still registering hot--higher than .2twa.
In the May 21st incident, employees were present where agent was
present and they were not in the proper protective clothing.
Level B clothing is not adequate protection for low pH agent.
Low pH ton containers were discovered approximately one year ago.
There are some unusual properties with those particular munitions.
There is a concern that protective suit material is inappropriate for
low pH. The exact source of the low pH agent could not be discovered.
Last week there was an incident where employees were exposed due to
handling bags of liquid agent. One of the bags was ripped and the
employees were in inadequate protective clothing for handling liquid
agent. Corrective Actions have not prevented recurrences.
Small carbon filter is relied on for protecting employees from being
contaminated by nerve agent present in air hoses which tether them to
air supply when they are doing hot entries. There have actually been
some agent readings.
Christopher William Bittner testified June 10, 1999.
He is the Environmental Scientist for the Division of Solid and
Hazardous Waste for the Utah Department of Environmental Quality.
He is responsible for conducting and reviewing Health Risk Assessment
for TOCDF.
GB Trial Burns for the Deactivation Furnace still have to be approved.
Included in the new Risk Assessment (RA) for TOCDF is an evaluation of
upset conditions combustion-related but incidents that have happened
at TOCDF have not been addressed. Specific incidents could result in
greater emissions than 10 times the normal emissions which is the EPA
guidance. New RA doesn't address fugitive release from stack. State has
made no determination whether big release would pose acceptable risk.
He recommended that the infant be omitted entirely from the RA. He
has not made a determination of what amount of dioxin would pose
harm to an infant. The decision to remove the infant is not informed by
the state judgment of how much dioxin would be harmful to an infant.
State does not plan to include health risk from total combined sources
in new RA. Non-cancer effects are not included. Each furnace would
emit some dioxin. At this time, state has taken no position on how
much additional dioxin is safe. RA doesn't use an RfD for dioxin but he
doesn't know where real threshold is for dioxin for exposure causing
harm. He agrees it would be more protective to use RfD than abandon
it. State could use dioxin RfD if it decided to.
In new RA worker risk is assessed using dispersion modeling. It is limited
to stack emissions. It doesn't include agent migration or direct skin
contact.
New RA is using Hazard Quotient (HQ) to figure risk. The HQ ratio is
with the predicted dose in the numerator and the safe dose in the
denominator. The predicted dose does not include existing dose plus the
new dose. Although the new RA is using EPA default assumption in the
HQ, he doesn't believe it would be adequately protective to use default
assumption if you know background exposure is higher than that. He
doesn't believe estimate for TOCDF and others sources for dioxin has
been made by state.
New RA will not look at synergistic effects of agent and pesticides.
In the June 4 Power Outage Event at TOCDF, the site masking alarm
sounded after normal power resumed.
Christopher Bittner testified again on June 16, 1999.
Dairy pathway for exposure is not included in the new RA
although he agrees that folks in TOCDF area could decide to
consume their goats milk in the future.
John David Jackson testified June 10, 1999.
He is the Assistance Project Manager, handling compliance issues.
The Issues being investigated by the Technical Review Team are:
1. migration of material thru airlock in which air pressure system wasn't
given time to do its job; 2. release of material in Toxic Maintenance Area.
The release from the bag is still being reviewed; 3. processing 105mm
projectiles, removing nose cones. The Review Team came to TOCDF
because it's required with a Chemical Event.
In the March 30, 1998 event, the Army relied on the contractor, EG&G to
notify the State. Overfeed of the MPF had to be reported within 24 hours.
There was no tracking of the DAAMS tubes at that time. The first peak
of the Automatic Continuous Air Monitoring System (ACAMS) agent
alarm in the metal parts furnace duct was at 750-850 allowable stack
concentration (asc). The second peak was at 400-500 asc. 90 % of the
activity was during the first 15 minutes.
Ole Wilson testified June 10, 1999.
He is an ACAMS technician who was working during the March 30, 1998
incident. At 4:00 am. he didn't proceed with removing the DAAMS tubes
from the common stack until he got instructions from his supervisor.
He was told to not count them as alarm tubes. These tubes were placed
down into a dirty tube box along with 40+ other tubes which were to go
to the lab for cleaning and reuse, not to be analyzed. One ACAMS alarm
in the common stack was saturated. He couldn't get it to perform
properly. Something in the stack got it saturated. He couldn't remember
that kind of saturation before. He worked on it for an hour and a half.
It was off-line all that time. ACAMS don't measure accurately if they are
saturated.
Matt Peterson testified June 10, 1999.
He is a former TOCDF employee who worked in the Hazardous Waste
Department. Matt was exposed to agent with a co-worker in the Toxic
Maintenance Area. After being decontaminated, he had non-zero ACAMS
reading in his undergarment.
Michael J. Rowe testified June 10, 1999.
He is President and General Manger of EG&G Materials. He has primary
responsibility from the corporate point of view of safety.
In the June 4, Power Outage event, it was 8-12 minutes before backup
power came on. There were several ACAMS alarms in category C areas.
The Munitions Demil Building was evacuated. The outage caused a
disruption of the system. The site masking alarm is sounded during the
process of all alarms in C areas. He believes there were two site masking
alarms--during the power outage and during the restart of the
deactivation furnace
Shane Ray Perkins testified June 10, 1999.
He is an ACAMS technician. At 6:21am on March 30, 1998 he changed
the preconcentrator tube (PCT) in the MPF duct which had become
saturated at 4 am. At 5:30, the agent gate was changed to 83 to 100.
The ACAMS was off-line approximately 20-30 minutes during
maintenance. Chemical being emitted at 80 seconds retention time
would not cause alarm if gate is set at 83.
Steven James Wade testified June 11, 1999.
He is the Monitoring Team Leader for Batelle. He supervises DAAMS,
ACAMS technicians. He inspected ACAMS in metal parts furnace duct
during march 30, 1998 incident. It read 153ASC. It was overwhelmed by
a chemical that had a retention time of 80 sec. -- the bottom of the agent
gate. There was no DAAMS in the duct to confirm. To challenge an
ACAMS properly you can't have activity over 1ASC. The ACAMS in the
duct was baked out after event which is an unusual occurrence. There
were no DAAMS tubes present in the duct during the event. There are
now.
He made no effort to quantify amount of chemical that came through
furnace duct. There was a peak that registered on one of the ACAMS in
the stack but he doesn't know how large or what it was. All three
ACAMS in the stack saw some kind of activity.
Ted Ryba testified June 14, 1999.
He is the Assistant Project Manager of TOCDF.
The Dunnage Incinerator (DUN) originally was planned to be used much
less than at the Johnston Atoll Incinerator. DUN trial burns are not
complete, systemization is not complete. There are no plans to use the
DUN at TOCDF.
Ryba was the tour leader for a tour group from Hermiston, OR in May,
1998. The group was in the Container Handling Building for 10-15
minutes. He was first told of agent presence in the bombs approximately
2 hours after the tour members were in the area. He didn't go back to
have a blood test. Tour members were notified later. They took a reading
on the inside of the bomb but took no scrapes or wipes on the surface.
He doesn't know if any tour members touched the bomb. Bombs had a
previous life. He had noticed during the tour that one or more bombs
had deconned to XXX. Any material classified XXX cannot be released
unless it is deconned to XXXXX.
Changes in procedures after tour event are: Requesting more
documentation about munitions received, no more non-official tour
groups in CHB.
Procedural Changes that were made after March 30, 1998 event are:
Must more clearly specify SOPs when there is a discrepancy between
weight of bombs and bubbler, for verification of a complete drain; need
visual verification or use a dipstick. Investigation showed that the drain
probe had moved upward. A clamp holds the drain probe in place and
an additional clamp was added. Also made a mark on probe as a point of
reference--so they're able to tell if it has moved.
In the May 21st Event, agent migrated into the Unpack Area. There now
is a plan to monitor airlock and work on timing sequence. They're still
investigating how they're going to deal with that scenario.
In the May 24th Event, it was an operation in the Unpack Area with
workers in B level clothing. They are looking at modifying the process to
include automatic removal of nose cones. It 's continuing to be investigated.
After the Mary 26, 1999 Event, the Changes effected are: Immediate
change was to further clarify SOPs for management of contaminated
materials, require more strict decontamination, etc; employees are
required to manage contaminated materials wearing DPE suits.
After the June 4th Event, the Changes made are: Largest change has
been to add 3rd diesel generator for part of HVAC system to ensure they
don't lose clean ventilation. They are increasing depth of maintenance and
inspections. There will be an increased frequency of checking fuel. Just
ensuring SOPs are followed more strictly. No radical changes.
The Uninterruptible Power System is intended to provide power to control
systems and ACAMS. It is designed to provide power for 20 minutes. The
Heating and Ventilation Air Control system is intended to remove agent
from air before it goes to outside environment. System is designed to not
allow migration during normal power. The ACAMS continued to ring off
through the process of returning to normal power.
Areas adjacent to the outside environment include: 2nd Floor UPA area,
Observations corridors, Processing areas, MPF room 1st floor-- LIC
secondary chamber room, Vestibule and monitoring room, Vestibule
between LIC and MPF chamber room, hydraulic room, DFS room, MPF
Control . C Areas adjacent to outside environment shouldn't have agent
present. Agent presence is neither desirable nor expected. He has seen
agent migration into C areas.
He is not aware of anyone measuring the agent that goes into the
Pollution Abatement System and the agent that is trapped there to
ensure that no agent is going out the stack.
The normal processing of projectiles is mechanical. There are occasions
when individuals are involved with something that doesn't work right.
There have been nose closures taken off by humans previously in
Unpack Area at TOCDF
TOCDF did have problems with one or both Uninterruptible Power
Systems a year and a half ago--one or both--burned out.
In the operation of ACAMS, they don 't alarm immediately as they identify
agent. They go thru sampling cycle, then alarm.
The State has been asked for permission to burn greater than 5% heels of
GB. TOCDF got approval to burn ton containers and rockets with
greater than 5% heels.
He is not aware personally of any study done to derive the number of
projectiles with agent in nose closure.
Agent is fed with rockets into the DFS.
In TOCDF Trial Burns ton containers that were fed were ones prepared
with measured agent. There were no "real" heels fed.
TOCDF is in the process of working thru 16 ton containers that have
been termed "pressurized" (low pH agent).
TOCDF had difficulties in 1 996 associated with a feed chute. Ryba is
responsible to see that Lessons Learned from JACADS are transferred to
TOCDF. He has no first hand knowledge of the worker death at
JACADS. The employee who was killed was working on a modified feed
chute. Ryba doesn't know if he was trained on the new modification.
Dunnage Incinerator was originally intended to burn protective suits.
Options are being explored for disposal of suits.
Carbon Filters were not installed in the stack at TOCDF. They are
being considered for other facilities. They were rejected for TOCDF.
The filter system wouldn't mitigate the risk of storage. There is a plan
to process full rockets which would slow down the processing rate and
increase storage risks.
The BRA is not currently being used.
ACAMS in the stack alarm from time to time. They are from interferents
that exit the stack.
TOCDF is under interim approval, not final EPA TSCA approval. There
were two Trial Burns under TSCA for the deactivation furnace. The first
failed partly because of PCBs DRE. Had to redo Agent GB Trial Burn as well.
A new SOP after March 30th event includes visual verification. SOP
wouldn't be invoked unless drains are less than 194 pounds. The new
SOP is tolerant of a 28-pound heel. They anticipate getting heels greater
than 11 pounds. The limit is higher than 5% heel for other munitions
also.
Since the May 21st Event, they are pursuing an investigation of setting
up ACAMS in airlock. Ryba doesn't know why they haven't had a
monitor in the airlock before now.
Since the May 24th Event, employees are required to wear protective
clothing. Before the event only a small probability of liquid agent in the
burster wells was anticipated. The probability was greater than
anticipated.
There is no buffer room if the air system doesn't work to prevent agent
from going out into the environment.
Since the June 4th Event, they are adding a third generator to a single
filter unit. There are 9 filter units. Seven are needed to be on line at any
moment for proper filtration of expected agent levels. Third generator will
be connected to one filter as a last resort to maintain ventilation. System is
not designed to run on one filter. They haven't tested to see what one filter
will do. It 's a diesel generator--the same technology that failed June 4, except
it's manual start, not automatic.
There was more than one incident on June 4th. There was a power
failure and during part of the recovery, the ACAMS sounded in the
airlock adjacent to the deactivation furnace. It was related to the power
outage, but it could be considered a separate incident. A preliminary
investigation indicates agent may have come from the deactivation
furnace room which houses the furnace. The source has not been
identified.
Judy H. Moore testified June 14, 1999.
She is a Control Room Operator. She was the Supervising Control Room
Operator on March 30, 1998.
There have been occasions when heavy bombs were bypassed and fed into
MPF. Some bombs are moved to be physically checked--DP entry
initiated with dipstick. Solidified heels wouldn't be identified with the
dipstick. She doesn't know for sure if the drain probe had been knocked
loose. She doesn't specifically recall if preventive maintenance occurred
prior to March 30th.
An Extreme Temperature Limit (ETL) caused the metal parts furnace to
shut down. They waited for it to clear. They started to quench the load
in the furnace. They relit the afterburner. Ray Winn decided it was
better to keep the bomb in the furnace than get it out. It was quenched
within minutes. She's not certain what time the Alarm in the duct was
in relation to the quench. As temperature reaches ETL, the quench goes
on automatically. Since it wasn't quenching rapidly enough, it was
manually quenched. Winn recommended we stop quench.
Any chemical causing the alarm would have passed on out. There was
no attempt to track the chemical that went out. No off-site sampling
was initiated.
The State expects ACAMS alarm to be treated as agent until DAAMS
analysis proves otherwise.
Steven O'Neill testified June 14, 1999.
He is in Quality Assurance Ammunition Surveillance.
A reconditioned ton container has been previously used, then cleaned
determine if any ton containers had previously contained Lewisite.
Before April 1997 they also noticed some ton containers had been
reconditioned--in December 1996. In January 1997 he did research on
GB for production conditions--Freon, Mustard and Lewisite were
specifically mentioned. Information on reused ton containers was
provided to the State. There is a set of ton containers that they
don't really know what they contained. It can't be ruled out that
containers with an unknown history previously contained Lewisite,
Mustard, et al.
The reconditioned ton containers with an unknown history came from
Pine Bluff. Folks at Rocky Mt. that got tons from Pine Bluff didn't
require testing because they didn't have funding. There are no records.
2000 came from Pine Bluff. They don't know the previous history, just
know that the containers are re-conditioned. They specifically have
records on 28 that previously had Lewisite. It is possible that of the
2000, many or all contained Lewisite. This information wasn't provided
to the state prior to startup of operations at TOCDF.
In testimony on June 15, O'Neill clarified the 2000 number. There are
963--he had problems transposing numbers. Groupings as of September 1997:
GB only--1577; GB/H--1877; Freon--287; Lewisite--25 (28 original number,
three destroyed); Unknown--276; Maintenance--34; Reconditioned--963;
Of the 5039 total approximately 3000 historically had previous contents
other than GB or their history is unknown.
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