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Agency That Investigates Plant Explosions "Grossly Mismanaged"

After plants like the one in Texas blow up, federal safety investigations can be frustratingly slow—if they happen at all.

| Thu Apr. 18, 2013 1:23 PM EDT
Inspectors from the Chemical Safety Board visit the site of a fire at the Chevron refinery in Richmond, California in August 2012.

This story was originally published by the Center for Public Integrity.

Editor's note, April 18: An explosion Wednesday at a fertilizer plant north of Waco, Texas, killed between five and 15 people, authorities say, and injured more than 160. The US Chemical Safety Board, an independent agency that investigates chemical accidents and issues safety recommendations, says it expects a "large investigative team" to arrive at the scene this afternoon. As the Center for Public Integrity reported Wednesday, the board has been criticized for failing to complete investigations in a timely manner.

On April 2, 2010, an explosion at the Tesoro Corp. oil refinery in Anacortes, Washington, killed five workers instantly and severely burned two others, who succumbed to their wounds.

Eighteen days later, the Deepwater Horizon drilling rig blew up in the Gulf of Mexico, killing 11 workers and unleashing a massive oil spill.

In both cases, the US Chemical Safety Board—an independent agency modeled after the National Transportation Safety Board—launched investigations. Like the NTSB, the Chemical Safety Board is supposed to follow such probes with recommendations aimed at preventing similar tragedies.

Yet three years after Tesoro and Deepwater Horizon, both inquiries remain open—exemplars of a chemical board under attack for what critics call its sluggish investigative pace and short attention span. A former board member calls the agency "grossly mismanaged."

The number of board accident reports, case studies, and safety bulletins has fallen precipitously since 2006, an analysis by the Center for Public Integrity found. Thirteen board investigations—one more than five years old—are incomplete.

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As members of Congress raise questions, the Environmental Protection Agency's inspector general is auditing the board's investigative process.

"It is unacceptable that after three long years, the CSB has failed to complete its investigation of the tragic Tesoro refinery accident," Sen. Patty Murray (D-Wash) said in a written statement to the Center. "The families of the seven victims and the Anacortes community deserve better, and the CSB must be held accountable for this ridiculous delay."

At Tesoro, a tube-like device called a heat exchanger came apart, triggering an inferno that melted aluminum 100 feet away. Shauna Gumbel, whose son, Matt, died 22 days after being burned in the blast, said the victims' families were told to expect news from the CSB on the tragedy's second anniversary. The date came and went. "Then we were told, 'Six more months,'" she said.

In a recent conference call with the families, board officials pledged to finish the Tesoro report by the end of 2013—more than 3½ years after the accident, Gumbel said.

"I think they're making excuses," she said. "Why aren't they assigning more people so they can get the investigation done in a timely manner and the families can move forward?"

Chairman Rafael Moure-Eraso and managing director Daniel Horowitz say the board, which has a $10.55 million annual budget, is stretched thin and must decide which of the 200 or so "high-consequence" accidents that take place in the United States each year merit its attention.

"We've made innumerable proposals over the years…pointing out the significant discrepancy between the number of serious accidents and the ones that we can handle from a practical standpoint," Horowitz said in an interview with the Center. "We've asked for a Houston office. We've asked for additional investigators for many years."

"The basic, bottom line is the agency is grossly mismanaged," says a former Chemical Safety Board member.

Congress, he said, has been unwilling to come up with more money.

Moure-Eraso, chairman since June 2010, said the Tesoro investigation was sidetracked by an explosion at the Chevron refinery in Richmond, California, last August that created a towering black cloud and prompted about 15,000 people in surrounding neighborhoods to seek medical evaluation. No one was killed but 19 workers were exposed to noxious hydrocarbon vapors.

"We have to make decisions," Moure-Eraso said. "Here we were, running along, working on Tesoro, and then this accident happened at Chevron. We decided that it was important to deploy [to Richmond] because the issues that were raised were issues that affect the whole refinery industry."
Current and former board members and staffers, however, contend the agency's investigations are poorly managed—an allegation the EPA's inspector general is exploring.

"They were jumping from one investigation to another, and when a new accident occurred they would pull people off an existing investigation to go investigate that one," said former CSB board member William Wark, whose five-year term ended in September 2011. Wark, who accompanied investigators dispatched to the Tesoro accident, said it's "embarrassing" that the investigation has not been finished.

"The basic, bottom line is the agency is grossly mismanaged," he said.

The board has 20 investigators—four more than it had in 2008. Adjusted for inflation, its budget has been essentially flat over the past five years. Yet earlier investigations were often completed more quickly.
The deadliest accident the board has investigated was the March 2005 explosion at the BP refinery in Texas City, Texas. Fifteen workers were killed and 180 injured. The board's final report was issued just under two years after the accident.

A February 2008 blast at the Imperial Sugar plant near Savannah, Georgia, killed 14 and injured 36. The final report was issued in 19 months.

Gerald Poje, a Bill Clinton appointee who served on the board from 1998 to 2004, finds it "painful" that more recent investigations have stagnated. He worries that an "erosion of the reputation of the institution" could cause Congress to question its value.

"I always considered the board to be in a race against time," Poje said. "When an event occurs, people want to know instantaneously why it happened, how it happened and what can be done to prevent it from happening again. Unfortunately, over time, people begin to forget and feel less obligated to pay attention to recommendations."


Falling productivity

The Chemical Safety Board had a rocky start. Created by Congress in amendments to the Clean Air Act in 1990, the board wasn't up and running until 1998. It was a relative weakling among government agencies, starved of funding and mistrusted by industry.

"Upon reflection as a former board member, it appears that neither administration nor Congressional support for the CSB has ever been very strong," Andrea Kidd Taylor, now a lecturer at Morgan State University in Baltimore, wrote in the journal New Solutions in 2006. "[F]unding for this small agency has been limited…So the agency's growth and the number of investigations it can conduct and complete in a year are minimal."

Still, Taylor wrote, "Given the CSB's current budget [then about $9 million], the average number of four root-cause investigations completed per year is exceptional."

Authorized for five members, the board currently has three, with a fourth awaiting confirmation. Its staff numbers 39. The NTSB, by comparison, had more than 400 people and a budget of $102 million in fiscal year 2012.

The chemical board appeared to hit its stride under Carolyn Merritt, a George W. Bush appointee who served as chair from 2002 to 2007 and died of cancer in 2008.

In 2006 the board released nine products—three full reports, three case studies and three safety bulletins. In 2007 it put out eight, including a widely praised, 341-page report on the BP-Texas City explosion.

Production has trended down ever since. Last year, the board released two case studies. So far this year, it has issued one full report and one case study. On Monday, it released an interim report on the August 2012 Chevron accident.

"It depends, ultimately, what Congress expects the agency to do," the board's Horowitz said. "If they expect us to look at all 200 of these high-consequence accidents, then that's a larger problem. With the resources that we have—which, like every other agency, are finite—we do tremendous good.

"Would we like to do more? Would we like to do it faster? Sure."

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