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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

Horowitz and Moure-Eraso say they are eager to complete the Tesoro investigation, which has consumed about 7,100 hours of staff time and $700,000 over the past three years. But, they say, Deepwater Horizon, an inquiry requested by two members of Congress that has cost nearly $4 million to date, required a diversion of staff.

"We've spent $4 million that we really didn't have, and we've committed, at times, over half our investigative staff," Horowitz said. Investigators, he said, have prepared a 400-page draft report that's "the most comprehensive we've ever done."

The Tesoro inquiry progressed in fits and starts. Within a few months of the accident in April 2010, investigators had drafted urgent recommendations for the company as well as a refining industry trade group and the Occupational Safety and Health Administration. Those recommendations were never issued.

"The board at that time didn't feel that they went far enough," Horowitz said. "They were company-specific. We didn't feel they went to the real heart of the problems, which are broader than Tesoro and reflect aging infrastructure in refineries [and] use of antiquated materials and systems."

A year earlier, however, the board had issued urgent recommendations stemming from a release of potentially lethal hydrofluoric acid from the Citgo refinery in Corpus Christi, Texas. They were no broader than the draft Tesoro recommendations.

"Perhaps even worse is the human cost of the delays. Families and coworkers feel abandoned by the board, and even abandoned by their government."

"Well, look, it was a different board, and they make their decisions on what recommendations they want to ultimately issue," Horowitz said.
The board's investigation of the Citgo accident, which occurred in July 2009, is unfinished. "That's a case we hope to get back to," Horowitz said.

Soon after the draft Tesoro recommendations were shelved, several experienced investigators—including Rob Hall, who was leading the Tesoro team—left the board. In the fall of 2011, an almost entirely new team essentially had to start over.

Team members have since been pulled into the Deepwater Horizon and Chevron investigations, among others. The current leader, Dan Tillema, spent months examining the failed blowout preventer implicated in the Gulf oil spill, a process that has cost about $1 million.

When the Tesoro report finally comes out, Horowitz said, it will reflect an exhaustive inquiry."We engaged top metallurgists from the National Institute of Standards and Technology and we are undertaking complex modeling to understand process conditions inside the heat exchanger," he said. "The investigative team has been continuing to obtain documents and interviews from Tesoro.

"Management problem"

The United Steelworkers union, which represents workers in refineries, chemical plants and other hazardous settings, has been among the board's more vocal critics.

At a public meeting in January, on an explosion that killed five at a Hawaii fireworks storage facility, Steelworkers official Mike Wright observed that "our workplaces have been the subject of more CSB investigations than any other union or corporation. We are your biggest stakeholder and, perhaps, your biggest fan."

Investigative delays "severely compromise the board's mission," said Wright, director of health, safety and environment for the Steelworkers. "Perhaps even worse is the human cost of the delays," he said. "Families and coworkers feel abandoned by the board, and even abandoned by their government."

The union didn't blame the board's investigators, Wright said. "This is a management problem."

The EPA's inspector general is looking into this very subject. In May 2012, the IG notified Moure-Eraso that it planned an audit "to determine whether CSB's investigative process can be more efficient to enable more investigative work."

Three months later the IG released the results of another audit, finding that the board did not press regulators, such as OSHA, and industry hard enough to make sure its recommendations were adopted. As of December 2010, the IG said, more than a third of the 588 recommendations issued by the board were still open; almost a quarter of these had been open more than five years. The board says 29 percent of its recommendations are open today.

"We are kind of full-time employment device for the IG," Moure-Eraso said. "I don't think that they are competent to basically understand how we work or understand how we conduct investigations."

The board was dealt a substantial blow in 2011, when four investigators quit. Two of them, Hall and John Vorderbrueggen, had been team leaders; both, now with the NTSB, declined comment.

Asked if he thought the departures reflected dissatisfaction, Moure-Eraso said: "Investigator is a very tough job. You are asking somebody to deploy for weeks at a time wherever the accident happened, to be away from their families, to deal with very unsavory situations. You have to deal with people getting killed, places destroyed…It's not for weak hearts."

Where to deploy?

The board's choice of investigative targets has been a point of contention.

Why, the Steelworkers ask, did the board follow up on an ink plant explosion in East Rutherford, New Jersey, that injured seven workers last October, but not a hydrofluoric acid release that killed a union member in December at the Valero Energy Corp. refinery in Memphis? Hydrofluoric acid, a toxic gas that can rapidly travel long distances in a ground-hugging cloud, is used at about 50 US refineries. "We have been harping on how dangerous it is for quite some time," said Kim Nibarger, a health and safety specialist with the Steelworkers.

The union thought the Valero accident afforded a "golden opportunity" for the board to reinforce the need for "inherently safer technologies," Nibarger said. "They said they were too busy."

Horowitz said the board was asked to go to New Jersey by one of the state's senators, Frank Lautenberg. No one in the Tennessee congressional delegation urged the board to look into Valero.

"We screen [accidents] very carefully," Horowitz said. "We look at the specific consequences—the number of deaths and injuries and things like that, the number of community evacuations. We look at qualitative factors, one of which is requests from Congress and from our authorizing committees to investigate these issues."

Poje recalls fielding congressional requests when he was on the board. "Sometimes," he said, "you have to answer back, 'Thank you so much for your interest. We wish we were resourced to meet this priority for your community but we aren't.'"

Debate continues over whether the board should have investigated the April 2010 Deepwater Horizon accident, already addressed in at least a half-dozen other federal inquiries, including one by a presidential commission.

Former board members Wark and William Wright, both appointed by George W. Bush, said they argued against it. "It was offshore. It was something that we had absolutely no business being in," Wark said. "They insisted on doing it anyway. They spent a lot of the agency's budget on that."

"I don't think there's anything they're going to say that's going to improve offshore drilling right now," said Wright, whose term expired the same day as Wark's in 2011. "Yet we have managed to invest $4 million in as many years and I am at a loss as to what value will be added by continuing to look at this incident now, particularly when the Interior Department has changed a number of regulations already."

Horowitz pointed out that the board, then chaired by John Bresland, was asked to investigate the disaster in early June 2010 by Reps. Henry Waxman (D-Calif.), and Bart Stupak (D-Mich.). Bresland agreed. Moure-Eraso assumed the chairmanship days later, having been handed a record-high caseload. Bresland declined to be interviewed.

"We told Congress at that time that we needed additional resources to conduct that work," Horowitz said, referring to $5.6 million in supplemental funding sought by Moure-Eraso. "Well, those resources were never provided."

The investigation was slowed by rig owner Transocean's refusal to comply with board subpoenas for records, lead investigator Cheryl MacKenzie said in a statement to the Center. "It took nearly two years of steady effort to get the issue before a federal court, and only this month did a decision finally come down in the CSB's favor," MacKenzie said.

Nonetheless, Horowitz said, the investigation, which should be completed this summer, was worth doing.

"We're the agency that's going to look in detail and depth at industry standards," he said. "The presidential oil spill commission took the 30,000-foot view, wrote a good report, but looked in broad strokes. The regulators looked at technical issues. We are looking at the effectiveness of those standards, and we'll have a lot of recommendations for improvement that we think will make a safer industry."
William Wright said the board should have focused instead on finishing long-overdue reports, like Tesoro, and delving into more recent accidents, like Valero.

"That's kind of why we were put in business in the first place," he said. "The public's not being well served by an agency that was created to improve chemical safety if it fails to put out timely reports on significant chemical incidents."

The Center for Public Integrity is a nonprofit, non-partisan investigative news organization in Washington, D.C. For more of its stories on this topic go to

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