by Dian Cucchisi, PhD, CHMM
At approximately 8:00 pm on April 17, 2013, an explosion occurred at a fertilizer plant in West, Texas. Fourteen people (including 11 emergency responders) were killed and more than 200 people were injured. Approximately 150 buildings, one EMS vehicle and two fire fighting vehicles, were damaged as a result of the explosion. The plant was located in a small town that numbers approximately 2,800 residents. The town has an all-volunteer first aid squad and fire department; three of the injured first aid responders were in training.
News reports in the days that followed compared the explosion to the Oklahoma City bombing and the BP Texas City explosion. Common factors between these and the West, Texas explosion are the presence of ammonia nitrate and the resulting devastation.
As the information unfolded in the days that followed the West, Texas tragedy, it was revealed that the facility had been a repeated target over the past 11 years for ammonia theft with intruders stealing about 4-5 gallons of anhydrous ammonia every 3 days. The anhydrous ammonia tank valves were damaged as a result of the theft and vandalism. The cause of the blast is still under investigation and it is not known if the damage to the ammonia tank valves was a contributing factor.
The reports also stated that the company was storing 54,000 pounds of ammonium nitrate and 54,000 pounds of anhydrous ammonia and it had been stated the facility underreported the quantity of material that was being stored. The quantities of ammonium nitrate and anhydrous ammonia stored at the facility trigger a number of regulatory requirements. The requirements include the Occupational Safety and Health Administration’s (OSHA) Process Safety Management Standard, the U.S. Environmental Protection Agency (EPA) Risk Management Program (RMP), the Department of Homeland Security’s (DHS) Chemical Facility Anti-Terrorism Standard (CFATS).
The news reports stated that the Texas Division of Environmental Quality had received many complaints over the past several months about a strong ammonia smell that seemed to be coming from the facility.
Many of the follow up news reports have focused on an area where gaps have been found in the operation of the facility. It appears that there were many interconnected problems that led to this disaster.
- The facility was storing a very large amount of ammonium nitrate and anhydrous ammonia without adequate protection.
- The company had not filed the Top Screen that is required by the DHS CFATS program. The exercise of completing the Top Screen would have forced management to look at the security of the facility. The lack of security resulted in theft and vandalism to tank valves which then compromised the safety of the anhydrous ammonia tank.
- EPA’s RMP and OSHA’s PSM require proper maintenance of equipment including tank valves.
- While the majority of the first responders were not prepared for what they were entering, one volunteer fire fighter worked at the facility and should have been aware of the hazards of the materials stored there. Many of the responders, including the plant employee, died as a result.
In the field of health and safety we often find that complacency and lack of training are key contributing factors in health and safety incidents. Company management and workers become complacent and believe that things won’t go wrong because “nothing has happened yet”. Rather than take a proactive stance and prepare for what could happen, action often is not taken until something does happen. The West, Texas fertilizer plant did not put security measures in place even though they had experienced theft and vandalism. Appropriate safety measures were not taken in repairing the damaged tank valves, upgrading to inherently safer technology, and ensuring proper storage and fire protection for the large amount of material that was stored at the facility.
Facility employees may have received the training required by OSHA but it appears that it was not effective. The volunteer fire fighter that was a plant employee did not take precautions before rushing in along with other first responders and became a casualty.
Many of the news reports have asked the question “where was OSHA (or the EPA, DHS, etc.)?” At times like these we often look at the regulatory agencies to see where they have fallen short in their enforcement of the facility. Asking “where were the agencies” is similar to asking “where were the police” when a car accident or other incident has occurred. The responsibility for safe operation of any facility falls to the management of that facility, just as it falls to the operator of a motor vehicle. Our regulatory agencies implement laws and are there to enforce them but it is up to the people in charge to run their operation safely.
So what can we do to help prevent a tragedy such as this?
- Effective health and safety training for workers, management, and line supervisors. To ensure that training is effective, an annual review of the training is recommended and sometimes required. A well trained employee is our best resource in the efficient and safe operation of a facility.
- A true management commitment to safety. The “Safety First” slogan is often posted at facilities where it has little meaning. Unless safety is a part of the culture of the company, incidents and often tragedies will happen.
- Management must be willing to commit personnel and monetary resources towards improving and providing a safe working environment.
- Partnership with the local emergency responders. First responders should be invited to tour the facility and become familiar with the operation.
- First responder training must include potential hazards they may face when responding to a particular location in addition to the firefighting and emergency medical training they receive. Responding to a location that stores chemicals is very different than responding to a fire or medical emergency at a residence.