Friday, August 21, 2015

Weekend longreads

First, this article by Lise Olsen in Texas Monthly on the LaPorte, TX deaths of 4 DuPont chemical operators is horrifying and quite thorough:
"Troubleshooting that alarm fell to a rookie operator named Crystle Wise, a 53-year-old, dog-loving, Harley-Davidson-riding grandmother with electric blue eyes. By chance, Wise had chosen to take her break in a spot dubbed the “smoke shack”—between the control room and the pesticide tower. Wise, one of the latest hires in the plant’s recent wave of turnover, was still finishing her nine-month training period with DuPont. She donned her safety helmet and goggles and grabbed an oversized wrench. Then she crossed a covered passageway to the Lannate tower and opened a heavy metal door that led to a stairwell. She headed for a complex set of valves on the third floor, to clear the clog and relieve the stress on the pipes—and on the rest of the crew. What Wise didn’t know was that she was walking into a disaster."
I tend to agree with the "Swiss cheese" model of accident analysis - in this case, you can really watch the holes line up. More on this later.

Also, does anyone have a good article on the Tianjin incident? I know there's a lot of sodium cyanide in the destroyed warehouse, but that doesn't explain the initial explosion.  

30 comments:

  1. http://www.bbc.com/news/world-asia-china-33923478

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  2. The initial suspicion is that the explosion was due to a large quantity of calcium carbide in storage. If it was stored in a sprinklered warehouse you would have a huge problem due to the production of acetylene gas.

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  4. Not to be a nit-picking Nate, but I don't believe "in the beach town of Escondido" is correct.

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    1. Depending on that area's subsidence levels, it soon will be.

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  5. Wow, has duPont's safety tanked!

    I worked for my Dad at the Experimental Station. He was the entomologist who retrieved Lannate from the waste bin after a problematic primary screen and worked on productizing it for years. It was the first summer after high school and I was waiting to start school for a chemistry degree. I think I spent three days in safety training (this was in the early 70's). Standard duPont uniform - prescription safety glasses (I already had a pair -- my safety indoc started when I was old enough to have a chemistry set. I even had a homemade fume hood at home!), safety shoes. Training on wearing the self-contained breathing apparatus hanging in the hallways of the lab.

    I worked for Dad all summer on 1179 (Lannate) formulations. I knew the score after he showed me a toxicology report from Haskell Labs on it. Needless to say, I was VERY careful.

    That was my first and last experience at duPont. The following summers I spent at Ft Detrick, Edgewood Arsenal, and Dugway Proving Grounds. The duPont training was very useful.

    What happened at LaPorte is past criminal if the article is accurate. A lot of people at the plant and in Wilmington belong in prison for manslaughter.

    Someone is DC needs to grow a pair and shut their plants down - all of them, until they cleanup their act.

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    1. DC would just make the mess bigger and more expensive for everybody, and the only benefit would accrue to DC.

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    2. What an awful story. The fines are a pittance.

      Anon 4:20, how do you envision DC making the mess bigger and more expensive? Can you suggest alternatives? (I have cousins living in Pasadena and worry about this story. I am sure DuPont isn't the only plant in that area that needs to be cleaned up.)

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    3. DC has a track record. Yes, it is terrible. Let the courts and torts take care of it - it's more effective, and also cheaper for just about everyone.

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    4. I guess so, but isn't that how we got here? Doesn't it come down to courts and torts after people have died? And is anyone going to prison for manslaughter like oldnuke suggested? The reference in the article to the Union Carbide disaster was chilling.

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    5. Not entirely. DC has already been involved - belatedly - and their main response has been to hit duPont up for some fines. What good did that do anybody, other than money for bureaucrats? Clearly it's not much of a disincentive and helps no-one else. Also having DC at the party just ensures more redundant industry regulation at immense cost to everyone - it punishes a large number of uninvolved parties to no effect. Furthermore it is a mistake to assume that DC is some sort of impartial arbiter. The feds are always an interested party - and composed of interested parties - with agendas of their own. Finally, regulation doesn't prevent accidents, people do. You cannot regulate a culture that values safe practices into being.

      No, courts and torts are the way to go. Let the survivors sue duPont for millions, let the court determine culpability, and let duPont address their own shocking lapses through fear of a repeat episode and increased public exposure. DC isn't going to do it for them. Besides, recent events demonstrate that involvement of at least one of the related agencies leads to historic disasters of massive proportions, and their best excuse is that they were unbelievably and massively incompetent.

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    6. That just sounds like it will come down to legal teams duking it out. DuPont's versus the families'?

      Don't you think there should be more serious penalties already in place to discourage practices that jeopardize the lives of workers and of the people who live in close proximity?

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    7. Not really - the damages awarded, unfavorable publicity, and resulting loss of business should be penalties enough - and incentive enough - to get it right.

      Regulation doesn't prevent accidents. There has been an increase in the number and ubiquity of regulations, and accidents continue to occur. In fact, one of the cited causative factors of this accident was an (expensive) attempt to comply with environmental regulators. Sound people and sound practices prevent accidents. Neither can be regulated into being.

      The issue with penalties has to do with their disposition. I'd rather that the money went to the victims' families and towards repairing the facility and improving procedure and safety awareness at duPont, than to some armchair intermediary trying to justify its existence and retain jobs (or worse yet, engaging in active sabotage so as to create work for itself). If the federal government had somehow taken a more active role in managing this accident, it's just as likely that half of Houston would have been exposed and we'd now be talking about thousands of fatalities.

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    8. Perhaps regulation is not effective at preventing accidents (it sounds like the plant was not compliant with environmental or safety regulations), but obviously neither is the threat of litigation or this wouldn't have happened. Although I am in agreement that the damages should not disappear completely and without a trace into the coffers of an "armchair intermediary," it seems that DuPont has walked away from this relatively unscathed. A small fine and some unfavorable publicity are likely to be soon forgotten by those not deeply impacted by the incident.

      I don't see how it could be just as likely that the neighborhood exposure would have been more widespread if there had been a more active role taken at some level of government. I wonder if this would have happened if there had been a real possibility of the government shutting the plant down for the types of violations described. Perhaps we should agree to disagree.

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    9. Possibly that's all we can do.

      Just to clarify, when I said "the damages awarded, unfavorable publicity, and resulting loss of business should be penalties enough - and incentive enough - to get it right." I meant that they had to be sufficient - should be adequate to - force a change in the safety culture of the company.

      On the neighborhood exposure being more widespread if the relevant agency had taken a more active role at the time of the accident, the agency in question has actually caused major disasters twice in the last five months. The resulting damages have been and will be extensive, long-lasting, and one of the disasters will devastate a number of cultures. "Oops" is not good enough in such a context, especially when it is suspected that the intent was deliberate. Also, there are two other federal agencies where politics and ignorance of fundamentals routinely overrun sound practice, resulting in conditions causing hundreds of millions of dollars in damages, environment damage, and also multiple lives lost every year. The objective should not be to compound or worsen disasters, but the federal government frequently goes out of its way to actually create them.

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    10. Granted, this may be naive, but the idea of the federal government going out of its way to create catastrophes of this magnitude (and I am under the impression here that we are referring to the recent devastating calamity in the southwestern U.S.?) just seems like something out of John Grisham plots; those stories may have realistic literary details or components with some basis in reality, but ultimately they are fiction.

      I find it much more likely that these are matters of incompetent negligence rather than deliberate sabotage. There's too much at stake for both wrongdoers and victims. You are right, though: "oops" is absolutely not good enough.

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    11. This letter was published in the Silverton Standard a week before the disaster.

      EPA Plan Is Really a Superfund Blitzkrieg

      Knowing something about these agencies, who they hire, what they have done and why, and what they are presently trying to accomplish, necessarily has an impact on consideration of their motives.

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    12. I read the Silverton link when when it was posted the first time. Taylor is certainly in a position to say "I told you so," but that doesn't constitue evidence that the EPA is guilty of anything disregard for good advice.

      I don't believe anyone woke up thinking "how many lives can I destroy in order to make work for myself" any more than I think that Patrick Harran or anyone at DuPont deliberately intended to harm anyone, but some things obviously need to change.

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    13. ...of anything BUT disregard...

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    14. I believe the thinking is more along the lines of, "We have to burn the huts to save the village." This justifies the action in terms of anticipated future benefits. If anyone happens to be inside the huts - well, that's regrettable, but they died for a righteous cause.

      If the EPA was really concerned about fulfilling its mandate, why did it wait almost 24 hours before notifying anyone? As it was, the first reports of the Silverton disaster were from downstream affected parties. Why did the EPA withhold information on the contamination despite requests? Finally, why did the EPA send agents around parts of the Navajo reservation collecting signatures for legal action waivers? None of these are the actions of a responsible agency.

      Finally, the result seems to have been a semi-desirable one for the EPA - there are now public calls for the EPA to be involved in the treatment and management of other mining toxic waste sites in the West, which means more Superfund designations, more money, an expansion of agency power, and more work. Totally nonsensical, but that's what's happening. Even if you take the EPA at its word, this is like giving the keys to all the city buses to the drunk that blew up a gas station by running a station wagon into it.

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    15. Also, more broadly, there are the issues of behavior of past employees (Beale's tenure with the agency should make one wonder about the extent to which his ethics were reflected in his day-to-day work) and the current behaviors of present employees - none of which says anything good about the agency's abilities. Also the fact that the Army Corps of Engineers has been trying to get any mention of itself removed from WOTUS because of misrepresentation of data it supplied.

      Anyway, I'd have trusted the EPA to have "fixed" the duPont disaster about as much as I'd trust the VA to take care of my Uncle Henry. I'd want someone else to handle the crisis response, someone else to be involved with the environmental remediation, and someone else to be involved with addressing the issues at duPont. Also I would take a cue from the Army Corps of Engineers and distrust any legislation that the agency might try to produce as a consequence.

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  6. @Chemjobber,

    Thanks for the link to the Texas Monthly article. It was well-written, interesting and disturbing. I look forward to your future posts on this accident.

    @oldnuke,

    In China, officials of Ruihai Logistics were arrested. http://shanghaiist.com/2015/08/18/10-execs-detained-over-tianjin-explosions.php
    I don't see that happening to DuPont execs.7

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    1. In the People's Republic of China, if an embarrassment or accident occurs, heads roll. These often are not the appropriate heads. The present mainland Chinese government (and many past Chinese governments) generally have been of the opinion that it is far more important to be seen to be punishing someone quickly, than actually addressing the relevant problem. If the scapegoat happens to be made to order to fit some policy imperative, then so much the better.

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  7. The Wall Street Journal did a series of articles on the Tianjin explosion. I would provide a link but it's been pointed out to me that such links hit a paywall. Try looking up "Tianjin explosion" and select the WSJ story "Tianjin Explosion Erodes Faith in Leadership for Many in China" (8/20/15 update) which has titles of the other articles. You may be able to then look up the other articles similarly.

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  8. I worked at DuPont in the 1990s, at a site far from Wilmington, and the safety training was lax. When I asked my first boss about safety training for working in the lab, he told me to go find a technician to show me the ropes. That was it. And the site lauded itself on its fantastic 'safety culture'. It was a joke.
    Over time, the technicians themselves put together a safety training course, and it became mandatory at one point for everyone to take it. The lab management was not involved at all.
    When there were lab accidents, what routinely happened was the lowest ranking person would get blamed, and there would be an investigation, and then the matter would be forgotten.
    Bizarrely, there was also an 'off-the-job' safety culture, by which I mean that even off the job, a employee was not supposed to be involved in any accidents, because 'All Accidents Are Preventable'. Even if a drunk driver plowed into your car on the highway, you were still supposed to have somehow avoided the situation. This happened to our lab director, and even though his car was totaled, he refused to go to the hospital, because then it would be an 'official accident'. People were willing to sacrifice their health, in order to keep an accident off the records.
    I could go on and on, but I'll stop. Sadly, I'm not surprised about the four deaths at the LaPorte plant.
    One thing that might force a change at DuPont is that OSHA has put the company on its 'repeat offenders' list, though I don't think that's the correct name.

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    1. I disagree about auto accidents. It is a good thing if companies recognize them, and far too few do in the US.

      DuPont has about 60000 employees. At 20 miles per day, that's about 280 million miles per year in commuting. Overall fatality rates are about 1 per 100 million miles driven, but commutes are probably safer than the average (generally in daylight, few drunks), so its probably about one DuPont worker who dies every year on the way to or from work. And that is not even considering the ill health effects of driving, which is highly stressful and completely sedentary, or the effects of the related pollution on the public.

      Any company serious about the health and safety of its workers and the public would absolutely be thinking about how to minimize the impact of commuting.

      And why would your lab director risk his health and committ a dismissable offense in order to hide an accident that was the fault of a drunk non-employee? To avoid some paperwork? Something to do with a very poorly designed bonus?

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    2. Bingo – You hit the nail on the head. It was (and probably still is) the bonus program that DuPont had set up, which amply rewarded the upper management at each site. We had heard that ~30% or more of these managers’ yearly pay was bonuses, which were tied into profits, safety incidents, site costs, and the like. Naturally, these individuals did all in their power to protect these bonuses, and hence the warped safety culture. Oddly, the same management did not see that there was a systemic problem that stemmed from the perverse incentives inherent in this set-up, probably due to their benefiting from the incentives so handsomely. Instead, they would pat themselves on the back repeatedly about the lauded safety culture.
      As for the lab director and the car accident he was in, courtesy of a drunk driver – if an employee was not absent from work for an entire day, then an incident was not counted as a recordable injury. Hence, his decision not to go to the hospital, given that those pesky ER doctors might want to do tests and keep him at the hospital too long. He was luckily only badly bruised and had no other injuries, though he absolutely looked like hell when he came into work the day of the accident. Of course, the director proudly displayed a photo of his totaled Volvo in the cafeteria, as an example for all of us to emulate.
      I do agree with you that a person can seriously decrease their chances of being in a car accident or being seriously injured, by wearing their seatbelt, keep tires inflated, not driving drunk, etc. And we had an infinite number of safety meetings emphasizing the same. We used to joke though – if you were in a car accident and were found to not be wearing you seatbelt, it would be better off if you died, than having to come back to work and explain this serious lapse in judgment to the management.

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    3. I heard from a colleague who used to work at Dupont agribusiness research that any workplace mishap that could be covered up would be covered up: Every lab mishap - even if it was just a spill where no-one got hurt - triggered a massive safety investigation with record for everyone involved: you just end up with a juicy accident report in your HR file, and should you have another mishap few years later, they were going to fire you for "violating safety rules" and you were automatically presumed guilty until proven innocent...

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  9. Jyllian Kemsley posted about the accident in the Safety Zone blog on July 10: http://cenblog.org/the-safety-zone/2015/07/dupont-named-severe-violator-by-osha/

    " OSHA has also placed DuPont in its Severe Violator Enforcement Program, which 'concentrates resources on inspecting employers who have demonstrated indifference towards creating a safe and healthy workplace by committing willful or repeated violations, and/or failing to abate known hazards. It also mandates follow-up inspections to ensure compliance with the law', OSHA said in the press release."

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