The Safety Agency At War With Itself

Personnel disputes are tearing the Chemical Safety Board apart, leaving the panel’s work unfinished — and workers at risk.

Fire department personnel walk among the remains of an apartment complex next to the fertilizer plant that exploded in April 2013 in West, Texas. House lawmakers are advancing legislation meant to extend the life of a Homeland Security Department program meant to help shield such facilities from terrorist attacks.
National Journal
Jason Plautz
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Jason Plautz
July 24, 2014, 1 a.m.

The me­mori­al is fin­ished. A bench sits out­side a re­tired met­al-re­cyc­ling plant in Mon­aca, Pa., a me­mori­al to two work­ers who lost their lives when an ex­plo­sion in a re­finery column triggered a fire. As of this month, that was four years ago. The plant has sinced closed and, with the help of an Eagle Scout, the bench is be­ing moved off the aban­doned lot and in­to town.

When it ar­rives, the bench won’t just be a me­mori­al; it will be a pain­ful re­mind­er of a prom­ise un­ful­filled. After the fire, a fed­er­al agency was tasked with study­ing the causes of the fire and then fil­ing a re­port on how to keep a sim­il­ar fatal ac­ci­dent from hap­pen­ing again. But that re­port is yet to ma­ter­i­al­ize, and the friends, fam­il­ies and cowork­ers of the two men — James Taylor, 53, and Corey Keller, 41 — are still wait­ing for an­swers.

“We have two fam­il­ies out there won­der­ing what happened to their loved ones,” said John Jef­fers of the loc­al United Steel­work­ers uni­on. “Was it caused by an ac­ci­dent where someone made a wrong move, or was it caused by com­pany neg­lect or something else? We won’t know.”

Mon­aca’s story is an in­creas­ingly com­mon tale for the Chem­ic­al Safety Board, the agency whose prin­cip­al pur­pose is to in­vest­ig­ate and is­sue re­com­mend­a­tions on chem­ic­al dis­asters like the 2013 fer­til­izer-plant ex­plo­sion in Texas that killed 15 people or the Janu­ary chem­ic­al spill in West Vir­gin­ia that left thou­sands without clean wa­ter. But the re­ports aren’t com­ing as in­ten­ded.

The board’s lead­er­ship paints a pic­ture of a pinched agency hit­ting above its weight class, pro­du­cing sub­stant­ive re­ports that will change safety policy go­ing for­ward. But a host of cur­rent and former em­ploy­ees blame Chair­man Ra­fael Moure-Era­so and his in­ner circle, ac­cus­ing them of cre­at­ing a dys­func­tion­al work en­vir­on­ment that has left the board’s em­ploy­ees in des­pair and their work in shambles.

Re­gard­less of who’s right about the agency’s tra­ject­ory, there’s no ques­tion about its cur­rent real­ity: Un­fin­ished cases have piled up, and the crit­ics are pil­ing on.

The Chem­ic­al Safety Board was cre­ated in the 1990 Clean Air Act amend­ments to study chem­ic­al dis­asters and is­sue re­com­mend­a­tions on how to pre­vent them in the fu­ture. The board has no reg­u­lat­ory power — its in­flu­ence is felt when it is­sues re­ports and re­com­mend­a­tions on fed­er­al policy, in­dustry stand­ards, and work­place cul­ture.

CSB has re­leased five such re­ports this fisc­al year — well above pace from pre­vi­ous years when just nine re­ports came out between 2011 and 2013. There are 11 open in­vest­ig­a­tions lis­ted on its web­site, in­clud­ing a Pu­erto Rico re­finery-tank ex­plo­sion from 2009 and a 2010 am­mo­nia re­lease from an Alabama re­fri­ger­ated-ser­vices fa­cil­ity. But that tally doesn’t in­clude some cases that were dropped or re­solved without full-scale re­ports.

For ex­ample, the board in 2009 opened a probe in­to a fire at a CIT­GO re­finery that burned for days and left one work­er in­jured. There was hope that the in­vest­ig­a­tion would spur a deep­er look in­to the use of the tox­ic gas hy­dro­fluor­ic acid at re­finer­ies, seen as a pub­lic threat be­cause of the gas’s po­ten­tial to travel far if re­leased (the Cen­ter for Pub­lic In­teg­rity has covered that is­sue). The board later iden­ti­fied at least two more cases deal­ing with hy­dro­fluor­ic acid (one at the same plant) that wer­en’t closed.

Since the CIT­GO case was opened, however, lead in­vest­ig­at­or Rob Hall left CSB (over frus­tra­tion with man­age­ment, he has said), as have oth­er in­vest­ig­at­ors. Re­com­mend­a­tions were made in 2009, but the full case is cur­rently sit­ting idle and Man­aging Dir­ect­or Daniel Horow­itz said it’s one of a num­ber of cases that is un­der re­view, pos­sibly to be com­bined in­to a lar­ger study on re­finery is­sues that would in­clude oth­er re­finery in­cid­ents.

Jeff Wanko, an in­vest­ig­at­or who left CSB in 2011 to take a po­s­i­tion with the Oc­cu­pa­tion­al Safety and Health Ad­min­is­tra­tion, said in an in­ter­view that it wasn’t clear if that pro­ject would ever get off the ground again.

“I think you’ll find that in­vest­ig­a­tions like that, they’re go­ing to flounder,” Wanko said, be­cause in­vest­ig­at­ors can’t re-cre­ate the find­ings just from pa­per­work.

And clos­ing in­vest­ig­a­tions isn’t much good, stake­hold­ers say, if it’s hap­pen­ing years after the ac­ci­dent. It took CSB four years to com­plete an in­vest­ig­a­tion in­to the Ana­cor­tes-Te­soro re­finery ex­plo­sion in Wash­ing­ton state that killed sev­en people, prompt­ing a re­buke in Feb­ru­ary by the state’s two Demo­crat­ic sen­at­ors and Rep. Rick Larsen. Mike Wright, dir­ect­or of health and safety for the United Steel­work­ers, said that pat­tern doesn’t help any­one.

“When the board does a re­port, nor­mally it’s a pretty good product,” he said. “It just takes so long that its util­ity is greatly di­min­ished.”

Former board mem­ber Beth Rosen­berg, who left this spring after serving just 17 months of a five-year term, said in­vest­ig­a­tions be­come more dif­fi­cult the longer they take, but delays also means solu­tions don’t ma­ter­i­al­ize.

“Pri­or­it­ies fade,” she said. “You lost mo­mentum. When an ac­ci­dent hap­pens in the first year there’s in­terest and en­ergy to fix whatever caused it. After that, oth­er pri­or­it­ies be­come more im­port­ant. You’ve got to strike while the iron is hot.”


The back­log isn’t new — a 2013 En­vir­on­ment­al Pro­tec­tion Agency in­spect­or gen­er­al re­port found the Chem­ic­al Safety Board was “not con­sist­ent in ac­com­plish­ing its ob­ject­ive to com­plete timely in­vest­ig­a­tions.” But it’s be­come a po­tent piece of am­muni­tion for crit­ics who say that the board is de­teri­or­at­ing un­der Moure-Era­so’s lead­er­ship. A House Over­sight and Gov­ern­ment Re­form Com­mit­tee hear­ing last month aired plenty of dirty laun­dry and an ac­com­pa­ny­ing re­port al­leged that Chair­man Ra­fael Moure-Era­so and oth­er CSB ex­ec­ut­ives were bul­ly­ing em­ploy­ees, block­ing polit­ic­al in­vest­ig­a­tions and for­cing ex­per­i­enced in­vest­ig­at­ors out the door.

It wasn’t the typ­ic­al brand of par­tis­an at­tack from Over­sight Com­mit­tee Chair­man Dar­rell Issa — Demo­crats joined in the cri­ti­cism of Moure-Era­so and the EPA in­spect­or gen­er­al raised ques­tions about pro­duc­tion dur­ing his ten­ure. Issa and five oth­er Re­pub­lic­ans sub­sequently signed a let­ter to Pres­id­ent Obama call­ing for Moure-Era­so’s re­mov­al.

There’s been no pub­lic fol­low-up from Con­gress or the White House yet, but in­tern­ally CSB lead­er­ship is work­ing to im­prove mor­ale and bol­ster its im­age.

All the while, that in­vest­ig­at­ive back­log con­tin­ues to loom over the agency at a time when the White House has made chem­ic­al se­cur­ity a pri­or­ity. Cur­rent and former CSB em­ploy­ees who spoke to Na­tion­al Journ­al say the slowed pace is the res­ult of a dys­func­tion­al body with an “abysmal” at­mo­sphere. Some em­ploy­ees are even count­ing down the re­main­ing 11 months of Moure-Era­so’s term, or hop­ing his time is cut short (the chair­man has said he won’t resign).

“The agency is so far be­hind on its work and with such a low level of pro­ductiv­ity,” said one em­ploy­ee, speak­ing an­onym­ously for fear of re­pris­al. “When you have a de­mor­al­ized work­force, it doesn’t trans­late in­to them feel­ing a sense of ur­gency or en­ergy in the work they’re do­ing.”¦ If we wait 11 months, there may not be an agency left.”

Man­age­ment, however, sees things dif­fer­ently: The back­log ex­ists, but it’s slowly be­ing eased with bet­ter and more sub­stant­ive re­ports. A small staff and budget makes it dif­fi­cult, but the re­ports be­ing pro­duced now deal with policy and have the power to make in­dustry-wide changes.

“We’re on the job,” said Moure-Era­so, even amid the polit­ic­al com­mo­tion. “We are com­mit­ted to con­tin­ue do­ing our re­ports and make re­com­mend­a­tions that are go­ing to pre­vent ex­plo­sions and pre­vent people from dy­ing.”

The back­log ex­is­ted at the start of Moure-Era­so’s term in 2010 and the pileup began un­der the chair­man­ship of Car­o­lyn Mer­ritt and in­ter­im Chair­man John Bres­land. Ac­cord­ing to CSB man­age­ment, there were 22 un­fin­ished cases at the start of his term, com­pared with just 11 now.

Moure-Era­so has ex­plained the back­log as the res­ult of a budget short­age and a small staff. And while that may be true — CSB’s fisc­al 2014 budget was roughly $11 mil­lion and it has around 40 em­ploy­ees — the budget and staff were also small in pre­vi­ous years when in­vest­ig­a­tions were cleared in a year or two.

In fact, there’s little ap­pre­ciable dif­fer­ence in the board’s budget and staff com­pared with the high-wa­ter mark of 2007, when 11 in­vest­ig­a­tions were com­pleted (in­clud­ing, at the time, the CSB’s longest). There were 17 in­vest­ig­at­ors on staff that year, com­pared with 19 in 2013, and the budget today is roughly $2 mil­lion high­er. Aside from a dip between 2006 and 2011, the in­vest­ig­at­ive staff has in fact grown.

So what’s changed? There are more — and more com­plex — in­vest­ig­a­tions go­ing on, high­lighted by the CSB’s con­tro­ver­sial entry in­to the Deep­wa­ter Ho­ri­zon blo­wout in the Gulf (typ­ic­ally CSB wouldn’t deal with off­shore in­cid­ents, but ven­tured in after a con­gres­sion­al re­quest).

It’s that re­port, Moure-Era­so said, that demon­strates what CSB is do­ing well and why its in­vest­ig­a­tions must take so long. The first two volumes of the re­port ap­proved in June, he said, were the only ones to use a full set of test­ing data to de­term­ine why the rig’s blo­wout pre­venter failed and de­vel­op sol­id re­com­mend­a­tions on how to pre­vent sim­il­ar in­cid­ents. It’s part of a “sub­stan­tial evol­u­tion” in how CSB works, mov­ing from in­dustry con­sulta­tions to policy mat­ters that take a big­ger bite.

“We’ve learned to look at the root causes, we have to look at pro­cess safety man­age­ment, rather than just the en­gin­eer­ing lapses that we found,” Moure-Era­so said. “We have to look at policy is­sues and we have got­ten very good at this “¦ I be­lieve we are be­ing an agent of change.”

For ex­ample, he said, a re­port re­leased last week on an ex­plo­sion at AL Solu­tions met­al-re­cyc­ling plant in West Vir­gin­ia in­cluded re­com­mend­a­tions to the Oc­cu­pa­tion­al Safety and Health Ad­min­is­tra­tion on how to ad­dress com­bust­ible dust, an is­sue CSB has made a pri­or­ity in re­cent years. A 2013 re­port on an ex­plo­sion at a fire­works-dis­pos­al op­er­a­tion in Hawaii in­cluded first-ever re­com­mend­a­tions on safety con­di­tions for fed­er­al con­tract­ors.


Sources in­side and out­side CSB ques­tioned how much more sub­stan­tial the re­ports were, adding that the delays render some of the im­pact moot. That ex­plan­a­tion, they say, is a spin from a man­age­ment team look­ing to shield it­self from well-de­served blame for lead­ing the agency astray as polit­ic­al pres­sure looms.

Em­ploy­ees told Na­tion­al Journ­al that de­bate is dis­cour­aged with­in the CSB and that man­age­ment has forced ex­per­i­enced in­vest­ig­at­ors to leave. And, they say, Moure-Era­so and man­aging dir­ect­or Daniel Horow­itz seem un­will­ing to simply put to­geth­er a pub­lic doc­u­ment list­ing the status of on­go­ing in­vest­ig­a­tions, pos­sibly to blunt neg­at­ive press.

Board mem­bers have long pushed for an ac­tion plan to be hashed out in the open — Mark Grif­fon and then-mem­ber Rosen­berg asked for a pub­lic agenda meet­ing at a 2013 meet­ing, but were over­ruled by Moure-Era­so.

In an in­ter­view, Rosen­berg said the in­cid­ent was frus­trat­ing — as a board mem­ber, she felt a right to have some in­put on CSB’s dir­ec­tion. “We got up­dates, but no big-pic­ture ideas. And we’re sup­posed to be do­ing the big-pic­ture stuff,” she said.

It’s an ef­fort that goes back well be­fore Rosen­berg’s ten­ure. Former board mem­ber Wil­li­am Wark, whose term ended in Septem­ber 2011, said in an in­ter­view that he and fel­low board mem­ber Wil­li­am Wright (who left the same time as Wark) would ask for a man­age­ment in­form­a­tion sys­tem so of­ten “it be­came a joke of sorts.” The amount of ef­fort be­ing de­voted to in­vest­ig­at­ing the Deep­wa­ter Ho­ri­zon spill — up­wards of 30 per­cent of the budget and at one point 55 per­cent of man hours, ac­cord­ing to Wright — heightened that de­sire.

Even with 16 or 18 in­vest­ig­a­tions go­ing on un­der Moure-Era­so, Wark said he had no idea of an over­arch­ing plan. “This is Man­age­ment 101 and it wasn’t be­ing ad­dressed in any sense of the word.”

While he didn’t agree with the Deep­wa­ter Ho­ri­zon in­vest­ig­a­tion — it was one where there was little “value-ad­ded” po­ten­tial, he said — Wright said the board’s oth­er work dur­ing his time had a big im­pact and built a strong repu­ta­tion. But the prob­lems that have sur­faced since then have tar­nished the brand, pos­sibly past the point of re­pair.

“Dur­ing my ten­ure, I was pretty proud of a lot of the work we had done pri­or to [Moure-Era­so’s] ar­rival,” Wright said. “Now, I’m em­bar­rassed to say I was there. It’s be­come a bit of a laugh­ing­stock.”

Com­ing next week: How the Chem­ic­al Safety Board Came Apart.

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