Twenty years ago, if a worker was killed in an industrial accident, the task of investigating what went wrong and why fell either to the employer or to the government safety regulator — precisely the two parties most likely to have been at fault. Though slow to change, federal lawmakers eventually created the independent Chemical Safety Board (CSB), a small, seemingly insignificant agency funded in 1998 and tasked with determining the root causes of industrial accidents and recommending changes to prevent them. Over its lifetime, CSB has investigated and analyzed more than 130 accidents responsible for more than 200 deaths, 1,200 injuries, and hundreds of billions of dollars in property damage.
Twice, President Donald J. Trump has tried to eliminate that board, threatening to return us to the era when discovering and making public the cause of a refinery or plant accident is left to those responsible for the accident in the first place. Trump should sit down and have a talk with Tammy Miser.
Years ago, Miser’s brother Shawn was injured at work. She remembers receiving the late-night call at her home in Lexington, Kentucky, and speeding five hours to the St. Joseph Regional Burn Center in Fort Wayne, Indiana. When she arrived, she rushed inside and was told that an unidentified, badly burned male had come in.
“We hoped and prayed it wasn’t Shawn,” Miser said. “A hospital pastor told me to prepare for the worst. There was no body hair, no physical markings. My Shawn was ultimately identified by body weight and type. They told us his internal organs were burned beyond repair.”
“It was horrible,” she said, “but we took him off life support and watched him take his last breath.”
Miser learned from CSB that Shawn had been killed by an explosion and fire fueled by dust — in this case, common metal shavings. Mixed with the right amount of oxygen and exposed to an ignition source, the seemingly innocuous dust explodes and burns.
The explosion that killed Shawn was one of three deadly dust accidents investigated in 2003 by the CSB. In all, some 200 accidents each year — explosions, fires, leaks, spills — qualify for a CSB investigation under its mandate. Often, it’s not just the workers but also the surrounding communities that are harmed: For instance, a 2012 Chevron refinery explosion in Richmond, California forced 15,000 residents to seek medical aid; a 2014 tank leak in Charleston, West Virginia, contaminated the drinking water of some 300,000 people.
Yet CSB remains perennially underfunded, understaffed, and under attack. Although the agency was established in 1990, it received no funding until 1998, in the wake of a series of deadly accidents that proved too much for the Environmental Protection Agency and the Occupational Safety and Health Administration to handle. As it happened, one of the accidents killed five New Jersey workers near the home of the senator who wrote the legislation that created the board. So began a disturbing pattern that continues today: When a horrible accident occurs, support for CSB grows; but as the accident fades from memory, support wanes.
Today, the agency has the resources to investigate only a sliver of the industrial accidents that occur each year. Its budget has never topped $11 million, a pittance compared to the $100 million a year appropriated to the National Transportation Safety Board, on which CSB is modeled. But NTSB investigates transportation accidents, and all of us — Congress members and CEOs included — take trains and airplanes. Most of us do not work in refineries or on factory floors.
The legitimacy of the board and its decisions have been challenged by nearly everyone — companies and trade associations, safety regulators, members of Congress, even labor unions. When a plant blows up, however, everybody wants to know what happened and why, but no one wants the finger publicly pointed at them.
After the Richmond refinery explosion, for instance, Chevron played down the accident and challenged CSB’s authority to investigate. But the investigation moved ahead anyway, in part because the accident was so visible: Black smoke could be seen throughout the San Francisco Bay area, and dangerous particulates were blasted into the nearby community. It was the last straw in a long-running and volatile relationship between the community and the company.
The board found that the explosion was caused by a broken and badly corroded pipe, which released flammable hydrocarbon fluid that subsequently caught fire. The board also found that on at least six occasions spanning more than a decade, Chevron management had been advised by its engineers that the carbon-steel piping was prone to corrosion and should be replaced, or at least subjected to an intense inspection program. However, management ignored the recommendations.
CSB investigations over the years revealed that such mishaps were widespread in the petrochemical industry. Agency reports uncovered fundamental flaws in plant management and government regulatory oversight at facilities nationwide. In 2012 alone, 125 significant accidents — leaking tanks, fires, piping failures — occurred at the nation’s 150 refineries, and financial losses from refinery accidents in the U.S. were three times higher than in other countries.
As a result, CSB staff and board Chairman Rafael Moure-Eraso urged sweeping changes in U.S. refinery regulations, beginning with Chevron. The board recommended that the U.S. adopt a “safety case” approach — a regulatory scheme commonly used in Europe that places the onus for safety management on the operator and calls for company-developed regulations to be overseen by the safety regulator and plant workers. The recommendations were backed by residents, safety advocates, and local union leaders. California legislators even adopted CSB’s broad recommendations and used them as the foundation to overhaul the state’s refinery safety regulations. Washington state officials are now considering doing the same.
But for some CSB members, national unions, and Chevron executives, the board’s recommendations went too far. The safety case approach was put on hold, a CSB member quit, and some CSB staff left and brought complaints about the board’s management to Congress.
The squabbles, charges, and countercharges caught the eyes of Republicans on a congressional oversight committee, and the committee began an investigation. The investigation dragged on and eventually members sought Moure-Eraso’s resignation. In a terse statement in March 2015, a White House spokesman announced that the White House had “asked for and received Dr. Rafael Moure-Eraso’s resignation.”
A few months later, the Senate confirmed a new chairperson who had no experience in chemical manufacturing. Years later, the board is still working to rebuild, replenish staff, and increase its investigatory presence.
It does so in an unfriendly political climate. President Trump called to eliminate funding for the CSB in his 2018 and 2019 budget proposals, and he’s shown no indications that he’ll change that stance. Despite his recommendations, Congress has continued to fund the board, albeit at the same low levels it’s received in the past.
Amid the chorus of criticism, one group has consistently supported increased funding for the CSB: family members, like Tammy Miser, who have seen loved ones hurt or killed in industrial accidents. Shortly after her brother’s death, Miser formed the United Support and Memorial for Workplace Fatalities, a nonprofit that helps people whose lives have been devastated by an on-the-job death. She’s also testified to Congress and pressed OSHA to adopt better industrial safety laws. Although the U.S. has yet to adopt regulations to prevent industrial dust explosions like the one that killed her brother, a new industry has sprung up to promote dust safety, she notes.
“None of this would have been possible,” she says, “without the Chemical Safety Board.”
Jeff Johnson is a Washington, D.C., based reporter who has written on the environment and industrial practices for 30 years. Much of his research on industrial safety was funded by The Alicia Patterson Foundation.
Comments are automatically closed one year after article publication. Archived comments are below.
I disagree with Ellen Silbergeld. The CSB is valuable for several reasons:
1. OSHA and EPA don’t look for root causes of incidents, only whether specific standards or regulations were violated. Thing like the effect of fatigue, the presence of reactive hazards, “new” hazards like combustible dust and general systemic failures are either ignored or not adequately addressed by the enforcement agencies.
2. The CSB provides a bit of oversight over EPA and OSHA, again looking for other causes of incidents that the agencies may have missed and adding other issues to the agency’s agenda. Many of the issues being considered now for OSHA’s PSM update come from CSB recommendations. They can also point out shortcoming in the agencies’ regulations or enforcement policies.
3. CSB is able to make recommendations to companies, industry associations, labor union and government agencies — again which go beyond OSHA or EPA regulations.
In conclusion, the CSB definitely provides added value — at least when it’s functioning properly. But the internal issues the agency is currently experiencing have little or nothing to do with the how the agency is functioning. Right now, you have the left-overs from the previous Chairs, the President’s continue efforts to eliminate the agency and now, the government shutdown.
With reference to Ellen Silbergeld comments: It is true that in 1998 the CSB was “about dead on arrival” giving the strong opposition from the Clinton administration, some in the chemical industry and OSHA and EPA on the grounds of being “unnecessary and duplicative”. The Trump administration used the same rational for trying twice (unsuccessfully) to de-fund the agency in 2017 1nd 2018.
But the CSB persisted and proved to be very effective and efficient (given the modest budget allocated). Twenty year later, it can show more than 160 major investigations with more than 800 recommendations adopted by stakeholders (including OSHA, EPA, CalOsha, ACS, API, NAFP, AIChE, BP, Chevron, Tesoro and dozens of others in the petrochemical industry). CSB complemented the investigative efforts of (by far) better funded federal regulatory agencies (OSHA and EPA)– that have not been able to conduct effective root cause investigations of mayor chemical catastrophes. The regulatory agencies investigation work is hamstrung by having always to refer to the current obsolete regulations on the books to make prevention recommendations. CSB work is not encumbered by current regulations.
The work of the agency has been recognized nationwide and internationally by the petrochemical industry and by the petrochemical workers as a “great value”. Of course we should support the institutional regulatory federal agencies but if the objective is to prevent catastrophic chemical fires and explosions, the CSB has a proven its sterling value as an effective agent of prevention. We certainly will not be “doing better” by suggesting non support to the CSB on the grounds that in 1998 it was almost but not quite “dead on arrival”.
In California, the CSB’s investigation of the 2012 Richmond, Chevron refinery vapor cloud explosion played a crucial role in the subsequent development of California’s groundbreaking, 10,000-word, 2017 Process Safety Management (PSM) regulations for refineries (GISO 5189.1).
CSB found that Chevron’s own engineers had warned the company on six different occasions about the problem of sulfidation corrosion in the plant’s crude unit, including warning of the possibility of a catastrophic failure that could cause loss of life. Chevron managers chose not to act on these warnings, and the crude unit failed in one of the locations the engineers said it would–and it did so catastrophically, endangering the lives of 19 workers and causing thousands of residents to seek medical attention.
The CSB’s findings led to strong new authorities in the 2017 PSM regulation for workers (nearly all USW-represented) to participate “throughout all phases” of PSM decision-making at each of the state’s refineries. See subsection (q) on page 24 of the attached. They also provided a more general foundation and rationale for drafting regulatory language that is meaningful, practice and enforceable, something the industry’s lobby, the Western State Petroleum Association, vigorously opposed.
Washington State will adopt a CA’s PSM regulation in 2019, and one of CA’s members of Congress, Mark DeSaulnier, introduced a December 2018 Resolution calling for a federal PSM standard that reflects the CA language.
In light of all this work, I guess it’s not a surprise that the CSB is under attack.
the chemical safety board was just about dead on arrival. Moreover, it was an end run about OSHA and NIOSH with their much deeper experience and resources in investigating health and injury risks in occupational settings.
We would do better to support these institutions
To equate safety in plants today with an time in the past is to recognize the changes that have taken place. First most manufacturing, especially by large companies operate under SAFETY FIRST. Not all manufacturing does, and manager do ignore the OSHA rules. Companies are run by people and some people are just bad and in some cases evil. The processes of 50 years ago are gone and replaced several times over, each time with improved worker safety. The changes reduced employment and increased efficiency. For example is automation keeping workers off the plant floor in a safe environment. Society moved from using steel, glass and paper to chemicals, mainly plastics. Plastics use much less energy to produce and improved cost performance. In 1960 the steel consumption per US citizen was around 1,000 pounds by 2000 steel consumption dropped to around 600 pounds per person. The population about doubled so total steel demand was flat. Plastic’s demand increased both in total and on a per capita basis.
There are a lot of factors that caused an increase in worker safety: cost, insurance, unions and government regulation. The government regulation that probably protects workers the most is OSHA. Dealing with OSHA is a pain and workers often do not like the rules. However, the safety of American workers is better due to OSHA. I believe in small government but I have also experienced working in a steel mill where bad safety practiced got you fired on the spot (45 years ago) and at a company where the head of R&D ignored safety (6 years ago), OSHA and because of his lack of leadership injured workers and imperiled others and the financial stability of the whole company.
We all remember the ignoring of safety by Massey Energy. Prison time for the executives (maybe not enough but some) and the company bankrupt. Leadership ignores safety at their own freedom and personal wealth!
It is management’s responsibility to ensure a safe work place.
I was confused about what happened long time ago, on my advice I wish CSB to take full investigation about this case and I wish it will resolve before it will take another year