From: rosera**At_Symbol_Here**COMCAST.NET
Subject: Re: [DCHAS-L] C&EN article: The uneven world of chemical accident investigation
Date: Fri, 2 Sep 2016 07:21:17 +0000
Reply-To: DCHAS-L <DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU>
Message-ID: 1108643611.11806628.1472800877953.JavaMail.zimbra**At_Symbol_Here**

It is indeed an interesting article about the CSB, and especially telling about those who admire its work from a distance.  However, from the point of its birth with the 1990 Clean Air Act Amendments, it seems to have been treated as the "red headed stepchild" of federal agencies.  Neither President Bush (41) nor President Clinton deigned to activate the CSB until pressure from Congress (especially Senator Lautenberg of New Jersey, following the joint EPA/OSHA investigation of the 1995 reactive chemical fatalities in Lodi, NJ; see finally resulted in meager funding & appointment of five Board Members in January 1998.

While the CSB is nominally independent, and its investigation reports are widely admired as objective, it is a federal agency that is not immune to political pressure.  For instance, it is particularly vulnerable to requests from Senators & Representatives for investigation of accidents in their states or districts (see for an example).  Also, while Senator Lautenberg was alive, it was a virtual certainty that any significant accident in New Jersey would be subject to a CSB investigation.  With Senator Lautenberg's passing, the CSB is left without a strong advocate in Congress, and the long-term continuation of even its starvation-level funding is questionable.

The article mentions the EPA Inspector General's audits of the CSB, which have left a backlog of issues for the CSB Board to address.  The latest can be viewed at  Reports during the regime of former CSB Board Chair Dr. Rafael Moure-Eraso led to accusations of whistleblower retaliation, cited evidence of low morale & high turnover at the CSB, and finally culminated in bipartisan condemnation of CSB management in Congressional oversight hearings, forced resignation of Dr. Moure-Eraso, and subsequent suspension of the CSB General Counsel & Managing Director.  A good portion of Chair Vanessa Sutherland's first year has likely been devoted to fixing internal problems, improving external political relationships, and finishing past investigations without (until recently) committing to new investigations.

The major criticisms of CSB investigations are:  (1) there are not enough of them (see the EPA Inspector General's report); (2) they take too long to complete, and thus the impact of the lessons learned is diminished.  Part of the problem, of course, is the meager funding & staffing.  Committing to an investigation of the Macondo disaster in the Gulf of Mexico proved to be a disaster for the CSB, which never received the additional funding from Congress requested at the time of commitment; as a result, this investigation either limited the CSB response to chemical accidents or took resources away from other investigations, thereby prolonging them.  A more subtle problem is the ability of parties involved in investigations to provide less than full cooperation with CSB requests, thereby prolonging the investigation & causing the CSB to expend resources (e.g., the resistance of Transocean to subpoenas during the Macondo investigation).  A current example is the resistance of ExxonMobil, in the explosion at the Torrance Refinery in January 2015, to provide documents in connection with handling of modified hydrofluoric acid, the storage system for which the CSB contends had a "near miss" from equipment that was blown away from the explosion and landed near the storage system.  Aside from the resistance of the owners of sites being investigated, there is also the past lack of cooperation from other investigative agencies - the most significant example being the ATF & Texas State Fire Marshal blocking initial CSB access to the West Fertilizer explosion site in 2013 (see, while allowing OSHA access.  My personal experience is that I have yet to encounter any fans of the CSB at other federal agencies.

Finally, one fundamental problem which was not highlighted in the C&EN article concerns the appointment by the President & confirmation by the Senate of CSB Board Members.  Although there are supposed to be five, at present there are only four (for the first half of 2015, most of the time there were only two!), all of whom were confirmed in 2015.  All of their terms expire in 2020, a presidential election year.  The recent history of CSB Board appointment versus the time for the Senate to confirm the appointment is not good (about two years, in the case of Rick Engler), and is almost certain to become a problem if the parties of the President and the Senate majority are different - it can only get worse in a presidential election year.  We may yet end up with a leaderless CSB!

Richard Rosera
Rosearray EHS Services LLC

From: "Ralph Stuart" <Ralph..Stuart**At_Symbol_Here**KEENE.EDU>
Sent: Monday, August 29, 2016 7:34:40 AM
Subject: [DCHAS-L] C&EN article: The uneven world of chemical accident investigation

There's a very interesting article in this week's issue of C&EN at
about the challenges of investigating chemical accidents, particularly in industry. It points out similar challenges to those we in academia face in attempting to make the best use of teachable moments in the laboratory. I recommend it to everyone interested in the idea of a Lessons Learned database in general.

- Ralph

Ralph Stuart, CIH, CCHO
Chemical Hygiene Officer
Keene State College


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