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Haz Mat Issues
Tacoma, WA - March 10, 2008
Susan Gordon’s story on Page 1 today – about a dangerous chlorine gas leak on the Tacoma Tideflats that sent two dozen people to hospitals, including a dozen firefighters – appears just more than a year after the accident.
Part of the reason the article took so long to prepare is related to its complexity.
The state Department of Labor and Industries had to complete two investigations. Susan had to listen to and transcribe Fire Department radio transmissions. She pored over records from the state departments of Health and Ecology and the Puget Sound Clean Air Agency.
Susan also spent weeks researching the dangers of chlorine gas and the proper response of hazardous materials teams that try to control and mitigate leaks. She interviewed dozens of witnesses and experts – firefighters, investigators, the chlorine plant manager and employees at nearby businesses.
But the longest delay occurred when the Fire Department refused to talk with us for half a year.
Our “big interview” with the department – with a deputy chief, an assistant chief, the hazmat team leader and the department’s City Hall lawyer – took place June 28. There we wanted to take what we’d learned so far and ask them about their views of the incident and, critically, what lessons they’d learned.
We got many questions answered but never completed the heart of the interview.
We wanted to know what went right and wrong at the accident scene and how and whether the department planned to fix any mistakes. But Fire Chief Ron Stephens interrupted the interview and ended it, saying he needed the room for another meeting.
We asked to reschedule a time to finish the interview. Rejected. We asked to individually interview incident commanders who had been on the scene, or the chief if he preferred to speak for the department. Refused.
Our central question about “lessons learned” and whether any response methods were corrected went unanswered for months.
Through a records request we obtained a PowerPoint presentation the Fire Department created as a training tool after the incident. One slide was even titled “lessons learned,” but the presentation was full of acronyms and was essentially an outline for a talk. Without being able to talk to the hazmat team leader or others, we still had no clear picture of how the department evaluated its response.
We were repeatedly pointed to the L&I investigation, which found some fault with specific actions, but exonerated the department’s response in general. (We also found problems with that investigation.)
So when the department wouldn’t cooperate, we decided we’d have to come to our own conclusions by finding standards for hazmat response to chlorine gas leaks elsewhere and measuring what we knew of the department’s response against those standards.
Susan’s research amounted to a crash course in the principles of emergency response to airborne poisons such as chlorine. She reviewed industry recommendations and talked with experts across the nation. But primarily she used the department’s own Hazardous Materials Emergency Response policy as her standard and measured how well the department’s response that night measured up to the policy.
I remained exasperated by the department’s refusal to speak about the incident. Finally, a couple of weeks ago I called the city manager, Eric Anderson, about the matter. Within a day or two we arranged an interview that took place early last week with the chief and the hazmat team leader, one of two incident commanders and a deputy chief.
Our last communication from the chief was an e-mail from him that arrived Thursday. In it he commended the bravery and skill of the firefighters who stemmed the leak and evacuated the neighborhood. But he also wanted to take personal responsibility for any errors made at the accident scene.
The department’s response throughout our reporting on this story seemed to me to focus primarily on not admitting fault and avoiding blaming any individuals for errors.
That’s interesting because we never sought to blame anyone for errors either. We, too, think the firefighters were courageous and quickly and skillfully stopped what could have been a deadly accident.
But we were singularly focused on precisely what the department resisted so long: producing a comprehensive report on exactly what went right – and wrong – in an accident that injured and could have killed firefighters or Tideflats workers.
Reporting their successes and their failures to the citizens who commission their work and pay the bills should have been the department’s first responsibility after the accident.
Its second responsibility still remains: to use the mistakes we now know occurred that night as lessons to be learned so the same mistakes don’t happen again.
Susan Gordon’s story on Page 1 today – about a dangerous chlorine gas leak on the Tacoma Tideflats that sent two dozen people to hospitals, including a dozen firefighters – appears just more than a year after the accident.
Part of the reason the article took so long to prepare is related to its complexity.
The state Department of Labor and Industries had to complete two investigations. Susan had to listen to and transcribe Fire Department radio transmissions. She pored over records from the state departments of Health and Ecology and the Puget Sound Clean Air Agency.
Susan also spent weeks researching the dangers of chlorine gas and the proper response of hazardous materials teams that try to control and mitigate leaks. She interviewed dozens of witnesses and experts – firefighters, investigators, the chlorine plant manager and employees at nearby businesses.
But the longest delay occurred when the Fire Department refused to talk with us for half a year.
Our “big interview” with the department – with a deputy chief, an assistant chief, the hazmat team leader and the department’s City Hall lawyer – took place June 28. There we wanted to take what we’d learned so far and ask them about their views of the incident and, critically, what lessons they’d learned.
We got many questions answered but never completed the heart of the interview.
We wanted to know what went right and wrong at the accident scene and how and whether the department planned to fix any mistakes. But Fire Chief Ron Stephens interrupted the interview and ended it, saying he needed the room for another meeting.
We asked to reschedule a time to finish the interview. Rejected. We asked to individually interview incident commanders who had been on the scene, or the chief if he preferred to speak for the department. Refused.
Our central question about “lessons learned” and whether any response methods were corrected went unanswered for months.
Through a records request we obtained a PowerPoint presentation the Fire Department created as a training tool after the incident. One slide was even titled “lessons learned,” but the presentation was full of acronyms and was essentially an outline for a talk. Without being able to talk to the hazmat team leader or others, we still had no clear picture of how the department evaluated its response.
We were repeatedly pointed to the L&I investigation, which found some fault with specific actions, but exonerated the department’s response in general. (We also found problems with that investigation.)
So when the department wouldn’t cooperate, we decided we’d have to come to our own conclusions by finding standards for hazmat response to chlorine gas leaks elsewhere and measuring what we knew of the department’s response against those standards.
Susan’s research amounted to a crash course in the principles of emergency response to airborne poisons such as chlorine. She reviewed industry recommendations and talked with experts across the nation. But primarily she used the department’s own Hazardous Materials Emergency Response policy as her standard and measured how well the department’s response that night measured up to the policy.
I remained exasperated by the department’s refusal to speak about the incident. Finally, a couple of weeks ago I called the city manager, Eric Anderson, about the matter. Within a day or two we arranged an interview that took place early last week with the chief and the hazmat team leader, one of two incident commanders and a deputy chief.
Our last communication from the chief was an e-mail from him that arrived Thursday. In it he commended the bravery and skill of the firefighters who stemmed the leak and evacuated the neighborhood. But he also wanted to take personal responsibility for any errors made at the accident scene.
The department’s response throughout our reporting on this story seemed to me to focus primarily on not admitting fault and avoiding blaming any individuals for errors.
That’s interesting because we never sought to blame anyone for errors either. We, too, think the firefighters were courageous and quickly and skillfully stopped what could have been a deadly accident.
But we were singularly focused on precisely what the department resisted so long: producing a comprehensive report on exactly what went right – and wrong – in an accident that injured and could have killed firefighters or Tideflats workers.
Reporting their successes and their failures to the citizens who commission their work and pay the bills should have been the department’s first responsibility after the accident.
Its second responsibility still remains: to use the mistakes we now know occurred that night as lessons to be learned so the same mistakes don’t happen again.
Replies to This Discussion
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Permalink Reply by Texas HazMat on
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Tacoma, WA - March 10, 2008
HazMat checklist
The Tacoma Fire Department’s “Hazardous Materials Emergency Response” policy spells out duties and procedures for firefighters and supervisors.
The News Tribune used portions of the policy to analyze the response to the Feb. 12, 2007, chlorine leak at a bleach plant on the Tideflats. The newspaper’s evaluation is based on a review of recordings, e-mails, investigative records and other public documents; interviews with state safety inspectors, evacuated workers, the bleach plant manager, and emergency-response and safety experts; and interviews with eight Tacoma Fire Department officials.
Tacoma Fire Chief Ron Stephens, who declined an offer to review the newspaper’s evaluation before publication, said the emergency-response policy provides guidance, but is not supposed to be a template. “It is not an exact science,” he said. “We don’t have a cookie-cutter approach to each incident.”
Tacoma Fire Department requirements, quoted from the policy manual, are in bold type.
The News Tribune’s evaluation of whether the department followed its policy is in red.
That is followed by an explanation of the evaluation.
The primary objective in any hazardous materials response is to protect human life and prevent harm or risk to human life, including the lives of Tacoma Fire Department personnel and other responders.
Partially met
The firefighters who entered the bleach plant and plugged the leak wore chemical suits and respirators. But some firefighters in the perimeter were not wearing respirators. No one monitored gas concentrations outside the building, and firefighters were caught off guard when the wind changed direction twice. People who work at neighboring businesses on the Tideflats complained that they weren’t told what was going on until the situation spiraled out of control.
To ensure adequate protection of personnel, the Incident Commander shall:
a. Create a ‘safe’ perimeter (Hot Zone, Warm Zone, Cold Zone).
b. Establish a protocol for entering the incident site.
c. Select proper protective clothing, include self-contained breathing apparatus.
Not met
The initial incident commander designated the bleach plant property as the hot zone. But the boundary between the warm zone and the cold zone was not well defined. Also, some firefighters outside the plant did not have respirators handy.
When determining the size and shape of control zones, the Incident Commander shall consider the following variables:
a. Properties and qualities of the hazardous material(s),
b. Size, shape and condition of the container,
c. Dispersion patterns of the hazardous material,
d. Existing and anticipated weather,
e. Geographic features surrounding the incident.
Partially met
The incident commander set the control zones based on the assumption that the chlorine leak was contained inside the building and that the wind was blowing from the north. Firefighters admit they did not anticipate a wind change, even though the commander of the hazardous materials team said he’s familiar with the ever-changing wind patterns in that area.
The Cold Zone is considered safe and therefore access is unrestricted.
a. The circumstances of the incident, however, may make it appropriate to restrict access to the area to emergency service personnel, keeping the public several hundred feet beyond the outer perimeter of the Cold Zone.
b. Hot Zone support functions are located in the Cold Zone, including:
i. Command post.
ii. Medical.
iii. Rapid intervention team/Backup.
iv. Decontamination team (prior to decontamination).
v. Rehabilitation.
Not met
The backup team was in the warm zone, and the command post was set up along the border between the cold and warm zones.
To prevent hazardous materials exposure to response personnel and the public, the Incident Commander shall take the following precautions:
a. Conduct operations at a hazmat incident from an upwind and, when possible, uphill location.
b. Ensure that personnel stay out of smoke, fumes, dust, etc. when the incident involves fire or material subject to wind movement.
c. Ensure that personnel stay out of all spilled products, including liquid and vapors, unless such action by properly trained and protected personnel is necessary for incident mitigation.
Not met
Firefighters were exposed to chlorine gas because access was not limited to personnel wearing respirators. Also, firefighters disregarded the possibility of a wind change.
Tacoma Fire Department personnel shall determine hazardous materials health hazards by gathering and examining toxicological information.
Met
Dispatchers looked up records about chlorine at the bleach plant.
All Tacoma Fire Department personnel responding to a hazardous materials incident shall be able to identify and understand the hazards presented by a material in order to ensure effective and appropriate mitigation decision-making.
a. Operations level personnel shall use good judgment in assessing whether incidents are beyond his/her scope of training and request additional (hazmat team) assistance as appropriate.
EXAMPLE: Although operations level first responders may be able to predict vapor movement from a routine gasoline fuel spill, technician trained personnel using air monitoring equipment will be required at large spills to monitor vapor hazards.
Unclear
A trained hazardous materials team, plus several additional technicians, were called to the scene. However, they didn’t use the air-monitoring equipment until the situation got out of hand.
All operations level personnel at hazardous materials incidents shall:
a. Wear structural firefighting clothing and self-contained breathing apparatus, in use or in standby as required by the Incident Commander.
b. Remain upwind and out of the potential hazards areas until the material has been identified and the hazards evaluated.
Partially met
The hazardous materials technicians who entered the plant were properly equipped. Later, firefighters were exposed to chlorine in part because they were not prepared for a wind change and did not have respirators handy.
The Incident Commander shall consider containment tactics when:
a. The hazardous material is in a gaseous form and threatens to migrate away from its container.
b. The hazardous material is in a solid, powder form and weather conditions threaten to carry it away from its original site.
c. Confinement tactics have not produced the desired results.
d. The situational risk is increasing as time goes by.
Met
Firefighters chose to contain the leak by sending in a two-person team to plug it.
Containment operations shall be preceded by a thorough Incident Commander-directed reconnaissance in accordance with the needs of the incident such as:
a. An individual relaying his/her observations of the situation.
b. Complete entry team survey.
Met
The incident commander and the hazmat team leader interviewed the worker who accidentally released the gas. The worker helped them map the scenario.
When working to stabilize an emergency by stopping further release of hazardous materials, Tacoma Fire Department personnel shall:
a. Always wear full protective clothing and self-contained breathing apparatus.
b. Avoid overhead leaks that splash onto or saturate protective clothing.
c. Shut off a remote valve to control the leak if possible.
d. Plug or slow the leak with available compatible material.
Met
The two firefighters who entered the building wore the requisite chemical protective suits and respirators. They carried a tool kit to close the valves.
Approach all hazardous material incidents from upwind, uphill, upstream; positioning vehicle and apparatus headed away from the incident scene.
Partially met
Firefighters approached the bleach plant from an upwind direction. But they parked their vehicles facing downwind and had to abandon some of them when the wind changed.
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Tacoma, WA - March 10, 2008
Firefighters failed in several key areas
Tacoma firefighters didn’t shrink from danger the night in February 2007 when a Tideflats worker accidentally released lethal chlorine gas.
Within 90 minutes after the first fire engine arrived, a specially trained, two-man team entered the gas-filled building and stopped the leak.
But what began as a carefully plotted mission was undermined by errors that injured firefighters and others and failed the primary objective of any emergency response: to prevent additional harm.
A News Tribune investigation, based on public records and interviews with experts and key firefighting personnel, concluded that members of the Tacoma Fire Department:
• Neglected to prepare for a wind change that put firefighters and others at risk.
• Failed to monitor concentrations of poison gas outside the chlorine plant until after firefighters were overcome.
• Did not keep respirators handy for immediate use.
• Ignored department policy stating that the incident command post and hazmat backup teams should stay in a “cold” zone, or out of danger.
• Failed to call for evacuation of the area near the leak until after firefighters were exposed. Although firefighters notified a few enterprises and asked police to block some streets, they didn’t tell people to leave the Tideflats until hours after the accident occurred.
Twelve of the 25 people taken by ambulance to area hospitals that night were firefighters. Although everyone was treated and released, at least one firefighter was coughing up blood the next day. Some workers in the neighborhood complained about breathing problems for months afterwards.
In what appears to have been a cursory safety investigation, the state Department of Labor and Industries exonerated the Fire Department. The News Tribune uncovered problems with that investigation.
While the state didn’t cite the Fire Department for wrongdoing, L&I inspectors did recommend that the department make procedural changes, such as more closely monitoring weather and air quality, and keeping respirators ready.
“Those firefighters should not have been exposed to chlorine,” said Don Lofgren, an L&I industrial hygiene compliance supervisor who was in charge of a two-person team of safety inspectors.
FIRE CHIEF BLAMES WIND
Tacoma Fire Chief Ron Stephens defended his department’s efforts the night of the Tideflats chlorine leak.
If it weren’t for a sudden change in wind direction, he said, firefighters and local workers would not have been exposed to the gas.
“Once the wind shifted, everything changed,” he said in an interview Tuesday. “It’s pretty hard to move operations at a moment’s notice.”
However, two internal documents cite lessons learned from the incident, signaling awareness that firefighters should have done some things differently.
“The men and women firefighters that were on the scene of that incident deserve credit for risking their lives and their well being and for solving the problems that led to the successful termination of that incident,” Stephens wrote Thursday in an e-mail to The News Tribune. “I’m proud of the risks they took and the work they accomplished.
“The responsibility for any and all errors made and or the perception of any and all errors made rests on my shoulders. I willingly accept that responsibility.”
Lessons learned are summarized in a presentation prepared last spring for training purposes by Battalion Chief Jim Zuluaga, who led the department’s hazmat team and was himself overcome by chlorine.
In the presentation, Zuluaga stressed the importance of air monitoring and limits on access to the danger zone and said all firefighters should have had respirators ready. He also called for more high-tech equipment and said firefighters should park vehicles with escape or retreat in mind.
In an interview last June, Zuluaga acknowledged that firefighters erred by parking their rigs facing downwind.
“You try to put the vehicles in a way you can leave in a hurry,” he said. “We didn’t take the time to turn them around.”
Later, in an annual health and safety presentation, Tacoma fire officials reiterated Zuluaga’s recommendations and added another:
“More closely monitor air/wind movement.”
An attached note also stated: “Warm zone should have been much larger, at least to East 11th Street.”
While those presentations highlight what went wrong with the Fire Department’s response, Stephens didn’t acknowledge specific mistakes during last week’s interview. Also, the chief discounted inconsistencies between what happened the night of the leak and the procedures spelled out in the department’s hazardous materials response policy. Incident commanders have the authority to override policy when the need arises, he said.
For example, the incident command post was on the edge of what was designated as the “warm” zone, a risky area where access should be restricted. The department’s policy states that the command post belongs in the “cold” zone, where it’s safe.
Stephens described the policy manual as “guidelines,” even though the document is clearly labeled as “policy.”
‘IT WOULD HAVE BEEN OVER’
In interviews with The News Tribune, other department leaders explained why firefighters took the actions they did.
Initially, firefighters assumed the Pioneer Americas plant would contain the chlorine, Zuluaga said. After firefighters plugged the leaky tank inside, they decided to vent the building. But as the gas drifted out, the wind shifted.
“You can’t rely on the winds for 30 seconds,” Zuluaga said. “We got a taste of that that night.”
Even so, Stephens said he wouldn’t second-guess firefighter decisions to hold off on calls to evacuate the Tideflats while firefighters entered the gas plant.
“If the wind didn’t shift, the incident would have been completed,” the fire chief said. “It would have been over. We wouldn’t have needed to evacuate those businesses.”
After firefighters were exposed, the priority was to rescue victims, Stephens said.
Then firefighters went through the neighborhood, banging on the sleeper cabs of semitrucks parked on side streets, firefighters said.
Before the two-man team plugged the leak, firefighters notified only a few businesses near the Pioneer Americas plant.
“The focus was downwind,” said Capt. Dave Sherk, the initial incident commander. At that time of night, relatively few people are still at work on the Tideflats, he said.
In general, it’s problematic for firefighters to urge people to leave the Tideflats, Sherk said. Some industrial operations are so risky that operators cannot abandon them. And people resent it if they are told to leave and it turns out to be unnecessary.
“There’s no winning,” he said.
As for the firefighters who were overcome by chlorine, Stephens said those who didn’t keep respirators handy are themselves responsible for exposure.
That includes firefighter Mark Maderos, who was coughing up blood the following day.
“If he was in that close to the hot zone he knew full well what he was supposed to do,” Stephens said. “The incident commander doesn’t have time to evaluate everybody.”
In a separate interview Thursday, Maderos said that although he had completed hazmat technician training just before the chlorine leak, he didn’t fully understand the risk.
“There was probably some lack of experience and lack of judgment on my part,” he said.
He left his respirator on a nearby firetruck because he mistakenly believed he could retrieve it as needed. As it turned out, he was overcome before he got there, he said.
Fire Department officials also believe additional high-tech gear could help in response to future accidents.
Assistant chief Tom Henderson said the department planned to buy additional chlorine monitors and was considering an upgrade to its portable weather station.
As part of a Pioneer Americas settlement with the Environmental Protection Agency, the company promised to buy the Fire Department two high-tech portable weather stations, four hand-held gas monitors, a thermal-imaging camera and two gas-tight protective suits.
QUESTIONS ABOUT L&I REVIEW
State Labor and Industries inspectors conducted two investigations after the accident: one on the bleach plant and one on the Fire Department’s response.
Most of the attention was on the Pioneer Americas bleach plant, whose owners paid a $1,650 penalty to the state for violating regulations governing analysis of industrial hazards.
The News Tribune reviewed the records of both L&I investigations. The L&I report on the plant stacked up in a pile about a foot tall at the agency’s Tumwater headquarters. L&I’s investigation of the Fire Department’s response was about a quarter-inch thick, slim enough to fit in an 81/2-by-11-inch envelope, which was mailed to The News Tribune.
A summary of the conclusions said the inspectors interviewed the Fire Department’s incident command chief. But other records show that inspectors did not interview the two incident commanders, despite specific e-mail directions from Lofgren, the L&I industrial hygiene compliance supervisor.
The two inspectors confirmed in an interview that L&I did not interview them.
L&I’s investigation of the Fire Department ends with a summary that’s about a page long. It concludes:
“Recommendations were made at the closing (interview) for proper setup and monitoring of the weather station so the incident commander can make changes based on new developments such as changes in the wind direction; air monitoring at the different zones would be helpful to take proper actions depending on the air concentrations of the chemicals; and have respirators ready (and) available for all personnel.”
The report does not elaborate. But Lofgren said in an interview that the Fire Department’s inadequate response to changing conditions risked firefighters’ health.
He commended the two-man team of firefighters who he said “saved the day” by plugging the 1-ton chlorine tank.
“The Fire Department did quite well providing for the safety of the entry personnel. Those individuals went into some dangerous conditions with high concentrations of chlorine,” he said.
But things went wrong after the team emerged from the plant. When they left a door open, gas escaped. The wind, which had changed direction, pushed the poison toward firefighters gathered outside the plant.
Lofgren and his inspection team did not attempt to evaluate whether the door should have been left open.
‘THE CONFLICTS ARE OBVIOUS’
The L&I report might have been compromised. At the time of the investigation, one of the two state inspectors was an applicant for a City of Tacoma safety job.
The inspector told his supervisor, Lofgren, about the application, but wasn’t removed from the case. One of the first people the inspector contacted when he began the fire investigation would have been his supervisor if he had been hired by the city. In the end, Tacoma did not hire him.
Lofgren stood by his decision to allow the inspector to continue to work on the investigation.
But it was the kind of conflict government officials should avoid.
“Generally speaking, you don’t want somebody who’s applying for a job to have to be interviewing their prospective boss and to investigate whether their prospective boss or agency made a mistake,” said John Strait, a Seattle University law professor whose classes in professional responsibility deal with conflicts of interest. “It’s plain common sense. The conflicts are obvious.”
Strait also said the circumstances could cut two ways. The investigator seeking a safety job might be just as tempted to take a hard line to demonstrate his commitment and depth of knowledge, Strait said.
‘A WIDESPREAD PROBLEM’
Large accidental releases of airborne toxic chemicals like the Feb. 12, 2007, event on the Tideflats don’t happen often.
But officials at the U.S. Chemical Safety and Hazard Investigation Board, a nonregulatory federal agency that investigates the worst ones, said emergency responders frequently make mistakes.
“Among the accident cases we investigate, a deficient emergency response is more often the rule than the exception,” Carolyn Merritt, chemical safety board chairman, told the U.S. Senate Homeland Security and Government Affairs Committee in April 2005.
“It’s a widespread problem,” said agency spokesman Daniel Horowitz. Typical issues include poor communication and lack of equipment, training, procedures and preparation, he said.
Independent experts say it’s crucial to track airborne concentrations and the weather when responding to a chlorine release.
“You always have to be aware of your surroundings at all times,” said Larry Aleksandrich, a former New Jersey fire chief and mutual aid coordinator who teaches emergency responders how to handle hazardous materials. “The bottom line is you never want anybody to get hurt.”
“Winds change,” said Jim Lay, a U.S. Chemical Safety and Hazard Investigation Board investigator. “That can require people to be adaptable and move out of harm’s way.”
Key elements of a safe emergency response to an accidental chlorine release are outlined in a video prepared for first responders by The Chlorine Institute, an Arlington, Va., trade group. It recommends vigilance:
“The constant monitoring of wind speed, condition, direction and of available chlorine levels is necessary to maintain the buffer zone and guide the containment process.”
Susan Gordon: 253-597-8756
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TheNewsTribune.com
Thousands could have been exposed to deadly gas on Tacoma's Tideflats
His was a routine repeated thousands of times before without mishap.
But at 6:40 p.m. that Monday in February 2007, Isaksson was distracted. While thinking about whether or when to break for lunch, he made mistakes that could have killed him and jeopardized the health of hundreds on the surrounding Tacoma Tideflats.
So much poison gas escaped from the Pioneer Americas plant – nearly 900 pounds vaporized into greenish clouds – that it threatened for hours to suffocate people.
But initially, at least, Tacoma Fire Department officials believed the building would contain most of the leaking chlorine.
The department reacted quickly to the Feb. 12, 2007, emergency, taking actions that demonstrated its strengths. About an hour and 40 minutes after Isaksson’s error, two firefighters plugged the leaky cylinder that he had failed to secure.
But shortly afterward, when the wind changed, firefighters outside the plant were overcome by the gas because they hadn’t anticipated a wind shift, and they left a door open, enabling chlorine to escape. The situation deteriorated, becoming what Fire Department officials later described as a “mass casualty incident.”
Medics took about 25 people – including a dozen firefighters, among them the leader of the department’s hazardous materials response team – to hospital emergency rooms. At least one firefighter continued to cough up blood the following day.
“The number one rule of emergency responders is supposed to be, don’t make more victims,” said Rick Gleason, a University of Washington industrial safety lecturer and former federal and state safety inspector.
The city’s emergency response to the chlorine incident also revealed fire commanders’ hesitance to alert all but a few downwind BankWest Credit Cards businesses to potentially lethal airborne chemical releases.
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Permalink Reply by lutan1 on
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A News Tribune investigation, based on public records and interviews with experts and key firefighting personnel, concluded that members of the Tacoma Fire Department:
• Neglected to prepare for a wind change that put firefighters and others at risk.
• Failed to monitor concentrations of poison gas outside the chlorine plant until after firefighters were overcome.
• Did not keep respirators handy for immediate use.
• Ignored department policy stating that the incident command post and hazmat backup teams should stay in a “cold” zone, or out of danger.
• Failed to call for evacuation of the area near the leak until after firefighters were exposed. Although firefighters notified a few enterprises and asked police to block some streets, they didn’t tell people to leave the Tideflats until hours after the accident occurred.
There's some pretty major failures here and hopefully it is a lesson learnt for them and others...
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The point I attempting to make was that we all train we have SOP/SOG's but none of it is worth a crap if we dont follow them. I have countless stories about FD's getting themselves and civilians injuried by not following the basic rules.
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Permalink Reply by Engineco913 on
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I agree with you entirely. The part I don't understand is Cameo/Aloha/Marplot would have given them another tool to safely mitigate the area around the leak. It seems from all I have read that there was a lot of "tunnel vision" and also a major case of "nothing can happen to us" going on.
In the case mentioned, they ALL are lucky to be alive, firefighters and civilians.
Civilians rely on us to not only do our job (stop the leak) but they rely on us to keep them safe. Without notification of the intensity of a spill, or the affects, the public was BLINDSIDED.
As Texas has stated, this is a perfect example of having SOP's and SOG's and not using them. You can't fly by the seat of your pant's and come out smelling like roses every time, hense why we have rules and procedures in place.
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Permalink Reply by John Sherman on
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Because The News Tribune (TNT) Tacoma Washington has presented a more-current article http://www.thenewstribune.com/news/environment/story/309746.html that indicates WA L&I agency will review the initial findings related to this chlorine gas release. This article followed the initial TNT article about the chlorine gas release accident http://www.thenewstribune.com/331/story/304409.html it follows and it appears that all attention is placed upon the first-responders and their process, procedures, and equipment to mitigate this chlorine release and provide medical aid; as a result, the response process seems to become the primary focus of this incident response critique effort.
But, I question from within the original TNT chlorine accident article that stated "[w]orked alone in the gas house, filling 7-foot-long pressurized containers with chlorine...."; it follows, in my thought process, this is a confined space situation within a place of employment; therefore where was all the other supporting people, gas detectors, confined space pre-plan, and supporting equipment with resources that the employer must have in place for the protection of this employee working within a confined space with a chemical hazard?
I think that if the employer of this chlorine plant had considered their "gas house" enclosed space with a chemical hazard present as a confined space and just following rules and practices required for any person working withing a confined space with gas hazard; as a result, all the necessary first responders actions to support actions to the the employers chlorine confined spaces plan and people already present would have helped to mitigate this actual chlorine release accident. So, if the employer does not have an already active confined space plan and practice elements of the plan on a routine calendar basis; it follows, the public response fire and EMS services would not be well trained or have the necessary continual training for any chlorine tank gas releases or personnel extractions from within a chlorine gas cloud environment.
Just-my-thoughts, not from an EMS for fire background, but because of my past work with one-ton chlorine gas tanks, gas detectors, SCBA training, PPE required, and applied instrumentation related to CL2 gas presence and CL2 piping systems, but now retired.
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