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.