# Presentation: 562331

## Reducing Chemical Facility Vulnerability by Training Workers: Effective Models from the NIEHS Hazardous Waste Worker CommunityDOE Chemical Management WorkshopWashington, DCMarch 8, 2005 

**Joseph “Chip” Hughes, Jr., MPH**
**Bruce Lippy, Ph.D., CIH, CSP**
** **

**Notes:**
I am Bruce Lippy and I’m delighted to be here today. I had hoped to catch at least one more day of yoiur conference, but I had to go to a meeting in Seattle sponsored by Homeland Security about training workers for WMD response. You know if I didin’t go there because of the preferable climate. Dark clouds and rain for two days. I am happy to join you because PACE has been very supportive of the Clearinghouse. Doug Stevens helped us out when we needed to show a delegation of chemical workers from South Africa how we train workers here in the U.S. The group really got into your Systems of Safety Training and I got glowing reports from the sponsoring agency here in the U.S. Allow me to publically thank you, Doug. I also want to thank Herman Potter for explaining your program to the advisory board for the IH/ODS Advisory Board in D.C. several weeks ago. 

## --DOE/NIEHS Training Partnership--Program History & Overview--Case Examples of Worker Training and ISM Principles

**Introduction and Objectives**

## DOE-NIEHS Partnership

** ****NATIONAL DEFENSE AUTHORIZATION ACT:   **
**  ****Section 3131 **
** ****Interagency Agreement  with DOE to develop model **
**  ****worker safety and health training programs at DOE    **
**  ****facilities for the past 12 years.**
** ****Support worker safety & health training for the purpose of DOE site clean-up activities, waste management and hazardous materials response. **

## DOE/NIEHS Training Delivery

- Over 20,000 DOE workers trained annually at over 30 cleanup sites
- Over 1,000 workers trained at Hanford, Oak Ridge, INEEL, Savannah River
- Over 500 workers trained at Rocky Flats, Paducah, Pantex & Rocky Flats
- Wide range of hazardous waste & emergency response classes offered

## DOE-NIEHS Training Goals

- Create training partnerships with DOE contractors drawing on skilled workers
- Promote a culture of continuous learning and integrated safety management
- Blend advanced training technology with classroom and hands-on learning
- Reduce redundancy and draw on DOE lessons learned in training delivery

## NIEHS and DOEA decade of partnership

**Latest report available at: www.wetp.org**

## Craft-specific for
Critical populations
Construction workers
Fire fighters
Chemical workers
-- Professionals

**Critical populations**
- Construction workers
- Fire fighters
- Chemical workers
- -- Professionals

**Importance****of****NIEHS ****Training**

## DOE Worker Trainers

**A cornerstone of the program is the use of “worker-trainers,” employees well-versed in performing a given task in a hazardous environment who are trained to instruct other workers. **
**Trainers build partnerships by fostering cooperation between management and workers, improving efficiency and quality of training, improving the ability to address worker concerns**
**Training goal is to empower all stakeholders to address site-specific safety and health needs. **

## Emphasizes Hazard recognition
Incorporates ISM principles into all training
Builds on the expertise of plant workers for training

**Incorporates ISM principles into all training**
**Builds on the expertise of plant workers for training**

**Importance of DOE/NIEHS ****Training**

## NIEHS Grantee Training atHAMMER for DOE/Hanford Site

- More than  26,047 student days trained October 2003 through March 2004 for workers in high risk tank farm jobs
- Over 2,000 workers trained in respiratory protection at the tank farm
- Worker Trainers spearheaded a site wide respirator certification program

## Operating Engineers DOE Refresher Classes

- IUOE includes skilled craft workers; environmental, industrial hygiene, and radiation professionals; waste treatment specialists; and company managers.
- Build around ISM principles and site specific examples.
- Work Planning and Job Hazard Analyses are key components.

## PACE Refresher Training

- The PACE union has developed an innovative Systems of Safety (SOS) program
- employs peer trainers to teach other workers to evaluate accidents and near misses for root causes during refresher training
- management-labor teams perform system safety analyses, such as Failure Modes and Effects Analysis and develop Lessons Learned Process.

## Case Examples

**Bruce Lippy**
**Director, National Clearinghouse for Worker Safety and Health Training**

## The case for peer training

**Notes:**
Peer training, as Steven Deutsch pointed out (New Solutions, Spring 1996) emanates from the philosophical roots that workers are best qualified to become trainers. This country, through OSHA’s standards-based compliance system, has placed responsibility for safety and health totally in the hands of employers, who must meet the minimum level of compliance. By contrast, in Scandinavia from the 70’s there has been a great deal of research that shows that activating the workforce, empowering and educating workers was a powerful way to make real and continuous change in the accident and injury rates. Deutsch calls it a simple, perhaps even obvious, but also profound approach because it involves important shifts in thinking.

## Peer Training EvaluationMcQuiston et al., JOM, 12-94

**Long-term evaluation of chemical emergency training by ICWU**
**Training used participatory empowerment approach**
**Telephone interviews 12 months later**
**481 workers (91% response)**
**50 managers (62% response)**

**Notes:**
Tom McQuiston and Al ( I think that’s what that means) conducted an excellent study of the training. The International Chemical Workers Union conducted chemical emergency training under the NIEHS program. The training was 60% classroom, involving small group research, problem-solving exercises, interactive video, and 40% hands-on with full dress out.

This training  is a participatory empowerment approach based  on the work of Brazilian educator Paulo Freire. Trainers act as resources rather than as experts. The curriculum deliberately invited worker experiences and knowledge into the classroom.

The ICWU hired an independent organization to conduct phone interviews one year later. They got an excellent response 481 workers answered, 91% and 50 managers, 62%, which is still acceptable.

## McQuiston Results

**Less than 5% of students were familiar with written resources at start of training**
**After training 88% of workers reported using the NIOSH pocket guide, 62% the DOT ER Guide**
**78% of trainees had taught coworkers**
**Average number of coworkers taught, 70 (total of 26,390)**

## McQuiston StudyHandling Spills

**20% reported a “serious chemical spill or accident” within last 12 months**
**342 serious chemical incidents**
**57% of workers and 62% of managers indicated spills were handled differently because of training**

**Notes:**
20% reported a serious chemical spill or accident within last 12 months. That was a total of 342 serious incidents including 10,000 gallons of hydrofluoric and sulfuric acid,  a loss of 30,000 gallons of trichloroethane, and release of benzene. One coupling break produced a leak of 400 gallons of methylene bisphenyl isocyanate. The trainee indicated:

“After the training, we had the proper equipment. Everything was done by the books. WE have come a long way since we formed a team. We don’t have to worry about the company, now we can judge for ourselves what we need.”

Note that managers indicated handling spills differently.

## Training of Skilled Support Personnel

**Training of Skilled Support Personnel**

**NIEHS trained the workers at WTC **
** ****3 months late and 3 hours of training**

**Notes:**
This is a quote from John Henshaw, the head of OSHA. READ. I want to tell you how terribly proud I have been of the work of the heavy equipment operators at this site. I submit that one of the reasons that we have avoided a fatality at this site has been the incredible skill that was demonstrated by the members of my union, operating in one of the most dangerous environments with hundreds of people with no previous construction experience constantly moving all over the site they had to keep track of, it is a real tribute to them. If you think that is union propaganda, then I would guess you were never at Ground Zero.

## OSHA-NIEHS PartnershipThe Disaster Site Worker Course

**OSHA 7600 – 16 hour for workers**
**OSHA 5600 – 32 hour for instructors**
**Incident command**
**Evidence preservation**
**Stress management**
**Two cards issued**

- www.osha.gov

## Respirators: 

**Respirators: **

**Not part of the safety culture**
**Many are still ill as a result**
**OSHA DSW course requires wearing respirator**

## TOPOFF 2 Lesson Learned

- Dirty bomb scenario for Seattle
- ICS called in a crane that sat for 8 hours onsite
- Unaware of HAZWOPER and Rad II heavy equipment operators in Richland

**Notes:**
The second of these exercises, TOPOFF 2 (T2), took place in Seattle, Washington and Chicago, Illinois in May 2003 with participation in Washington, D.C. as well.  All parties knew of their involvement at least 18 months beforehand.   During T2, two major simulated terrorist attacks occurred.  The first was a large “dirty bomb” or radiological dispersal device (RDD) in Seattle and the second was an outbreak of pneumonic plague in Chicago.  Woven into the disaster in Washington State, a cyber event affecting the communication infrastructure hit the week before.  To further complicate the situation, a hostile takeover of a Washington State ferry and a hostage event south of Seattle were included.  In all, the event was meant to overwhelm local, state, and federal agencies with the result of having better preparedness, response, and recovery capabilities in the future.  There were more than 8500 direct participants and many more were indirectly impacted.  TOPOFF2 was the most comprehensive and “real” test of local, state, and national response capabilities ever conducted in our nation’s history.  It was also the first to test the country’s response to an RDD. 

## Graniteville Train Derailment

**Graniteville Train Derailment**
**January 6, 2005**

## Slide 23

## Slide 24

## DOE-NIEHS Response Training

**International Association of Firefighters (IAFF) training of emergency responders at DOE Savannah River Site**
**Included local volunteer responders and Hazmat Teams in the training**
**Joint DOE-supported training helped with preparedness and coordination**

## Slide 26

## EPA: 123 chemical facilities have toxic “worst case” scenarios with more than a million people at risk nearby
GAO: “federal government has not comprehensively assessed chemical industry vulnerabilities to terrorist attacks.”
Process Safety Management is old but effective
Inherent safety strategies reduce quantities available for terrorist actions

**Chemical Plants **

**Sonat plant explosion, CSB, 1998**

- EPA: 123 chemical facilities have toxic “worst case” scenarios with more than a million people at risk nearby
- GAO: “federal government has not comprehensively assessed chemical industry vulnerabilities to terrorist attacks.”
- Process Safety Management is old but effective
- Inherent safety strategies reduce quantities available for terrorist actions

**Notes:**
March 2003, GAO report on chemical security reported an EPA finding that 123 chemical facilities in this country have what they called toxic “worst case” scenarios that could expose more than a million people living near the plants. The GAO concluded that the federal government has not comprehensively assessed chemical industry vulnerabilities to terrorist attacks. 

## PACE survey of members (10/04)

**Mailed survey to 133 sites, 125 responded**
**82% were chemical plants, primary paper mills, or oil refineries**
**Self-administered by members at site**

**Notes:**
Company Preventative Actions. In response to these vulnerabilities respondents’
reports suggest that most employers assessed their sites vulnerabilities (66%) and
worksite security (64%). Company actions appeared to focus more frequently on
security, with almost three-quarters (73%) of the respondents reporting improved
systems to guard and secure the plant.
All other company actions were reported to be taken at less than half of the study sites.
These actions included improved communication systems (43%), improved training and
procedures to prevent possible terrorist attacks (38%), updated warning systems (38%),
improved containment of potential hazardous releases (34%), and improved quality and
availability of personal protective equipment (30%). Some preventative actions, that
could directly reduce the likelihood of a catastrophic event, were reportedly taken with
the least frequency, such as: reduced volumes of hazardous substances (17%),
strengthened plant vessels, tanks, piping or other structures (17%), and improved the
siting of hazardous substances or processes (14%).
Company Actions To Prepare To Respond. When preparing to respond to an event
caused by a terrorist attack, 68% of the companies provided emergency response
training to employees in the past 12 months, and 59% conducted emergency response
drills for the plant site. About half (47%) of the respondents reported that the
companies at their worksites had updated facility emergency response plans since 9/11.
Other company actions to prepare for responding to an event included: 46% informed
local fire and police departments, HazMat teams, etc. about specific plant hazards; 42%
put additional procedures in place to inform employees of emergencies; and 30%
updated shutdown procedures.
Respondents used the don’t know choice considerably more frequently in the set of
questions about actions to inform local community services, or nearby residents or
update the community Emergency Response Plan than when responding about
actions at their facility. While, 23% knew their employers had informed local hospitals,
health departments and emergency medical personnel about potential health threats
from plant-specific exposures, 20% said these community health services were not
informed, and 57% reported don’t know.

## PACE survey of members They reported that:

**67% had assessed vulnerability since 9/11**
**43% had improved communication systems**
**38% had improved training to prevent attacks**
**30% reported PPE more available**
**17% had reduced volumes of hazardous substances**
**46% had informed local fire and police about specific plant hazards**

**Notes:**
Company Preventative Actions. In response to these vulnerabilities respondents’
reports suggest that most employers assessed their sites vulnerabilities (66%) and
worksite security (64%). Company actions appeared to focus more frequently on
security, with almost three-quarters (73%) of the respondents reporting improved
systems to guard and secure the plant.
All other company actions were reported to be taken at less than half of the study sites.
These actions included improved communication systems (43%), improved training and
procedures to prevent possible terrorist attacks (38%), updated warning systems (38%),
improved containment of potential hazardous releases (34%), and improved quality and
availability of personal protective equipment (30%). Some preventative actions, that
could directly reduce the likelihood of a catastrophic event, were reportedly taken with
the least frequency, such as: reduced volumes of hazardous substances (17%),
strengthened plant vessels, tanks, piping or other structures (17%), and improved the
siting of hazardous substances or processes (14%).
Company Actions To Prepare To Respond. When preparing to respond to an event
caused by a terrorist attack, 68% of the companies provided emergency response
training to employees in the past 12 months, and 59% conducted emergency response
drills for the plant site. About half (47%) of the respondents reported that the
companies at their worksites had updated facility emergency response plans since 9/11.
Other company actions to prepare for responding to an event included: 46% informed
local fire and police departments, HazMat teams, etc. about specific plant hazards; 42%
put additional procedures in place to inform employees of emergencies; and 30%
updated shutdown procedures.
Respondents used the don’t know choice considerably more frequently in the set of
questions about actions to inform local community services, or nearby residents or
update the community Emergency Response Plan than when responding about
actions at their facility. While, 23% knew their employers had informed local hospitals,
health departments and emergency medical personnel about potential health threats
from plant-specific exposures, 20% said these community health services were not
informed, and 57% reported don’t know.

## PACE Training ApproachSmall Group Activity

**Small Group Tasks**
**Report-backs**
**Summary**

**Student manual graphic on PPE**

**Notes:**
An activity can take from 30 minutes to an hour.

## The approach emphasizes exercises like risk mapping

## The training stresses root cause analysis

## Supporting ISM

- PACE SOS training meets requirements for 1910.120 and DOE orders
- Workers will be writing their own lessons learned
- Peer trainers emphasize more worker involvement, a key part of ISM and VPP

## ICWUC Basic Chemical Emergency Response Class

- Focuses on what to do in the event of an uncontrolled release of hazardous chemicals
- Based on OSHA's HAZWOPER std
- Uses a mix of classroom, tabletop exercises, open discussions with subject matter experts, and hands-on simulations

## ICWUC has used major scenarios with chemical plant

**Worked with Cabot Chemicals**
**Coordinated a community-wide emergency scenario of a catastrophic chemical release**
**Provided findings at NIEHS conference**

## Cabot Chemical ScenarioLessons Learned

**Getting outside plant is critical**
**Emergency responders weren’t sure which of the 5 plant entrances to use**
**The plant straddles a county line so jurisdiction was unclear for emergency response**

## Chemical incidents don’t have to be large or inside

**November 2000 Explosion at Portsmouth, Ohio**

**Notes:**
On August 22, 2000 a workers was seriously burned from a chemical reaction during an innovative technology demonstration at the Portsmouth Gaseous Diffusion Plant. This incident is particularly telling because it involved an oxidative chemical - in this case, sodium permanganate – injected into the ground in a similar manner to the process that exploded in the Wisconsin incident. These techniques are supposed to be safer than the older baseline approach because the reaction takes place in the ground rather than being brought to the surface for treatment. A major investigation of the incident found that the develop and the site contractor: 
failed to analyze the hazards for all field activities. This failure resulted in inadequate development and implementation of control measures for and knowledge of the potential hazards.[1]

A review of the extensive accident analysis provided no indication that anyone within the DOE headquarters and field staff responsible for the development of this technology had ever heard of the incident in Wisconsin although it occurred three years previously.  Additionally, in July of 1998, the in situ chemical oxidation technology had undergone a rigorous peer review by engineers from the American Society of Mechanical Engineers at Oak Ridge, TN.  After four days of discussions, the seven engineers concluded that, “The demonstration plans included detailed health and safety documentation that addressed the more common regulatory and stakeholder concerns. However, the more fundamental risk associated with injecting large quantities of KMnO4 should be evaluated.”[2]  This statement addresses one of the fundamental difficulties surrounding the safety of new technologies: it is possible to generate enormous amounts of safety information “addressing more common regulatory and stakeholder concerns” without doing a sufficiently penetrating nor comprehensive system safety analysis. Indeed, a plethora of electronic templates available over the web for creating generic safety programs (some from governmental agencies) permit an individual to enter minimal information and generate large safety documents – without ever talking to other stakeholders or even looking at the technology or process.  
The third recommendation of the peer review team was that the evaluation of the more fundamental risks should proceed before any site demonstrations were conducted. The DOE Office of Science and Technology’s response was published in the report: “We concur with this recommendation and will implement it.”[3] I could find no documentation on the implementation of this recommendation, which was a clear warning two years prior to an event that severely disfigured a worker. [1] U.S. Department of Energy. (2000). Type B Accident Investigation: Injury resulting from violent exothermic Chemical Reaction at X-701B Site Portsmouth Gaseous Diffusion Plant. Oak Ridge Operations. 6.

[2] American Society of Mechanical Engineers. (1998, July 24). In situ chemical oxidation using KMnO4  Technical peer review final report. ASME/CRTD-FR-98-18. 309.

[3] Ibid. 310.

## A personal case study  The importance of planning and design

**Notes:**
Let’s work through a case study that helps us understand the importance of integrating safety into design. I was the project safety officer for this project. I didn’t know it until the crew dropped this 20’ long scrubbing tower they were putting in as an environmental control process and the Army Corps of Engineers shut the job down. They were attempting to lift it over these two tanks of acid and sit it on the other side. They had two cranes: one to do the pick and one to stabilize the load. They started with cables but couldn’t keep it stable, then moved to straps. They kept lift it and it kept shifting. They would set it down, make some adjustments and lift it again. They thought they had it and began lifting higher. The load shifted and one of the bolts at the flange cut through one of the straps. The load was now too heavy and the other strap failed and the unit came tumbling down about 10 feet from these acide tanks. The crew had no emergency plan, no assembly point, no spotter, no critical lift plan. The guy who was in charge told me he had told “them knuckleheads” to be safe but they never listen. I noted he wasn’t wearing his seat belt in the pickup as he drove me to this site. 

Is this a classic case of operator error?  What are some of the things we could have done to reduce the risk of this happening?
[Lead discussion to “What could we have done from a design standpoint. Work towards welding lifting lugs on the tower.]

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***	****If it weren’t for the people, the damned people always getting tangled up in the machinery. If it weren't for them, earth would be an engineer’s paradise*.
- 	Kurt Vonnegut,  Player Piano