HETA 95-0047-2485 NIOSH INVESTIGATORS:

FEBRUARY 1995 Ted A. Pettit, M.S., R.E.H.S.

VALDOSTA FIRE DEPARTMENT Thomas K. Hodous, M.D.

VALDOSTA, GEORGIA

SUMMARY

On November 15, 1994, the Division of Safety Research (DSR)

received a request from three fire fighters with the Valdosta

Fire Department for a health hazard evaluation in investigating

the circumstances of a hazardous materials incident, which

occurred August 5, 1994, at the Lowndes Correctional Institute

(LCI) in Valdosta, Georgia. The fire fighters requested

technical assistance in reviewing both general and specific

issues relating to this hazardous materials emergency response:

proper incident command structure; training of personnel; the use

of proper chemical protective clothing, including the provision

of identically trained and equipped backup personnel during

operations; medical evaluations of personnel, including baseline

and routine periodic physicals and medical evaluations after

exposure; and proper decontamination procedures.

The observations and findings made during this health hazard

evaluation were as follows: when chemicals are being measured and

mixed at the chemical plant, the facility manager or a supervisor

should be present at all times; the fire department should

develop written standard operating procedures for hazardous

materials responses; fire fighters should be trained on hazardous

materials responses, using newly developed procedures; and fire

fighters should receive routine periodic medical evaluations.

_________________________

KEY WORDS: SIC 9224 (Fire Departments), fire fighters, chlorine

exposure, hazardous materials.

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
INTRODUCTION

On November 15, 1994, the Division of Safety Research (DSR)

received a request from three fire fighters with the Valdosta

Fire Department for technical assistance in investigating the

circumstances of a hazardous materials incident on

August 5, 1994, at the Landaus Correctional Institute (LCI) in

Valdosta, Georgia. The fire fighters requested technical

assistance in reviewing both general and specific issues relating

to this hazardous materials emergency response which included

proper incident command structure; training of personnel; the use

of proper chemical protective clothing, including the provision

of identically trained and equipped backup personnel during

operations; medical evaluations of personnel, including baseline

and routine periodic physicals, and medical evaluations after

exposure; and proper decontamination procedures.

From December 5 to 7, 1994, NIOSH investigators from the Division

of Safety Research travelled to Valdosta, Georgia, to conduct an

investigation of this incident. The investigation was

coordinated through the Valdosta Fire Department and the Georgia

Department of Corrections, and consisted of three phases: (1) a

site visit to LCI; (2) interviews with several fire fighters,

personnel at the incident site, and the emergency room physician

who examined the fire fighters after the incident; and (3) review

of fire department policies, procedures, and equipment.

BACKGROUND

On Friday, August 5, 1994, at 1530 hours, a call was placed to

the Valdosta Fire Department from the Landaus Correctional

Institute (LCI) in Valdosta, Georgia, reporting a hazardous

materials incident at the chemical plant. LCI is a medium

security institution with approximately 350 inmates. Within the

grounds of the institution, LCI operates a chemical plant (part

of Georgia Correctional Industries) that formulates raw materials

into 48 different products, including floor waxes, dishwashing

liquids, window cleaners, low-sudsing detergents, and powdered

laundry bleach. The finished products are shipped to a main

warehouse, where they are sold and distributed throughout the

state to tax supported facilities. Approximately 44 inmates work

in the chemical plant, along with a staff of 5 state personnel;

the facility manager, 3 supervisors, and a data entry clerk.

On the day of the incident, one of the products being mixed at

the chemical plant was 14% powdered laundry bleach. This product

is formulated in 1000-pound batches by mixing various percentages

of sodium sulfate, sodium tripoly- phosphate, soda ash, and 60%

sodium dichloroisocyanurate. According to the Material Safety

Data Sheet(MSDS), inhalation of dichloroisocyanurate may produce
throat and respiratory tract irritation; however, the MSDS did

not reference any chronic effects from overexposure. A small

amount of liquid chlorinated oil is added to the mixture for dust

control.

A supervisor or the facility manager is present for the mixing of

all products. However, the supervisor for the mixing of this

product was called away for a few minutes when the oil was being

added to the mixture. Upon returning, he realized that three

times the amount of oil had been added to the mixture of two

batches. At this time, other than an abnormal texture, there was

no indication of any problem with the mixture. Since the plant

closes at noon on Fridays, and it was then approximately

0900 hours, the supervisor decided to store the improperly mixed

product in paperboard barrels on pallets, for proper reformulation the following Monday. The product was contained in its

standard shipping containers: small, plastic lined, 100-pound

paperboard barrels with lids. (A few 50-pound barrels were also

included). The chemical plant closed at 1130 hours.

At approximately 1500 hours, an officer at LCI noticed smoke

issuing from the window at the chemical plant. He notified the

lieutenant in charge, and three officers responded to the

chemical plant to investigate the smoke. Upon entering the

plant, they observed the building half full of smoke and

smoldering barrels of powdered laundry bleach. A forklift was

used to move the three pallets of smoldering powdered laundry

bleach to a concrete drive outside the building. The exothermic

reaction of the product created a vapor cloud, but did not result

in any fire.

In response to the initial call, the Valdosta Fire Department

responded with Car 200; Engines 1, 2, and 4; Rescue 1 with

trailer; and Tower 2. The captain in Car 200 arrived at the

front gates of LCI, assumed command, and gave the order for the

engine companies and rescue unit to take-up position behind his

car. The captain met with prison officials outside the fence and

discussed the situation. The captain had two fire fighters from

Rescue 1 suit up in Class A suits and self-contained breathing

apparatus (SCBA), enter the grounds and chemical plant to survey

the situation. The fire fighters reported there was one,

possibly two, broken, smoldering barrels on the floor in the

chemical plant that had fallen off the pallets when they were

moved. The barrels on the pallets on the outside were also

smoldering. When Rescue 1 exited the fenced area, a second team

suited up and entered to attempt clean up of the chemical plant
(NOTE: one of the fire fighters from Rescue 1 stated his suit was

leaking around the cuff). Car 101, with the deputy fire chief

arrived at this time and assumed command of the incident.

At approximately 1600 hours, the facility manager of the chemical

plant arrived at LCI. He met with the deputy fire chief and

informed him the product they were dealing with was powdered

laundry bleach. The facility manager then entered the prison

grounds without any type of respiratory protection, and wearing

only a disposable plastic suit--and began to physically move the

barrels from the pallets so the product would not be clustered in

one location. (NOTE: According to the facility manager, he was

exposed to the smoldering product probably as much, if not more,

than anyone else and did not experience any ill effects.)

After the facility manager told the deputy fire chief the product

was powdered laundry bleach, a decision was made to break open

all smoldering barrels with pike poles and flood them with water

to diffuse the reaction. Several firemen assisted in breaking

open the barrels; their personal protective equipment and

clothing varied. Some fire fighters wore Class A suits, some

wore turnout gear with SCBA, and some wore turnout gear without

SCBA.

Engine 1 was moved into the prison grounds to spray water

(initially a thin foam spray) on the smoldering barrels. At

first, the wind was blowing to the north, carrying the vapor

cloud away from the fire fighters. However, a rain storm from

the north moved in, which caused the product reaction to

increase, and the change in wind direction sent the vapor cloud

right over the path of the fire fighters and the decontamination

(decon) area. The fire chief arrived on the scene and

recommended the trucks and decon area be moved further down the

road, out of the vapor cloud, which now covered the area. The

deputy fire chief gave the order to move the vehicles and the

decon area down the public road which fronted LCI, away from the

vapor cloud.

Medical Aspects: Reports conflict with regard to the nature and

degree of irritation caused by the large vapor cloud which

engulfed the fire fighting scene for a time during the rain

storm. Some fire fighters, with no respiratory protection, and

close exposure, cited only a mild laundry bleach odor and no

irritation. Others noted a stronger odor or chlorine smell,

tearing of the eyes, and coughing.

At the advice of the EMT personnel at the scene, seven staff from

LCI and approximately 17 fire fighters were advised to be

examined at the local hospital. All of the LCI staff were

discharged back to duty, apparently with no significant symptoms

or medical findings. All but three of the fire fighters were

also discharged from the local emergency room. Three were kept

overnight for observation, and were discharged the next morning.
According to the emergency room staff, initial findings were mild

upper respiratory tract and throat irritation. Two fire fighters

have reported subsequent upper respiratory tract conditions

including sinusitis, although the exact relationship of these

conditions to the incident under discussion has not been fully

elucidated by examining physicians.

INVESTIGATION

On August 5, 1994, a hazardous materials (chemical spill)

incident at the Landaus Correctional Institute (LCI) was reported

to the Valdosta Fire Department. Some fire fighters said they

detected a strong chlorine odor; others did not notice any odor.

Several fire fighters were treated at the hospital emergency

room, and three remained overnight. Primary complaints were

respiratory and sinus problems. Three fire fighters with the

Valdosta Fire Department requested an investigation be conducted

into the circumstances of this hazardous materials incident.

On December 5, 1994, the NIOSH investigators met with the

Director for Safety and Environmental Regulations for the Georgia

Department of Corrections, and a chemical consultant for Georgia

Correctional Industries. This meeting was to discuss their final

reports submitted on this incident, and to gather information on

the circumstances of this incident from the Correctional

Industries' viewpoint.

On December 6, 1994, the NIOSH investigators conducted an opening

conference with the Valdosta Fire Department fire chief in his

office to discuss the purpose of the NIOSH investigation and the

proposed schedule of events, and to obtain a list of fire

fighters to interview. After the opening conference, the NIOSH

investigators proceeded to the LCI to conduct a site visit with

the Director for Safety and Environmental Regulations for the

Georgia Department of Corrections, and a chemical consultant for

Georgia Correctional Industries. Discussions were held with the

chemical plant facility manager, the deputy warden, and several

correctional facility officers. These individuals explained the

plant's operation and provided information on the events that

occurred on the day of the incident.

On the afternoon of December 6, 1994, the NIOSH team returned to

the main fire station to interview the fire fighters who were

involved in or concerned over this incident. All interviews were

conducted in private using the office of the deputy fire chief.

All fire fighters interviewed were informed of the purpose of the

visit and their cooperation was requested during this

investigation. The interviews covered the following areas: the

hazardous materials incident at LCI, incident command, training

on hazardous materials response, standard operating procedures

for hazardous materials response, personal protective clothing

and equipment, respiratory protection, medical evaluations after
the incident, and baseline and periodic physicals.

On December 7, 1994, the NIOSH team returned to the main fire

station to complete the interviews with fire fighters and other

staff, observe the equipment used during a hazardous material

response, visit the fire station where respirator maintenance is

performed, check respirator maintenance records, review training

records, interview the deputy fire chief, and interview and

conduct a closing conference with the fire chief.

The NIOSH team received full cooperation and assistance from all

parties during all aspects of the HHE. The observations and

findings made by the NIOSH team during this investigation are

outlined below:

When chemicals are being measured and mixed at the LCI

chemical plant, either the facility manager or a supervisor

is present to observe correct measurements and procedures.

However, on the day of the incident, the person supervising

the mixing of the dry chlorine bleach was called away for a

few minutes, and an incorrect mixture was made.

The fire department does not have any written standard

operating procedure for hazardous materials responses.

Fire fighters receive only an entrance medical examination.

No routine periodic medical evaluations are done to assess

the fire fighters' ability to carry out their fire fighting

or hazmat activities, or to safely wear a respirator. This

deficiency also makes it difficult to determine the extent

to which the continuing medical complaints of a few of the

fire fighters are related to the incident versus preexisting conditions.

Class A suits were stored in a large wooden box on the

rescue trailer. One of the suits was caught between the lid

and the box. Possible damage to the suits may occur from

this type of storage.

General respirator maintenance procedures appeared to be

well organized and carried out according to appropriate

regulations and guidelines.
RECOMMENDATIONS/DISCUSSION

Recommendation #1: The fire department should develop written

Standard Operating Procedures for hazardous materials

responses.1-7

Discussion: The Valdosta Fire Department should develop and

implement a written procedure that includes, but is not limited

to, the following areas: responsibilities, training, and

competencies of responders, incident response planning, fire

department policies, application of procedures for incident

levels, incident command, personal protective equipment,

decontamination, safety, and communications.

Recommendation #2: The fire department should provide periodic

medical examinations of fire fighters. 1,4,6,8-10

Discussion: Periodic physical examinations as stated in 29 CFR

1910.120, 40 CFR 311, NFPA l582, and ANSI Z88.6. They are

intended to help ensure that fire fighters are able to safely

carry out their often strenuous work activities. Periodic

medical examinations would also allow the determination of the

medical fitness of fire fighters to wear SCBA, as required under

29 CFR 1910.134 for general industry. Periodic medical

evaluations would also help assess any adverse effects from

workplace exposures.

One factor contributing to the absence of periodic medical

examinations appeared to be the belief that an extensive

potential exposure list (all chemicals used by all industries in

the county) was needed to determine which required screening

tests should be included. The NIOSH team believes this view is

clearly in error, and that periodic medical evaluations should be

conducted for all fire fighters as soon as possible.

Recommendation #3: The Landaus Correctional Facility should

require a supervisor be present 100% of the time when chemicals

are being mixed.

Discussion: The improper handling and mixing of chemicals at the

Landaus Correctional Facility chemical plant have the potential

for significant adverse results. Therefore, it is recommended

that a supervisor be present 100% of the time during this

process. If the supervisor must be called away from the

operation, another supervisor should assume responsibility, or

the operation should be temporarily halted.

REFERENCES

1. NFPA [1992]. NFPA 1500: Standard on Fire Department

Occupational Safety and Health Program, National Fire

Protection Association, Quincy, MA.
2. NFPA [1990]. NFPA 1561: Standard on Fire Department

Incident Management System, National Fire Protection

Association, Quincy, MA.

3. NFPA [1992]. NFPA 471: Recommended Practice for Responding

to Hazardous Materials Incidents. National Fire Protection

Association, Quincy, MA.

4. 29 Code of Federal Regulations 1910.120, Hazardous Waste

Operations.

5. 40 Code of Federal Regulations 355.30, Emergency Planning

and Notification.

6. 40 Code of Federal Regulations 311, Worker Protection.

7. 40 Code of Federal Regulations 300.215, National Hazardous

Substances Pollution Contingency Plan.

8. NFPA [1992]. NFPA 1582: Chapter 2, Standard on Medical

Requirements for Fire Fighters. National Fire Protection

Association, Quincy, MA.

9. ANSI Z88.6-84: Standard for Respiratory Protection -

Respirator Use - Physical Qualifications for Personnel.

American National Standards Institute, Inc. NY, NY.

10. 29 Code of Federal Regulations 1910.134, Respiratory

Protection.

AUTHORSHIP AND ACKNOWLEDGEMENTS

Report Prepared by: Ted A. Pettit, M.S., R.E.H.S.

Chief

Trauma Investigations Section

Surveillance and Field

Investigations Branch

Division of Safety Research

Thomas K. Hodous, M.D.

Chief

Science and Policy Coordination

Activity

Division of Safety Research

Fire Department Richard M. Ronk

Policy Review: Fire Protection Engineer

Information Management and

Dissemination Activity

Division of Safety Research

Editorial Review: Linda Morton
Writer-Editor

Information Management and

Dissemination Activity

Division of Safety Research

DISTRIBUTION AND AVAILABILITY

Copies of this report may be freely reproduced and are not

copyrighted. Single copies of this report will be available for

a period of 90 days from the date of this report from the NIOSH

Publications Office, 4676 Columbia Parkway, Cincinnati, Ohio

45226. To expedite your request, include a self-addressed

mailing label along with your written request. After this time,

copies may be purchased from the National Technical Information

Service (NTIS), 5285 Port Royal, Springfield, Virginia 22161.

Information regarding the NTIS stock number may be obtained from

the NIOSH Publications Office at the Cincinnati address. Copies

of this report have been sent to:

1. Chief, Valdosta Fire Department

2. City Manager, City of Valdosta

3. Director, Safety and Environmental Regulations, Georgia

Department of Corrections

4. Director, OSHA Region IV

5. Director, Division of Public Health, Georgia Department of

Human Resources

6. Administrator, EPA Region IV

7. Valdosta Fire Fighters

For the purpose of informing affected employees, copies of this

report shall be posted by the employer in a prominent place

accessible to the employees for a period of 30 calendar days.