Graniteville, SC: One Year Later

One of the more chilling workplace and environmental incidents of last year was the chlorine release in Graniteville, SC that killed nine workers, the train's engineer and eight workers in an adjacent Avondale Mills factory, after a train carrying pressurized chlorine gas crashed into a parked train on Jan. 6, 2005.

In addition to the nine workers killed -- 240 were injured and more than 5,000 residents were forced to flee the poisonous gas that seeped into their homes for days.

That event was over a year ago, but the effects linger, not just in the physical health of the residents, but in the economic and social health of the community.

"It has been one thing after another," said Logan, an inspector for the Douglas Schmidt Law Office, which represents 600 residents and business owners who say the spill harmed their property or their health.

As a result of the corrosive gas, Patricia Courtney's clocks stopped telling time; Melinda Borst's television turned itself on and off; and the organ at Graniteville's First Baptist Church emitted sound erratically.

Many residents fear that this close-knit community will never recover from the train derailment, the deadliest train wreck involving hazardous material since 1978. They worry about the future of Avondale Mills, the 13-acre industrial complex in the heart of town. In October, the company announced plans to lay off 350 workers and sue Norfolk Southern for "catastrophic damage" to its machinery.

Norfolk Southern has estimated that it would spend $39 million cleaning up the accident and paying legal claims.

"The chlorine damage is more insidious than anyone expected," said Stephen Felker, Avondale Mills' manager of corporate development.

According to papers filed with the Securities and Exchange Commission, the company had spent $52.5 million on cleanup costs by August, the end of its fiscal year.

And the physical and emotional health of the residents isn't great either:

Within 48 hours of the crash, the department conducted an epidemiological assessment of nearly 300 people. Nearly 80 percent experienced symptoms such as severe coughing, burning eyes, chest pains, skin rashes, headaches, dizziness and nausea.

Jerry Gibson, director of the department's Bureau of Disease Control, said a follow-up of half of those people last summer found that 80 percent were still experiencing symptoms.

Inside her Graniteville home on Laurel Drive, Melinda Borst notices that fewer neighbors walk outside or spend time in their yards.

"They just do what they have to do, and then they come inside," she said. "It's like the whole community has suffered a death."

Graniteville is a small community. Imagine the incredible devastation if this had happened in the middle of a large city....


Related Stories

• Transportation Safety Board Recommends Actions To Prevent & Reduce Impact Of HazMat Train Accidents, December 6, 2005
• "The uninterrupted flow of hazardous materials is necessary for the health and safety of the U.S" January 8, 2005
• Just Be Careful Not To Breathe, January 6, 2005

Transportation Safety Board Recommends Actions To Prevent & Reduce Impact Of HazMat Train Accidents

It's common practice following an industrial accident to blame the workers involved because they made mistakes or didn't follow proper procedures. And on a shallow surface level, this analysis is not wrong. Workers are human, and being human, they make mistakes.

But stopping with that superficial "blame the worker" analysis doesn't get to the real reason, or "root cause" of the incident. And if you don't address the root causes, similar accidents will continue to happen.In fact, it may make matters worse: punishing the workers involved may give management a false sense that the problem has been resolved.

On January 6th, 2005 a freight train carrying chlorine gas struck a parked train, puncturing the chlorine tanker. Nine workers died of chlorine inhalation: the train's engineer and eight workers in an adjacent factory. 5,400 people within a 1-mile radius were evacuated and 75 were admitted to a hospital for treatment.

The surface cause of the crash was the failure of the crew of the parked Norfolk Southern train to return a main line switch to the normal position after the crew completed work at an industry track, allowing the moving train to switch onto the wrong track and collide with the parked train.

Transportation Secretary Norman Mineta blamed the accident on "human error." Noting that is that type of human error is not addressed by Federal Railroad Administration regulations, he proposed a program that would provide more training and possible civil penalties. In the worst case, employees could be barred from certain train assignments.

Problems solved? Not quite.

The National Transportation Safety Board, which issued its report on the accident at the end of November, agrees that the railroads and the FRA need to look much deeper than just worker error as a cause, and punishing workers as the solution, as summarized by the New York Times.

The crew normally had a set routine of resetting the switch as they moved the train to the the siding that they had not planned to use. But on this night, the crew strayed from that normal routine because they were just coming off of a 12-hour workday, had a taxi waiting to take them back to their depot and were anxious about finishing before their work hours would violate federal rules.

In addition,

the tracks in the Graniteville area, near Aiken, S.C., were "dark," meaning that they had no electronic signals that would have allowed a dispatcher to realize that the first crew had forgotten to reset the switch. About 40 percent of the rail network is dark.

The second train, which was moving at 47 miles an hour in a 49-mile-an-hour zone, would have needed half a mile to stop but had less than an eighth of a mile, investigators said.

The engineer, who died in a hospital from chlorine inhalation, was doomed before he got there, they said.

To prevent similar accidents, the Board recommended

• A strobe light like those carried on some school buses, or a radio device that sent signals to beepers or cellphones, might have reminded the first crew to reset the switch when leaving the train for the night, investigators said. Where no automatic signals exist, trains should be operated at speeds that will allow them to be safely stopped in advance of misaligned switches


• Positioning cars carrying chlorine, anhydrous ammonia, and other liquefied gases that pose an inhalation hazard at the rear of the train and reducing speeds through populated areas


• Train employees should be provided with emergency escape breathing apparatus and training for all crewmembers on freight trains carrying hazardous materials that would pose an inhalation hazard.

As the Times article pointed out, "crashes caused by misaligned switches are common." And one member of the NTSB Board was not happy with the Federal Railroad Commission's response:

Debbie Hersman, a member of the safety board who accompanied the investigators to the scene in January, said that the Federal Railroad Administration had proposed fines for failing to reset switches, but questioned the effect.

"Do we think these things are going to change operating behavior?" she asked.

Like any workplace hazard, slapping workers on the wrist for being human isn't going to help. As the NTSB noted, there are other, more effective ways of preventing these accidents from re-occurring.

The NTSB Synopsis can be found here.

Related Stories

• Blaming Workers: In Texas City and On The Rails, May 18, 2005
• "Engineers and conductors sleep on trains. Anyone who tells you different is not being straight with you," May 9, 2005
• Deaths and Injuries at US Steel: Blame the Workers?, Feb 24, 2005
• Behavioral Safety Comes To The Railroads, November 15, 2004
• Blame the Worker: Chinese Style, January 3, 2004
• Worker Error Department (cont'd), April 14, 2003
• Worker Error Department, Part 2 April 11, 2003
• Worker Error Department, April 10, 2003

'Turning and Burning' and Asleep on the Job? Fire Their Asses, Right?

With all we're learning about the functioning of the human body and how work organization (including hours of work) affect human attentiveness, it never ceases to amaze me that employers are still so successful at blaming workers for what is obviously an organizational failure of management systems.

A freight train conductor blamed for a crash that killed three Metrolink passengers and injured more than 260 in Placentia three years ago was tired after weeks of long hours and erratic sleep, attorneys say, citing sworn statements taken for dozens of lawsuits.

***

The attorneys, who represent the injured Metrolink passengers, cite the sworn depositions of conductor Dean E. Tacoronte, 41, and engineer Darrell W. Wells, 51. Both were fired by Burlington Northern, which blamed their inattentiveness for the accident in which their mile-long freight train plowed head-on into a stopped Metrolink train the morning of April 23, 2002.

"Me and Darrell, we were both tired that day," Tacoronte said in his deposition. He had worked 29 days straight in the weeks before the crash. "We were real, real busy.... I worked all the time."

"Turning and burning," was how he described his routine.

I hate to repeat myself all the time, but until people (particularly employers) stop doing stupid things like neglecting the real root causes of accidents and firing workers so they look like they're taking decisive action, I have no choice.

This is what I wrote previously about fatigue on the rails:

As happens in so many other accident investigation, the root causes of these problems have been covered by conclusions that essentially blame the worker for falling asleep or "poor judgment, miscommunication and failure to follow operating procedures — errors that experts say can be triggered by fatigue."The root cause of the fatigue is not careless workers, but scheduling problems:

A 1997 survey of more than 1,500 freight crew members by the North American rail Alertness Partnership — a group of industry, government and union officials — found that about 80% had reported to work while tired, extremely tired or exhausted.

Though fatigue can affect passenger train crews, it is primarily a problem for the 40,000 to 45,000 engineers, brake operators and conductors assigned to unscheduled freight service.

Many put in 60 to 70 hours a week, sometimes more. They can be called to work any time during the day or night, constantly disrupting their sleep patterns.The irregular shifts often place bleary-eyed crews at the controls between 3 and 6 a.m., when experts say the body's natural circadian rhythm produces maximum drowsiness.

Engineers, brake operators and conductors liken on-the-job fatigue to being in a constant state of jet lag."There is no set rest schedule. It changes all the time, and it is hard to adjust," said Doug Armstrong of Huntington Beach, a veteran Union Pacific engineer who often works 12-hour days, six days a week. "People have a normal rest cycle, but a railroad is anything but normal."

And the problem is that there are antiquated laws, in this case, the 98 year old federal Hours of Service Act. The act requires train operators to have 8 hours off, but that doesn't allow for commuting, family obligations, meals -- as well as adquate sleep. In addition, it's legal for engineers, conductors and brake operators to work 432 hours a month, as opposed to truckers who are allowed to drive no more than 260 hours.

This isn't just a problem of fairness and justice. The problem with ignoring the root causes of accidents (poor scheduling, forced fatigue, etc.) is that you can fire the tired workers, and then you can fire the next workers who fall asleep, and on and on, but you'll never be preventing the problem from happening over and over again. Because humans need to sleep or they make mistakes, and no amount of discipline or punishment will ever solve that problem.

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Blaming The Worker: In Texas City and On the Rails

BP blames employees for fatal blasts

Mineta: Railroad safety plan will deal with human errors

Headlines like these always make me wonder about the human tendency to find scapegoats to blame after a tragedy. Is it just a matter of companies wanted to point the finger elsewhere, anywhere away from themselves or the decision makers, or away from problems that are hard or expensive to resolve? And why don’t journalists generally look deeper than the simple “worker screwed up” story. Does blaming workers satisfy a basic urge in people to always have a readily understandable villain to blame. Blaming incompetent workers for accidents is so easy. Just fire them and the problem’s solved. Right?

Not quite. In October 2003, NASA released a report on the Columbia Space Shuttle Disaster. When I reviewed the report, I urged readers to study Chapter 8, which was written by Dianne Vaugh, who wrote the classic work on the original Challenger disaster. Vaugh explores the systemic failures of the NASA safety system and how the problems uncovered after the Challenger disaster reappeared to cause the Columbia's problems. The most interesting parts of the report focuses on the management system problems rather than individual failures. Vaughn cautions however that

the Board's focus on the context in which decision making occurred does not mean that individuals are not responsible and accountable. To the contrary, individuals always must assume responsibility for their actions. What it does mean is that NASA's problems cannot be solved simply by retirements, resignations, or transferring personnel.

The footnote accompanying this paragraph states

Changing personnel is a typical response after an organization has some kind of harmful outcome. It has great symbolic value. A change in personnel points to individuals as the cause and removing them gives the false impression that the problems have been solved, leaving unresolved organizational system problems.

The fact is that human beings inevitably make errors and errors by operators must be expected. But rather than focusing on the operators who make the errors, effective accident analysis – analysis that actually wants to get to the root causes and effective solutions -- looks for the conditions which made the errors possible.

These errors can be rooted in poor design, gaps in supervision, undetected manufacturing defect or maintenance failures, unworkable procedures, shortfalls in training, less than adequate tools and equipment. In addition, these conditions can be present for many years before they combine to result in a tragic incident. In fact, BP made the point that they had been operating with questionable equipment for many years with no problem.

Lets take a short look at the stories behind the headlines above.

According to an Interim Report issued by BP yesterday, the Texas City refinery incident occurred in the isomerization (ISOM) unit. A processing tower, called the raffinate splitter that housed hydrocarbon liquid and vapor, overfilled and overheated. The liquid and vapor mix was overpressurized, flooded into an adjacent Blowdown Drum & Stack, overflowed and escaped into the atmosphere around the unit. The resulting vapor cloud was then ignited by a still-unknown source.

The basic message of the press conference was that worker error was to blame:

If ISOM unit managers had properly supervised the startup or if ISOM unit operators had followed procedures or taken corrective action earlier, the explosion would not have occurred, the investigation team said….. "The mistakes made during the startup of this unit were surprising and deeply disturbing. The result was an extraordinary tragedy we didn't foresee," said Ross Pillari, president of BP Products North America, Inc.

Reading more deeply into BP's report, however, one finds two factors that actually get much closer to the root causes of this incident

• The alternative to using the blowdown stack is a flare system that burns off the excess material. In fact, the report states that “Blowdown stacks have been recognized as potentially hazardous for this type of service, and the industry has moved more towards closed relief systems to flare” and that ”The investigation team also concluded the use of a flare system, instead of a blow down stack, would have reduced the severity of the incident." In fact the report noted that there were several times over the past ten years when the relief line could have been tied into a safer flare system, but that “the true level of the hazard was not seen.” In fact, use of the blowdown stack was increased and changes were made to reduce its effectiveness over the past several years.
  
  
• The reason so many people were killed is that they were located in trailers directly adjacent to the blowdown stack. Turns out that the Texas City Refinery has a management of change process to evaluate hazards associated with the placement of temporary structures. This process was designed to ensure that the trailers were safe to use and that they were put in a safe place. Although these hazard reviews were conducted prior to placing the trailers, they “did not recognize the possibility that multiple failures by ISOM unit personnel could result in such a massive flow of fluids and vapors to the blow down stack.” Pillari noted that “Plans could have been made to move them away before the startup operation”

Now, let’s go back for a moment to the “surprising and deeply disturbing” worker error elements. The company stated that there should have been a plan to move non-essential personnel away from the area before the startup operation, and that operators failed to sound the evacuation alarm at crucial times which led to personnel remaining in place and being exposed to the hazard. Supervisors failed to provide appropriate leadership and hourly workers failed to follow written procedures. Supervisors did not verify correct procedures were being used or followed by unit operators. Furthermore supervisors were absent from the unit during critical periods and there was confusion about who was in charge.

Consequently, BP is firing several workers and disciplining others.

Crucial to any root cause investigation, however, is one word: “Why?” Investigators need to keep asking “why?” until the root causes are identified. For example, why didn’t workers follow proper procedures? Were they lazy and incompetent, smoking weed and napping? Or were the procedures too complicated? Were the procedures normally followed to the letter, or generally ignored or circumvented? Were workers adequately trained to respond to this type of emergency even though it had never happened before and, according to the report, was never anticipated? Were the operators too overwhelmed with handling the emergency itself to think about sounding the alarm? And why were supervisors absent during critical periods? Was it common practice for them to be absent? And whose responsibility was it to address “confusion about who was in charge.”

I don’t know the answers to any of these questions, but the need to be asked.

One of the few reporters who seem to have actually read the report was Dina Cappiello of the Houston Chronicle who wrote an article, based on BP’s report, about the company’s failure to replace the blowdown stack:

BP continued to release dangerous and flammable vapors from a ventilation stack at its Texas City refinery, despite chances over the last decade to replace it, an internal investigation by the company has found.

While other refineries swapped the outdated stacks with more modern flares that burn off gases, BP passed on two opportunities — in 1995 and 2002 — to replace the 50-year-old vent stack that erupted into a geyser of flammable vapor and liquid March 23 after a nearby tower was overfilled and overheated.

That choice likely led to the explosion being called one of the deadliest industrial accidents in U.S. history, said Ross Pillari, president of BP Products North America at the investigation's release.

"The report notes that ... use of a flare system, instead of a blowdown stack, would have reduced the severity of the incident," said Pillari. "There was other work going on in the refinery and these would have been opportunities to take this unit to a flare. There is no documentation as to why this didn't happen."

Another Chronicle article covered the reaction of the union and others critical of the BP report:

Union officials, victims and attorneys representing dozens of injured workers or the families of the deceased, said Pillari made scapegoats of the low-level refinery workers while sidestepping management's own responsibility.

"Blaming workers doesn't solve the problem of unsafe conditions in that refinery," said Gary Beevers, Region 6 director of the United Steelworkers union.

***

Then there was the article about Secretary of Transportation Norman Mineta blaming worker error for the Graniteville, South Carolina accident last January that released chlorine, killing 9 workers.

Preliminary findings in the Jan. 6 Graniteville wreck, which killed nine people and injured hundreds, have placed the blame on the crew of a Norfolk Southern train who failed to switch the main track into its proper position. An oncoming train then crashed into the parked cars on the side spur, rupturing a chlorine tanker and releasing a toxic cloud over the tiny textile town about 60 miles southwest of here. Some 5,400 residents were evacuated.

That type of human error, the largest single factor that accounted for 38 percent of all train accidents in the past five years, is not addressed by Federal Railroad Administration regulations, Mineta said. Railroad company operating rules address human error, and employees who violate those rules can be disciplined or dismissed.

The plan that Mineta proposed contained a number of measures that go far beyond just preventing workers from screwing up, including requiring

more training from the federal agency and possible civil penalties. In the worst case, employees could be barred from certain train assignments, said Dan Smith, the federal agency's associate administrator for safety.

The plan also would address crew fatigue, help develop technology that can alert crews to broken rails and improve hazardous materials safety by letting local emergency workers know immediately what material could be involved in a crash.

Again, the headline and Mineta’s main message focus on worker error, although reading deeper you find mention of fatigue and lack of warning devices. I wrote last week about how rail scheduling issues and antiquated regulation put train crews in a permanent state of jet lag.

Rebecca Schmidt of West Columbia, who lost her son, 28-year-old train engineer Chris Seeling, in the accident, had a pretty good handle on the problems faced by train crews:

"I'm really excited about this and hope something positive comes out of it - especially the electric signals and I know that fatigue is a huge issue,...I definitely think that you cannot rely on human judgment, especially when a crew has worked 12 hours and they're tired. There needs to be some type of electronic signal," she said, as a train roared through the city of Columbia, blasting its horn.

She also said there should be a clean air supply on trains and more should be done to reduce speeds.

The point is that human error may be one of the "direct causes" of an incident, but it’s almost never one of the root causes. A direct cause is the action that directly results in the occurrence, while root causes are usually management system problems which, if corrected, would not only have prevented that specific problem, but other similar problems as well.

The problem with solely blaming (and firing) workers, you’re taking actions that will prevent future incidents. If, as in the BP case, the root causes had more to do with the management systems that allowed the continued use the blowdown drums and located the trailers in the danger zone, then just firing a few workers who didn’t follow proper procedures (which may have been confusing) isn’t going to keep the same incident from happening again. And disciplining workers for not following proper rail procedures isn't going to be too effective if scheduling issues mean that no on is getting enough sleep.

Despite the "headlines" from their report, BP itself obviously knows better than to just blame the workers. In addition to firing and disciplining employees, they announced that they will modify or replace all blow down systems which handle heavier-than- air hydrocarbon vapor or light hydrocarbon liquids and locate trailers far from any danger areas.


BP News release here
PIllari Statement here

More BP Texas City Explosion Stories.

Related Stories

• "Engineers and conductors sleep on trains. Anyone who tells you different is not being straight with you," May 9, 2005
• Deaths and Injuries at US Steel: Blame the Workers?, Feb 24, 2005
• Behavioral Safety Comes To The Railroads, November 15, 2004
• Blame the Worker: Chinese Style, January 3, 2004
• Worker Error Department (cont'd), April 14, 2003
• Worker Error Department, Part 2 April 11, 2003
• Worker Error Department, April 10, 2003
  
  

"Engineers and conductors sleep on trains. Anyone who tells you different is not being straight with you,"

It's late, I'm tired and I'm still writing. At least I'm not driving a train.

Here we have a story of well-known fatigue problems among workers responsible for carrying the 1.7 million carloads of the nation's hazardous materials every year, and the Association of American Railroads who would rather deny that obvious fatigue issues exist despite clear evidence to the contrary:

When a Union Pacific freight train thundered into tiny Macdona, Texas, just before dawn June 28, the engineer and conductor had clocked more than 60 hours in the previous week, working the long, erratic shifts that are common in the railroad industry.

They flew through a stop signal at 45 mph and slammed into another freight train that was moving onto a side track. No one even touched the brakes.

Chlorine gas from a punctured tank car killed the conductor and two townspeople, while dozens of others suffered breathing problems and burning eyes as the toxic cloud drifted almost 10 miles. Hundreds were evacuated within a 2-mile radius of the accident.

Federal investigators suspect that both of the Union Pacific crewmen had fallen asleep. In the weeks before the crash, each man's work schedule had at least 15 starting times at all hours of the day.

The Macdona crash illustrates a grim fact of life for thousands of engineers, brake operators and conductors who guide giant freight trains across the country: Exhaustion can kill.

Two decades after federal officials identified fatigue as a top safety concern, the problem continues to haunt the railroad industry, especially the largest carriers responsible for moving the vast majority of the nation's rail-borne freight.

"Engineers and conductors sleep on trains. Anyone who tells you different is not being straight with you," said Diz D. Francisco, a veteran engineer and union official who works out of Bakersfield for the Burlington Northern Santa Fe Corp.

I've written about this incident before, but in the context of transporting hazardous cargo. Combined with hazardous material problems (like the train crash that killed nine in South Carolina several months ago), the incidents cited in this article are chilling:

National Transportation Safety Board records show that entire crews have nodded off at the controls of mile-long freight trains weighing 10,000 tons, some of them loaded with hazardous materials.

In a 1984 Wyoming crash, a Burlington Northern engineer had only 6 1/2 hours of sleep in the 48 hours before the accident; his conductor had five hours of sleep.

Outside St. Louis in 2001, a Union Pacific engineer who had been up for 24 hours with only a short nap failed to heed three warning signals and orders to limit his speed before triggering a chain-reaction crash involving two other trains. The wreck injured four and caused $10 million in damage.

A year later, in Des Plaines, Ill., a Union Pacific engineer fighting to stay awake after more than 22 hours without sleep blew past warning signals and broadsided another train, severely injuring two crew members.

After a Chicago & North Western train collision in March 1995, engineer Gerald A. Dittbenner sued the railroad — and received a $500,000 settlement, his lawyers say — over his incessant 12-hour shifts and irregular work schedules.

Dittbenner, 49, misread a stop signal after being awake almost 30 hours and hit the rear of an empty coal train outside Shawnee Junction, Wyo. Seconds before the impact, Dittbenner jumped from the locomotive and broke his neck. Unable to do strenuous work because of persistent pain, he now works as a locksmith in Scottsbluff, Neb.

As happens in so many other accident investigation, the root causes of these problems have been covered by conclusions that essentially blame the worker for falling asleep or "poor judgment, miscommunication and failure to follow operating procedures — errors that experts say can be triggered by fatigue."The root cause of the fatigue is not careless workers, but scheduling problems:

A 1997 survey of more than 1,500 freight crew members by the North American Rail Alertness Partnership — a group of industry, government and union officials — found that about 80% had reported to work while tired, extremely tired or exhausted.

Though fatigue can affect passenger train crews, it is primarily a problem for the 40,000 to 45,000 engineers, brake operators and conductors assigned to unscheduled freight service.

Many put in 60 to 70 hours a week, sometimes more. They can be called to work any time during the day or night, constantly disrupting their sleep patterns.

The irregular shifts often place bleary-eyed crews at the controls between 3 and 6 a.m., when experts say the body's natural circadian rhythm produces maximum drowsiness.

Engineers, brake operators and conductors liken on-the-job fatigue to being in a constant state of jet lag.

"There is no set rest schedule. It changes all the time, and it is hard to adjust," said Doug Armstrong of Huntington Beach, a veteran Union Pacific engineer who often works 12-hour days, six days a week. "People have a normal rest cycle, but a railroad is anything but normal."

And the problem here is antiquated laws, in this case, the 98 year old federal Hours of Service Act. The act requires train operators to have 8 hours off, but that doesn't allow for commuting, family obligations, meals -- as well as adquate sleep. In addition, it's legal for engineers, conductors and brake operators to work 432 hours a month, as opposed to truckers who are allowed to drive no more than 260 hours.

And it seems that no story of workplace -- or community -- hazard is complete without an industry association trying to deny that the problem exists. The Association of American Railroads (AAR), the industry's trade organization and lobbying arm, commissioned a study of the fatigue problem and finding ways to reduce accidents. But the study was canceled in 1998 when it found that "engineers who put in more than 60 hours a week were at least twice as likely to be in an accident as those working 40 hours."

"They did not want this finding," said [the former AAR analyst Donald]Krause, who once studied rail safety for the federal General Accounting Office and is now a business writer living outside Chicago. "The railroads fear it could lead to restrictions on hours and government regulation, which could cost them money. But something needs to be done. One of these days, they are going to wipe out a town."

Association officials say Krause's research was halted because of budget cuts, not out of a desire to bury the conclusions.

Yeah, I'm sure.

Among the reasons for the ARA to not want to see those results:

Hiring has not kept pace with a steady increase in rail freight volumes, about 4.4% a year on average since 1991, federal data show.

Corporate mergers and cost-cutting during the 1990s led to staff reductions. In 2002, a change in pension rules led to 12,000 railroad worker retirements, twice as many as the year before.

Since 1990, overall railroad employment has declined more than 25%. Department of Labor statistics show that, until recently, the hiring of engineers has been flat for years.

There seems to be some dispute about the role of unions. According to the article, rail unions have supported the resulting overtime:

Railroad unions have at times resisted proposed solutions to the fatigue problem if they threatened to limit the freedom of their members to work long hours and maximize earnings. With overtime and high mileage, salaries for engineers can reach $100,000 a year.

"It is a two-edged sword," said Brian Held, 47, a Burlington Northern Santa Fe engineer for 10 years. "The company wants to save money and doesn't hire what it needs to. Union members don't want the boards so full of workers they can't make the money they want. It makes for a dangerous situation."

Although, on the other hand:

In December 2003, Union Pacific unsuccessfully sued a group of unionized conductors alleging that they were taking too much time off during weekends and holidays, disrupting commerce along a major Kansas line in violation of the Railway Labor Act.

The United Transportation Union countered that the railroad was severely understaffed in the area and many conductors were exhausted from working for weeks — sometimes months — without a day off.

"We were running with a skeleton crew," said union official Greg Haskin. "Guys were burned out and calling in sick. They were working 12- to 16-hour days up to 90 days straight. You can't expect people to work like that and be safe."

Union Pacific declined to discuss the case.

In 1999, the NTSB recommended that the Federal Railroad Commission

Establish within 2 years scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and restrequirements.

But, of course, we are faced with the usual debate in this administration about whether or not the railroads should be left to voluntary programs to reduce fatigue, or whether there should be regulations.

Guess which side is winning.

The FRA has announced that it

will continue to monitor the results from these various cooperative arrangements and research projects on fatigue and, as the need arises, take relevant regulatory action and/or recommend legislative action.

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Right to Know: RIP? Happy Sunshine Week

Happy Sunshine Week!

Huh?

Yes, this is the first national Sunshine Week, an event sponsored by more than 50 news outlets, journalism groups, universities and the American Library Association to focus on the issues that surround the freedom of the press and government openness.

And it has never been needed more than it is now. There is a great debate raging in this country, mostly behind the scenes, that will impact the safety of this nation's first responders, as well as citizens living in the vicinity of industrial facilities that use significant amounts of chemicals. The debate is over the right of workers and citizens to know what chemicals they may be exposed to. It's a battle that was largely fought and won years ago, but is being refought again under the specter of terrorist threats.

Last week I wrote an article entitled "First Kill The Responders" about a Homeland Security Department proposal to remove the hazard identification placards from railroad chemical tank cars in order to protect the country from train-targeting terrorists. First responders who have a need to know what they're confronting are not amused.

Meanwhile, an rail accident last week in Salt Lake City shows that while the battle over the right-to-know, it's apparent that we've still got a long way to go before right to know, actually becomes the ability to know:

A railroad tank car that leaked toxic fumes, forcing thousands of people from their homes, was not designed to hold the mixture of highly corrosive acids with which it had been filled, the car's owner said Monday.

Some 6,000 people were allowed to return home and highways were reopened Monday after crews pumped the hazardous brew of waste out of the tank car.

Tests showed the tank car had been filled with a mixture of acetic, hydrofluoric, phosphoric and sulfuric acids, which easily corroded the car's lining, said Louie Cononelos, a spokesman for Kennecott Utah Copper of Magna, Utah.

Cononelos said the car was supposed to be used only for hauling sulfuric acid.

The copper mining company owned the car, but Philip Services, a hazardous waste handler, had leased it, and was using it to haul waste belonging to its customers. Philip Services spokesman Paul Schultz said the load complied with federal Transportation Department guidelines on the shipment of hazardous materials.

South Salt Lake Fire Chief Steve Foote said the incident could lead to a criminal investigation.

Officials said 6,000 gallons of liquid was pumped out of the car and it was believed about 6,500 gallons more had leaked and soaked into the ground. Contaminated soil will have to be neutralized with lime and removed, they said.

And the plot thickens. On one hand, this tanker had one of the placards that the Department of Homeland Security is proposing should be removed. On the other hand, it was wrong. Even thought the tanker was carrying a variety of highly dangerous acids, the placard showed only sulfuric acid. And although the shipping manifests were recovered, they were so confusing that it took two days to figure out what was in the tanker.

The spill at the Union Pacific rail yard in South Salt Lake sent an orange cloud of potentially lethal gases over a several-block area. Several roads and highways, including a stretch of Interstate 15, were shut down for almost a day.

Watching a crew member poke a pen through the tanker's solid steel wall, South Salt Lake Fire Chief Steve Foote had no clue exactly what he was dealing with.

"It wasn't until two days after the incident that we had the state lab bring the results," Foote said Wednesday. "There was a lot of misinformation."

At issue is the tanker's Uniform Hazardous Waste Manifest, a federal government form as bureaucratic as it sounds - full of confusing numbers and dry legalese.

It's supposed to provide a complete paper trail of a hazardous shipment, and it should be a source for police, firefighters and any others who need accurate and accessible information to safely respond to toxic spills.

But critics say police and firefighters, who respond to a wide range of emergencies, can't be expected to make sense of the arcane jargon on the form.

"It's a whole plethora of numbers, codes and abbreviations, and that makes it difficult to follow through on what these things mean," Foote said. The manifest for last weekend's tank car was so puzzling that he assigned an entire team to make sense of it.

The Association of American Railroads, which likes to boast of the safety of chemical transport by rail, thinks this is all much ado about almost nothing:

Rail is the safest method of shipping hazardous materials. Railroads have an outstanding track record in safely delivering hazardous materials – 99.9998 percent of hazardous materials carloads arrive at their destination without a release caused by a train accident. Hazmat accident rates have declined 87 percent sine 1980 and 34 percent since 1990.

That railcar in Salt Lake City (as well as January's South Carolina chlorine train accident that killed nine), must have been among the .0002 percent. And this statistic kind of misses the point. We're concerned here about low probability, high impact accidents. 99.9998 percent sounds good, unless that .0002 percent is really bad stuff that get's released in a highly populated area.

All of these accidents, as well as the continuing debate over chemical plant safety, heighten the stakes of the Right-to-Know debate. Is there too much easy information available for our security? Is there too little? Is what's available too hard to understand or is it too easy to understand?

Last month we even saw chemical manufacturers and the government of the chemical-laden state of New Jersey actually keeping the unions that represent the workers in the chemical plants in the dark while developing chemical plant security plan.

Meanwhile, the American Railroad Association, along with the Departments of Homeland Security and Justice, are arguing that Washington D.C.'s recently passed ban on hazardous rail transport through the city will actually “increase exposure to possible terrorist action.” Their reasoning?

The Department of Justice and Department of Homeland Security said the DC law would “result in a dramatic increase in the total miles over which such materials travel and the total time the materials are in transit,” and "increase their exposure to possible terrorist action."

Well, yeah, but if re-routing the material through less densely populated areas -- even if it covers more distance -- means that a terrorist attack would kill far fewer people, wouldn't that actually reduce the threat of terrorism? Or am I missing something?

The issue seems to transcend normal political divisions. In solidly Republican Utah, for example, people are particularly concerned about their right to know:

In Utah, the public's right to know what is being shipped is an issue not only in the wake of the March 6 spill, but in the debate over plans to ship high-level nuclear waste to the Skull Valley Goshute reservation 50 miles west of Salt Lake City.

Chip Ward, co-founder of the Healthy Environment Alliance of Utah, said the potential transport of nuclear waste through the state underscores the importance of accessible information.

The risks, he said, "approach a whole different scale when you talk about transporting nuclear waste."

But there are signs that common sense seems to be breaking out -- at least among the front-line responders:

[South Salt Lake Fire Chief Steve]Foote said the likelihood of an accident is greater than a terrorist attack. Removing the placards is exchanging one risk for another, he said.

"We're starting to have more and more of these [accidents], but as far as I know, none of them has actually been sabotaged," he said.

Since 1973, 47 people have died in the United States as the result of tank cars either failing or derailing, Federal Railroad Administration statistics show. The most recent accident, on Jan. 6, killed nine people in Graniteville, S.C., when a derailed tank car spewed chlorine.

Between 1990 and 2004, there were 504 documented releases from 881 tank cars hauling hazardous materials,prompting the evacuation of a total of 144,497 people.

Warren Flatau, spokesman for the Federal Railroad Administration, did not believe any of the accidents were the result of sabotage.

And if we really need something to fear, let's not forget the recent National Transportation Safety Board (NTSB) report that warned that as many as half of the 60,000 tank cars in service in the United States do not meet current industry standards, making them more susceptible to rupture.

The media is slowly catching on to the threat. Orlando Sentinel columnist Myriam Marquez recently published widely syndicated op-ed strongly defending the public's right to know"

The public’s “right to know” stands as the centerpiece of any democracy. Without informed citizens, there can be no real government accountability. Access to what government is doing is everybody’s business.

Since the terrorist attacks of Sept. 11, 2001, our rights have been dismissed as a threat to national security, and many Americans accept the blackout as necessary to secure liberty. That’s the tough sell democracy faces under today’s climate of fear from terrorism

***

Congress was duped when it gave companies the right to hide from the public information about the chemicals they store or information about other "critical infrastructure." That’s part of the law creating the Homeland Security Department.

If people living in the vicinity of, say, a chemical plant don’t know what’s being stored, how much of it, and what type of safety plans the company has in place, are those folks any safer than if they had that information and knew what they might face from an accident or even an attack on the plant?

It used to be that the Environmental Protection Agency’s Web site contained environmental reports filed by chemical plants so that the public could know what types of potentially poisonous materials were near their homes, businesses or schools. The EPA yanked those from its site post 9/11.

Accidents are more likely than terrorist attacks on such plants. Now people are more vulnerable, not less, because they haven’t a clue what risks they face. Until it’s too late.

The situation is getting so ridiculous that even conservatives are getting upset:

Last year a trade publication called Mine Safety and Health News asked the U.S. Labor Department for biographical information about a new deputy secretary it wanted to profile. The department refused.

The information, it said, would invade his privacy.

Privacy and national security are big reasons for the clampdown on public information from Washington. From Vice President Dick Cheney's energy task force to information about the safety of dams in the Carolinas, many federal records have become off-limits. But critics say secrecy has become part of the culture.

"In the last 30 years, we've never had an environment that's been as hostile to openness as we have now," says Pete Weitzel, coordinator of the Coalition of Journalists for Open Government.

***

In Congress, many Republicans and Democrats are trying to open the doors of government wider.

"Conservatives are realizing that transparency is big government's biggest enemy," Mark Tapscott, director of the conservative Heritage Foundation Media and Public Policy Center, told a Newhouse News reporter last month. "Some conservatives have had a tendency to mistake an emphasis on the importance of transparency with long-haired college professors."

Let's all have a happy Sunshine Week. It may be your last.

Worker Advocates Win Journalism's Polk Awards

Two safety advocates whose articles have been covered in Confined Space have won Polk Awards awards for extraordinary journalism. The 2004 Awards will be presented at a luncheon on April 21, 2005.

Walt Bogdanich of the New York Times won the national reporting category, his fourth Polk award, for his series on how railroad companies were able to sidestep regulations.

Justin Pritchard, the AP's news editor for Southern California, won the labor reporting prize for his investigation into the high rate of work-related deaths among Mexican workers in America.

These are the kind of articles (along with David Barstow's articles on Death in the Workplace and Andrew Schneider's asbestos coverage) that you should be showing to your local reporters when they don't quite know how to handle a workplace accident. These journalists know how to investigate the root causes of these incidents and show how politics affects peoples' chances of staying alive and healthy. But they can also show other journalists the fame and awards that can be won by following up on these stories that are otherwise relegated to a few paragraphs in the back pages.

All of Bogdanich's original articles can be found here.

Confined Space articles that cover Bogdanich's investigations are here:

Blood On (and near) The Tracks

Head of Federal Railroad Administration Resigns Under Pressure

Behavioral Safety Comes To The Railroads

Look Both Ways -- And Then Pray

As If That Wasn't Bad Enough...More on Rail Safety

Links to Pritchard's orginal articles can be found at the Polk Awards webpage (scroll down). Confined Space stories based on Pritchard's articles can be found here:

What is OSHA Doing About Immigrant Worker Safety?

Mexican Workers in the U.S.: Impaled, Shredded in Machinery, Buried Alive


.

As If That Wasn't Bad Enough...More on Rail Safety

New York Times reporter Walt Bogdanich who has been following the safety problems of the rail industry and weakened oversight by the Bush administration is giving us even more to worry about in the wake of the South Carolina rail accident and chlorine leak that has killed eight nine (or more?).

First, more than half of the nation's 60,000 pressurized rail tank cars did not meet industry standards:

Just how ruptured tank cars can endanger a community was underscored three years ago when a Canadian Pacific Railway freight train derailed just outside Minot, N.D. Five tank cars carrying a liquefied type of ammonia gas broke open, releasing toxic fumes that killed one resident and injured more than 300.

The National Transportation Safety Board, in a report on the accident released last year, said the steel shells on the five ruptured tank cars had become brittle, causing a "catastrophic fracture" that released clouds of toxic vapors. Those cars, the safety board found, were built before 1989 using steel that did not - as it does now - undergo a special heat treatment to make it stronger and less brittle. Tank cars built after 1989 use this specially treated steel.

***

The safety board warned that of the 60,000 pressurized tank cars in operation, more than half were older cars that were not built according to current industry standards, leaving them susceptible to rupture. And because these cars may remain in service for up to 50 years, some older ones could still be hauling hazardous materials until 2039.

Among the hazardous materials carried by the tank cars are liquefied ammonia, chlorine, propane and vinyl chloride. In most cases, the cars are owned by chemical or leasing companies, not the railroads.

And if that wasn't reassuring, it seems that more than three years after 9/11, the security of rail cars carrying highly hazardous chemicals is not much better than the security of chemical plants:

Federal authorities have been working with railroads and the chemical industry to improve security for trains. But there is still much to be done, particularly given the structural weaknesses of many tank cars, current and former federal officials say. George Gavalla, a former associate administrator for safety at the Federal Railroad Administration, said railroads had promised to beef up security when there was a credible terrorist threat.

So when such a threat arose a year ago in Las Vegas, Mr. Gavalla said, he sent an inspector there on New Year's Eve to assess the security measures in place. Those measures, he said, were virtually nonexistent.

When the inspector visited a rail yard 13 miles from the airport, he found no one watching over six tank cars with markings indicating that they might contain chlorine gas, according to a memorandum that he wrote about his visit. Two hours later, he visited another rail yard with four tank cars possibly carrying poisonous gas and they, too, were unguarded, the memorandum stated.

Finally, if all that's not bad enough, John Lowe over at Impact Analysis reveals that a request for comments on "the need for enhanced security requirements for the rail transportation of hazardous materials that pose a toxic inhalation hazard (TIH)," presented by the Departments of Transportation and Homeland Security last summer states that the agencies are considering whether to require the removal from rail tank cars used to transport TIH materials of identifying marks, names, stenciling, placards, or other markings that could help a terrorist or criminal identify a target.

Great idea, if you want every emergency responder in America to resign. The key to addressing hazardous materials accidents safely -- to protecting the lives of the emergency responders and the surrounding community -- is swift and accurate identification (preferably from a distance) of the material that has been released. Nothing would undermine the safety of the American people more than hiding the identify of the contents of the fleets of trucks and railcars carrying hazardous materials through our towns and cities every day.

Can the safety of rail cars be improved? Who's going to make sure its done and that it's effective. Is it really possible to have safe transport of highly hazardous substances? The best solution is, of course, right under our noses:

Rick Hind, a toxics specialist at Greenpeace, the environmental group, said that the best answer would be for industrial plants to substitute less toxic substances for chlorine and other hazardous materials.

Safer technologies have emerged in some areas, Mr. Hind said, and switching to them would reduce the sense that the plants and trains are "a target-rich environment."

"The uninterrupted flow of hazardous materials is necessary for the health and safety of the U.S"

Following up on yesterday's post about the ">South Carolina chemical train accident that killed eight, mostly due to exposure to chorine fumes (and particularly the chilling photo at the end), I ran across this article that a friend sent me a few months ago.

The vulnerability of chlorine shipments through the capital has become a hot topic since the Sept. 11, 2001, al-Qaeda attacks on the United States. Activists say the availability of high-powered rifles and other weapons and the accessibility of urban rail lines make shipping highly toxic materials through cities such as Washington a bad idea.

In an oft-cited presentation to the District of Columbia Council, U.S. Naval Research Laboratory scientist Jay Boris said the rupture of a rail tanker carrying a toxic chemical in central Washington could quickly cause mass death.

In a "worst-case scenario" involving a stiff breeze, a large holiday crowd on the National Mall and "the absence of an early warning and concerted action," Boris said, "Over 100,000 people could be seriously harmed or even killed in the first half an hour."

Turns out we don't really have to worry about such an eventuality. Why not? Could it be that the Department of Homeland Security or maybe the Transportation Department decided to reroute hazardous cargo around large cities like Washington D.C., instead of right through the middle?

Of course not. The rail companies oppose it. Instead, the administration is developing a voluntary program with the industry. After all, as Association of American Railroads President Ed Hamberger testified at a hearing last May (presumably with a straight face,) "The uninterrupted flow of hazardous materials is necessary for the health and safety of the U.S., as well as its economic growth." Yeah, I'm sure we'd all agree with that. (Well, maybe not the families and friends of the 8 people killed in Graniteville earlier this week, or the two killed by chlorine last year in Texas after a rail accident released chlorine gas.)

This is all very interesting on a number of levels.

• 
  It took 9/11 to raise to the front pages the hazards involved in transporting highly hazardous chemicals through highly populated areas, even though the hazard has existed for many decades.
  
  
• We've never a chemical-related fatality from terrorism, although we've had a number of fatalities due to just plain chemical "accidents."
  
  
• We've invaded two countries, killed tens of thousands of people, and spent hundreds of billions of dollars to get tough on terrorism; we force little old ladies to remove their shoes at the airport and then feel them up pat them down; we keep terrorism "suspects" in prison indefinitely despite the fact (or because) we don't have enough evidence to charge them with a crime -- but meanwhile, here at home, we relax government oversight of the railroads and rely on voluntary standards to protect ourselves from terrorism and very real accidents that are killing innocent people.

I mean, we wouldn't want to piss off any big contributors or anything.

So, am I missing something here, or are we living in a crazy screwed up world?

With January 20th less than two weeks away, I guess the answer is obvious.

Just Be Careful Not To Breathe

This is pretty damn scary:

Graniteville, S.C. — A freight train carrying chlorine gas struck a parked train early Thursday, killing eight people and injuring at least 200 others, nearly all of them sickened by a toxic cloud that persisted over a small South Carolina textile town at nightfall.

Authorities ordered all 5,400 people within two kilometres of the crash to evacuate in the afternoon because chlorine was continuing to leak and the gas was settling near the ground as temperatures dropped. They were unsure when the gas leak might be sealed.

State Senator Tommy Moore said Thursday night officials at Avondale Mill, the textile plant where the crash happened, told him eight people were found dead following the accident, including five inside the mill.

Eight people were in critical condition Thursday night after the wreck of Norfolk Southern trains, in which 16 cars derailed.

Mr. Moore said he was told all the deaths were caused by inhaling chlorine fumes, except for the engineer of the moving train, who died in the crash. Sheriff's Lieut. Michael Frank said one person was found dead in a home and another was found in a vehicle.

This is depressingly reminiscent of a train derailment involving chlorine last summer that killed two people in their home over a mile away.

Unfortunately, this seems to be the kind of thing that we can expect more frequently as federal oversight over the railroads is weakened and the foxes take more control over our national chicken coops.

Is this what people voted for on November 2?



Anyway, I'm sure glad it can't happen in my neighborhood:

Thanks to a reader for the heads up on this.



UPDATE: They've been having a bad time with trains in Graniteville lately and especially at Avondale Mills. This is from November 11:

GRANITEVILLE, S.C.

Five textile mill workers were killed Wednesday morning when their car collided with a Norfolk Southern research train about 12 miles from the Georgia-South Carolina state line.

The train, which consisted of a locomotive and two cars, was traveling 45 mph in a 49 mph zone and collided with the four-door Buick at Ascauga Lake Road Crossing in Graniteville around 8:15 a.m.....The five victims had just finished an 8 p.m. to 8 a.m. shift at an Avondale Mills Inc. plant nearby.

***

Working the late-night shift can be tiring, said Lucy Padgett, a lab technician and 15-year employee who now works an earlier shift. Padgett said she would be extremely tired going home after the 12-hour shift when she hadn't gotten much sleep the night before.

"I have drifted off" at the wheel, she said

***

Some residents complained about the lack of crossing arms at the crash site, which is at the intersection of two state roads. The site's flashing lights were working, officials said.

"If you ask me, the state ought to put those bars there," said Christopher Davis, a former mill worker who lives a few miles from the accident site.

***

"Anytime you got a railroad crossing and you got all these mills here ... changing shifts at the same time, and you got all these people rushing to get to work and you got a bad railroad crossing, you got a recipe for disaster, and you're going to get one," Tom Ryan, [a mill retiree] said.

Look Both Ways -- And Then Pray

Walt Bogdanich at the New York Times continues his series on railroad hazards today with a story on malfunctioning signals at rail crossings.

A Times computer analysis of government records found that from 1999 through 2003, there were at least 400 grade-crossing accidents in which signals either did not activate or were alleged to have malfunctioned. At least 45 people were killed and 130 injured in those accidents, according to the records, although in most cases the role of signal malfunctions was unclear. Federal rules require that railroads maintain signals on tracks they own.

The problem is that either the railroads nor the Federal Railroad Administration which regulates the railroads have an effective or accurate method of reporting, tracking or confirming malfunctions in crossing mechanisms. Malfunctions reported by citizens are often not confirmed, even after accidents occur. And the railroads would rather blame accidents on driver error, than on their own malfunctioning equipment.

"My concern is that this is just the tip of the iceberg," said James E. Hall, a
former chairman of the National Transportation Safety Board. "If we had that
type of record in aviation, it would be unacceptable."

Bogdonovitch's previous stories have talked about the failure of the Bush administration's Federal Railroad Commission to effectively enforce rail safety and the rail company's efforts to blame crossing accidents on driver error, rather than equipment problems. Other stories about the NY Times series here, here and here.