Eighteen days later, the Deepwater Horizon drilling rig blew up in the Gulf of Mexico, killing 11 workers and unleashing a massive oil spill.
In both cases, the U.S. Chemical Safety Board — an independent agency modeled after the National Transportation Safety Board — launched investigations. Like the NTSB, the Chemical Safety Board is supposed to follow such probes with recommendations aimed at preventing similar tragedies.
Yet three years after Tesoro and Deepwater Horizon, both inquiries remain open — exemplars of a chemical board under attack for what critics call its sluggish investigative pace and short attention span. A former board member calls the agency “grossly mismanaged.”
The number of board accident reports, case studies and safety bulletins has fallen precipitously since 2006, an analysis by the Center for Public Integrity found. Thirteen board investigations — one more than five years old — are incomplete.
As members of Congress raise questions, the Environmental Protection Agency’s inspector general is auditing the board’s investigative process.
“It is unacceptable that after three long years, the CSB has failed to complete its investigation of the tragic Tesoro refinery accident,” Sen. Patty Murray, D-Wash., said in a written statement to the Center. “The families of the seven victims and the Anacortes community deserve better, and the CSB must be held accountable for this ridiculous delay.”
At Tesoro, a tube-like device called a heat exchanger came apart, triggering an inferno that melted aluminum 100 feet away. Shauna Gumbel, whose son, Matt, died 22 days after being burned in the blast, said the victims’ families were told to expect news from the CSB on the tragedy’s second anniversary. The date came and went. “Then we were told, ‘Six more months,’ ” she said.
In a recent conference call with the families, board officials pledged to finish the Tesoro report by the end of 2013 – more than 3 ½ years after the accident, Gumbel said.
“I think they’re making excuses,” she said. “Why aren’t they assigning more people so they can get the investigation done in a timely manner and the families can move forward?”
Chairman Rafael Moure-Eraso and managing director Daniel Horowitz say the board, which has a $10.55 million annual budget, is stretched thin and must decide which of the 200 or so “high-consequence” accidents that take place in the United States each year merit its attention.
“We’ve made innumerable proposals over the years … pointing out the significant discrepancy between the number of serious accidents and the ones that we can handle from a practical standpoint,” Horowitz said in an interview with the Center. “We’ve asked for a Houston office. We’ve asked for additional investigators for many years.”
Congress, he said, has been unwilling to come up with more money.
Moure-Eraso, chairman since June 2010, said the Tesoro investigation was sidetracked by an explosion at the Chevron refinery in Richmond, Calif., last August that created a towering black cloud and prompted about 15,000 people in surrounding neighborhoods to seek medical evaluation. No one was killed but 19 workers were exposed to noxious hydrocarbon vapors.
“We have to make decisions,” Moure-Eraso said. “Here we were, running along, working on Tesoro, and then this accident happened at Chevron. We decided that it was important to deploy [to Richmond] because the issues that were raised were issues that affect the whole refinery industry.”
Current and former board members and staffers, however, contend the agency’s investigations are poorly managed – an allegation the EPA’s inspector general is exploring.
“They were jumping from one investigation to another, and when a new accident occurred they would pull people off an existing investigation to go investigate that one,” said former CSB board member William Wark, whose five-year term ended in September 2011. Wark, who accompanied investigators dispatched to the Tesoro accident, said it’s “embarrassing” that the investigation has not been finished.
“The basic, bottom line is the agency is grossly mismanaged,” he said.
The board has 20 investigators — four more than it had in 2008. Adjusted for inflation, its budget has been essentially flat over the past five years. Yet earlier investigations were often completed more quickly.
The deadliest accident the board has investigated was the March 2005 explosion at the BP refinery in Texas City, Texas. Fifteen workers were killed and 180 injured. The board’s final report was issued just under two years after the accident.
A February 2008 blast at the Imperial Sugar plant near Savannah, Ga., killed 14 and injured 36. The final report was issued in 19 months.
Gerald Poje, a Bill Clinton appointee who served on the board from 1998 to 2004, finds it “painful” that more recent investigations have stagnated. He worries that an “erosion of the reputation of the institution” could cause Congress to question its value.
“I always considered the board to be in a race against time,” Poje said. “When an event occurs, people want to know instantaneously why it happened, how it happened and what can be done to prevent it from happening again. Unfortunately, over time, people begin to forget and feel less obligated to pay attention to recommendations.”
The Chemical Safety Board had a rocky start.
Created by Congress in amendments to the Clean Air Act in 1990, the board wasn’t up and running until 1998. It was a relative weakling among government agencies, starved of funding and mistrusted by industry.
“Upon reflection as a former board member, it appears that neither administration nor Congressional support for the CSB has ever been very strong,” Andrea Kidd Taylor, now a lecturer at Morgan State University in Baltimore, wrote in the journal New Solutions in 2006. “[F]unding for this small agency has been limited … So the agency’s growth and the number of investigations it can conduct and complete in a year are minimal.”
Still, Taylor wrote, “Given the CSB’s current budget [then about $9 million], the average number of four root-cause investigations completed per year is exceptional.”
Authorized for five members, the board currently has three, with a fourth awaiting confirmation. Its staff numbers 39. The NTSB, by comparison, had more than 400 people and a budget of $102 million in fiscal year 2012.
The chemical board appeared to hit its stride under Carolyn Merritt, a George W. Bush appointee who served as chair from 2002 to 2007 and died of cancer in 2008.
In 2006 the board released nine products — three full reports, three case studies and three safety bulletins. In 2007 it put out eight, including a widely praised, 341-page report on the BP-Texas City explosion.
Production has trended down ever since. Last year, the board released two case studies. So far this year, it has issued one full report and one case study. On Monday, it released an interim report on the August 2012 Chevron accident.
“It depends, ultimately, what Congress expects the agency to do,” the board’s Horowitz said. “If they expect us to look at all 200 of these high-consequence accidents, then that’s a larger problem. With the resources that we have – which, like every other agency, are finite – we do tremendous good.
“Would we like to do more? Would we like to do it faster? Sure.”
Horowitz and Moure-Eraso say they are eager to complete the Tesoro investigation, which has consumed about 7,100 hours of staff time and $700,000 over the past three years. But, they say, Deepwater Horizon, an inquiry requested by two members of Congress that has cost nearly $4 million to date, required a diversion of staff.
“We’ve spent $4 million that we really didn’t have, and we’ve committed, at times, over half our investigative staff,” Horowitz said. Investigators, he said, have prepared a 400-page draft report that’s “the most comprehensive we’ve ever done.”
The Tesoro inquiry progressed in fits and starts. Within a few months of the accident in April 2010, investigators had drafted urgent recommendations for the company as well as a refining industry trade group and the Occupational Safety and Health Administration. Those recommendations were never issued.
“The board at that time didn’t feel that they went far enough,” Horowitz said. “They were company-specific. We didn’t feel they went to the real heart of the problems, which are broader than Tesoro and reflect aging infrastructure in refineries [and] use of antiquated materials and systems.”
A year earlier, however, the board had issued urgent recommendations stemming from a release of potentially lethal hydrofluoric acid from the Citgo refinery in Corpus Christi, Texas. They were no broader than the draft Tesoro recommendations.
“Well, look, it was a different board, and they make their decisions on what recommendations they want to ultimately issue,” Horowitz said.
The board’s investigation of the Citgo accident, which occurred in July 2009, is unfinished. “That’s a case we hope to get back to,” Horowitz said.
Soon after the draft Tesoro recommendations were shelved, several experienced investigators — including Rob Hall, who was leading the Tesoro team — left the board. In the fall of 2011, an almost entirely new team essentially had to start over.
Team members have since been pulled into the Deepwater Horizon and Chevron investigations, among others. The current leader, Dan Tillema, spent months examining the failed blowout preventer implicated in the Gulf oil spill, a process that has cost about $1 million.
When the Tesoro report finally comes out, Horowitz said, it will reflect an exhaustive inquiry.
“We engaged top metallurgists from the National Institute of Standards and Technology and we are undertaking complex modeling to understand process conditions inside the heat exchanger,” he said. “The investigative team has been continuing to obtain documents and interviews from Tesoro.”
The United Steelworkers union, which represents workers in refineries, chemical plants and other hazardous settings, has been among the board’s more vocal critics.
At a public meeting in January, on an explosion that killed five at a Hawaii fireworks storage facility, Steelworkers official Mike Wright observed that “our workplaces have been the subject of more CSB investigations than any other union or corporation. We are your biggest stakeholder and, perhaps, your biggest fan.”
Investigative delays “severely compromise the board’s mission,” said Wright, the union's director of health, safety and environment.
“Perhaps even worse is the human cost of the delays,” he said. “Families and co-workers feel abandoned by the board, and even abandoned by their government.”
The union didn’t blame the board’s investigators, Wright said. “This is a management problem.”
The EPA’s inspector general is looking into this very subject. In May 2012, the IG notified Moure-Eraso that it planned an audit “to determine whether CSB’s investigative process can be more efficient to enable more investigative work.”
Three months later the IG released the results of another audit, finding that the board did not press regulators, such as OSHA, and industry hard enough to make sure its recommendations were adopted. As of December 2010, the IG said, more than a third of the 588 recommendations issued by the board were still open; almost a quarter of these had been open more than five years. The board says 29 percent of its recommendations are open today.
“We are kind of full-time employment device for the IG,” Moure-Eraso said. “I don’t think that they are competent to basically understand how we work or understand how we conduct investigations.”
The board was dealt a substantial blow in 2011, when four investigators quit. Two of them, Hall and John Vorderbrueggen, had been team leaders; both, now with the NTSB, declined comment.
Asked if he thought the departures reflected dissatisfaction, Moure-Eraso said: “Investigator is a very tough job. You are asking somebody to deploy for weeks at a time wherever the accident happened, to be away from their families, to deal with very unsavory situations. You have to deal with people getting killed, places destroyed. … It’s not for weak hearts.”
Where to deploy?
The board’s choice of investigative targets has been a point of contention.
Why, the Steelworkers ask, did the board follow up on an ink plant explosion in East Rutherford, N.J., that injured seven workers last October but not a hydrofluoric acid release that killed a union member in December at the Valero Energy Corp. refinery in Memphis?
Hydrofluoric acid, a toxic gas that can rapidly travel long distances in a ground-hugging cloud, is used at about 50 U.S. refineries. “We have been harping on how dangerous it is for quite some time,” said Kim Nibarger, a health and safety specialist with the Steelworkers.
The union thought the Valero accident afforded a “golden opportunity” for the board to reinforce the need for “inherently safer technologies,” Nibarger said. “They said they were too busy.”
Horowitz said the board was asked to go to New Jersey by one of the state’s senators, Frank Lautenberg. No one in the Tennessee congressional delegation urged the board to look into Valero.
“We screen [accidents] very carefully,” Horowitz said. “We look at the specific consequences — the number of deaths and injuries and things like that, the number of community evacuations. We look at qualitative factors, one of which is requests from Congress and from our authorizing committees to investigate these issues.”
Poje recalls fielding congressional requests when he was on the board. “Sometimes,” he said, “you have to answer back, ‘Thank you so much for your interest. We wish we were resourced to meet this priority for your community but we aren’t.’ ”
Debate continues over whether the board should have investigated the April 2010 Deepwater Horizon accident, already addressed in at least a half-dozen other federal inquiries, including one by a presidential commission.
Former board members Wark and William Wright, both appointed by George W. Bush, said they argued against it. “It was offshore. It was something that we had absolutely no business being in,” Wark said. “They insisted on doing it anyway. They spent a lot of the agency’s budget on that.”
“I don’t think there’s anything they’re going to say that’s going to improve offshore drilling right now,” said Wright, whose term expired the same day as Wark’s in 2011. “Yet we have managed to invest $4 million in as many years and I am at a loss as to what value will be added by continuing to look at this incident now, particularly when the Interior Department has changed a number of regulations already.”
Horowitz pointed out that the board, then chaired by John Bresland, was asked to investigate the disaster in early June 2010 by Reps. Henry Waxman, D-Calif., and Bart Stupak, D-Mich. Bresland agreed. Moure-Eraso assumed the chairmanship days later, having been handed a record-high caseload. Bresland declined to be interviewed.
“We told Congress at that time that we needed additional resources to conduct that work,” Horowitz said, referring to $5.6 million in supplemental funding sought by Moure-Eraso. “Well, those resources were never provided.”
The investigation was slowed by rig owner Transocean’s refusal to comply with board subpoenas for records, lead investigator Cheryl MacKenzie said in a statement to the Center. “It took nearly two years of steady effort to get the issue before a federal court, and only this month did a decision finally come down in the CSB’s favor,” MacKenzie said.
Nonetheless, Horowitz said, the investigation, which should be completed this summer, was worth doing.
“We’re the agency that’s going to look in detail and depth at industry standards,” he said. “The presidential oil spill commission took the 30,000-foot view, wrote a good report, but looked in broad strokes. The regulators looked at technical issues. We are looking at the effectiveness of those standards, and we’ll have a lot of recommendations for improvement that we think will make a safer industry.”
William Wright said the board should have focused instead on finishing long-overdue reports, like Tesoro, and delving into more recent accidents, like Valero.
“That’s kind of why we were put in business in the first place,” he said. “The public’s not being well served by an agency that was created to improve chemical safety if it fails to put out timely reports on significant chemical incidents."