Issue Date: April 7, 2008
New Chief At CSB
"WE ARE NOT the big Environmental Protection Agency, the big Occupational Safety & Health Administration, or the Department of Energy; we are a small agency," says John S. Bresland, the new chairman of the Chemical Safety & Hazard Investigation Board (CSB). Despite its small size—a staff of a little more than 40 and an annual budget of $10 million—CSB is an agency with deadly serious responsibilities. Its charge is to identify significant U.S. chemical accidents and search out their root causes.
Last year, CSB screened some 900 chemically related U.S. accidents and chose a handful of the most important to investigate. In its 10-year history, the five-member board has completed 43 investigations and has nine that are works-in-progress. The board looks for problems and trends in a wide range of industries that handle many different chemicals. The board's staff is on the lookout for those details of operation and behavior that can lead to the signatures of accidents: deaths, injuries, and damage.
Newly at the helm of this agency is Bresland. Weeks after taking the reins on March 14, he has laid out his plans for CSB. He says he would like to have more investigators available to look into more accidents. He also would like to make clear that fire departments, unhappy company officials, or lawyers cannot interfere with CSB investigators. And he would like state and federal officials and company executives to readily comply with recommendations from this independent board.
During an interview last month with C&EN in CSB's suite of offices in downtown Washington, D.C., Bresland described all of these plans in a soft Irish lilt that belies his job running an organization whose sole purpose is to investigate the cause of fires and explosions that destroy businesses and bring about mayhem and death. A chemical industry veteran, Bresland is well suited for his new position (C&EN, March 31, page 6).
CSB has no regulatory authority; its power is its independence as well as its skill in discovering what causes accidents. It was established after complaints over the quality and quantity of accident investigations led by the Occupational Safety & Health Administration and EPA, which are regulatory bodies that govern operational areas of chemical plants that can contribute to accidents. Indeed, CSB has on several occasions recommended that EPA and OSHA toughen their regulations as a result of CSB's accident investigations.
The board was created through provisions of the Clean Air Act of 1990, but no funds were provided until 1997, when then-president Bill Clinton urged Congress to kick in a few million dollars to set up the board. Internal difficulties almost killed CSB in its first years, but for the past half-dozen years, CSB has been on an even keel, enjoying support from many members of Congress, state and federal agencies, health and safety officials, labor unions, and even most chemical companies.
MUCH OF THE CREDIT for the turnaround goes to former board chair Carolyn W. Merritt, whose term ended last summer. Merritt and Bresland were first appointed to the board in 2002. Both worked to improve the board's operations over those years, and both complained about the limited resources and the small number of accidents that CSB can afford to investigate within a budget that has remained pretty much flat (C&EN, Aug. 13, 2007, page 38).
Bresland would like to see the board increase its budget by $1 million and its annual investigations from a high of eight to an average of around a dozen. Not all of these, he stresses, would yield the big 200-plus-page reports the board sometimes produces; some would be smaller, more focused examinations. Its biggest report ran 341 pages and was of the 2005 BP Texas City, Texas, refinery explosion that killed 15 workers and affected one of the world's largest oil companies. The investigation drained much of the board's resources, but its investigation and recommendations gained the board credibility and thrust it into an international spotlight.
But conducting more investigations will be difficult, Bresland notes, because of tight competition for federal funds and the scarcity of staff qualified to do the work.
"The staff conducting the investigations and the fieldwork is the same people who are writing the reports on last year's investigations," he points out. "So we have to balance going out and doing more investigations versus finishing up the investigations we've started. The investigations and reports are ongoing issues, especially when you consider we have fewer than 20 investigators out of a staff of around 40 to 45."
Bresland points out that these numbers compare poorly to the 400 that staff the National Transportation Safety Board, which investigates transportation accidents and upon which CSB is modeled.
"The chemical industry is a complex business that requires a lot of expertise, and the people running it are Ph.D.s. It takes chemical engineers, chemists, and mechanical engineers," he explains. "We need the same kinds of people to do the investigations. We have a very good staff here, and we'd like to get more people on board, but it has been difficult to attract highly qualified people to move to Washington, which is a very expensive place to live."
Consequently, CSB is exploring telecommuting and has suggested establishing field offices for investigators outside of the Washington metropolitan area.
IN ADDITION to finding qualified investigators, Bresland also notes the importance of selecting which accidents to investigate.
"Internally, we produce a report each morning about accidents that have taken place around the country," he says. "We have a process to look at these accidents and decide which ones we should actually go out and investigate."
There is no single database of chemically related U.S. accidents, Bresland notes. Indeed, one of the board's initial charges was to put together regulations to require companies to report all chemical accidents. "We have never taken that on," he adds. "Our 40 people would need to grow to three times that amount to do it. In the end, it would be nice to have that information but I don't think it would add much to the totality of chemical safety."
In the absence of a national database, the board uses a combination of press accounts, a mix of government data, and its own knowledge to accumulate and assess accidents. If it decides to do an investigation, CSB immediately dispatches a team that includes one member of its five-member board.
"The board member is the public face of the agency," Bresland explains. "He or she meets with the mayor, the police and fire chief, and coordinates the board's work with other emergency responders."
These days, he says, there are a "multitude of agencies" at an accident site. Nearly all accidents are first treated as a crime scene because of terrorism concerns, he says. That practice brings in the Federal Bureau of Investigation; the Bureau of Alcohol, Tobacco & Firearms; and local police.
In the immediate chaos of an accident, difficulties have emerged occasionally in which CSB has been unable to control the accident scene sufficiently to collect evidence and conduct an investigation. For example, when CAI/Arnell, a small printing-ink manufacturer in Danvers, Mass., exploded in 2006, state and local fire officials, who were conducting their own investigation, blocked CSB from the site for seven days. When they finally got on-site, CSB investigators found the site disturbed and potential evidence removed. The board continued its investigation, however.
Bresland says CSB has been talking to members of Congress and is seeking legislation to ensure it has timely access to an accident site—after emergency responders clear the site and have it safe for entry.
In a report to Congress, CSB laid out several other tense moments with state, local, and federal officials during investigations. The conflicts cited in the report often involve state fire marshals, but in some instances, company officials have hindered CSB investigations. During some 18 investigations, CSB staff were restricted in gathering evidence or the potential evidence had been removed by responders or the company.
Even during the board's biggest investigation—BP's Texas City refinery—the company challenged CSB's authority to look beyond the accident's impact at the plant level. BP disputed whether CSB had the authority to make recommendations addressed to the safety culture of BP's global management and its lack of corporate attention to safety.
ANALYSIS OF these larger issues has resulted in many of CSB's most influential recommendations. They have come about through the board putting together disparate pieces of accident evidence or from the board recognizing the relationship among similar accidents.
"Often accidents look alike. But what we find is what looks like a fairly straight-forward incident, turns out to be much more complex," Bresland says. "A broader picture begins to emerge that is more interesting. And we wonder how this accident was allowed to happen in the first place."
That review has occasionally pushed the board to issue general reports on related conditions that led to accidents. Two of the more far-reaching special investigations resulted in detailed reports on accidents caused by reactive chemicals and combustible dust.
In both cases, CSB has recommended that OSHA, as a regulatory agency, develop better and more comprehensive industry regulations to address reactive chemicals and combustible dust (C&EN, June 30, 2003, page 20; C&EN, Nov. 13, 2006 page 30). But in both cases, OSHA has refused and instead offered voluntary and less restrictive regulatory protocols. The debate is likely to persist, however, as reactive chemical and dust accidents continue to occur.
The board has done better in getting the safety message out to safety professionals, particularly through multimedia presentations on the Internet and videos that are based on CSB investigations, reports, and recommendations. Ten videos have been produced, and they have been well received. One—based on BP's Texas City refinery explosion—has been downloaded a half-million times; a longer DVD version generated 1,000 requests in the first three days after being released in mid-March.
CSB videos use a combination of interviews and three-dimensional animations to condense the message of a 100-page report into a few minutes. Many companies and communities are using the videos, according to engineers, electricians, plant managers, and fire captains who have requested CSB material.
"One of the most important things we do is put this material out in the open," Bresland says. He notes that companies usually conduct their own accident investigations, and although many are good, those investigations stay inside the company and aren't always used to improve the industry's safety behavior.
LOOKING TO THE FUTURE, Bresland expects the CSB investigation of the recent dust-triggered fire and explosion at Imperial Sugar in Georgia, which killed 13 workers, will result in industrywide safety recommendations. He notes that OSHA inspectors recently visited an Imperial Sugar plant in Louisiana, a sister to the Georgia facility, and found combustible dust problems so great that OSHA shut down the plant.
He also expects CSB to begin considering the influence of sleep deprivation on accidents. For instance, he notes that contract workers at the BP accident had been working 12 hours every day in the month that led up to the accident.
The board is also likely to continue to closely watch BP's response to CSB recommendations and those of another independent panel that studied BP's corporate structure. Particularly important, he says, is BP's compliance with the recommendation that the company put a person who is familiar with safety and process safety management on the company's board, Bresland says, "There has been pushback by BP on this recommendation."
For the long-term future, Bresland stresses that CSB must maintain the quality of its reports and especially its recommendations, which he calls the "lifeline" of the board's activities. "We have to be careful. When we do an investigation, our reputation is on the line and the company's financial responsibility is on the line. We have to continue to make sure we do it properly."
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