No Accident! How Industry and Government Agencies Are Failing to Prevent Chemical Spills Profits? or Safety? Major Accidents and Serious Incidents: 1999-2000 Communities for a Better Environment-California and Contra Costa Building and Construction Trades Council "The first steps toward accident prevention are identifying the hazards and assessing the risks. Once information about chemical hazards in the community is openly shared, industry, government, and the community can work together toward reducing the risk to public health and safety." "The County recognizes that regulatory requirements alone will not guarantee public health and safety, and that the public is a key stake holder in chemical accident prevention, preparedness, and response at the local level. Preventing accidental releases of regulated substances is the shared responsibility of industry, government, and the public. The first steps toward accident prevention are identifying the hazards and assessing the risks. Once information about chemical hazards in the community is openly shared, industry, government, and the community can work together toward reducing the risk to public health and safety." "The success of a Safety Program is dependent upon the cooperation of industrial chemical and oil refining facilities within Contra Costa County. The public must be assured that measures necessary to prevent incidents are being implemented, including changes or actions required by the Department or the Stationary Source that are necessary to comply with this chapter." i EXECUTIVE SUMMARY No Accident! presents the results of an analysis of County records of industrial hazardous materials incidents and accidents. In 1999 and 2000, fires, explosions and toxic releases continued to kill and injure workers and sicken hundreds of nearby residents. Major accidents continued at the rate of almost one per month despite various new agency efforts to prevent chemical spills. Analysis of the most recent data on file reveals an alarming failure of industry and government to come to terms with the problems of industrial accidents. Data maintained by the Contra Costa County Hazardous Materials Division reveals that: The County experienced 13 major accidents 2 in 1999 and 12 major accidents in 2000. Four workers lost their lives during the period, making it the deadliest 2year period in County refinery history. Refineries are responsible for the vast majority of major accidents and serious incidents. 1Industrial Safety Ordinance, Ordinance No. 98-48, adopted by the Contra Costa Board of Supervisors, 1998. 2This study reviewed official incident report records on file at the Contra Costa County Hazardous Materials Division. See the discussion of methodology below. • A large percentage of accidents were actually worse than the facility first reported, which may have prevented appropriate response and investigation. Some facilities, especially Chevron's Richmond refinery, failed to notify the County of some accidents until confronted by offsite complaints. • County staff failed to verify self-reported facility claims by conducting on-scene investigations 95 percent of the time in connection with serious incidents and 80 percent of the time in connection with major accidents. Many accidents recur at the same "repeat offender" processes that are never made fully reliable. No Accident! concludes with a number of recommendations for action to address the need for industrial safety, including proposals designed to: Fulfill the promise of easy access to information regarding industrial hazards. Focus inquiry on industrial processes most likely to cause accidents. Ensure the effective participation in problem solving by the communities most at risk. It is no accident that Communities for a Better Environment and the Contra Costa Building and Construction Trades Council present this report at the time that the County Board of Supervisors are considering the effectiveness of the Industrial Safety Ordinance and the need to increase participation by affected communities. Although the County has made some progress in taking regulatory initiatives to control industrial hazards, much remains to be done. The first step is to understand the scope of the continuing problem. METHODOLOGY Communities for a Better Environment (CBE) and the Contra Costa Building and Construction Trades Council (CCBCTC) have tracked fires, explosions and toxic releases at Contra Costa County refineries since 1989. Increasing media coverage has also generated information about major chemical spills in the area. More recently the Hazardous Materials division of Contra Costa Health Services has begun to compile its own data. This report is based on that data. Definitions CBE and CCBCTC have used a consistent methodology to analyze data on accidents in producing reports over the years. 3 Although Contra Costa County ordinances have repeatedly changed the definitions of "major accident" and "serious incident," CBE and CCBCTC have consistently analyzed data using the following definitions: Serious Incident-an unplanned event at a facility that uses, stores or manufactures hazardous materials or waste that causes or has the potential to cause a significant impact on or offsite. If a serious incident causes an injury, death or offsite impact, it becomes a "major accident." Major Accident-an incident in which the release of toxic gases, fire or explosion causes a serious impact to workers, the community, or the environment. These impacts include death, injury, illness, shelter-in-place orders (confinement), evacuations, and activation of the Community Warning System. By contrast, the current Industrial Safety Ordinance defines "major accident" more restrictively to include only those incidents that result in the release of a Regulated Substance and meet one or more of the following criteria: (1) result in one or more fatalities; (2) result in greater than 24 hours of hospital treatment of three or more persons; (3) cause property damage (on and/or offsite) initially estimated by the Stationary Source at $500,000 or more; (4) meet the definition of a Level 3 or Level 2 Incident in the Community Warning System incident level classification system defined in the September 27, 1997 County guideline for the Community Warning System; or (5) result in flammable vapor clouds of more than 5,000 pounds. The current ISO has also eliminated entirely the definition of “serious incident." Data Compilation CBE reviewed summary lists issued monthly by the County to identify possible serious incidents and major accidents. For events that appeared to meet the definition of serious incident, ČBE reviewed the initial intake form on file at the County as well as subsequent documentation for that event. Incidents meeting the serious incident criteria were entered into a data base containing the facility identification, 3See Neighborhoods at Risk, A Report on Industrial Accidents in Contra Costa County: 19891996 (July 29, 1996) and Rising Risks to Refinery Communities, the Troubling Trend of Toxic Spills in Contra Costa County California 1989-1997 (July 8, 1997). the date, and a summary description of the incident. For each incident, other data elements were extracted from available documentation, including whether action was taken by the County, whether an on-scene investigation was conducted, whether the incident was more severe than initially estimated, whether workers were injured, whether a fire or explosion occurred, whether flaring or a pressure relief valve was triggered, whether a vapor cloud or smoke was released, whether a written report was prepared, and whether a root cause investigation pursuant to the ISO was undertaken. In some cases, lengthy notes were condensed to a brief description. In other cases, only brief descriptions of the incident were available, lacking some essential information. 4 Finally, CBE reviewed all serious incidents to determine whether they met the criteria for a major accident. Potential For Error Given the lack of independent monitoring data, the reliance on the County's current incident reporting program creates the potential for error in analyses such as this. In cases where data supplied to the County was flawed or incomplete, the classification of incidents as major accidents may also introduce a potential for error. Other potential sources of error include hand written incident forms by County staff which are illegible in some cases, the large number of incidents, missing forms in County files at the time of review, missing or incomplete information, lack of standard terms, and self-reporting by involved parties. CONCLUSIONS The Rate of Major Accidents Remains Unacceptably High There were 25 major accidents in Contra Costa County industrial facilities in 1999 through 2000. This is more than one major accident every month. In comparison, the previous analysis reported one major accident every 5 weeks during the period January 1996 to June 1997.5 Clearly, major accidents continue at the same unacceptably high rate. Note that the data for the 1999/2000 period confirms the conclusion in the previous analysis that the rate of reported major accidents has risen since 1989. In the period from 1989 to June 1997, the reported major accident rate was one every 2 months. However, in the last 18 months of this period, from January 1996 to June 1997, the reported major accident rate was one every 5 weeks, leading CBE/ CCBCTC to suspect an increase in the statistic. The data for the last 2 years showing more than one major accident reported every month confirms this conclusion. 4See the discussion below of the problems of self-reporting and the County's failure to investigate incidents. 5See Rising Risks to Refinery Communities, the Troubling Trend of Toxic Spills in Contra Costa County California 1989-1997 (July 8, 1997) p. 1. Concern should be heightened by the fact that the County has adopted and implemented new programs to reduce these incidents. While some progress has been made in implementing new safety procedures and equipment, the fact that significant numbers of incidents continue to occur indicates that not enough has been done. Some observers attribute the increase in major accidents to better reporting by industry. There is no doubt that since 1989 industry has improved its reporting in response to requirements developed by the County. The question remains whether the rate is tolerable to communities and workers. Refineries Are Responsible for the Vast Majority of Major Accidents and Serious Incidents : With 23 out of 25 major accidents, refineries were the leading source of major accidents in 1999 and 2000. This most recent data is consistent with past studies, which also indicate that refineries are the leading source of major accidents. With 7 major accidents at both the Rodeo and Avon Facilities, Tosco had the poorest record in the County. Chevron had 6 major accidents in the 2-year period. The Shell refinery in Martinez had 2 major accidents. Chevron is not covered by one of the new County programs designed to reduce industrial accidents, the Industrial Safety Ordinance, because it is located in the city of Richmond rather than in County jurisdiction. Richmond has failed to adopt a parallel Industrial Safety Ordinance, despite the passage of a City Council action and the participation of Richmond City staff in a parallel environmental review process with the. County. Because of this lack of action, Chevron enjoys less safety oversight than any facility in the County. It appears that workers and local residents may have paid a price for this lack of oversight. In addition to major accidents, serious incidents at Contra Costa industrial facilities continue to plague the region. Review of County Hazardous Materials Division files shows that most of these incidents occur at oil refineries. Chevron, Tosco Rodeo, the Avon refinery (Tosco/Ultramar), and Shell were responsible for 202 of the total 216 serious incidents in 1999 and 2000. The fact that refineries in the County are responsible for 94 percent of serious incidents is consistent with past analyses. It may well be that refining industry pressures to exceed past performance and to increase competitive advantages have overwhelmed remedial efforts. Many facilities may have engaged in cost cutting measures, increased production and delayed maintenance, which in turn may have out-paced any new safety improvements. During this period, refineries have been bought, sold, and affected by mergers. These industry efforts together with other market forces have led most oil companies to post extremely high profits in 1999 and 2000. Major Accidents Continue to Kill and Injure Workers Worker deaths and injuries on the job continue to occur at alarming rates at Contra Costa County refineries. In 1999 and 2000, at least 16 injuries and 4 deaths were reported to the Contra Costa County Hazardous Materials Division. In fact more injuries may have occurred because workplace injuries are not always reported to the County. Worker injuries are usually reported to CAL OS HA, which is responsible for worker health and safety issues. 1999/2000 Contra Costa County Refinery Worker Deaths and 16 Worker Injuries Worker Deaths When four workers were killed and one seriously injured while working on an operating unit at Tosco Avon, the accident became the County's worst. In response, the public pressured County Supervisors to request closure of the facility so an independent safety review could be conducted. Tosco reluctantly accepted the recommendation of a committee of various stakeholders that it submit to a broad review of the facility's safety culture. The review by A.D. Little revealed serious flaws in Tosco management's approach to safety at the facility. Other plants have not been subject to this kind of review. Facilities Underestimate Incident Severity The survey of reports made to the County of serious incidents at industrial facilities indicates that in at least 29 percent of serious incidents the facility acknowledged that it had initially underestimated the problem. Because many of the County incident forms did not contain this information, it was unknown in over two-thirds of the cases whether industry had accurately reported incident information. Thus the underreporting problem may be even more serious. Percent of 1999/2000 Serious Incidents Proving Worse than Orginally Reported Worse than Initially Reported 29% Unknown In several cases in 1999 and 2000, Chevron did not report serious incidents until neighbors or the Sheriff alerted the County of a problem. On one incident report, a frustrated county staff member wrote that Chevron was not following the notification process in a proper and legal manner. In many cases, a refinery reported a process upset that was expected to have no offsite impact. However, the facility was forced to report later that it had underestimated the problem. In some cases, these incidents became major accidents. |