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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities 5 Preparing for Potential Future Chemical Events at Baseline Chemical Demilitarization Facilities SUMMARY OF CHEMICAL EVENTS ANALYSES The committee’s analyses of past chemical events at Johnston Atoll Chemical Agent Disposal System (JACADS) and Tooele Chemical Disposal Facility (TOCDF) indicate that the causal factors are similar to those associated with breakdowns of other safety-critical systems. Release of chemical agent may be triggered by equipment design flaws and failures, by procedural deficiencies, and by human actions—i.e., by both latent and active failures (see Chapter 2). The task of dismantling and destroying chemical weapons is inherently hazardous, but the Program Manager for Chemical Demilitarization (PMCD) has incorporated extraordinary safety precautions into both plant design and personnel training. The chemical demilitarization incineration plants are virtual fortresses built to withstand the consequences of accidents, and, to date, releases of chemical agent from these facilities have been rare, isolated events involving only small amounts of agent, even under upset conditions (NRC, 1996, 1997, 1999a). State-of-the-art quantitative risk assessments have determined that the major hazard to the surrounding communities arises from potential releases of agent from stockpile storage areas, not the demilitarization facilities (U.S. Army, 1996a; NRC, 1997; see also Chapter 1 and Appendix E). Further, to date by far the largest releases of agent have occurred in the storage areas, as described in Chapter 1. The Army has sought to build in the process of learning by experience to avoid accidents where possible, and to avoid repeating them in any case. The centerpiece of this effort, the programmatic lessons learned (PLL) database, is admirable as a personnel-training tool but requires further modification to improve its accessibility (see Chapter 4). Despite considerable effort in plant design and personnel training, mistakes have been made and problems have occurred in the chemical demilitarization process. The Army has established extraordinarily low agent threshold concentrations to trigger site alarms and a subsequent shutdown of the plant (see Chapter 1). While laudable as an effort to protect worker and public health, these overly sensitive alarms introduce their own kinds of operating problems. Difficulty in reliably detecting agent at such low concentrations leads to recurring false positive alarms. It also means that alarms triggered by chemical events in which agent levels stay near threshold will actually pose no risk to the worker or the public. Given the inherent complexity of the chemical demilitarization task at the assembled weapons stockpile sites, it is almost certain that new problems will continue to arise, particularly from aging and deteriorating weapons and the challenges of demilitarization plant closure and decommissioning. There will be future chemical events, and serious consequences to both plant personnel and surrounding communities cannot be ruled out. This chapter focuses on prudent ways to reduce their number and to minimize their consequences. CHEMICAL EVENT RESPONSE AND REVIEW BY MANAGEMENT Army Regulation 50-6 presents in detail the response to a chemical event and its reporting expected from the depot commander (U.S. Army, 1995). The objective is to: . . . encompass those actions to save life, preserve health and safety, secure chemical agent, protect property, prevent further damage to and remediate the environment, and help maintain public confidence in the ability of the Army to respond to a military chemical accident or incident. . . . The major army commands (MACOM) commanders will establish procedures to review each chemical event and to initiate safety investigations when warranted . . . . The extent of the review process generally varies with the seriousness of the incident. The review process for a
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities serious incident can be quite lengthy. Every chemical event should be investigated promptly, particularly those considered potentially or actually serious. Memories of the event will change with time. Having people identified in advance as potential candidates for a review team would appear worthwhile. One of the objectives of Army Regulation 50-6, stated above, is to “help maintain public confidence.” The committee believes that building trust requires regular and reliable communication between the Army and the communities around the demilitarization plants. It does not appear that these communities feel that such communication has been achieved. Public trust is not easily established and is very difficult to rebuild once lost. The recent report of the U.S. Commission on National Security (a commission headed by former senators Gary Hart and Warren Rudman) comments on the general lack of confidence in federal employees (USCNS, 2001). This general lack of confidence, exacerbated by the unfortunate pattern of interactions between PMCD and external stakeholder groups (NRC, 1996), has created a serious deficit of trust in the Army’s chemical demilitarization program on the part of important segments of the public. In addition to addressing the public’s lack of confidence in federal officials, at some sites PMCD must also deal with public distrust of state and local officials. A recent NRC letter report (NRC, 2000c) points out that: . . . open, two way communications between PMCD and stakeholders are necessary, but insufficient. PMCD needs to encourage public trust in official representatives of the public (i.e., Citizens Advisory Commissions and local regulatory bodies) as much or more than it needs to build trust in the Army. The memorandum of understanding between TOCDF and Tooele County (see Appendix G) should help build confidence that public officials are fully informed and responsive to chemical events, thereby contributing to building trust. This approach might serve as a model for other communities with similar concerns (Utah DEQ, 2000b). BUILDING ON THE RESULTS OF RISK ASSESSMENT Risks associated with the chemical demilitarization facilities have been studied in depth, through quantitative and health risk assessments and systems hazards analyses (see Chapter 1). The quantitative risk assessment, in particular, is a living document, subject to change as new information arises or facilities or operations are altered. It provides excellent guidance on where risk is the highest, and thus where the greatest care is needed. The Army’s “Guide to Risk Management Policy and Activities” provides a process for managing risks, particularly when changes are made, and for communicating information on change to the public (U.S. Army, 1997b). Understanding and building on the results of risk assessment implies more than knowing the summary numerical results of quantitative and health risk assessments. It also requires knowing the details, including the assumptions, simplifications, and omissions, of the analyses. The results must be viewed in the full context of the risk assessment, as well as in the context of the actual safety performance of the plant. This perspective must be accompanied by a better understanding of explicit and implicit uncertainties. Understanding the results of risk assessment also means knowing the significant contributors to risk, i.e., knowing how improved performance can reduce risk and how degraded performance could increase risk. With this knowledge: Managers and workers can develop options for reducing risk or for ensuring that risk does not increase. They can also consider how proposals for change affect risk. Workers, emergency response personnel, and others can better understand their personal risks and how best to protect themselves and each other. Emergency preparedness managers can focus their planning and training programs on the most important scenarios or sources of risk to the surrounding communities. State and local officials can provide more informed oversight in their decision making. Everyone can participate knowledgeably in the risk management process. Quantitative and health risk assessments are complex and, of necessity, include simplifications. The plant safety professionals should review the assessments thoroughly to be aware of their basic assumptions and/or limitations. Plant operating requirements may change, and changes need to be viewed in the light of the risk assessments. Several lessons can be learned about risk management from thinking about possible responses to certain kinds of chemical events. False positive alarms. The history of false positives has contributed to a number of chemical events as described in Chapter 2. These result from a mind-set that develops in operators. Faced with a series of false positive alarms, they tend to disbelieve future alarms, at least to the extent that they seek confirmation before taking action. A question that has been raised is whether a similar complacency could develop among emergency response managers and even the general public? If they too are subjected to false alarms, they may delay ordering or responding to orders for evacuation or sheltering. Generally, these people have not been subjected to the false alarms, but if it should happen, similar problems could arise.
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Evacuation versus sheltering. At some sites, there has been controversy over the question of evacuation versus sheltering. Countering the belief that evacuation is always the safe path are at least two circumstances. First, evacuation itself can create hazards. It disrupts the economy and daily life and can create high stress. It has led to injuries due to traffic accidents and improper use of safety equipment. Second, analyses by Chemical Stockpile Emergency Preparedness Program (CSEPP) planners have shown that for some release scenarios, evacuation can place the evacuees directly in the path of the hazardous plume (Blewett et al., 1996). For some scenarios, sheltering in place (remaining indoors with the doors and windows sealed) as the plume passes, followed by evacuation, can greatly reduce exposure. Continued sheltering after the cloud has passed may lead to exposure as severe as being caught in the plume. In these cases, sheltering as the cloud passes, followed by evacuation through contaminated areas, can be the most effective protective action. BUILDING A SAFETY CULTURE TOCDF has clearly made an effort to promote plant safety. Two examples are (1) the use of the Safety Training Observation Program (purchased from the DuPont Company) and (2) the use of the Voluntary Protection Program developed by the Occupational Safety and Health Administration (OSHA). A good safety organization on paper, however, does not ensure a high-quality safety culture. Some of the past events at both JACADS and TOCDF arose from obviously poor safety practices. The recordable injury rate (RIR) at TOCDF, for example, has been unimpressive (Chapter 4). The NRC has emphasized the need to focus on safety with constant attention to detail, starting with a complete and persistent commitment from management (NRC, 1999a). OPERATIONAL CHANGES It is clear that (1) serious mistakes have been made in chemical demilitarization plant operations in the past and (2) strict standards of operating practice have not been uniformly enforced (see Chapters 2 and 3). These are failures of management to fulfill their responsibilities. Improvement will come only with serious management effort, significantly greater than in the past. Strong safety cultures and an adherence to defined operating procedures have been established in other industries. The goal for chemical demilitarization plants should be to match the best achieved in industry. A criticism that is easily voiced but difficult to respond to is the general acceptance of the status quo by chemical demilitarization operating people and management. Changes are made in response to chemical events or obvious operating difficulties, but based on the committee’s site reviews, a culture of questioning processes and constantly improving operations does not seem to exist. To be fair, it is clear that plant management is aware of the importance of being proactive on safety, rather than being reactive only. Certainly there has been real improvement in plant layout, equipment, and so on (see Chapter 4). Based on the committee’s observations and discussions with operating personnel, TOCDF is clearly a better designed and engineered plant than JACADS, and the third-generation incineration plants, as exemplified by the Anniston Chemical Agent Disposal Facility, appear to be a significant improvement1 on TOCDF. Many of these improvements were made by seeking better ways of doing things, and anticipating possible future problems rather than reacting after a problem has occurred. The committee encourages a continued vigorous questioning of plant operation and equipment by management and operating personnel. This open-minded, questioning approach should apply to operating practices and even equipment design. 1 Although the basic processes for weapon destruction will remain the same three lines of incineration as at TOCDF and JACADS (a furnace for injecting and burning liquid agent, a rotary furnace for propellant and explosive materials, and a furnace with a moving conveyor primarily for metal parts), improvements have been made compared with TOCDF and JACADS. For example: • The pollution control systems of the new plants will include activated carbon filters for the incinerator exhaust gas. This is fairly new technology, not in common use when JACADS and TOCDF were designed. Trial burn data on those two early plants showed that carbon filters were not needed to meet environmental standards. More recently, however, some samples of mustard have shown unexpectedly high levels of mercury that could be a problem in exhaust emissions. Carbon filters represent the technology of choice for handling this problem. Other changes in the pollution abatement system are required to accommodate the carbon filters. The exhaust gas must be cooled and its humidity reduced to maintain the carbon filter’s function. • The ventilation air through the plant as well as the combustion air will have variable-speed motors driving the fans. This should be a great improvement in controlling airflow rates, particularly at low rates (a problem in the May 8, 2000, TOCDF incident). The technology for doing this with very large motors was just being introduced when TOCDF was designed and was not included. • Isolation valves are included in the duct between the DFS burner and after burner. (The same valve was added to TOCDF after the May 8, 2000, event.) They should permit improved control during start-up. • The DFS tipping gate has been redesigned to prevent jamming (part of the problem in the May 8, 2000, event). • The large isolation valves on the individual HVAC carbon filter banks have a small “bleed” valve connecting to the exhaust flow in the new plants. The purpose is to maintain the filter bank at negative pressure even when the filter is temporarily out of service. This should prevent migration of agent from the filter bank into the connecting vestibule when the filter is out of service, a problem in the past. • The DFS cyclone is in an enclosure that is to be monitored with an ACAMS and that has a carbon-filter on an exhaust. (This modification was made in response to a JACADS event where VX was detected on the cyclone ash.)
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities The 2000 letter report of the NRC Stockpile Committee recommended a similar open-minded approach for a public involvement program (NRC, 2000b), naming as one requirement for a successful program “the capability to identify (even anticipate) serious problems and the flexibility and creativity to address them.” The current study suggests that this approach is also needed in plant operations and technology. A better understanding of the limitations of plant equipment might also be helpful. In the May 8-9, 2000, incident at Tooele, for example, there were some serious operating errors. But they were compounded by the operator’s struggle to bring the system back under control. It is the judgment of the committee that some technical education and more hands-on testing on the system simulator would have helped (see Chapter 2). There are usually surprises when new processes are first tried. In view of the particular sensitivity of the chemical agent disposal program, the committee emphasizes the need for a hazardous operations (HAZOP) analysis for any new process (see Chapter 4). A HAZOP analysis by suitably trained people, and with input from operating people, could be particularly useful: it might identify problems and at the same time warn the operating people about what to expect. New plant start-up represents a special problem with inexperienced people. Trial burns with surrogate feeds and with the pollution abatement system in full operation, as well as disassembly trials with blank munitions, should provide substantial operating experience before any chemical agent is fed to the process. It is fairly common experience in industry to include design people on start-up teams for new facilities. As suggested earlier, their detailed knowledge of the process equipment and its limitations could be helpful to the operating people. WORKER EDUCATION, TRAINING, AND INVOLVEMENT Safe plant operation depends on an educated, welltrained staff. The risk to workers in an incineration plant is greater than the risk to the public (NRC, 2000c). Training should emphasize that processing agent demands a mind-set that always accepts a positive analysis as “real” until proven otherwise. One approach to safe operation is through the use of standard operating procedures (SOPs). These have been used extensively at JACADS and TOCDF. The most serious chemical events of the past have occurred, however, when there was no SOP. There will always be combinations of circumstances for which no SOP has been written and the operating people must rely on knowledge-based decision making. Even with SOPs, there is no guarantee that mistakes will not occur. It is vital that decisions be made on the basis of accurate operational knowledge. Operating people should know their equipment and its limitations. They need to know the why of their job as well as the what. Bringing the systems engineers with design knowledge into the training program could help convey that knowledge to the operators. These engineers are probably in the best position to know the equipment and its characteristics and limitations, information that plant operators need when unusual or unexpected conditions occur. Many plant operators seemed to the committee to have only a superficial knowledge of the operating principles and data processing algorithms of important process instrumentation and controls. But such knowledge is crucial to determine how to interpret reported instrument console readings during upset conditions which may exceed the normal ranges over which key instruments are calibrated or can be expected to operate reliably. A careful walk-through of any new procedure should precede its start-up. The Army’s more recent quantitative risk assessments (QRAs) include detailed human reliability analyses that identify potential human performance problems. Bringing this information into the training program will provide operators with a view of what activities are especially vulnerable and why that is so. In addition, training simulators, which mimic the operation of the various components of the instrument and control systems and demonstrate the effects of various operator actions or inactions, are now being provided in the chemical demilitarization plants. Targeted training with simulators and knowledge-based thinking exercises on plant operation need to be developed. Training on overall plant operations should cover everyone in the plant and analytical laboratory, not just the operating and control people. However, this training has to be tailored to the specific jobs and knowledge levels of each group of workers. Workers need to understand how what they do fits into the overall operation and how things going wrong in their operations affect the whole plant and the likelihood of accidents and releases. The QRA and HAZOP analysis are a good potential source of this information. Some of the reports of operational mistakes coming from within the plant and circulated widely within the affected communities have come from people who are simply uninformed and do not know normal procedures. Box 5-1 provides examples of such uninformed observations. Chemical demilitarization plants are complex. A better knowledge of the complexity of the plant and the care and design that have been incorporated may instill pride in being part of the important national effort of weapons disposal. The potential costs (e.g., lost trust) of having the local public alarmed by reported misperceptions of uninformed workers can be substantial. DESIRED PRINCIPAL-AGENT INTERACTIONS It is imperative that officials at the chemical demilitarization facilities communicate openly, frequently, and in a timely fashion with nearby residents and officials. The pattern of communication with and responsiveness to the local
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities BOX 5-1 Examples of Observations That the Committee Concluded Were Uninformed “December 9, 2000—Agent break through in HVAC filter bank. ACAMS readings of 3.01 [TWA].” “October/November 1997: Sources inside TOCDF (who wish to remain anonymous) communicated to CWWG [Chemical Weapons Working Group] several shutdowns/incidents at TOCDF due to computer malfunctions, slag build-up in the PAS, numerous agent migrations within the facility, and alarm ring-offs in the common stack, MDB [munitions demilitarization building] and HVAC stack (averaging 2-3 per week).” These entries suggest that agent may have been released through the heating, ventilation, and air conditioning (HVAC) filter to the environment. In fact, the HVAC was operating as designed. The carbon filter bank consists of six carbon beds, with exhaust gas flowing through all six in series. The gas spaces between beds 1 and 2, 2 and 3, and 3 and 4 are monitored by an automatic continuous air monitoring system (ACAMS) (on a timer). Eventually agent will break through bed 1 as that bed approaches saturation, and this is undoubtedly the “agent break through” referred to by the whistle-blower. Agent breakthrough of bed 1 usually follows many weeks of operation, and with the gas having to traverse 5 more beds the agent breakthrough of the first bed does not call for immediate shutdown. However, it does indicate that the carbon should be replaced soon. A video given to the committee and referred to in Appendix C showed rockets being sheared and the pieces dropping to the deactivation furnace system (DFS) below. Approximately every 1½ minutes a large cloud of condensing vapor, referred to by the citizen group as “agent volatization,” rose into the picture, undoubtedly coinciding with opening of the gate to the DFS. In fact it was a cloud of condensing steam, as cooling water from the shear blade and the sliding gate dropped into the hot furnace to be instantly vaporized. “Site-masking alarm and/or stack alarm. Potential case of chemical warfare agent release or release of other related toxic chemicals (unidentified to date).” [the most common incident listed by the CWWG (Appendix C)] It is almost certain that the ACAMS alarm was not due to agent, because there was no depot area air monitoring system (DAAMS) confirmation. The committee concluded that the event reports as written are misleading but considers them to be from a source unfamiliar with the stringent laboratory procedures used to analyze DAAMS samples taken coincident with each ACAMS alarm to confirm or deny the presence of agent and to attempt to identify the cause of the alarm in the absence of agent. NOTE: Observations quoted are drawn from the Chemical Weapons Working Group list of events provided to the committee (Appendix C). public and local officials can have substantial effects. Beyond addressing the immediate health and environmental concerns posed by a chemical event, frequent and open dialogue can alter perceptions of risk and trust, influence demands for policy change, and mitigate undesirable effects on local economic growth and property values. As discussed in Chapter 3, the agents in the demilitarization process (regulatory agency officials, the Army, and contractors at the chemical demilitarization facilities) must gain and retain the trust of the principals (local public and the officials who represent them) in order to effectively destroy the chemical weapons stockpile in a safe and timely manner. Absent complete trust, the mechanisms by which principals gain confidence in adequate performance by agents include effective monitoring of agent behavior and appropriate inducements and sanctions to obtain desired performance. The lower the level of trust, the greater the need for monitoring and incentives. At the same time, more stringent monitoring and incentives can limit the discretion necessary for agents to effectively and efficiently accomplish their complex task. The trade-off between effective monitoring and controls by principals over agents and optimal conditions under which agents can carry out the demilitarization task (where some discretion may be essential) requires engendering and maintaining a degree of trust by principals for agents. Effective handling of the principal-agent relationship in the chemical demilitarization program setting appears to the committee to require (1) demonstrable and timely assessments of the problems leading to chemical events and means for their correction, (2) complete and timely disclosure of events by the agents, and (3) overview processes that assure principals of effective oversight. In its assessment of chemical events (Chapter 2), the committee found specific instances (e.g., the TOCDF May 8-9, 2000, incident) that resulted in a damaging erosion of the confidence of principals in the monitoring and control processes. It is essential that plant operators remain cognizant of the needs of principals for high degrees of confidence in the monitoring and control protocols (incentives and sanctions) and mechanisms over the entire chemical demilitarization program. Apparent weaknesses or failures at one facility or in one phase of operations will be seen to carry over to others. Protocols for reporting and responding
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities to events should stress meeting the needs of the array of external principals for assurance of timely, accurate reports of events and rapid, thorough assessment and corrections. One important step to increase confidence in the monitoring process will be to ensure that representatives of principals (e.g., local stakeholder groups) are included in the teams assembled to investigate any serious chemical events. In addition, each site should develop clear and specific protocols that reflect the need to quickly, openly, and thoroughly inform all relevant principals of chemical events. More broadly, program officials should consider ways in which principals and their representatives can participate in ongoing oversight efforts. The NRC has suggested elsewhere (NRC, 1999b) that representatives of the local public serve on monitoring teams whose purpose is to ensure that chemical weapons destruction processes (and the associated organizations) are operating as they should. Such an effort— ranging from temporary appointment of community observers on investigation teams to more permanent participation of community representatives in incident review boards— may increase the confidence of local principals that effective oversight is in place. RAPID AND SAFE RESTART REQUIREMENTS Restarts After Changeovers and Maintenance The chemical weapons plants have very frequent shutdowns and restarts—“frequent” compared with industrial plants of comparable size. These shutdowns are required by the variable nature of the plant feed: a variety of weapon types with differing disassembly requirements, containing three different chemical agents. The times required for changeover have been estimated to be surprisingly long (U.S. Army, 2000c). For example: A change in agent: 17 weeks—the time required for decontamination, monitor conversion and baselining, and some equipment changeovers. A change in munitions type: 5 weeks without complete equipment removal (e.g., projectile to projectile types). 8 weeks with equipment removal (e.g., mines or rockets to projectiles). There are other normal maintenance items that require extended shutdown periods but can probably be scheduled during other changeovers. For example: Slag removal from the liquid incinerator (LIC) secondary burner. [The slag removal system at TOCDF failed before the refractory failed, so that slag had to be removed manually.] Time required: 10 days. The experience at JACADS and TOCDF permits an estimate of the required frequency of slag removal, e.g., for TOCDF, after 250,000 lb of agent destroyed. Mist eliminator candle replacement (plugged during deactivation furnace system (DFS) rocket runs, probably due to fiberglass). Time minimized by having a spare eliminator on hand. LIC rebricking, maintenance that can also probably be planned ahead and done during “contingency time” (i.e., when the plant will be shut down for other activities such as agent changeover). Rebricking is needed after approximately 2,000,000 lb of agent (with decontamination fluid) have been processed. A further complication arises from the age of the weapons as well as their varied history—“leakers” and “gelled agents” require changes in “standard” operations, for example. The shutdowns and restarts resulting from these feed stock variations can be planned for and shutdown times can be minimized. The Operations Schedule Task Force 2000 recommended study teams to suggest how to minimize downtime (U.S. Army, 2000c); these teams should be very helpful. The committee suggests that industrial experience with carefully planned shutdowns for maintenance at regular intervals might be applicable. It is not clear that “project management,” which has developed into a distinct engineering subdiscipline, is being fully integrated into the chemical demilitarization program. The suggested study teams noted above would represent a step in that direction. Restarts After a Chemical Event Major chemical events can impose further shutdowns with unpredictable shutdown times. Some of these have led to major structural changes and changes in some operating procedures. These changes stem from the incident reviews, and they all require regulatory approval. Shutdown times may be long, e.g., 4 ½ months for the May 8-9, 2000, incident at TOCDF. The Operations Schedule Task Force 2000 suggested that a 2-week outage every 6 months be included in advance planning, to accommodate unplanned major maintenance (U.S. Army, 2000c). The committee believes that this unplanned shutdown allowance is less than past experience would indicate is necessary, but these unplanned shutdowns should decrease with time, as operating experience is gained. There also may be opportunities for reducing the required shutdown times after such incidents. Maintaining a larger inventory of critical spare parts has been suggested as one strategy to reduce lost operational time. Obtaining regulatory approval to restart after a chemical incident may cause delays, although the committee heard no specific complaints of this. The Army Audit Agency, however, has been critical of the chemical demilitarization program for its handling of funds, based in part on regulatory
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities delays. Funds obtained for current planned programs could not be spent because of delays in regulatory approvals (U.S. Army, 2001g). It is not clear, however, that regulatory delay has been a serious problem in connection with unpredicted shutdowns, where there was no opportunity for advance planning. Finally, as noted in Chapter 3, effort spent on the multiple investigations of the May 8-9, 2001, Tooele chemical event probably extended the post-event shutdown associated with that event unnecessarily. Preagreement at each demilitarization site on the composition of a joint event investigation team, representing all regulatory and operational stakeholders and chartered to produce a single, comprehensive investigation report, could save significant shutdown time and clearly focus all parties on the steps necessary to achieve safe restart of operations after future chemical events.
Representative terms from entire chapter: