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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities 6 Findings and Recommendations Based on its review and analysis in Chapters 1 through 5 of incidents at two operating chemical demilitarization sites, JACADS and TOCDF, the Committee on the Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities developed the following findings and recommendations. Finding 1. Despite considerable Army security and stewardship activities, the remaining chemical weapons stockpiles are significant hazards to the communities surrounding them. The potential for significant release of agent to the atmosphere, triggered by either accidental or deliberate detonation of agent-loaded munitions within storage igloos, constitutes the greatest risk to the public. Accidental or deliberate release from a chemical demilitarization facility, while potentially serious, is a lesser threat because the agent inside the facility is maintained under stringent and effective engineering controls and because there is substantially less agent present in the demilitarization facility at any given time than there is in the storage facility. While chemical demilitarization operations at both Johnston Atoll Chemical Agent Disposal System and Tooele Chemical Disposal Facility have released small amounts of chemical agent into the environment, these releases were negligible compared with environmental releases from chemical weapons stockpiles (U.S. Army, 2001e). The rate of agent leaks and releases from storage facilities does decrease significantly as the stockpile is processed. Recommendation 1. The destruction of aging chemical munitions should proceed as quickly as possible, consistent with operational activities designed to protect the health and safety of the workforce, the public, and the environment. Finding 2. The criteria used by the Army to identify and determine the severity of the impact of an event are site and time specific, and the event classification decision is made at the discretion of the Depot Commander. The recognition of a chemical event is often subjective, and the tendency of personnel to discount initial indicators because of frequent false positive automatic continuous air monitoring system alarms is a persistent problem in declaring a chemical event. The lack of uniform criteria can result in inconsistencies between and among sites that make it difficult to compare and analyze events and that constrain and discourage the application of lessons learned to other locations and situations. Recommendation 2. The Army should establish a consistent set of criteria to be used by all chemical-agent-processing facilities to ensure uniformity in the classification of events, and to facilitate event analysis and comparison. Finding 3. Risk assessments, including the quantitative risk assessment and the health risk assessment, are critical inputs to the dialogue necessary to ensure adequate public involvement in, and understanding of, chemical demilitarization activities. A prudent balance between the public’s right to know the risks they face and the need to protect sensitive information will be an ongoing challenge for the chemical demilitarization program. Without adequate risk information available to the public, it will be difficult to develop or maintain the level of public trust necessary for the Program Manager for Chemical Demilitarization to accomplish its mission. Recommendation 3. The Army should continue its practice of making available to the public the results of its quantitative risk assessments and health risk assessments for each chemical demilitarization site. Finding 4. Of the wide range of Program Manager for Chemical Demilitarization risk analyses, the quantitative risk assessments (QRAs) are most closely linked with chemical events. They calculate the frequency and consequences of modeled events, and their analysts study real operational
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities events to help ensure the completeness of the models. The QRAs, and an understanding of their results, provide a framework for managing the risk from chemical events. As concern has focused on worker risk as well as risk to the public, recent QRAs have added extensive human reliability analysis—analysis of the human actions that can lead to a chemical event. While hazard analysis is a qualitative analysis primarily of single-failure events, it provides a catalog of possible failures that QRA analysts can use to improve the completeness of their models. Hypothesized chemical events, including those that might arise from sabotage, terrorism, and war, can also be incorporated into the QRA scenarios to determine their range of consequences. Actual events can be used to test and improve the completeness of the QRA and continue the effort to improve the human reliability analysis and focus on causal factors. Recommendation 4. The quantitative risk assessment (QRA) for each chemical demilitarization site should be iterative. Actual chemical events should be used routinely to test the completeness of the QRA, which should be routinely utilized to hypothesize the frequency and consequences of chemical events. The Program Manager for Chemical Demilitarization and the U.S. Army Soldier and Biological Chemical Command should use the QRAs to evaluate measures to control future chemical events. The Army should also consider using QRAs to examine scenarios associated with sabotage, terrorism, and war. Finding 5. Alarm thresholds for airborne agent monitoring used in the Army’s chemical demilitarization program are very conservative (i.e., 20 percent of the applicable control limit, resulting in alarm thresholds that, depending on the agent, are either below or only moderately above the level of agent deemed safe for continuous exposure of an unmasked worker over an 8-hour shift.) These alarm thresholds are near the detection limits for the automatic continuous air monitoring system (ACAMS). As a result, there are frequent false positive alarms as well as actual alarms for events that pose no threat to workers or the public (NRC, 2001a). These conservative stack-monitoring thresholds ensure that no significant amounts of agent can be released into the ambient air without the facility alarming and the agent incineration feed automatically terminating. In-plant air breathed by unmasked workers and the output of the scrubbing system for air exiting the chemical demilitarization plant are monitored at similarly conservative thresholds. Recommendation 5. The Army should maintain conservative chemical demilitarization exhaust stack and in-plant airborne agent exposure thresholds. If current limits for exposure to stockpiled chemical agents are further reduced, the Army should not further reduce existing monitoring thresholds unless chemical agent monitors can be made both more sensitive and more specific so that lower thresholds can be instituted without significant increases in false positive alarm rates or unless health risk assessments demonstrate that lower thresholds are necessary to protect workers or the public. Finding 6. Relatively frequent false positive ACAMS alarms for airborne agent and the lack of true real-time (<10 s) monitoring for airborne agent have long been a concern of National Research Council (NRC) committees assessing and examining the chemical demilitarization program (NRC, 1994, 1999a, 2001a). Improvements in the sensitivity, specificity, and time response of the ACAMS system and the development of an additional airborne-agent-monitoring technology robust at the parts-per-trillion level have previously been recommended. (Recent NRC reports have also noted the poor state of agent-monitoring technology for liquid waste streams and solid materials suspected of possible agent contamination (NRC, 2000a, 2001a).) Although the Program Manager for Chemical Demilitarization has made some efforts to develop better agent-monitoring technology, results to date have been disappointing. Development and deployment of airborne-agent monitors with shorter response times and lower false alarm rates would enhance safety and reduce the tendency to discount agent alarms. Recommendation 6. To reduce the rate of false positive alarms for both airborne and condensed-materials agent contamination, the Program Manager for Chemical Demilitarization and the relevant Department of Defense research and development agencies, such as the Army Research Office, the Army Research Laboratory, the Defense Advanced Research Projects Agency, and the Defense Threat Reduction Agency, should invigorate and coordinate efforts to develop chemical agent monitors with improved sensitivity, specificity, and time response. These efforts should be coordinated with, and take advantage of, the increased level of interest in and increased resources available for developing chemical weapons detectors for homeland defense. Finding 7. Chemical demilitarization facility and process design has contributed to the mitigation of incident severity in that, for most of the incidents examined by the committee, engineering controls functioned as designed. These incidents have been investigated honestly and thoroughly using straightforward techniques, but investigation could benefit from the use of other methodologies such as event tree analysis and human factors engineering to aid in understanding the complete set of causal factors associated with each incident. Recommendation 7. Incident investigation teams should use modern methodologies of incident investigation routinely at all chemical demilitarization sites to help uncover a broader set of causal and contributing factors, and to enable greater understanding of the interrelationships between and among these factors. Experts in human performance modeling should be included on any incident investigation team. A
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities standing incident review board at each site should be established to identify chemical events requiring in-depth investigation and to ensure that the lessons learned appropriately influence ongoing operations. These boards would meet regularly to review accidents and incidents, including chemical events, and would be fully informed of any findings and recommendations made by chemical event investigation teams. Finding 8a. Repeating patterns of causal factors evident in the incidents at Johnston Atoll Chemical Agent Disposal System and Tooele Chemical Disposal Facility reviewed by the committee included, in particular, deficiencies in standard operating procedures, design failures, and understandable, although inappropriate, assumptions made by operations personnel. In part, these inappropriate assumptions grew from development of dangerous mind-sets associated with frequent false-positive alarms. Repeating patterns of causal factors in most incidents do not appear to have been used by management to generalize incident findings beyond the immediate context of each incident. Finding 8b. The programmatic lessons learned (PLL) database is a large undertaking, and the Program Manager for Chemical Demilitarization is to be commended for creating it. However, if the data were organized in a different manner that included a priority system and the operators were aware of its uses, the database would be more useful. “Mining” of data might yield patterns in events and information that would allow broader generalization and understanding of causes derived from specific information on individual incidents. To this end, experts in each area of use have to specify exactly what they need to find in the data, before programmers develop software to search and set priorities. Recommendation 8a. The Program Manager for Chemical Demilitarization should analyze all chemical-agent-related incidents at chemical demilitarization plants for patterns of causal factors and should institute program-wide actions to address the causes found. Recommendation 8b. Any improvements made in investigation procedures should become part of a systematically organized programmatic lessons learned (PLL) database that makes information easier for the non-expert to find and/or use. This can include prioritization and developing a drop-down “tree” list. Lastly, the Program Manager for Chemical Demilitarization should ensure that, at the plant level, the data are available to, known by, and useful to operations personnel. The proposed contractor for the PLL program should address these issues. For the program to be useful all stakeholders need to buy into its use and structure. Finding 9. Gaussian puff/plume dispersion modeling techniques embedded in the D2PC computer model used to predict the extent of an agent emission plume are representative of the state of the art as of the late 1970s. Adoption of more modern and accurate emission plume models seems to have been delayed by the failure to integrate better plume models into standard Chemical Stockpile Emergency Preparedness Program emergency response models. Recommendation 9a. Stockpile sites that still use the D2PC computer model should, at a minimum, upgrade their emergency response models to take advantage of the improved capabilities available in the D2-Puff model. Consideration should be given to testing and possibly optimizing the D2-Puff model at each site by performing tracer release experiments under a variety of meteorological conditions. Recommendation 9b. The Chemical Stockpile Emergency Preparedness Program should undertake a continuing evaluation of alternative approaches to modeling the release and impact of chemical agents. Recommendation 9c. Accurate agent plume dispersion modeling capability should be coupled with timely communication of results and appropriate responses to the stockpile site and surrounding communities. Finding 10a. Communications during and after chemical events have not always occurred as intended between and among the various stakeholders. The lack of a call-forwarding mechanism for getting information directly to people or a hot line dedicated to notification that an event has occurred has contributed to an inadequate communication process during chemical events. The lack of notification and warning between the Deseret Chemical Depot (DCD), Tooele County, and other Utah responsible agencies reflects in part a lack of coordination between components of the two programs (Federal Emergency Management Agency / Chemical Stockpile Emergency Preparedness Program and the Army’s Emergency Operations Centers) and in part the DCD’s perspective that its emergency management responsibilities “end at the fence.” This perspective, if carried to other communities where chemical demilitarization facilities are to be operated, can endanger an effective coordinated emergency response to incidents. The memorandum of understanding recently agreed to by the DCD and Tooele County (Appendix G) for information exchange could serve as a model for every community with a chemical weapons stockpile, to ensure very close oversight of the disposal plant operations. Finding 10b. The Army’s recent and sincere effort to build public trust in its actions has not been sufficiently successful, although the degree of trust or mistrust has not been effectively measured. Of equal or greater importance is public trust in the governmental agencies that monitor the Army’s activities. It is essential that these agencies be seen by the public as being fully cognizant of the Army’s actions and of
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities being, in effect, in command—a result that will require an extraordinary level of communication between the Army and relevant government oversight agencies and can lead to contradictory advice and requirements that will have to be resolved. Recommendation 10a. Chemical demilitarization facilities should develop site-specific chemical event reporting procedures and an accompanying training program that tests and improves the implemented procedures and communication system. Recommendation 10b. The standing incident review board recommended by the committee for each site should include a qualified member of the public who can effectively represent and communicate public interests. Recommendation 10c. Each chemical demilitarization site should consider the establishment of a reporting and communication memorandum of understanding (MOU), of the sort developed between the Deseret Chemical Depot and Tooele County, which specifies reliable and trusted means of alerting and informing local officials about chemical events. These MOUs should be designed to permit ready evaluation and updating of the terms of the MOU to take full advantage of learning across the array of chemical demilitarization sites. Recommendation 10d. The Army Emergency Operations Centers and the Chemical Stockpile Emergency Preparedness Program should establish a stronger capability and capacity for the coordination of training, equipment, and plans necessary to respond effectively to an emergency incident, and the commitment to do so in a coordinated and cooperative fashion. Additionally, the Army should continue its program of outreach—including listening to public concerns and responding to them, as well as engaging in more conventional public information efforts—to both the public and the relevant government oversight agencies to enhance general understanding of the chemical demilitarization program. Finding 11. A major chemical event can result in several months of lost processing time at chemical demilitarization plants. This delays the destruction of the chemical agents, requiring that they remain in the stockpiles where they could create a hazard. When incidents have led to plant shutdown, multiple investigations and responses have contributed to additional delays in restarting operations. All aspects of chemical incident investigations and resumption of operations should be accelerated, consistent with safe operations. Recommendation 11. All stakeholders and involved regulatory agencies should agree that a single team will investigate chemical events requiring outside review. This investigation team should comprise already-appointed representatives from all stakeholder groups and agencies, including members of the public who can effectively represent and communicate with local officials and the affected public. Incident findings should be documented in a single comprehensive report that incorporates the findings, proposed corrective actions, and concerns of the various oversight agencies. Finding 12. Safety programs and performance appear to be adequate to ensure that chemical demilitarization operations are being conducted safely. Even so, there is considerable opportunity for improvement. Many of the incidents at Johnston Atoll Chemical Agent Disposal System (JACADS) and Tooele Chemical Disposal Facility (TOCDF) could have been significantly mitigated—if not prevented—had a true “safety culture” been in place and functioning. Recommendation 12a. Much of the needed improvement in safety at chemical weapons facilities can come from increased attention to factors that contribute to and/or cause chemical events. For example, the Program Manager for Chemical Demilitarization and chemical demilitarization facility managers should ensure that standard operating procedures are in place, up to date, and effective, performing hazard operations analyses on new process steps and design changes even when such changes are viewed as trivial and recognizing that chemical hazards are posed by things other than agent (e.g., waste). Recommendation 12b. Management at the Tooele Chemical Agent Disposal Facility (TOCDF) and the new third-generation facilities should develop or identify and implement programs that will result in the establishment of a pervasive, functioning safety culture as well as improved safety performance. In doing so, TOCDF and the new chemical demilitarization sites should draw on experience in the chemical industry, obtained through industry associations or other appropriate venues. The Army should revise the award fee criteria to encourage each new chemical demilitarization site operator to demonstrate better safety performance than that at the older sites. Finding 13. It is probable that conditions will arise in plant operation for which no standard operating procedure has been written. Operators need an in-depth knowledge of their equipment and its limitations to handle these unusual conditions and maintain plant security. New plant start-up can be a difficult learning experience for new operating crews. They need to know how and why procedures are to be performed. It is common practice in other industries to include engineers with “design” knowledge and experience in the startup crew for new plants. Recommendation 13. A generous allotment of time should be given to training and retraining chemical demilitarization
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities plant operating personnel to ensure their total familiarity with the system and its engineering limitations. All plant personnel should receive some education on the total plant operation, not just the area of their own special responsibility. The extent of this overall training will be a matter of judgment for plant management, but the training should focus on how an individual’s activities affect the integrated plant and its operational risk. Each facility should develop training programs using the newly designed in-plant simulators to present challenges that require knowledge-based thinking. The training programs should include a process for judging the effectiveness of the training. Including “design” experts in the start-up crew for new plants could be helpful in identifying latent failures in process and facility design.
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