03-10-2008, 09:44 PM #1
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Tacoma--Haz Mat Response Criticized
Thousands could have been exposed to deadly gas on Tacoma's Tideflats
SUSAN GORDON; firstname.lastname@example.org
Published: March 9th, 2008 02:00 AM | Updated: March 10th, 2008 10:16 AM
It was a slow night at the bleach plant. Randy Isaksson worked alone in the gas house, filling 7-foot-long pressurized containers with chlorine.
His was a routine repeated thousands of times before without mishap.
But at 6:40 p.m. that Monday in February 2007, Isaksson was distracted. While thinking about whether or when to break for lunch, he made mistakes that could have killed him and jeopardized the health of hundreds on the surrounding Tacoma Tideflats.
So much poison gas escaped from the Pioneer Americas plant – nearly 900 pounds vaporized into greenish clouds – that it threatened for hours to suffocate people.
But initially, at least, Tacoma Fire Department officials believed the building would contain most of the leaking chlorine.
The department reacted quickly to the Feb. 12, 2007, emergency, taking actions that demonstrated its strengths. About an hour and 40 minutes after Isaksson’s error, two firefighters plugged the leaky cylinder that he had failed to secure.
But shortly afterward, when the wind changed, firefighters outside the plant were overcome by the gas because they hadn’t anticipated a wind shift, and they left a door open, enabling chlorine to escape. The situation deteriorated, becoming what Fire Department officials later described as a “mass casualty incident.”
Medics took about 25 people – including a dozen firefighters, among them the leader of the department’s hazardous materials response team – to hospital emergency rooms. At least one firefighter continued to cough up blood the following day.
“The number one rule of emergency responders is supposed to be, don’t make more victims,” said Rick Gleason, a University of Washington industrial safety lecturer and former federal and state safety inspector.
The city’s emergency response to the chlorine incident also revealed fire commanders’ hesitance to alert all but a few downwind businesses to potentially lethal airborne chemical releases.
By the time workers at some neighboring businesses found out they had to evacuate, firefighters were retreating. Many people had to escape on foot.
“Everybody's nose and eyes and throats were burning. I tied rags around my face,” said Leslie Lewis Jr., who worked at a shingle factory diagonally across East Thorne Road. Months later, asthmalike symptoms still bothered him, he said.
“They just blew us off. It didn't matter that we were down there,” said another shingle plant worker, Tom McElroy, who said he had to hitch a ride out of the Tideflats with fleeing longshoremen.
“It was really poorly handled,” said Randy Smith, lead mechanic at Penske Truck rental, about two blocks from Pioneer. “We were basically at the crisis stage before they came and got anybody.”
Tacoma Fire Department officials are proud of the way they contained the leak and blame the subsequent problems on an unexpected wind shift.
“We were operating in the moment with the chlorine in our face,” said Chief Ron Stephens. “At the time we did what we thought was appropriate.”
But an internal report listed lessons learned from the incident, including the importance of air monitoring, the use of respirators and limits on access to the danger zone.
It could have been much worse. Some 10,000 people work in the Tideflats industrial area, but most had gone home for the night.
Fire Department dispatcher Steve Proper at 6:48 p.m.: “Tacoma Fire Department. Location of your emergency?”
Alarm company representative: “Tacoma, Washington.”
Alarm company: “2001 East Thorne Road.”
Proper: “House or business?”
Alarm company: “Biz … ahhh … business.”
Proper: “What is it?”
Alarm company: “Pioneer Americas Inc.”
Proper: “Pioneer America?”
Alarm company: “Yes.”
Proper: “What kind of alarm is it?”
Alarm company: “It's a fire.”
Proper: “What type of detection?”
Alarm company: “Chlorine.”
Proper: “Chlorine? Wait a minute, it's a fire alarm?”
Alarm company: “Yes.”
Proper: “OK, is it a smoke detector or a heat detector? What's a chlorine detector?”
Alarm company: “Umm … it, it (stutters) just says chlorine detector.”
Proper: “I need to know what that is. You need to find out what that is for me, OK?”
Alarm company: “OK, well. One minute, please.” (She puts dispatcher on hold with background music.)
Proper to co-worker (with music playing in background): “You ever heard of a chlorine detector? No, she's telling me it's a fire alarm. The alarm is a chlorine detector. Should I check what that is before I dispatch it or dispatch it and then check?”
(Proper again speaks briefly with the alarm company representative, then puts her on hold.)
Proper: “Signal 1-11, Signal 1-11, for Engines 6, 1, Ladder 1, Battalion 2, 2001 Thorne Road, Pioneer America, reported fire alarm. Some type of chlorine detector activation. Engine 6, Engine 1, Ladder 1, Battalion 2, 2001 Thorne Road, Pioneer America, you're on channel 3. Will advise you en route. (Will) try to get more information.”
‘WE'RE GONNA NEED HAZMAT HERE'
A burst of highly concentrated greenish gas had rushed past Isaksson's face as he fiddled with a fill line. To correct his mistake, he held his breath, picked up a wrench and tried to shut a valve, he told state investigators the following day.
When he realized he couldn't fix the problem, Isaksson immediately left the gas house. Only two other men – the usual second-shift skeleton crew – were working at the bleach plant that night. Isaksson alerted them, and they also left the plant. The chlorine release triggered an automatic alarm, which shut the gas house doors.
At 6:48 p.m., Proper answered the call from the woman at the alarm company.
Although she knew nothing about the bleach plant, dispatchers found Fire Department records that showed that 720,000 pounds of chlorine was stored there.
After Proper dispatched the first crews and equipment, he radioed Battalion Chief Tom Haneline, who was on his way, and told him how much chlorine was on site. Proper also telephoned then-Capt. Jim Zuluaga, leader of the hazardous materials team, at his station and alerted him that his expertise might be needed at Pioneer.
At 6:53 p.m., the first firefighters arrived at the plant and spoke with Pioneer workers waiting outside.
“We have a ton container in the gas house that's reportedly leaking. We're gonna need hazmat here,” Capt. David Sherk, the initial incident commander, said over the radio.
At 6:56 p.m., Zuluaga and six other hazmat team members showed up outside.
THE WIND AND THE HOT ZONE
The former Pioneer Americas complex at 2001 E. Thorne Road – it was sold last August and is now called the Olin Chlor Alkali Products Tacoma bleach plant – straddles an inconspicuous corner in an industrial neighborhood. Ordinarily, the air smells of hot asphalt from PABCO Building Products, the shingle factory across the street.
Pioneer also is a few blocks from the Port of Tacoma's headquarters. A port-owned auto warehousing lot occupies adjacent property. In the Pioneer yard, 90-ton chlorine tank cars are partially screened from view. It was Isaksson's job to repackage chlorine drawn from those tank cars.
That night in February 2007, as firefighters approached the bleach plant, they avoided the chlorine by keeping a north wind at their backs.
“We could tell by the smokestacks at the paper mill what direction the wind was blowing,” Zuluaga said an interview.
But while firefighters parked their rigs upwind and northwest of the plant gate, the trucks, including the hazmat rig, faced south.
Later, that proved to be a problem.
Before the first ambulance arrived, Zuluaga spoke with Isaksson. The plant worker explained what happened and drew firefighters a map, Zuluaga said.
Incident commander Sherk designated the 5-acre Pioneer plant site as the hot zone, or exclusion area. People who entered had to wear protective suits that made them look like space explorers. They also had to breathe through respirators.
Firefighters believed the building would help contain the gas, Zuluaga said.
The hazmat team brought along two chlorine sensors that could instantaneously detect and record evidence of dangerously high concentrations of the gas. The team didn't carry the sensors around the building to measure the downwind danger. Instead, firefighters left the monitors on the hazmat rig, parked northwest of the plant.
Zuluaga said they didn't use the monitors because they believed the gas largely was contained inside the building, that the gas would destroy the monitors if firefighters took them inside, and that they didn't have enough trained personnel to measure concentrations outside.
“We already knew it (the chlorine) was getting out,” Sherk said later. Employees of the nearby U.S. Oil & Refining Co., south and east of Pioneer, could smell it, he said.
The initial incident command post was about half a block farther north near the corner of East Thorne Road and Maxwell Way.
At the Port of Tacoma, security officers first learned about the chlorine leak at 7:50 p.m. Port officials received an e-mail warning about it from Pierce County's Department of Emergency Management at 8:07 p.m. Firefighters also placed several calls to the port, starting at 8:30 p.m., according to port records.
Firefighters repeatedly asked police to block neighborhood traffic. But cops didn't show right away.
Police dispatcher Cara Stephens: “Do you have anybody that can go up to the 11th Street bridge and contact the sergeant for further info, 'cause they're talkin' gas masks and the whole deal?”
Proper, the fire dispatcher: “No. They're OK. They don't need gas masks.”
Stephens: “The sergeant is asking for someone to meet them up there. Is that possible or not?”
Proper: “Yeah, um, do you have his (cell) phone number (so) can I call him directly?”
Stephens: “Um, just a half-second here. I'll get back to you.”
Proper received the police sergeant's number from Stephens, alerted the fire incident commander by radio and told him to look at his message display terminal. A minute or two passed. Then Proper's dispatch partner, Mike Langendorf, answered a related radio message, this time from Battalion Chief Haneline.
Haneline: “Yeah, we got no sign of TPD here. Ah, I want 'em to be here ASAP. Lincoln and Port of Tacoma, Lincoln and Milwaukee and 11th and Thorne. If we can get some help from 'em. Give 'em another call and tell 'em we need 'em here to block traffic.”
Langendorf: “Battalion 2, check your MDT (message display terminal) for a call – correction – a number and you can talk directly to the sergeant. They will not come in until they know a safe route.”
‘A TACTICAL DECISION'
Two members of the Fire Department's hazmat team suited up. Lt. Gerald Parkhurst inspected the plant the previous November; John Melchiorre had 30years of experience.
Melchiorre toted their gear in a small wagon. They had a chlorine emergency tool kit and a camera with a live feed to the hazmat rig where Zuluaga and others could track their progress and provide guidance.
The puffy moon suits they wore made walking difficult. They had enough air strapped on their backs to survive for only about an hour.
As they got ready, Parkhurst ripped a glove, forcing a last-minute outfit change.
Inside the gas house, the two found that a chlorine cloud had blanketed an area 3 or 4 feet deep, Melchiorre later told state investigators.
The video showed grainy images of greenish gas funneling furiously out of the cylinder Isaksson had filled. The firefighters quickly shut three valves.
When they entered the gas house, the firefighters put a block in the door to prevent it from accidentally locking them inside. When they were done, Zuluaga said Parkhurst radioed and asked whether to leave the door open.
Briefly, four people - Zuluaga, assistant chief Tom Henderson, a hazmat technician and the plant's production supervisor - talked it over and decided to let the gas drift out.
“Do we keep it in the building or do we want to slowly release the product and let it dissipate? It was a tactical decision,” Sherk said later.
“In hindsight, they should have closed the door when they left. The fumes would have released a lot slower,” Haneline said.
Then came the event that sent the situation out of control. About 8:30 p.m., the wind changed direction.
“It (blew) from the back of the building straight towards the hazmat rig,” Zuluaga said later.
Firefighters near the decontamination area noticed a smell. Initially, firefighter Mark Maderos, who was in charge of decontamination, believed the gas was coming off the moon suits of the firefighters who had capped the leak. He wasn't wearing a respirator.
The designated incident safety officer, firefighter Tom Owen, was standing nearby, also without his respirator, when he realized something had gone wrong. He went to the hazmat team.
When Zuluaga got out of his truck to check, Maderos ran by, going after the respirator he had left on his rig.
“Almost immediately, the chlorine detectors were in full alarm and I knew we had a big problem,” Zuluaga later recalled.
Chlorine eventually overcame nearly all of the firefighters who had gathered on Thorne Road, leaving them gagging, coughing and short of breath. Although none was kept at the hospital, paramedics gave many oxygen, records show.
“I was one of those people who got a snoutful. I couldn't stop coughing,” said Zuluaga, who was later promoted to battalion chief. He and Maderos, who coughed up blood at the hospital, were among the first firefighters rescued, according to Fire Department records.
Firefighters tried to move north, but realized their vehicles were pointed south. They backed some of them up, but temporarily abandoned others.
Three days later, firefighters held a meeting to go over what happened. A video camera recorded parts of the meeting.
“It's great seeing you all here as opposed to the alternative,” Haneline joked at the outset. Later, he acknowledged that Maderos was absent.
Haneline and others recalled the disorder and confusion of their escape from the poison gas.
“It really spooled out of shape when that wind changed,” said paramedic David Germain, who coordinated the rescue.
It was “such a light wind,” he said, and wondered aloud what might have happened if it had been stronger.
Haneline said a chlorine cloud followed the retreating crew north.
“There was no way to get out,” he said.
After 8:40 p.m.
Medic 3: “Levels at the corner of Maxwell and Thorne Road are untenable. We're movin' back to Ross.”
Incident commander: “Received. Everybody's moving back to at least Ross and Thorne Road.”
Medic 3: “We're going to have to evacuate those other businesses in that area.”
Langendorf, the fire dispatcher: “We're working on that right now.”
‘I WAS GETTING A LITTLE DIZZY'
Before the two firefighters entered the bleach plant at 8:03 p.m., others warned managers at two nearby businesses, U.S. Oil & Refining Co. and ABF Trucking, about the chlorine hazard.
At one point early on, Haneline, who was coordinating communications, said he was approached by a PABCO employee, who walked out of the shingle plant and asked what was going on. Haneline said he told the man there had been a chlorine leak and that it was going to be contained, but that for safety reasons it would probably be a good idea for PABCO employees to leave. The man from PABCO replied that they didn't want to abandon their production line, which could catch fire or explode.
Firefighters didn't attempt to notify other workers along Thorne Road and elsewhere on the Tideflats.
North of the bleach plant, Tideflats workers smelled the chlorine.
At Concrete Tech Corp., foreman Mike McLean said he was loading a barge on the Blair Waterway when he noticed an odor he didn't recognize.
“I was getting a little dizzy, a little light-headed, and I asked everybody else if they felt that way, too,” he recalled. About half an hour later, firefighters told workers at Concrete Tech to evacuate. McLean and about 20 others had time to drive away.
After the chlorine drifted out of the gas house, firefighters barged into the PABCO plant and ordered workers to leave.
“Everybody just rushed out,” said Lewis, one of about two dozen workers at the shingle factory that night. Firefighters didn't allow Lewis and others to go to their lockers to retrieve their car keys. They walked out in hard hats and coveralls.
“They had no evacuation plan,” Lewis said. “The Fire Department comes and tells us after the chemical has escaped. We should have been warned earlier.”
Lewis and three others walked about half a block before a deputy fire chief stopped to give them a ride.
“We breathed that gas at least a half hour, 45 minutes,” McElroy said. “It was just ridiculous. Almost everybody on our shift got sick.”
NO WORD FROM FIREFIGHTERS
At Penske Truck Rental, two businesses north of PABCO, lead mechanic Randy Smith and his crew of seven had trouble breathing. Earlier, Smith had seen the firetrucks pull up outside Pioneer. Authorities had closed both ends of Thorne Road, but side streets were open.
Firefighters never alerted Smith or his co-workers, he said. But as the evening wore on, their chests and throats burned. It got so bad, they finally closed the shop doors.
To find out what was going on, Smith punched numbers into his cell phone. First, he connected with someone at a fire station who told him the Pioneer problem was localized and that he shouldn't worry. When he tried to call emergency managers, he got a recording. Eventually, he reached a police dispatcher, who asked him his address. When Smith told him 1460 Thorne Road, the dispatcher told him to leave.
At that point, Smith stuck his head out the door to see what was going on. Firetrucks previously parked near Pioneer had backed up toward the port. Leaving his crew behind, Smith walked out on Thorne Road to make contact. A Fire Department aid unit came toward him. Inside were two men dressed in hazmat suits and wearing masks.
They picked him up and took him to East 11th Street, where a new command post had been set up. Smith told firefighters about his co-workers, and another aid unit returned to the shop for the men.
At 8:46 p.m., after the Fire Department's incident commander had pulled back to East 11th Street and Thorne Road East, he asked dispatchers to activate the Pierce County emergency alert system, which can send emergency messages to thousands of telephone numbers at once.
Almost two hours had passed since dispatcher Proper answered the call from the woman at the alarm company. About 25 minutes had passed since firefighters outside the bleach plant were exposed to chlorine.
At that point, the wind changed again. Firefighters knew the poison had escaped the gas house. But they weren't sure where it was.
Remaining hazmat team members moved to the Port of Tacoma Road/Highway 509 overpass, where gas monitors detected no chlorine in the air. The incident commander, still on East 11th Street, asked dispatchers to get Pierce Transit to send a bus for about 50 Tideflats workers who had gathered at East 11th Street and Port of Tacoma Road. It was about 9:15 p.m.
Medics continued to take exposed firefighters to hospital emergency rooms.
But Haneline, the incident commander, still didn't know how large an area had to be evacuated. He asked firefighter Ed Heileson, a hazmat technician, to work up a computer model.
At about 9:25 p.m., Heileson got on the radio and listed key intersections that defined the evacuation area: most of the Tideflats between Portland Avenue and Port of Tacoma Road.
“We're sending a scout to determine the edge of the plume as we speak,” he told the incident commander.
Haneline over the radio to Heileson: “We have a problem at the roofing company across the street from that plant. Their boilers are on and they could have a potential fire and/or explosion there. So that's all been evacuated and we need to get people in there as soon as possible to turn those things off. So if you can work up air monitoring or something there and we'll see if we can handle that problem, too.”
‘WE'VR GOT ZERO READINGS'
Two firefighters had already taken the chlorine monitors and headed out. On Dock Street, near downtown Tacoma, one detected nothing, then began working his way back to the area of the leak and PABCO, the shingle plant.
It was after 9:45 p.m. when Haneline called for another hazmat team from Puyallup.
“We need chlorine-monitoring meters is what we really need from 'em,” the battalion chief said.
Meanwhile, the firefighters with the two monitors continued surveillance.
“Are you able to monitor by that asphalt company?” Haneline asked via radio. “If we can get unprotected people into that plant, we need to get plant employees in to shut some of their equipment down.”
The two air-monitoring teams approached the engine-and-ladder truck left idling on Thorne Road.
“We're at the site walking around,” firefighter Pete Jasper radioed from PABCO. “We've got zero readings. If you want to escort those plant personnel in we can let 'em in to shut down their equipment.”
Firefighters asked dispatchers to relay a message to Tacoma police: Let the PABCO folks through police lines at Port of Tacoma Road and Highway 509. Soon after, firefighters on Thorne Road said they could see four or five vehicles approaching.
It was about 10 p.m., some three hours after the initial call, when Jasper got on the radio and reported that chlorine was still coming out of Pioneer Americas.
“If you can make contact with those (PABCO) plant people, make sure they get in and out as fast as they can,” Haneline responded.
Jasper continued to report that he could see chlorine puffing out of Pioneer, specifically from a vent on the south side of the gas house.
Two teams of Pioneer workers returned to the site accompanied by firefighters. They shut down valves connected to the 90-ton rail tank cars outside, then purged other lines.
At 11:32 p.m., the Coast Guard announced that the Port of Tacoma was closed and would be until morning.
Additionally, the Guard reported that seven Korean sailors from a ship called the New Giant, tied up on the Sitcum Waterway, had been taken to the hospital as a precaution. They were treated and released, officials said.
Ninety-five percent of the chlorine had dissipated, the Coast Guard said, based on Fire Department information.
After midnight, firefighters returned to Thorne Road to retrieve an abandoned engine-and-ladder truck, plus decontamination gear.
At about 2:30 a.m. the Fire Department declared the emergency over, but left dangerous concentrations of chlorine inside the gas house, which had been secured by plant workers and remained off-limits.
‘EVERYBODY FELT SICK'
Later in the morning, the gas had disappeared, but it had formed acids that damaged electrical contacts inside the building.
Because of repairs, Pioneer Americas did not immediately resume operations. Isaksson went through nearly a week of retraining before returning to work, said plant manager George Karscig.
On March 27, six weeks after the incident, state safety investigators questioned some of the firefighters exposed to chlorine. Everything firefighters did, they did right, said hazmat team member Melchiorre, according to a safety inspector's notes of the interview.
But firefighter Maderos said he still hadn't fully recovered. A day after he was exposed, he was still coughing up blood. Maderos and others were too close to the leak, the firefighter said, and he should have been wearing a respirator.
At Penske, “everybody felt sick for two or three days” after the accident, said Smith, the lead mechanic. A couple of his co-workers visited doctors, he said. Lewis said he was having trouble convincing state officials to recognize his chlorine-related workmen's compensation claims.
Since the accident, escape planning has become a frequent topic of conversation in the truck maintenance shop, said Smith.
“It's pretty scary,” he said. “Let's say something else happens, a natural disaster, terrorism. We are ill-prepared. The next time we're going to take matters into our own hands and get out of here. We cannot rely on the City of Tacoma to help us out. There's no way.”
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