An industrial painting contractor’s lack of training, planning and “zero” safety rating were among the “vital safety failures” that caused a 2007 plant tunnel blast in which five painters perished, the U.S. Chemical Safety Board has ruled.
The board said that the deadly flash fire Oct. 2, 2007, deep inside an Xcel Energy hydroelectric plant tunnel in Georgetown, CO, had been caused by:
- A lack of planning and training for hazardous work by Xcel and its contractor, RPI Coating, Inc.;
- Xcel’s selection of RPI, despite its having a the lowest possible safety rating (zero) among competing contractors; and
- Allowing volatile flammable liquids to be introduced into a permit-required confined space without necessary special precautions.
"This tragedy should never have happened," Chemical Safety Board member William B. Wark said in a statement Wednesday (Aug. 25), when the report was released.
“The companies did not effectively plan for the dangers of bringing significant amounts of flammable liquids into the tunnel, which was a hazardous confined space” said Wark. “Doing so was an unacceptable deviation from good safety practices."
The CSB also released a 15-minute safety video, No Escape: Dangers of Confined Spaces, which includes a detailed animation depicting the disaster that unfolded inside the mountain tunnel at Xcel’s Cabin Creek plant.
The accident occurred in the water tunnel, or penstock, of the hydroelectric plant 45 miles west of Denver. The penstock carries water from an upper reservoir to a lower one, driving power turbines. The RPI painting contractors were recoating a 1,530-foot steel portion of the 4,300-foot penstock when a flash fire erupted as vapor from a cleaning solvent ignited, probably from a static spark near the spraying machine. The fire quickly grew, igniting additional buckets of the solvent, methyl ethyl ketone (MEK), and other combustible epoxy materials stored nearby.
Ten workers were in the tunnel and one was at the entrance at the time of the fire. Five were unable to get around the fire on the painting platform to get to the only available exit—the improvised tunnel entrance. Five workers on the other side of the platform made it to safety, although three suffered injuries.
No Rescue Crews
The CSB also found that Xcel and RPI failed to have technically qualified confined-space rescue crews standing by at the penstock in case of emergency, as required by regulations. Workers called 911 for help, but responders entering the penstock had to retreat in the thick smoke, as did workers who had approached the fire with extinguishers.
The closest confined-space technical rescue unit was about one hour and 15 minutes away. The trapped workers died about one hour before this response unit arrived, their escape blocked by a steep vertical section of the tunnel deep inside the mountain.
“The five trapped workers communicated with co-workers and emergency responders using handheld radios for approximately 45 minutes, desperately calling for help, before succumbing to smoke inhalation,” said CSB Investigations Supervisor Don Holmstrom. “Their lives likely could have been saved had qualified, company-provided rescuers been in a position to respond immediately to a fire or other emergency.”
‘Stage was set for disaster’
Board member Mark Griffon said “the stage was set for disaster” even “before the operation began.”
“Xcel not only did not adequately plan for the operation, but it selected the painting contractor with the lowest possible safety rating among the bidders, and it did so mostly on the basis of cost,” Griffon said. “It was the lowest bid.”
Xcel hoped to compensate for RPI’s safety record by closely supervising the contract work, but it did not do so even after learning of safety issues during the initial penstock work, the investigation found.
Xcel and RPI managers were all aware of the plan to operate the epoxy sprayer in the tunnel and to use flammable solvent to clean the sprayer and other equipment, investigators said.
Numerous recommendations were made to RPI Coating, particularly regarding its confined-space entry program and guidance.
CSB investigators and board members cited difficulties encountered in the investigation resulting from efforts by Xcel Energy and RPI Coating to impede the investigation and prevent the release of the investigation report.
Citing a formal Letter of Admonishment sent to the Xcel chief executive officer earlier in the week, Wark said, “The lack of cooperation and efforts by Xcel to impede our investigation are unprecedented. Mr. Griffon and I join our chairman in criticizing these actions in the strongest terms.”
The letter, signed by CSB Chairperson Rafael Moure-Eraso, states Xcel Energy did not fully comply with CSB requests for documents or answers to questions in formal interrogatories. This required the CSB to seek assistance from the U.S. Attorney’s office in Denver, resulting in delays to the investigation and additional costs to taxpayers. In May, Xcel took the extraordinary and unprecedented step of going to federal court seeking to block release of the CSB report and the safety video. The court sided with the CSB in favor of release.
‘Disappointing pattern’ of conduct
Xcel was given an advance draft copy of the report in April to review for accuracy and for confidential business information in accordance with CSB review protocols. Xcel never responded, but released the draft to a news organization earlier this month, in violation of a confidentiality agreement attached to the utility’s receipt of the draft.
Moure-Eraso’s letter to Xcel’s CEO concludes: “In light of this disappointing pattern of corporate conduct, I am writing you directly to ensure that you are personally aware of the actions taken by Xcel to delay the CSB investigation, block publication of the CSB final report, and distort the conclusions of the investigation by releasing an unauthorized draft copy of the CSB report."
Recommendations for OSHA
CSB also had recommendations for other individuals and groups, including the governor of Colorado, the Colorado Public Utilities Commission, trade groups, and the U.S. Occupational Health and Safety Administration.
Although companies are required to perform a hazard analysis before issuing permits for work in confined spaces, regulatory standards pertaining to the use of flammables within confined spaces are inadequate, CSB said.
The agency urged OSHA to tighten its rule regarding hazardous atmospheres in permit-required confined spaces. The current standard “does not prohibit entry or work in confined spaces where the concentration of flammable vapor exceeds 10 percent of the chemical’s lower explosive limit, or LEL,” CSB said in a statement. The LEL is the concentration of vapor in air below which ignition will not occur.
“OSHA’s rule does state that an atmosphere exceeding 10 percent of the LEL creates an atmosphere ‘immediately dangerous to life and health’ and that steps should be taken to define safe entry conditions; however, the rule does not define what those safe entry conditions should be or specifically prohibit entry into such hazardous atmospheres,” CSB said. It urged OSHA to “establish a fixed maximum percentage of the LEL for entry so that work in potentially flammable atmospheres would be prohibited.”
Xcel said in a statement that the company has become increasingly careful about which contractors it hires and has beefed up oversight of contractors. The company also has increased safety training for its project managers and for contractors who work for Xcel.
"We have and will continue to work to prevent anything like this from happening in the future," the company said in the statement.
Nationally, the investigation identified 53 serious flammable atmosphere confined-space accidents that occurred from 1993 to April 2010, causing 45 fatalities and 54 injuries, the majority since 2001.
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. The board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.
Read the full CSB report here.