Fluoride Action Network

Lancing. Documents: BWL took hours to call 911 after Wise Road incident

Source: Lansing State Journal | April 27th, 2014 | By Steven R. Reed
Location: United States, Michigan

2011 incident caused $23M in damage

Before the Wise Road Water Plant filled with a toxic yellow cloud, before employees risked their health obeying conflicting orders, and hours ahead of the evacuation of a south Lansing neighborhood, a gauge on a chemical tank provided the first sign of trouble.

On the July 2011 morning when he checked a holding tank to be sure it was rising with the delivery of thousands of gallons of bleach from the truck parked at the loading dock, Board of Water & Light plant operator Chris Thompson noticed the tank level inexplicably holding steady.

Filling in for the scheduled plant operator who had called in sick, Thompson — the only person on duty in the massive building — called a supervisor at the Dye Water Plant downtown. He asked about level indicators on the bleach tanks. Seconds later, the first whiff of the chemical cocktail bubbling up in the building got his attention.

As the whiff morphed into choking fumes and alarms began to sound, the danger became apparent even if its source was not.

According to the results of BWL’s internal investigation, released last week to the State Journal in response to a Freedom of Information request, Thompson rushed to the loading dock and realized the tanker truck was pumping its load of bleach (sodium hypochlorite) into the fluoride tank. It was an unprecedented error among U.S. water treatment plants, BWL’s water director would say later.

The proper response to an emergency chemical hazard, as specified in BWL’s Wise Road operating procedures document, is to evacuate the building, activate the fire alarm and call 911 before calling anyone else.

Starting at 8:06 a.m., call after call was made for hour after hour across supervisory levels and through BWL’s chain of command. Three calls in particular seemed to expose the utility’s culture.

BWL’s Human Resources Department was notified of the emergency at 9:10 a.m. and updated at 10:08.

No one called the Lansing Fire Department until 10:25 a.m. By then, three people were at or were being transported in a company vehicle to a hospital emergency room.

Firefighters took control of the plant at 10:33. The Metro Hazmat team was activated. Streets leading to the plant were blocked. Homes and a nearby community center were evacuated.

Until then, BWL’s sole first responder had even avoided using her self-contained breathing apparatus (SCBA) outside the building out of her concern neighbors might notice.

Until this month, details of BWL’s handling of the accident and its consequences — $23 million in damages plus citations and fines for serious workplace safety violations — were closely held within BWL. Many aspects were unknown even to the Board of Commissioners.

Though supplemented with recent interviews, this account of what happened on July 26, 2011 is based largely on BWL’s internal investigation.

Initial response

Water production shift supervisor Marilyn Olger was working downtown at the Dye plant when Thompson called at 8:04 a.m. about the tank levels and again two minutes later when he indicated something else was wrong.

She could tell he was having an adverse physical reaction to what was happening around him. She told him to evacuate the plant and she headed out the door for the six-mile drive to Wise Road, wondering as she drove if a line had broken.

She found Thompson leaning against the front door of the plant with an SCBA in his hand. She later told BWL investigators Thompson said he was OK and acknowledged he “simply messed up” by putting bleach in the fluoride tank.

Water production helper Alex Martin, who later drove from the Dye plant to Wise Road with more SCBA tanks and floor fans, said the delivery driver “seemed out of it and very lethargic and didn’t say anything.”

Thompson told Olger “only 15 gallons or so” of bleach had entered the fluoride tank. The amount later was determined to be 2,150 gallons. Olger told him to put on SCBA gear, go back inside the plant and unplug the fluoride pump to prevent possible contamination of the public water supply.

She watched from the back door as Thompson climbed the stairs and unplugged the pump. Outside, she told Thompson and truck driver Dan Wheaton to move away from the building. It was 9 a.m. — 54 minutes since Thompson’s distress call. The situation was far from under control.

Olger was calling and being called by various BWL supervisors, including shift supervisor Carrie Pung, who called Water Production Manager Tim Hyde, who instructed Pung to call Safety Department Supervisor Oscar Rodriguez-Franco, who told Pung to call Human Resources and to call Olger and tell her to ventilate the area.

Ventilating the plant involved opening the doors and keeping them open. Nevertheless, when Olger walked to the front door, she made “a conscious decision to not take a SCBA to the front of the plant to avoid alerting” neighbors.

Olger said she held her breath and positioned a cone to keep the door open. She saw a yellow-green cloud developing inside the main floor. She had never witnessed anything like it in her life, she said.

“Suddenly the wind picked up and the draft nailed her,” according to the investigative report. While ventilating the plant had been ordered at 9:10 a.m., “keep the gases contained” was Rodriguez-Franco’s instruction 25 minutes later. “He suspected that the Lansing Fire Department may need to be called,” according to the internal report.

That would not happen for almost another hour, after another call to H.R.

Authorities notified

An hour and a half after Thompson’s distress call, Olger still was the only person who had responded by coming to the plant. By 10 a.m., however, others — including the Dye employee bringing the fans that no longer would be used to ventilate the plant — had begun to arrive.

By phone from the Dye plant, Pung told Olger that environmental technician Fritz Domres was en route “to close the building down.” Olger donned an SCBA and closed the back doors to the plant. Still determined not to alert the community, she ditched the safety gear before heading around the building to close the front door.

Domres arrived and they agreed Olger would put on SCBA gear and close the front door. After she did that, Olger handed Domres the SCBA and rejoined Thompson and Wheaton. The three were driven to the hospital where Pung, carrying material safety data sheets (MSDS) for treatment of sodium hypochlorite and hydrofluorosilicic acid exposure, met them.

Andrew Wright, another environmental technician, arrived at Wise Road at 10:20 and consulted with Domres. They decided to call the fire department. First, they called Pung to inform her of their decision.

Finally, at 10:25 a.m., Wright made the call. Eight minutes later, BWL no longer was in control of its plant.

$23M in damage

BWL’s investigative report does not specify how many hours passed before anyone donned hazmat gear and entered the plant.

Water Director Dick Peffley told the State Journal last month that BWL employees entered after 12 hours to find the plant’s highly automated equipment ravaged by the corrosive cloud. Only in recent weeks was the plant fully restored. With the exception of the $500,000 deductible, the utility’s insurance company reimbursed BWL for all of the $23 million repair costs, he said.

The copy of the report provided to the State Journal did not specify the treatment Olger, Thompson and Wheaton received at the hospital. Peffley said Olger was kept overnight after she complained of a sore throat and that Thompson was examined and released.

“Nobody lost any time because of this incident for medical reasons,” Peffley said.

Thompson cooperated with the BWL investigation, but retired without ever returning to work. Olger returned to work but no longer is with BWL.

After investigating BWL’s operation of the plant and its response to the accident, the Michigan Occupational Safety and Health Administration cited BWL for 10 violations — seven deemed serious — and levied $13,700 in fines.

MIOSHA faulted BWL for not having an emergency response plan to handle situations such as the “uncontrolled release of chlorine resulting from the mixing of” bleach and fluoride. Ironically, when appealing the violations, BWL cited the existence of its emergency chemical hazard procedures policy that requires the Wise Road operator to call 911 before calling anyone else. The appeal was denied.

BWL Wise Rd Incident Investigation Report