Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities (2002) / Chapter Skim
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2. Causal Factors in Events at Chemical Demilitarization Facilities
2. Causal Factors in Events at Chemical Demilitarization Facilities
Pages 17-25
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From page 17... ...
~ The following definition was developed by the committee and used for the selection process: iThe committee's purpose in reclassifying chemical events was solely to assist in selecting the events that it would review, and not to "secondguess" the Army's classification system. 17 Chemical event: Any incident associated with chemical demilitarization operations that resulted in an actual or potential release of chemical agent.
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Those concerns included six chemical events the commissioners wished the committee to evaluate. They also requested that the committee evaluate events described or concerns raised by groups of concerned citizens.
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Deactivation furnace system (DFS) DFS waste bin During processing of GB rockets the DFS interlock shut off all burners due to pollution abatement system air flow meter failure.
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The conclusions of the investigation team as summarized in the report were: "The process of sending VX contaminated liquid and saturated spill pillows to the DFS in excess of the decontamination capability of the furnace system appears to be the major cause of the chemical event. There are no other scenarios consistent with the physical evidence observed in bin 135 that could have resulted in the agent levels thatwere recorded during this chemical event.
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About 10:00 PM the DFS burners were automatically shut down and operators locked out by a malfunction signal sent by the DFS exhaust flow meter. While seeking approval to by-pass the lock out of the burners and restart the afterburner, the common stack automatic continuous air monitoring system (ACAMS)
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From page 22... ...
Causal Factors The committee's analysis of the seven chemical events listed in Tables 2-1 and 2-2 showed that there were multiple causal factors for all of the selected events. (Note: the committee could determine causal factors only for incidents for which sufficient investigation data were available.)
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In several incidents examined by the committee, entrainment of agent into nonagent areas by personnel leaving a demilitarization protective ensemble entry could have been avoided if a timed interlock had been designed into transitional airlocks to ensure sufficient purging of airlock. Design deficiencies were found to have contributed to six of the seven incidents reviewed by the 23 committee and to at least five others.
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In particular, the committee saw little evidence of the use of formal methods, such as event tree analysis, and little involvement of human factors engineering even though most of the incidents reviewed by the committee had a component of human behavior as a causal factor (see Table 2-4~. The committee found inconsistencies in the form and format of investigation reports within and between chemical demilitarization sites.
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niques can be greatly reduced, if not eliminated, through the development of a strong safety culture in the chemical demilitarization work environment. The "crying wolf" phenomenon of a decreased willingness to respond after repeated false alarms is an expected, and sensible, human behavior, but one that must be discouraged in chemical demilitarization operations by appropriate training and a recognized reward structure.
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