May 16, 2005, 12:35AM


Murky stats mask plant deaths

Government safety figures are misleading on contract workers at U.S. refineries


Long considered one of the nation's most dangerous industries, oil refining suddenly seemed one of the safest when the U.S. Bureau of Labor Statistics reported no refinery deaths in 2002 or 2003.

But at least nine people were asphyxiated, burned or fell to their deaths at our nation's refineries during those years, according to a Houston Chronicle review of media accounts, industry statistics and fatal accident reports to the Occupational Safety and Health Administration.

Twenty more have died since then 15 in the March 23 BP Texas City accident alone.

How do the refinery dead disappear?

The answer is fairly simple.

Increasingly, the accuracy of government safety statistics is undermined by the changing work force. These days, up to half of refinery workers are contractors, who generally get some of the most dangerous jobs.

Since these folks do not work directly for petroleum companies even though some toil for years at the same refinery their deaths get diverted to several catch-all construction or maintenance categories, such as "1799, Special Trade Contractors, Not Elsewhere Classified."

"They'll show up in the statistics but not as refinery workers," explained retired Bureau of Labor Statistics (BLS) economist Guy Toscano. "The more dangerous an occupation, the less likely a company would want to hire those people directly they want to boost their own safety rates and decrease their liability."

Nor are such deaths generally counted in the refineries' individual injury and accident logs, which OSHA uses to determine its "hit lists" of dangerous facilities targeted for more frequent inspections. The way the U.S. safety statistics are kept, a work site will not generally get a black mark if contractors from other companies are killed or injured there only if a permanent employee dies or gets hurt.

For former OSHA Administrator Patrick Tyson, that's a real hole in the workplace safety net. Without contractor fatality and injury data, OSHA inspectors may not pick up a problem refinery, said Tyson, now a safety consultant with the Altanta firm of Constangy Brooks & Smith.

"If the site gets picked up, it's going to be almost a fluke," Tyson said.

John Miles, the OSHA administrator for the five-state region that includes Texas, agreed in an interview that reporting that emphasizes the employer over the site of an accident can affect OSHA's ability to both find and target dangerous businesses in some cases. But he said right now no one is pushing for reforms in the reporting system.

Even though it's contract workers who are often injured or killed, refinery employees are often intimately involved in creating or monitoring working conditions.

Not a 'refinery death'

Michael Law, 22, was one of two people who died at the Valero refinery in Corpus Christi in the last four years though neither was recorded as a refinery death in OSHA logs.

On the day he died in February 2004, Law, a League City resident and employee of Cat-Spec in Houston, had been assigned to clean a vessel used for storing liquids.

Valero and Cat-Spec officials, who settled a lawsuit over the death last week, refused to comment on the incident. His widow's attorney, Craig Sico, provided this account of what happened next:

A monitor inside the vessel checked the levels of oxygen, carbon monoxide and hydrogen sulfide. The readings were good, so Law's supervisor and a Valero safety official authorized him to enter wearing a half-mask to protect against dust.

The interior of the vessel was dark, so Law asked a colleague to help hold a light as he vacuumed the vessel. After 45 minutes, both had enough.

Law's colleague got out but Law got within 8 feet of the exit and slipped off the ladder.

A "confined space permit" issued for the job required Law to have a retrieval device that would haul him out quickly in an emergency. By its own policies, Valero was supposed to inspect that equipment.

That didn't happen.

Instead, Law was wearing a "yo-yo" equipment used to arrest a fall.

Plant employees realized Law was in trouble and called for an ambulance. Several Valero employees went in after Law, but it took about an hour to get him out, Sico said.

By that time, there were no signs of life. An autopsy report showed that Law died from hyperthermia and dehydration.

A Valero spokeswoman, Mary Rose Brown, said the death had nothing to do with refining processes or operations. "There were complicating personal issues about this incident" that she could not divulge, Brown said.

OSHA officials said their investigation of Cat-Spec's role in Law's death is not yet complete.

In refineries, contractors are often assigned to do the most dangerous jobs, including maintenance "turnaround" cleaning and repairing and restarting equipment as well as hot work, like welding. Some are self-employed who are exempt from many OSHA rules.

If the usual guidelines are followed, none of the 15 people who lost their lives in the refinery fire in March in Texas City one of the worst refinery accidents in decades would be counted as refinery deaths since none worked directly for BP, the refinery owner.

In fact, if at the end of this year, only small numbers of deaths at refineries nationwide are left over after contractors are taken out say less than three the BLS would again report no deaths at all. That is to protect the privacy of the families of those who died and to honor confidentiality agreements made with states that provide the data.

Even industry groups such as the National Petrochemical and Refiners Association recognize holes in the BLS statistics. The association has asked for information about contractor deaths, injuries and illnesses in its own annual surveys since 1999. The association says its statistics are more complete than those kept by the government.

"Our members can benchmark their facilities against others in the industry using our statistics," said Tom Wigglesworth, who oversees surveys for the refiners association. "They can say I want to be as good as whomever they choose."

Data unavailable to public

But the NPRA does not provide its statistics on individual refineries to the public. And in recent years, 20 percent to 30 percent of refineries did not submit data. Over the last decade, NPRA surveys recorded fewer deaths than the Chronicle found in public records in every year except 2004.

Back in 1987, the Keystone Center in Colorado convened 46 people from labor unions, corporations, health professions, government and academia to discuss how to fix underreporting and other problems in the government statistics.

One of the problems they zeroed in on was the lack of accident information at specific sites, so they recommended requiring workplace-based logs to better reflect the safety record of construction contractors.

The AFL-CIO later encouraged OSHA "to (e)xpand this recommendation to all industries ... Many of the major chemical explosions and fatalities at steel mills, power plants and paper mills have been related to contract work. With more and more businesses contracting out services for on-site activities, the safety and health concern associated with these practices is growing."

OSHA staff recommended site logs in 1996, but six years later, the proposal died, in part because of industry opposition.


 Copyright 2005 Houston Chronicle


May 21, 2005, 8:37PM


Investigator answers call

Texas City blast inquiry is another challenge for 'safety theologian'


Plunging headfirst down Idaho's white-water rapids in a kayak may not seem a likely pastime for someone who preaches safety.

Neither does hiking the entire Continental Divide or hunting buffalo in South Dakota.

Despite his appetite for adventure, federal investigator Don Holmstrom has an uncommon passion for safety for workers and the public, if not himself that surpasses even his love of the great outdoors, those who know him say.

"It's his religion," said Leslie Moody, executive director of the Denver-based Front Range Economic Strategy Center, which works to strengthen public safety policies and practices in Colorado.

Holmstrom, 53, was the group's director of policy and training when he was chosen last month by the U.S. Chemical Safety and Hazard Investigation Board to lead the inquiry into the deadly BP Texas City refinery blast.

The March 23 explosion, the worst U.S. refinery accident in recent memory, killed 15 people and injured more than 170.

The CSB, once dogged by internal problems of its own, said it wanted the most experienced person it could find to lead the high-profile inquiry.

So the agency made a beeline for Holmstrom, who had worked for the CSB before and had key roles in two other refinery accident investigations.

"I always talk about Don as kind of our safety theologian," CSB chairman Carolyn Merritt said. "By that I mean that he has insight into the causes of accidents and what happened that goes far beyond the individual. He's able to look from 30,000 feet and see lots of different system issues that are involved in accidents."

For his part, Holmstrom says that even though he was reluctant to leave his beloved Colorado, he couldn't turn it down.

"This was a horrible disaster," he said. "And it was an opportunity for me to come back and serve my country and address safety on a scale I had not before."

Change of scenery

Now his temporary home is Texas City, where he's leading a team of investigators and consultants. They're analyzing blast patterns, interviewing witnesses, scouring control room records, reviewing plant designs and culling hundreds of pieces of physical evidence trying to determine why a section of the refinery's isomerization unit exploded. And why so many people died as a result.

In the end, Holmstrom will deliver to the board a comprehensive, root-cause report due out in about a year that already is expected to contain significant safety recommendations to not only BP but also the chemical industry.

"This is an investigation that has international interest," Merritt said. "Fifteen people died here, and it is an outrage. I think this is one of the things that brought Don back to us."

Holmstrom graduated in 1974 from Stanford University with majors in biology and English, then attended the University of Colorado School of Law, earning a degree in 1978.

Rather than go to work for a big law firm, however, he took a job as an operator at the Ultramar Diamond Shamrock refinery in Denver.

The flexibility of his position allowed him to travel throughout the West pursuing his passion for kayaking and other outdoor adventures. Meanwhile, he learned the ins and outs of refinery operations.

In 1986 Holmstrom began practicing law part-time, representing workers in employment, health and safety matters.

Union roots

He also became increasingly involved in the Oil, Chemical and Atomic Workers International Union, and became president of the Denver local in 1990.

During that time he was a high-profile voice for workers and focused heavily on worker safety issues, according to those who knew him then. He led several accident investigations at the Denver refinery, helped develop a process safety training program, and worked with the company to develop the first process safety management committee representing both union and management. He ultimately was promoted to chief operator.

"He is basically dedicated to better health and safety conditions for workers and the public," said Mike Sprinker, director of health and safety for the International Chemical Workers Union Council. "Plus, he is a very fair and objective person."

During his tenure as local union president, Holmstrom pushed for funding of the CSB, which had been created under the 1990 Clean Air Act but had received no federal money. Union and industry representatives alike supported creation of the CSB, and it was formed to conduct independent investigations of chemical accidents much like the National Transportation Safety Board investigates airplane crashes.

Like the NTSB, it cannot issue fines or citations, but it can make recommendations to companies, lawmakers and others to try to prevent similar accidents.

President Clinton was preparing to abolish the agency altogether when, under pressure from Congress and others, he agreed to finally fund it in 1998 with an initial allocation of $4 million.

The next year Holmstrom was recruited to work for the agency. Over the following four years he held several positions, including accident investigator, and helped develop its recommendations program.

Rocky start

But those early years were ugly for the fledgling agency. Political infighting among the board's five members, appointed by the president, prompted a scathing General Accounting Office report in 2000.

Among the findings were an unacceptable backlog of investigations, questionable spending and the lack of basic policies and procedures.

The board was revamped soon after the report was presented to a congressional subcommittee, and the agency began to turn around. While it had completed just one investigation in 1998 and two each in 1999-2001, it closed eight in 2003 and four more in 2004. It has 11 open investigations, including the BP blast and a tank explosion at the Marcus Oil and Chemical facility in Houston in December.

"It took them three or four years, but they finally hit their stride," said Scott Berger, director of the Center for Chemical Process Safety, noting that the CSB budget remains modest at $9 million. "If you think about what they are doing with the resources they they've got, I think they're doing darn well."

Gerald Poje, a former CSB member who stepped down in November, said Holmstrom was a valuable, reliable staff member during those initial rocky times.

"I thought that Don did a fair amount of good work analyzing the physical factors and the human factors involved in accidents," he said. "He played an important role in the resetting of the ship."

Making changes

Holmstrom led the investigation into a 1999 fire at the Tosco Avon refinery in Martinez, Calif., and he developed the recommendations following the investigation of a 2001 sulfuric acid tank explosion at the Motiva Enterprises refinery in Delaware City, Del.

He also helped develop far-reaching recommendations to New York City officials following the CSB inquiry into the 2002 explosion of a Kaltech Industries facility. Those led to a revamp of the city's 85-year-old fire code.

"Their recommendation to do a major revision of the fire code was embraced not instantaneously but fairly quickly here in New York, and that is not an easy thing to do," said Jonathan Bennett, a spokesman for the New York Committee for Occupational Safety and Health. "I can't imagine the fire code would have been amended had they not made that recommendation."

Other work by the CSB also has drawn praise.

The Tosco report, which criticized management oversight, was one of the most thorough of several generated by local, state and federal governments on the accident, said California lawyer Gary Gwilliam, who represented an injured worker.

"It didn't pull any punches," he said.

Gwilliam said he also had personal contact with Holmstrom, whom he called "not only very thorough but very sensitive to my client, who had been badly burned."

Stronger standards

Holmstrom left the CSB in the summer of 2003 to return to Colorado, where his daughters had decided to attend college. It wasn't long before he was recruited by Moody to work for Front Range.

While there, he organized more than 50 organizations to campaign for stronger state standards for the cleanup of the toxic chemical trichloroethylene, Moody said. And he helped persuade the University of Colorado to establish safety and environmental criteria in selecting construction contractors for a $400 million law school.

He was in the middle of other projects when in early April he got the call from the CSB.

Now back in his role as a neutral federal investigator, some in the industry wonder whether Holmstrom's strong union background will prevent him from being fair to manage- ment.

"I think that could influence how he looks at a job," said one industry source who knows Holmstrom but asked not to be named.

BP officials say they aren't worried that he won't give them a fair shake.

"We have not seen, nor are we looking for any reason to question the fairness or the objectivity of either agency or members of the investigation teams," BP spokesman Hugh Depland said.

Holmstrom offers reassuring words of his own.

"I think I am uniquely situated to be evenhanded," he said. "I worked in the industry for 18 years. I have been a union member, and I have worked with community groups. So I think I have seen perspectives from all sides."


  Copyright 2005 Houston Chronicle


May 24, 2005, 10:32PM



BP says its initial findings misstated

Employee error only partly to blame, company officials now say


BP backed off statements made last week that the root causes of its deadly Texas City refinery explosion were that workers weren't following procedures and supervisors were lax.

While those were indeed critical factors leading to the blast, they were not the deeper causes, as the company had said in releasing its interim report on the accident a week ago, BP spokesman Hugh Depland said.

"We simply used the wrong language to describe the report's findings," he said. "Our fault."

The true causes have not yet been identified, he said.

Fifteen people were killed and more than 170 injured in the blast, the worst United States refinery accident in recent memory.

Last Tuesday, BP Products North America President Ross Pillari said the company was releasing its interim report because he did not expect its ongoing inquiry "to change the root causes of the accident" being made public that day. He went on to describe operational and supervisory failures by workers.

Two days later, Depland reiterated, "The primary root cause was a failure to follow operating procedures and a failure of supervision."

Those statements, and the company's decision to fire several of the operators and supervisors, have prompted angry reactions from union leaders, victims and others. They said it appeared the company was laying blame at the feet of low- and mid-level workers while sidestepping broader responsibility for more systemic management problems, such as a lax attitude toward safety.

'Underlying root cause'

The Houston Chronicle reported Friday that BP's finding of worker error was at odds with guidelines of the nation's largest and most respected chemical safety organization.

According to the Center for Chemical Process Safety, citing workers "is a common premature stopping point" and "not a root cause, but instead a symptom of an underlying root cause."

The chairman of the subcommittee that developed those guidelines was then-BP executive Michael Broadribb. He is serving as a "root cause specialist" in the BP investigation.

Late Monday, Depland said via e-mail that he had consulted with Broadribb and that the company had used "some incorrect language."

"He told me the interim report has not identified root causes," Depland said. "The issues the team has identified are listed in the report as 'Provisional Critical Factors.' "

Some BP critics said Tuesday that the company is apparently backpedaling.

"They got called on it," said Houston attorney Rob Ammons, who is representing dozens of injured workers and families of those killed. "It was a botched public relations stunt."

Gary Beevers, region director of the United Steelworkers, said the real root causes for the fatal blast lie in management's decisions to overlook major safety issues raised for years by the union and others.

"As far as I'm concerned they tried to put the blame on lower-level workers and make them scapegoats," Beevers said. "We are going forward with our own investigation."

The blast occurred just after lunch as workers were restarting a section of the refinery's so-called isomerization unit after a maintenance turnaround.

The unit produces chemicals used to boost the octane of unleaded gasoline. The start-up of a unit is considered one of the most dangerous times in refinery operations.

According to BP, operators who weren't following procedures allowed hydrocarbons to flow too quickly into a raffinate splitter tower, where they were then heated too quickly. That caused the materials to overpressure and then flow into a relief area called a blowdown drum. When that quickly filled, the hot flammable hydrocarbon then filled a vent stack, causing the liquid and vapors to flow onto the plant grounds.

A truck, electrical switch or other electrical source then ignited the liquid and vapors, creating a blast heard and felt up to five miles away.

A fireball rolled over a nearby construction trailer, killing most of those inside.

Union officials have said they expressed concerns about the location of the trailer as well as BP's use of the vent stack as opposed to a flare system. Had a flare been in place, the excess liquid and vapors likely would have been burned off and the accident may have been prevented.

Management not blamed

BP said it is implementing new policies to locate trailers away from process units and to replace vent stacks with flare or closed systems.

But it stopped short of saying that the management erred by not doing so earlier and said that safety reviews did not consider that workers and supervisors would have so seriously ignored company procedures.

Officials with the U.S. Chemical Safety & Hazard investigation Board have said their own independent investigation has focused on BP's decision to continue using the vent stack.

They also have said they are examining the company's decision to place the doomed construction trailers so close to the isom unit, as well as its training practices.