Written Testimony of U.S. Chemical Safety Board Chairperson Rafael Moure-Eraso at
March 6, 2014, Senate Environment and Public Works Committee Hearing Entitled
“Preventing Potential Chemical Threats and Improving Safety: Oversight of the
President’s Executive Order on Improving Chemical Facility Safety and Security”
Chairman Boxer, Senator Vitter, and distinguished Committee members – thank you for inviting
me today. I am Dr. Rafael Moure-Eraso, Chairperson of the U.S. Chemical Safety Board.
The incidents that we are discussing – Chevron, Tesoro, Freedom Industries, West Fertilizer, and
Williams Olefins – are tragedies of the kind that were preventable.
The United States is facing an industrial chemical safety crisis. As we near the one-year
anniversary of the West Fertilizer Explosion that fatally injured fifteen, I view my goal as
Chairman of the CSB as ensuring that progress is made to prevent similar catastrophes from
occurring.
I wish every American could hear the frustration and heartbreak that the CSB encounters – at
accident sites and at public meetings following these accidents. Workers, emergency responders,
and the public continue to die and suffer injuries in horrendous explosions and fires.
Estus Ken Powell, who lost his daughter Kathryn in the 2010 fire at Tesoro’s refinery in
Washington State, stood up at a recent CSB public meeting to demand action to stop these
horrible accidents. Mr. Powell said, “My life was forever changed. All I want to know is, does
anybody care? It seems we can get nobody to have any teeth in anything, to get anything done.”
Of course, we all do care. And we want to get something done, something with teeth. And I
believe what we need is comprehensive regulatory reform. But achieving safety reforms is
complicated and time-consuming. In the interim, I advocate that the Environmental Protection
Agency step in and use its authority under the Clean Air Act’s general duty clause to encourage
chemical facilities to take steps to make their operations inherently safer where it is feasible to do
so.
The law assigns owners and operators of these facilities a general duty to identify hazards, design
and maintain safe facilities and minimize the consequences of leaks. But most importantly, the
EPA should follow up by adopting specific regulations to meet those goals, so that there are clear
requirements on the books.
My testimony includes a number of examples where companies could have used available,
feasible, safer technologies to prevent disastrous accidents, but chose not to do so.
After the West, Texas, explosion, President Obama issued an executive order requiring federal
agencies to review safety rules at chemical facilities. I am encouraged by the leadership of the
White House on this issue, and I hope that regulatory agencies respond in kind. The EPA is
working with other agencies to comply, but in the meantime, the agency has the authority to act
now, on its own, to require inherently safer design, equipment and processes which would
significantly aid in preventing more catastrophes.

 Refinery Safety
In a draft report released to the public on December 16, 2013, the CSB proposed
recommendations for substantial changes to the way refineries are regulated in California.
Entitled “Regulatory Report: Chevron Richmond Refinery Pipe Rupture and Fire,” the CSB draft
calls on California to replace the current patchwork of largely reactive and activity-based
regulations with a more rigorous, performance-based regulatory regime – similar to those
successfully adopted in the aerospace and nuclear sectors in the U.S. and overseas throughout the
European Union including countries such as the United Kingdom, Norway, and Australia –
known as the “safety case” system.
The draft report is the second part of three in the CSB’s investigation of the August 2012 process
fire in the crude unit at the Chevron refinery in Richmond, California. That fire endangered 19
workers and sent more than 15,000 residents to the hospital for medical attention.
In response to the incident, the State of California established an Interagency Working Group on
Refinery Safety, an initiative undertaken by Governor Jerry Brown.
I would like to take this opportunity to heartily applaud the findings and recommendations
contained in the working group’s final report entitled “Improving Public and Worker Safety at
Oil Refineries.”
This report is an important milestone for improving refinery safety across the State of California
and effectively addressing many of the CSB’s safety recommendations contained in our Chevron
refinery accident report released in April 2013.
The working group’s final report includes a number of strong recommendations which are in
alignment with the CSB’s recommendations: that refineries should implement inherently safer
systems to the greatest extent feasible; use formal techniques to evaluate the effectiveness of
process safeguards to drive risk to as low as reasonably practicable (ALARP); and perform
damage mechanism hazard reviews to ensure corrosion hazards are accurately identified before
accidents occur.
Furthermore, the Working Group report recommends requiring companies to complete root
cause analyses after significant accidents or releases, to explicitly account for human factors and
organizational changes, and to perform periodic safety culture assessments.
Finally, the report indicates California will continue to pursue broader regulatory reforms,
including the “safety case” system.
California is also in the process of tripling its force of specialized refinery safety inspectors, an
initiative that is essential for the success of any regulatory system. We have made similar
recommendations to federal OSHA, but they have taken only small steps.
On January 30, 2014, the CSB released a draft final report on the April 2010 fatal explosion and
fire at the Tesoro refinery in Anacortes, Washington. The report found that the incident was

 caused within a heat exchanger, by a damage mechanism known as “high temperature hydrogen
attack” or HTHA, which severely cracked and weakened carbon steel tubing leading to a rupture.
The draft report proposes far-reaching recommendations to the federal Environmental Protection
Agency, the Governor, and State Legislature of the State of Washington to more rigorously
protect workers and communities from potentially catastrophic chemical releases.
The accident at Tesoro could have been prevented had the company applied inherent safety
principles and used HTHA-resistant materials to prevent the heat exchanger from cracking. This
accident is very similar to the one that occurred at the Chevron refinery where corroded piping
failed catastrophically. The company was made aware of the corrosion, but didn’t take the
necessary steps to replace piping with inherently safer, corrosion-resistant materials. As a result,
19 refinery workers lives were endangered and more than 15,000 California residents sought
medical attention at hospitals.
Companies must do a better job of preventing refinery accidents, which occur all too frequently.
At both Tesoro and Chevron, warning signs were ignored over many years, and opportunities to
prevent accidents by implementing inherently safer designs were missed.
Our investigations have concluded that fundamental changes are needed. Our board tracked 125
significant refinery incidents in 2012 alone.
Chemical Safety Board investigations show state and federal regulators are not able to ensure
safety at refineries. They are under-resourced, outgunned by a powerful industry that seeks to
blunt and sometimes even roll back the already inadequate regulatory system in the U.S.
Freedom Industries
I will now discuss the CSB’s activities in Charleston, West Virginia – specifically in relation to
the release of hazardous chemicals into the water supply of about 300,000 residents in nine
counties.
First, I think it is important to discuss the history that the CSB has had investigating accidents in
West Virginia’s Kanawha Valley, a center of the state’s chemical enterprise. This is our third
deployment to a major chemical incident in the valley. In 2008 two workers were fatally injured
at the Bayer CropScience chemical plant in Institute, West Virginia, when a waste tank
containing the highly toxic pesticide methomyl violently exploded. Then in 2010, three
incidents occurred in a thirty-three hour period at the DuPont facility in Belle. There was a
release of highly toxic phosgene, which exposed a veteran operator and resulted in his death less
than one day later.
Following the CSB’s investigation into the Bayer and DuPont incidents the board recommended
that the county, working with the state, establish a hazardous chemical release prevention
program to enhance safety and optimize emergency response. The CSB recommended that the
health department establish an industrial safety authority, paid for using fees assessed on the
companies processing or handling potentially dangerous chemicals. As an example, we cited the
program in California's Contra Costa County, which has an equally dense industrial/chemical

 base. Although this was not immediately adopted in West Virginia, the legislature there is now
considering this approach in the wake of the Freedom Industries incident.
The CSB’s previous recommendations in West Virginia were aimed at empowering a
government agency to determine just what posed a high hazard. Perhaps qualified inspectors
would have considered pre-World War II vintage chemical storage tanks, located just one and
one-half miles upstream from the intake of a public drinking water treatment plant, to be
potentially “highly hazardous” and worthy of a closer look.
All of us here today are all too aware of the recent events that occurred at Freedom Industries.
On January 9, 2014, a 46,000-gallon steel tank experienced a leak of up to 10,000 gallons of
crude 4- methylcyclohexane methanol (MCHM) with an estimated 5.6% PPH, a poly glycol
ether. A significant amount of the chemical was released into the Elk River, a tributary to the
Kanawha River.
The CSB’s preliminary research indicates that there is a gap in the regulatory framework
covering aboveground chemical storage tanks.
In October of 2013, at the request of the company, Tank Engineering and Management
Consultants performed a review of the tank terminals located in Charleston and Nitro. The
evaluation was conducted and approved by an API-653 and 570 certified inspector, who also was
credentialed as a National Association of Corrosion Engineers (NACE) Certified Corrosion
Technologist. The review notes that the substances stored in tank 396 are considered “non
hazardous” by the Environmental Protection Agency and are therefore not regulated by the
federal Spill Prevention Control and Counter Measure Program, or SPCC rule. The review
further notes that the tanks have “been maintained to some structural adequacy but not
necessarily in full compliance with API-653 or EPA standards.” API-653 is considered the
prevailing voluntary good practice for aboveground storage tank (AST) inspection, repair,
alteration and repair, and was developed to establish a uniform national program that assists state
and local governments in AST regulations.
API 653 covers basically every age related damage mechanism known, including but not limited
to corrosion, brittle fracture and improper fabrication.
While EPA’s SPCC rule outlines requirements for prevention and preparedness of oil discharges
such regulations do not apply to tanks containing “non hazardous substances” like those found at
Freedom Industries. Under existing state and federal laws these tanks, including tank 396, were
not regulated by the state or federal government.
Moving forward the CSB will closely examine tank 396. We plan to complete a thorough
internal inspection of the tank to determine the tank’s condition and wall thickness at the time of
the incident. We will also examine tank design, materials of construction, inspection practices,
state and federal oversight of similar tanks as well as existing industry best practices. The tanks
in use at Freedom Industries were over one-half century old. Considering the best way to
improve the safety of tanks at facilities that have similar tanks in use is an important issue that
needs to be addressed.

 In addition to looking at the causes of the tank failure itself, the CSB team will also examine the
response to the leak once it was discovered. We are particularly interested in the adequacy of
information on MCHM and PPH hazards since the manufacturer’s material safety data sheet
repeatedly says “no data available” for numerous toxicological properties, especially chronic
toxicity.
Having information readily available for the public is an issue we will be further examining in
regard to ongoing reform of the Toxic Substances Control Act.
Emergency responders, local officials, regulators and public utilities must be provided the proper
information in order to protect the community from potential risks, and more than providing
information, there needs to be an obligation to require preventative measures.
I would like to also take this opportunity to strongly commend Senator Manchin, Senator
Rockefeller and Senator Boxer for promptly introducing legislation aimed at safeguarding water
supplies from chemical leaks. Modern standards are strongly needed in this area. I encourage
any effort, any legislative reform to follow the basic framework of accident prevention, known as
the hierarchy of controls – which is an effectiveness ranking of techniques used to control
hazards and the risk they represent. The further up the hierarchy, the more effective the risk
reduction achieved. In brief, the most effective accident prevention measures typically involve
what is called inherent safety. I realize this is a term that has drawn some controversy, but it is
really just a well-established industry- developed concept that focuses on prioritizing the
elimination of a hazard, or minimizing it. And, it looks to inherently safer chemical processing
and equipment design. For chemical storage tanks like this, the first question that should always
be asked is, do they need to be near the water supply for some reason? Unfortunately in the case
of Freedom Industries, the answer would have been “no.” The facility was simply a truck
terminal, and its position alongside the Elk River just upstream of the water intake had tragic
consequences. The facility just did not need to be where it was. And although relocating it
would have had some costs, those pale beside the costs that hundreds of thousands of West
Virginia residents and businesses are now paying for this disaster.
Another form of inherent safety, or safety in design, is using corrosion-resistant materials for
tank construction. That is something we will need to explore further, as we determine the failure
mode for this particular tank.
Moving down the hierarchy are engineering solutions that don’t eliminate the risk of an accident
but make it far less likely. These may include double-walled tank designs, leak detection
systems, and secondary containment structures like dikes and liners. A large segment of the
industry has moved in this direction over the many decades since the Freedom Industries tanks
were constructed.
Finally near the bottom of the hierarchy are measures such as inspections for corrosion or other
potential failure mechanisms. Now, inspections are absolutely essential in any sort of hazardous
process operation or storage site. But I would caution that, according to the hierarchy of
controls, they are among the least effective of safeguards. Hazards can be missed in inspections
– we see that frequently at the CSB. The effectiveness of inspections totally depends on the skill
and thoroughness of the inspector. And of course, there can be significant time intervals

 between inspections, and bad things can happen during those periods. So inspections are
essential, but they are not a complete solution by any means. What is needed – and what I hope
this legislation leads to – is a holistic approach to preventing these incidents.
West Fertilizer
The CSB has determined that ammonium nitrate fertilizer storage falls under a patchwork of U.S.
safety standards and guidance – a patchwork that has many large holes.
These holes include: the use of combustible wooden buildings and wooden storage bins,
sprinklers are generally not required, and no federal, state, or local rules restrict the storage of
large amounts of ammonium nitrate near homes, schools and hospitals.
A joint chemical advisory issued in August of 2013 by OSHA, EPA and ATF entitled Safe
Storage, Handling, and Management of Ammonium Nitrate is an excellent step forward in
addressing the hazards associated with the storage of AN, but the current regulatory coverage is
still in need of reform.
Fire codes have some useful provisions for ammonium nitrate. But they need significant
revision to strengthen the storage requirements for AN. Even if they were revised, we note that
Texas and most of its counties have no fire code. So at West, these fire code provisions were
strictly voluntary, and West Fertilizer had not volunteered. Almost a year later Texas and its
rural counties have not adopted a fire code.
OSHA has some similar provisions for ammonium nitrate fertilizer in its Explosives standard,
1910.109. However, OSHA has not focused extensively on ammonium nitrate storage and
hadn’t inspected West since 1985. It appears that few if any retail fertilizer operations have ever
been cited under this standard, and its provisions for fire protection are less rigorous than those
followed overseas for AN.
Other nations have gone much further than the U.S. on ammonium nitrate safety. The UK
recommends dedicated, noncombustible storage buildings and noncombustible bins. The U.S.
manufacturer, CF Industries, recommends the same and urges sprinklers as well.
But the fertilizer industry tells us that U.S. sites commonly store ammonium nitrate in wooden
buildings and bins – even near homes, schools, or other vulnerable facilities. This situation must
be addressed.
Preventing the risk of fire essentially eliminates the potential for an explosion as we saw in West,
by removing one of the preconditions for detonation.
Facilities like West fall outside existing federal process safety standards, which were developed
in the 1990’s and are list-based.
Ammonium nitrate would likely have been included, if the EPA had adopted our 2002
recommendation to cover reactive chemicals under its Risk Management Program.
Williams Olefins

 The Williams plant has over a hundred workers, producing ethylene and propylene.
On June 13, there was a catastrophic failure involving a heat exchanger and associated piping
which broke loose from a distillation tower. The ensuing explosion led to the deaths of two
employees.
The CSB found that the 46-year old heat exchanger did not have adequate pressure relief and
over-pressured, possibly due to problems with the materials of construction.
In collaboration with the company and OSHA the CSB has concluded its first round of
metallurgical testing on the exchanger metal. We’ll be looking at whether inherently safer
materials of construction should and could have been used in preventing this accident. The CSB
plans to publicly release a report on this testing in the next few months.
The CSB investigation is also looking into potential failures of regulatory enforcement at the
Williams plant as well as industry standards and regulations. Process safety management
systems at Williams are being examined and will be included in the final report.
Concluding Remarks
The bigger picture in process safety is that EPA and OSHA resources are under duress.
Regulations need to be modernized – but more inspection and prevention are needed as well.
In the meantime, I hope that the committee will find recent developments in California extremely
encouraging.
California’s decision to triple the number of dedicated process safety inspectors – funded by
industry fees – is an extremely progressive and important step to ensuring a well funded
regulator.
Another promising approach is the “safety case”– successfully used by the nuclear and aerospace
sectors in the United States and by European countries in the refinery sector – which insurers
say have much lower petrochemical accident rates than we do.
Many experts believe this is the best safety regime for complex, technological industries, rather
than the U.S. system which calls upon a prescriptive and often outdated rule book that is
incapable of adapting to new technology and identified hazards, until the next catastrophic
incident occurs.
Thank you again for the opportunity to testify today.