After the tragic explosion at the West Fertilizer Company (WFC) in April, 2013, I wrote that it would take months for experts to conclude what went wrong at the facility in West, Texas (see “Initial Observations on West Communications”). Now, nearly three years later, the U.S. Chemical Safety and Hazard Investigation Board (CSB) has completed its work.
A key CSB finding was that the high number of fatalities and injuries was due, in part, because the emergency personnel who arrived to battle the fire did not follow established response procedures during the critical minutes before the explosion. Of the 15 fatalities, 12 were first responders.
“CSB found that none of the responding emergency response personnel trained and certified in the National Incident Management System (NIMS) process formally assumed the position of Incident Commander (IC) …” The lack of an IC, a trained leader to take charge, resulted in the Incident Command System (ICS) not being followed, which was the presumed cause of the public emergency alert system not being activated before the explosion.
In the absence of an evacuation order, many of the nearby residents were left unaware of the risk and chose to watch the fire from inside their homes or vehicles or from the street. When the explosion occurred, many of the more than 260 people injured were hit by the blast wave and flying debris.
“If the West firefighters had executed a planned, tested, and practiced ICS and incident management plan,“ the report said, “the number of injuries and casualties sustained by both responders and neighboring residents could have been reduced.”
The CSB’s report also faulted the lack of adequate land use policies. “The WFC incident in West serves as yet another unnecessary and deadly reminder that little has been done to address the risks of locating communities near facilities handling hazardous chemicals such as FGAN (fertilizer grade ammonium nitrate). This incident represents a microcosm of the potential harms that many communities across the nation could endure.” In Texas alone, there are 24 FGAN facilities located a mile or less from a school.
Houston Chronicle reporters Mark Collette and Matt Dempsey concluded that the CSB report “has major implications for the entire U.S. chemical industry, finding fault with multiple state and federal agencies and holes in regulations that allowed one of the state’s worst industrial accidents to kill so many people, injure hundreds and level much of a town.”
Collette and Dempsey have been pursuing a story for months on chemical plant safety in the greater Houston area, a story they say is still in the works.
Click on the following link to view the CSB final report. (PDF)