Tragedy in West - Part II

February 04, 2016 at 1:00 PM

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)

Tags: crisis prepared NIMS ICS preparedness safety
Category: Articles


Posted by Tom Cox on
It is not enough to "use" ICS. ICS is the most effective emergency management system we know of but people still refuse to use it, even when they say they are using it.

The most common problems are:
1) Senior executive impose it on the organization but either don't take the training or treat the training as a "check-in-the-box". If senior executive of the organization fails to walk the walk, then ICS will fail at the lower levels every time.
2) Simply checking the box to get the certificate. Organizations feel the ICS training "takes too long". I am constantly asked to cut the two day courses to one day and the three day courses to two days. There is no follow-up, no exercises, no coaching afterwords and the classroom skills fade.
3) "We use a modified version of ICS". I have even seen one organization state in their emergency plan that they have modified ICS to meet the bureaucratic needs of day-to-day operations". As soon as you say "ICS is flexible" in the classroom, organizations bastardize the system so it is unrecognizable. What they don't understand is even small changes can ruin the effectiveness of ICS.
4) Some instructors have no passion for ICS nor understanding of the system. When training ICS instructors, you can literally see their eyes light up in class and the excitement in their voice as they say "Oh my god! Now I get it! This is EASY!" Those instructors come back with the coolest examples, most challenging questions for me and take that into the classroom for their students. We don't have enough instructors with passion or understanding.

I have three handouts I provide instructors in my jurisdiction. If you are an ICS instructor and would like copies, send me an email to (tell me your experience with teaching ICS and the organization you are with) and I will send you the handouts. They are designed for Canadian jurisdictions, but there should be enough tidbits in there to make it useful for anybody. If a State organization wants to get ten or twelve ICS instructors together, I will do a free two day professional development session on teaching ICS. I can't do that for everyone, so I am asking it to be State sponsored.
Posted by Michael Foster on
I have been teaching ICS since 2004, the most recent ICS-300 (MAG300 in AZ) course at our Douglas Prison Complex; I have over 40 years of public safety experience with hazardous materials technician, rail tank car specialist, in the fire service (8 years as Chief Officer) and am helping an often overlooked critical infrastructure (Correctional Facilities) translate their Incident Management System (IMS) to the NIMS ICS. I provide 14 handouts to the students, but am certainly wanting to learn more, and transfer that knowledge.
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