Tacoma firefighters didn't shrink from danger the night in February 2007 when a Tideflats worker accidentally released lethal chlorine gas.
Within 90 minutes after the first fire engine arrived, a specially trained, two-man team entered the gas-filled building and stopped the leak.
But what began as a carefully plotted mission was undermined by errors that injured firefighters and others and failed the primary objective of any emergency response: to prevent additional harm.
A News Tribune investigation, based on public records and interviews with experts and key firefighting personnel, concluded that members of the Tacoma Fire Department:
• Neglected to prepare for a wind change that put firefighters and others at risk.
• Failed to monitor concentrations of poison gas outside the chlorine plant until after firefighters were overcome.
• Did not keep respirators handy for immediate use.
• Ignored department policy stating that the incident command post and hazmat backup teams should stay in a "cold" zone, or out of danger.
• Failed to call for evacuation of the area near the leak until after firefighters were exposed. Although firefighters notified a few enterprises and asked police to block some streets, they didn't tell people to leave the Tideflats until hours after the accident occurred.
Twelve of the 25 people taken by ambulance to area hospitals that night were firefighters. Although everyone was treated and released, at least one firefighter was coughing up blood the next day. Some workers in the neighborhood complained about breathing problems for months afterwards.
In what appears to have been a cursory safety investigation, the state Department of Labor and Industries exonerated the Fire Department. The News Tribune uncovered problems with that investigation.
While the state didn't cite the Fire Department for wrongdoing, L&I inspectors did recommend that the department make procedural changes, such as more closely monitoring weather and air quality, and keeping respirators ready.
"Those firefighters should not have been exposed to chlorine," said Don Lofgren, an L&I industrial hygiene compliance supervisor who was in charge of a two-person team of safety inspectors.
FIRE CHIEF BLAMES WIND
Tacoma Fire Chief Ron Stephens defended his department's efforts the night of the Tideflats chlorine leak.
If it weren't for a sudden change in wind direction, he said, firefighters and local workers would not have been exposed to the gas.
"Once the wind shifted, everything changed," he said in an interview Tuesday. "It's pretty hard to move operations at a moment's notice."
However, two internal documents cite lessons learned from the incident, signaling awareness that firefighters should have done some things differently.
"The men and women firefighters that were on the scene of that incident deserve credit for risking their lives and their well being and for solving the problems that led to the successful termination of that incident," Stephens wrote Thursday in an e-mail to The News Tribune. "I'm proud of the risks they took and the work they accomplished.
"The responsibility for any and all errors made and or the perception of any and all errors made rests on my shoulders. I willingly accept that responsibility."
Lessons learned are summarized in a presentation prepared last spring for training purposes by Battalion Chief Jim Zuluaga, who led the department's hazmat team and was himself overcome by chlorine.
In the presentation, Zuluaga stressed the importance of air monitoring and limits on access to the danger zone and said all firefighters should have had respirators ready. He also called for more high-tech equipment and said firefighters should park vehicles with escape or retreat in mind.
In an interview last June, Zuluaga acknowledged that firefighters erred by parking their rigs facing downwind.
"You try to put the vehicles in a way you can leave in a hurry," he said. "We didn't take the time to turn them around."
Later, in an annual health and safety presentation, Tacoma fire officials reiterated Zuluaga's recommendations and added another:
"More closely monitor air/wind movement."
An attached note also stated: "Warm zone should have been much larger, at least to East 11th Street."
While those presentations highlight what went wrong with the Fire Department's response, Stephens didn't acknowledge specific mistakes during last week's interview. Also, the chief discounted inconsistencies between what happened the night of the leak and the procedures spelled out in the department's hazardous materials response policy. Incident commanders have the authority to override policy when the need arises, he said.
For example, the incident command post was on the edge of what was designated as the "warm" zone, a risky area where access should be restricted. The department's policy states that the command post belongs in the "cold" zone, where it's safe.
Stephens described the policy manual as "guidelines," even though the document is clearly labeled as "policy."
'IT WOULD HAVE BEEN OVER'
In interviews with The News Tribune, other department leaders explained why firefighters took the actions they did.
Initially, firefighters assumed the Pioneer Americas plant would contain the chlorine, Zuluaga said. After firefighters plugged the leaky tank inside, they decided to vent the building. But as the gas drifted out, the wind shifted.
"You can't rely on the winds for 30 seconds," Zuluaga said. "We got a taste of that that night."
Even so, Stephens said he wouldn't second-guess firefighter decisions to hold off on calls to evacuate the Tideflats while firefighters entered the gas plant.
"If the wind didn't shift, the incident would have been completed," the fire chief said. "It would have been over. We wouldn't have needed to evacuate those businesses."
After firefighters were exposed, the priority was to rescue victims, Stephens said.
Then firefighters went through the neighborhood, banging on the sleeper cabs of semitrucks parked on side streets, firefighters said.
Before the two-man team plugged the leak, firefighters notified only a few businesses near the Pioneer Americas plant.
"The focus was downwind," said Capt. Dave Sherk, the initial incident commander. At that time of night, relatively few people are still at work on the Tideflats, he said.
In general, it's problematic for firefighters to urge people to leave the Tideflats, Sherk said. Some industrial operations are so risky that operators cannot abandon them. And people resent it if they are told to leave and it turns out to be unnecessary.
"There's no winning," he said.
As for the firefighters who were overcome by chlorine, Stephens said those who didn't keep respirators handy are themselves responsible for exposure.
That includes firefighter Mark Maderos, who was coughing up blood the following day.
"If he was in that close to the hot zone he knew full well what he was supposed to do," Stephens said. "The incident commander doesn't have time to evaluate everybody."
In a separate interview Thursday, Maderos said that although he had completed hazmat technician training just before the chlorine leak, he didn't fully understand the risk.
"There was probably some lack of experience and lack of judgment on my part," he said.
He left his respirator on a nearby firetruck because he mistakenly believed he could retrieve it as needed. As it turned out, he was overcome before he got there, he said.
Fire Department officials also believe additional high-tech gear could help in response to future accidents.
Assistant chief Tom Henderson said the department planned to buy additional chlorine monitors and was considering an upgrade to its portable weather station.
As part of a Pioneer Americas settlement with the Environmental Protection Agency, the company promised to buy the Fire Department two high-tech portable weather stations, four hand-held gas monitors, a thermal-imaging camera and two gas-tight protective suits.
QUESTIONS ABOUT L&I REVIEW
State Labor and Industries inspectors conducted two investigations after the accident: one on the bleach plant and one on the Fire Department's response.
Most of the attention was on the Pioneer Americas bleach plant, whose owners paid a $1,650 penalty to the state for violating regulations governing analysis of industrial hazards.
The News Tribune reviewed the records of both L&I investigations. The L&I report on the plant stacked up in a pile about a foot tall at the agency's Tumwater headquarters. L&I's investigation of the Fire Department's response was about a quarter-inch thick, slim enough to fit in an 8 1/2-by-11-inch envelope, which was mailed to The News Tribune.
A summary of the conclusions said the inspectors interviewed the Fire Department's incident command chief. But other records show that inspectors did not interview the two incident commanders, despite specific e-mail directions from Lofgren, the L&I industrial hygiene compliance supervisor.
The two inspectors confirmed in an interview that L&I did not interview them.
L&I's investigation of the Fire Department ends with a summary that's about a page long. It concludes:
"Recommendations were made at the closing (interview) for proper setup and monitoring of the weather station so the incident commander can make changes based on new developments such as changes in the wind direction; air monitoring at the different zones would be helpful to take proper actions depending on the air concentrations of the chemicals; and have respirators ready (and) available for all personnel."
The report does not elaborate. But Lofgren said in an interview that the Fire Department's inadequate response to changing conditions risked firefighters' health.
He commended the two-man team of firefighters who he said "saved the day" by plugging the 1-ton chlorine tank.
"The Fire Department did quite well providing for the safety of the entry personnel. Those individuals went into some dangerous conditions with high concentrations of chlorine," he said.
But things went wrong after the team emerged from the plant. When they left a door open, gas escaped. The wind, which had changed direction, pushed the poison toward firefighters gathered outside the plant.
Lofgren and his inspection team did not attempt to evaluate whether the door should have been left open.
'THE CONFLICTS ARE OBVIOUS'
The L&I report might have been compromised. At the time of the investigation, one of the two state inspectors was an applicant for a City of Tacoma safety job.
The inspector told his supervisor, Lofgren, about the application, but wasn't removed from the case. One of the first people the inspector contacted when he began the fire investigation would have been his supervisor if he had been hired by the city. In the end, Tacoma did not hire him.
Lofgren stood by his decision to allow the inspector to continue to work on the investigation.
But it was the kind of conflict government officials should avoid.
"Generally speaking, you don't want somebody who's applying for a job to have to be interviewing their prospective boss and to investigate whether their prospective boss or agency made a mistake," said John Strait, a Seattle University law professor whose classes in professional responsibility deal with conflicts of interest. "It's plain common sense. The conflicts are obvious."
Strait also said the circumstances could cut two ways. The investigator seeking a safety job might be just as tempted to take a hard line to demonstrate his commitment and depth of knowledge, Strait said.
'A WIDESPREAD PROBLEM'
Large accidental releases of airborne toxic chemicals like the Feb. 12, 2007, event on the Tideflats don't happen often.
But officials at the U.S. Chemical Safety and Hazard Investigation Board, a nonregulatory federal agency that investigates the worst ones, said emergency responders frequently make mistakes.
"Among the accident cases we investigate, a deficient emergency response is more often the rule than the exception," Carolyn Merritt, chemical safety board chairman, told the U.S. Senate Homeland Security and Government Affairs Committee in April 2005.
"It's a widespread problem," said agency spokesman Daniel Horowitz. Typical issues include poor communication and lack of equipment, training, procedures and preparation, he said.
Independent experts say it's crucial to track airborne concentrations and the weather when responding to a chlorine release.
"You always have to be aware of your surroundings at all times," said Larry Aleksandrich, a former New Jersey fire chief and mutual aid coordinator who teaches emergency responders how to handle hazardous materials. "The bottom line is you never want anybody to get hurt."
"Winds change," said Jim Lay, a U.S. Chemical Safety and Hazard Investigation Board investigator. "That can require people to be adaptable and move out of harm's way."
Key elements of a safe emergency response to an accidental chlorine release are outlined in a video prepared for first responders by The Chlorine Institute, an Arlington, Va., trade group. It recommends vigilance:
"The constant monitoring of wind speed, condition, direction and of available chlorine levels is necessary to maintain the buffer zone and guide the containment process."