Worker Exposure Status Update #2
April 5, 2010
Umatilla Chemical Depot, Hermiston, Ore. - The following is an update on a worker's exposure to mustard agent March 17 while doing maintenance in the Umatilla Chemical Agent Disposal Facility's main processing building.
Aca,!Ac Independent laboratory analysis of the worker's urine samples confirmed mustard agent exposure. These results validate an earlier determination that was based on medical observation of the skin blister and a review of facility activities, records and monitoring. The worker's skin blister continues to heal well.
Aca,!Ac A Root Cause Analysis for the agent exposure has been completed. The analysis indicated four overarching issues contributed to the event: Conduct of operations, procedural compliance, mustard agent awareness and the entry planning process. The analysis requires immediate corrective actions that will be required to return to performing less-than-Demilitarization Protective Ensemble (DPE) entries, the highest level of protection. These changes include re-education and certification of employees involved in the entry process, modifications to procedures and the work authorization process, and enhanced management oversight of entries.
Aca,!Ac An Event Review Board will evaluate the implementation of the immediate corrective actions prior to resuming less-than-DPE entries.
Meetings have been ongoing with plant employees to share information about the incident. The "agent awareness" training re-emphasizes the importance of recognizing potential agent contamination and the risks from potential contact with agent or other substances that may be encountered during an entry. Refresher training on the "conduct of operations" (defined as the culture of behavior to safely, reliably and efficiently operate the facility) reaffirms that situational awareness must always be our No. 1 priority in the toxic areas, regardless of level of protective equipment.