Title: The Graniteville Disaster Mark T. Arden Chappell Smith and Arden
1The Graniteville DisasterMark T. Arden Chappell
Smith and Arden
- South Carolina Workers Compensation Educational
Association - 31st Annual Medical Seminar
- February 28-March 2,2010
- Francis Marion Hotel Charleston S.C.
2- There's a long black train Coming down the
line Feeding off the souls that are lost and
crying Tails of sin only evil remains Watch out
brother for that Long Black Train
3Facts Concerning the Disaster
- At approximately 239 a.m. on 1/6/05, NS Train
192 was heading north on the NS R-line between
August and Columbia. - Train 192 consisted of 2 locomotives, 25 loaded
cars, and 17 empty cars. Of the 25 loaded cars,
3 contained chlorine. - The ninth car, UTLX 900270 contained
approximately 90 tons of chlorine.
4Facts Concerning the Disaster
- Train 192 rounded a 1-degree curve approaching
the Avondale Mills Gregg Plant Lead Switch. - Train 192 was traveling approximately 49 m.p.h as
it approached the switch.
5Facts Concerning the Disaster
- Unbeknownst to the crew of Train 192, the
Avondale Mills switch was incorrectly lined for
the Avondale Mills industry track. - Train 192 entered the Avondale Mills industry
spur with no chance to stop prior to colliding
with parked Train P22. - Car UTLX 900270 was punctured, releasing a poison
chlorine gas cloud all around the Gregg Plant
area.
6- Damage to the lead locomotives of Train 192
(left) and Train P22 (right).
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9Chlorine Gas
10Chlorine Gas
- Chlorine Gas developed by German chemist Fritz
Harbor in 1915 for use as a poison gas in WWI. - Tear gas first was the first recorded gas attack
used by the French Army against the German Army
in August of 1914. Chlorine gas developed shortly
thereafter. - The density of chlorine gas is approximately 2.5
times greater than air, which will cause it to
initially remain near the ground in areas with
little air movement. - The strong oxidizing effects of chlorine produce
corrosive tissue damage. The oxidation of
chlorine will penetrate cells and react with
cytoplasmic proteins to destroy cell structure.
11Chlorine Gas
- The health effects resulting from most chlorine
exposures begin within seconds to minutes. - There is no antidote for chlorine poisoning.
- When liquid chlorine is released, it quickly
turns into a gas that stays close to the ground
and spreads rapidly. - When chlorine gas comes into contact with moist
tissues such as the eyes, throat, and lungs, an
acid is produced that can damage these tissues. - The gas causes both internal and external
blisters on the victim within hours of being
exposed to it.
12World War One French Soldier/ British Casualties
13Human Costs
Casualties From Gas- The Numbers
Country Total Casualties Deaths
Austria-Hungary 100,000 3,000
British Empire 188,706 8,109
France 190,000 8,000
Germany 200,000 9,000
Italy 60,000 4,627
Russia 419,340 56,000
USA 72,807 1,462
Others 10,000 1,000
14The Fallout
- 9 chlorine related deaths
- 554 injured who reported to hospital
- 75 hospital admissions
- 11 in critical care
- Over 5,000 people evacuated.
15Complexities of the Diagnosisfrom the
Graniteville DisasterCase Studies
- Pulmonary (reactive airways, restrictive lung
disorder, sleep apnea, cough variant asthma-
multiple diagnoses of bronchitis) Dyspnea and
hypoxia with exertion - Sinus Issues/Skin Rash Issues- recurrent
sinusitus-acute bilateral external otitis,
hypertropy of inferiror turbinates - Eye problems ocular injury
- Psychiatric Disorders- post traumatic stress
disorder, anxiety, major depression, nightmares,
flashbacks,
16Case Study A
- Case Study A
- Six days admitted in the hospital , 3 in ICU
- 64 saturation at the decontamination site,
spirometry shows primarily a restrictive pattern
with an FEV1 of 3.18 liters or 73 of predicted - Initial complaints difficulty breathing, severe
dyspnea, severe wheezing, burning sensation,
dizziness, nausea and vomiting - Diagnosis Acute lung injury associated with both
hypoxemic and hypercapnic respiratory failure - Reactive airways disease secondary to chlorine
exposure, obstructive sleep apnea, moderate
persistent asthma secondary to chlorine exposure - Subsequent right lower lobe pneumonia with
streptococcus pneumoniae - Impairment rating 30 to each lung and sinus
tract - Restrictions no exposure to airborne dust
particles, gases, fumes, extremes in temperatures
and molds- No walking distances greater than one
block-No freguent lifting more than 10 pounds - Post Traumatic Stress Disorder- persistent
symptoms of insomnia - Initial GAF 45. Last GAF50.
17Treatment
- Pulmonolgist reactive airways disease ongoing
visits-medicine regimine includes Advair 250/50
and as needed does of albuterol. - Psychiatrist Counseling and Effexor,Trazadone,
Clonidine, Seroquel and Wellbutrin
18Case Study A Clothing
19Case Study B
- One day ICU- Six Days Hospitalized
- Initial complaints-Dyspnea with exertion
- documented hypoxia tachycardia with simple
activities insomnia, ocular injury reactive
airways disease with restrictive appearing
spirometry obstructive sleep apnea recurrent
sinusitus, cough varient asthma multiple issues
of bronchitusImpotence - Initial FVC 51 of predicted, FEV1 53 of
predicted. - 4 months later- FVC 52 of predicted, FEV1 53
predicted - Low lung volumes- off medication patient
respiratory function is in the severe range. - Pulmonary Function Tests reveal severe airflow
limitation with noted bronchodialator response,
severe airway resistance, significantly reduced
diffusion capacity. - Diagnosis- Severe occupational-induced asthma
with a reactive airways syndrome
physiologysevere bilateral external otitis,
chronic sinusitis, hypertrophy of inferior
turbinates PTSD, Major depression - Impairment- 70 to both lungs as well as airway
sinus tract - Restrictions- Limited standing,lifting,bending or
strenuous activity Avoid exposure to airborne
dust particles, inicluding gases,fumes,extremes
of temperature and humidity, - lung capacity
restricts him to sedentary duties-Modified
sedentary FCE.
20Treatment
- Pulmonologist-It is expected that the patient
will suffer from recurrent bronchitis,pneumonia
and other lung infections in the future. Ongoing
hospitalizations,treatment and medicine regimine.
- ENT- visits for chronic sinusitus
- Psychiatrist- ongoing counseling and
medicine/treatment. - Obesity and onset of weight gain due to use of
oral steroids combined with inactivity.
21Psychiatric Issues
- Multitude of DSM IV diagnosis
- Most prevelant Post Traumatic Stress Disorder
- Unusual triggering factors- smells/crowds
hospitals, sirens verses trains - Common complaints involve sleep variations,
anxiety, cautious and on edge demeanor,
irritability, fearfulness, hypervigilance,
avoidance/anxiety related to social situations,
nightmares, flashbacks, and intrusive
recollections of the traumatic event
22Conclusion and Lessons Learned
- Same exposure-varied diagnosis
- Five different presentations can be from the same
type of exposure - The need for different medical specialist leads
often to a time lapse prior to acurate diagnosis.
It does not mean the patient is a poor historian
or exagerating his symptoms. - Minor exposures harder to assess/diagnose and
even harder to treat. - Effects of the exposure are lifelong and there is
no cure.
23Emergency Response Issues What Went Wrong in
Graniteville (Stephen Brittle)
- 1. Emergency responders from the local volunteer
fire department responded to the train crash and
subsequent chlorine release without first donning
personal protective gear. This severely hampered
and compromised their response. Some wound up
with blisters on their lungs. This volunteer fire
department had HAZMAT training and equipment due
to the proximity if the Savannah River Nuclear
Site. One would think that the scenario of a
train derailment involving hazardous materials
such as chlorine would have been part of their
training, as well as something the Aiken County
LEPC would have contemplated and prepared for in
preparing and updating its EPCRA Section 303
emergency plan. Neither law enforcement personnel
nor emergency responders seemed
trained/drilled/prepared for this scenario. - 2. Civilians were mostly on their own when it
came to evacuating. There were true accounts of
heroism and good Samaritans. Workers at the
Avondale Mills plant worked together to make sure
they got away. Some trying to flee had difficulty
starting their cars and trucks as the chlorine
worked with the humidity in the air on ignitions.
Cell phones also did not always work for the same
reason. - 3.The community had a rare resource, an emergency
telephone ring-down system, but it was not
activated for hours after the incident, then told
people to shelter-in-place at first, when it
should have told many to evacuate. Later, it was
used to tell people to evacuate. - 4.The railroad did not make the call to the
National Response Center required by CERCLA 103
until over an hour and fifteen minutes after the
release of chlorine. According to the NRC
report, the incident occurred on 06-JAN-05 at
0240 local time. Report taken by MST3 CREWS at
0358 on 06-JAN-05 It is unknown what effect
this had on the actual response, or if the delay
exacerbated the emergency response issues, but
the system set up by federal law was not properly
utilized. CERCLA requires an immediate phone
call. Under the EPA penalty policy, penalties
begin after a 15-minute delay, and the maximum
penalty is assessed after one hour. The
notifications from the NRC to the various state
and federal emergency response agencies came
after at least a fifteen-minute delay.
24- 5. EPA set up a chlorine monitor at the crash
site that maxed out at 1.5 ppm. Although the
incident response lasted for several days, a
better monitor that would show actual levels of
chlorine in the ambient air was not used. It
would have served the immediate community of
Graniteville, as well as the nearby community and
county seat of Aiken, to have had the information
and technical data about maximum concentrations
of chlorine at the site and a variety of off-site
locations. Again, one wonders why the local
volunteer fire department did not have this type
of monitor, as an incident such as a local train
derailment involving chlorine or other HAZMAT
would be a foreseeable contingency. - 6. The ALOHA modeling program distributed by EPA
(for use by responders and emergency planners in
modeling chemical spills) seems to have not
worked very well in modeling this particular
chlorine spill. The official account available in
the press was that only one railcar was breached
and leaking, but according to an ALOHA model, it
would have been expected to empty rather quickly,
certainly within hours. The report later was that
much of the chlorine in the breached railcar did
not leak into the atmosphere, and eventually was
neutralized and off-loaded. There was some
confusion about how many of the rail cars of
chlorine were breached. Utilizing this ALOHA
modeling, responders could have made an educated
guess about just how far away adverse effects of
the chlorine might have been felt, as well as the
infiltration of dwellings. - 7. The head of the local volunteer fire
department and designated incident commander was
also an employee of the railroad. It is unclear
whether this had an effect on the release of
information to the press and the public about the
incident. I certainly got the impression that the
Norfolk Southern Railroad was in control of the
command center and the flow of information. All
press statements and information seemed to be
carefully controlled to minimize embarrassment to
the company. Questioning would be cut off
whenever the press asked hard questions of the
rail company, at least when I was present. I was
able to find out the cause of the incident almost
immediately upon arrival at Breezy Hill (adjacent
to Graniteville) on the morning of the 6th of
January. I learned that the rail crew that parked
a locomotive and two cars on the side rail by the
Avondale Mills facility had not switched the
diversion switch back and had gone home hours
before the oncoming train with the chlorine
railcars arrived. The NTSB announced some of the
information
25- 8.As I wandered the incident command center area
the day after the crash, I noticed a very
distressed young black woman who seemed to be
ignored by the various officials and staff
present at the area. I asked her and found out
that she was trying to locate information about
her father, Willie Tyler, and that she had not
been able to get any kind of answer from
hospitals or anyone. I convinced a sheriffs
deputy to assist her, and she was referred to a
Red Cross center some miles away. Later, Willie
Tyler was found dead at the Avondale Mills plant.
He was the ninth victim. It seems wrong that he
was known to be missing and yet no one or
official had contacted his family. It also seems
wrong that she could not find out this vital
information easily. - 9. The area of evacuation was likely not
sufficient. I spoke with a woman who lived about
2.5 miles downwind from the rail crash site who
had not ever been evacuated by emergency
responders. She had heard the crash but thought
it was thunder. She awoke the morning of the
crash feeling weak, and noticed what she
described as a strange fog outside. She learned
about the disaster on television. When her
husband came home later that day, they left their
home and went further away to some relatives, but
the chlorine fumes came there also, so they went
back home. Considering that the potential
off-site consequence of a catastrophic release of
chlorine from a rail car can be up to 14 miles
away, according to EPA, it appears that the
emergency response and evacuation should have
looked further into the area outside the IDLH
(10ppm for Chlorine), and should have conducted
air monitoring periodically throughout the areas
downwind. This appears to be a common problem
going back to the mindset of the emergency
response community using ALOHA. The area of IDLH
(Immediate Danger to Life and Health) gets much
attention, but the levels of chlorine in the
ambient air outside an IDLH can still be at
harmful levels, certainly with chronic exposure.
Even the OSHA standard for workplace exposure is
0.5 ppm, TWA. People outside the designated IDLH
should have been warned to avoid exposure and
what symptoms might indicate an adverse effect. - 10. Some of the medical community, despite the
rail disaster, seems to have ignored the obvious.
This aforementioned woman did not go to an
emergency room until Sunday the 9th of January,
four days after the incident, because she did not
get any better. There was no notification to her
and others about potential health effects to
watch out for. The hospital, unfortunately,
diagnosed her with pneumonia and merely gave her
antibiotics, which did not help at all. She saw
her primary care physician on Tuesday, the 11th
of January, who realized her chlorine exposure,
and prescribed something to ease the inflammation
of her lungs and allow her to breathe easier.
26- 11. It is always helpful when the responsible
party steps up to the plate to assist in
relieving the problems caused by a chemical
accident. However, although Norfolk Southern
Railroad set up a relief center to give people
checks to cover motel and food expenses, but
people had to wait hours to process paperwork and
get these checks. It would have been better if
this had been expedited with more staffing and
resources, and it would have also looked better
for the railroad company if it had not put
releases for people to sign on these checks. (A
court action soon ruled that these releases were
invalid.) - 12. It is unbelievable and appalling that the
Federal Emergency Management Agency rejected Gov.
Mark Sanford's request for federal disaster
relief in the wake of the Jan. 6 train accident
and chlorine gas spill that killed nine and
temporarily displaced thousands in Graniteville.
A Feb. 9 letter from FEMA Under Secretary Michael
Brown told Sanford the agency didn't think the
Graniteville derailment and chemical spill
warranted an emergency declaration. - 13. The hazardous materials contents of the
railcars traveling through Graniteville or
anywhere need not be a mystery. OREIS is a
software tool that provides emergency responders,
emergency planners, on-scene fire, police and EMS
responders with vital information for dealing
with rescue, response and counter-terrorism
operations on or around railroads and highways,
including those involving hazardous materials.
The software provides responders with real-time
information about the chemical contents of
railcars and trucks that have been involved in an
incident, schematics for passenger railroads and
a host of other life and timesaving features for
emergency responders. The concept was born in
1995 in Houston, Texas and sprang from a Federal
Railroad Administration (FRA) initiative to
provide hazardous materials information to
emergency responders.
27- http//www.youtube.com/watch?vecEmm-ZSKU4