The Tampa Bay Times has published a fascinating and tragic investigative piece on the June 29, 2017 incident where five workers at Tampa Electric — Michael McCort, 60, Christopher Irvin, 40; Frank Lee Jones, 55, Antonio Navarrete, 21, and Amando J. Perez, 56 — lost their lives at the Big Bend Power Station after management forced them to do a procedure that they knew was hazardous. You need to read the article, but I will summarize here and identify a few lessons that can be learned.
The incident happened when a group of contractors, hired by the utility, attempted to clear a blockage in a tank that emptied liquefied coal slag from one of the power station’s boilers. The workers attempted to clear the blockage while the boiler was still running, with catastrophic results:
20 minutes into the job, thousands of gallons of slag gushed from the boiler, shooting out of the tank through the doghouse door and covering the workers. It formed a pool six inches deep and 40 feet wide.
Neighbors said they heard the boom miles away.
Navarrete called his mother. The call went to voicemail.
“Mom, help me,” he begged, steam hissing in the background. “Mom, I’m burning.”
McCort and Irvin died at the scene.
Navarrete died July 5. Jones July 8. Perez July 20.
Only Marine survived.
Mom, help me,” he begged, steam hissing in the background. “Mom, I’m burning.”
What made these deaths even more tragic is that the company knew the hazards of attempting to clear the blockage while the boiler was still running. A similar incident had occurred two decades earlier,in 1997. No one was killed in that incident, but the utility changed its procedures to prohibit clearing blockages while the boiler was operating. At some later date, the company began ignoring those procedures. The reporters interviewed a number of other utilities and utility safety experts around the United States that similar boilers and all were shocked that Tampa Electric did not turn off the boiler.
Randy Barnett, a program manager at industrial training company National Technology Transfer Inc., who worked in coal-fired power plants for decades, called the practice “obviously unsafe” because it exposes workers to a trio of hazards: slag, high temperatures and extreme pressure.
Said Charlie Breeding, a retired engineer who worked for the boiler manufacturer Clyde Bergemann: “It does not take a genius to figure out that it is dangerous. Common sense tells you that when you’re dealing with molten ash well above 1,000 degrees in temperature, it’s dangerous.” There is no guarantee the slag building up in the boiler will stay there. Even the smallest change in conditions inside the boiler — a slightly different composition of coal feeding its fire, for example — can cause a plug to melt, sending the molten lava rushing into the tank below. “All of a sudden, you’ve opened up the hole,” said George Galanes, who spent decades working in power plants in Illinois before becoming a consultant for Diamond Technical Services.
Galanes said the plants he worked at would never do that. “Too much risk,” he said.
So why didn’t they turn the boiler off, as safety experts recommended and their own procedures required? To save money.
Tampa Electric had a strong incentive not to turn the boiler off, experts say. Shutting down and restarting a boiler can cost utilities up to a quarter-million dollars. Much of the expense is in powering the unit back up. Plant operators must burn more fuel than normal to heat the boiler to the right temperature. The process takes 12 hours for Big Bend’s coal boilers, federal records show. For utilities, “it is a big deal,” said Mort Webster, an associate professor of energy engineering at Pennsylvania State University. “So they try not to do it.”
What’s more, if the company can’t meet demand with the boiler off, it must purchase electricity from another utility, usually at a higher price. Tampa Electric needed as much power as possible June 29. Across the Tampa Bay region, air conditioners were cranking in the 95- degree heat. And with the Independence Day holiday approaching, more people were likely to be home.
OSHA is still investigating this incident, and given the magnitude of the tragedy, will probably take the full 6 months to issue citations.
“We had told them as a group numerous times that that was wrong, that they were playing with fire” — R. Floyd Suggs, union business manager
Lessons (Not) Learned
There are a few observations and lessons that can be taken from this tragedy:
- Profit and Regulation: Saving money is often an incentive for employers to cut corners on safety. That’s why you need standards and regulations, and strong enforcement to ensure that those standards are complied with. It will be interesting to see if OSHA issues willful penalties and if there is a criminal prosecution.
- Labor Union: A union can help, but is not the ultimate solution. Tampa Electric employees belonged to a union, which was aware of the unsafe procedures, complained to management about them and filed a grievance in 2015. (They had also filed an OSHA complaint, but the incident they were complaining about had occurred more than 6 months before the complaint was filed.) Management’s response to the union’s complaint, according to union business manager Doug Bowden, was to contract out the work to Gaffin Electric, which employed Irwin and Jones. “They said, ‘Hey union, if you don’t want to do that work, we’ll hire it out,’ ” Bowden said. All of the workers killed, except McCourt, worked for contractors.The union had also warned the company after the 1997 incident: “We had told them as a group numerous times that that was wrong, that they were playing with fire,” Martinez said. The union business manager, R. Floyd Suggs, wrote a memo to Tampa Electric’s safety director that has been obtained by the Times. “This incident is one of several growing toward a major accident,” Suggs wrote. “We need you to make sure that our environment is the safest possible.”
- Normalization of Deviance: Normalization of deviance or of abnormality occurs when people become accustomed to violations of procedures or small incidents that don’t result in catastrophe. In this case, Tampa Electric CEO Gordon Gillette “said the boiler was running on June 29 because Tampa Electric had done similar work “hundreds of times” before and believed it was safe.”This, despite the similar 1997 incident. But “Gillette, who joined Tampa Electric in 1981, said he knew of the 1997 accident and the 2015 grievance. In the case of the grievance, he said, “we assured ourselves we weren’t the only ones in the industry doing online slag tank maintenance, and we got ourselves comfortable with operating that way.” The company, he added, is reevaluating that stance.”
- Run to Failure Maintenance: You may not change a light bulb until it burns out, but if you’re running a refinery, steel mill — or an electric utility — just letting things break down before you fix them isn’t a very safe way to operate. High reliability organizations have strong preventive maintenance programs. But after the 2008 recession started,
The company laid off about 200 employees, or 8 percent of its workforce, in 2009. It also began deferring or eliminating some “lower priority work,” including “major equipment inspections” and preventative maintenance to save money, Director of Engineering and Project Management Mark Hornick told the PSC in written testimony in 2013. Hornick acknowledged the practice was already causing some equipment to falter. “If this continues, unforeseen problems may develop, resulting in more costly corrective maintenance from forced or unplanned outages,” he wrote
- Safety Culture: This incident was not an isolated occurrence, but another example of Tampa Electric’s poor safety culture and systemic safety problems: “Over the last two decades, more workers have died at Tampa Electric’s power plants than at those run by any other Florida utility, the Tampa Bay Times has found. No other utility had more than three deaths, including much larger companies like Florida Power & Light and Duke Energy. Tampa Electric had nine.”The concept of “safety culture” often gets a bad rap because it is misinterpreted to mean ensuring that workers adopt the mind-set to “be careful.” Actually, safety culture is not about how workers behave or their individual attitudes and values. Safety culture is about collective practices of an organization that depend on safety structures and systems that are determined by management. Management needs to make the commitment to identify hazards, implement safe procedures, provide preventive maintenance, and, as the Occupational Safety and Health Act requires, provide a safe workplace. Tampa Electric failed in this incident and in numerous others.
- Beryllium: There is another interesting connection to this story. These workers were killed by molten coal slag. The coal slag, a waste product of the process, can be sold after it solidifies and is pulverized, to perform abrasive blasting. But coal slag also contains small amounts of beryllium that can cause serious lung disease. Earlier this year, OSHA issued a new beryllium standard that mostly addressed protection of manufacturing workers, but also contained measures to protect construction and maritime workers who use coal slag for abrasive blasting. In June, OSHA issued a proposal that would weaken protections for construction and maritime workers exposed to beryllium from coal slag. OSHA acted at the request of the coal slag industry which fears that companies may replace their product with safer alternatives.
If Tampa Electric had followed the guidelines, the men would still be alive.
The company is now taking action. But, according to the union, it’s too little — and, of course, too late for the five who lost their lives:
In the weeks since the June 29 accident, Tampa Electric has started a “top-to-bottom” review of its safety protocol, Gillette said. The company held a series of meetings with employees last month.
“What we have to do, some way, is learn from this and make sure it never happens again,” Gillette said.
There are no immediate plans to retire the units with slag tanks, the company says.
But no worker will clean out a slag tank with the boiler running until the company and OSHA finish investigating. “We’re not going to do it until we understand what happened,” Gillette said.
The union isn’t satisfied.
“This is a start,” Bowden said in a statement. “But we must ensure that that no employee, either company or contractor, is ever directed to or allowed to work on a slag tank when there is a potential that they can be injured.”
Union leaders filed a formal grievance on the issue last month.
The Times concluded that “If Tampa Electric had followed the guidelines, the men would still be alive.”