Chemical Safety Board’s missed opportunity to build public confidence, push reforms

By | 2018-01-22T21:01:20+00:00 October 5th, 2016|5 Comments

I wasn’t in the room, but watching the webcast I could feel the public’s lingering dissatisfaction and distrust. It was last week’s (Sept. 28) public meeting held by the Chemical Safety Board on its investigation into the 10,000 gallons of a toxic soup that poured in January 2014 into the Elk River in Charleston, WV. The river is the water source for residents of the city and surrounding communities. 300,000 residents were affected by the disaster. They did not have safe tap water for drinking, cooking, or bathing. Some still have no confidence that the water is safe to use.

Headlines about the January 2014 included:

Immediately thereafter, residents wanted answers to their questions about the chemicals in their water supply. But the answers didn’t come, and what they did hear were confusing, conflicting, and perplexing explanations. As the days went on, residents’ distrust of government officials grew, including of health officials from the CDC and its National Center for Environmental Health. The public received mixed messages and contradictory statements, such as

The water’s safe to drink, but pregnant women should drink bottled water.

The initial suspect chemical was as 4-methylcyclohexane methanol (MCHM), but further investigation revealed a mixture of toxic substances including dipropylene glycol phenyl ether and propylene glycol phenyl ether. Officials could not tell residents how the chemicals would affect their health in the short or long term because there was (and remains) scant toxicological data. Few people had confidence in the information provided by the company that caused the disaster (Freedom Industries) or the manufacturer of the chemicals (Eastman Chemical Company.)

With that as the backdrop—distrust, no confidence, skepticism—the U.S. Chemical Safety and Hazard Investigation Board (CSB) conducted its investigation of the chemical release and resulting contamination of the region’s drinking water supply. The CSB’s meeting last week was its way to share with the public the agency’s findings.

I watched the meeting via webcast. I wondered if the agency had a plan to build public confidence, to engage and listen genuinely to the residents, to show respect for the community’s expertise, to detour if need be from the game plan, and to set their agency apart as one that would answer questions clearly. The CSB’s report acknowledged the failures by local, state, and federal governments in communicating effectively with the community. Reading the CSB’s acknowledgement, I was eager to see if that lesson would be reflected in the agency’s own approach at their public meeting.

It didn’t seem so. The CSB followed its typical format for public meetings. I’ve heard colleagues refer to the events as dog-and-pony-shows. The evening event began with presentations by the investigation team, followed by Q&A between the four board members and the team. It seemed prescribed—a set-up to pave an easy path to the end of the meeting when board members would vote to approve the report and three recommendations. The public comment period began one hour into the meeting.  As it progressed, the phrase “missed opportunity” kept coming to mind.

Some of the residents were (or had become) experts on the disaster. One concerned citizen has a PhD in chemistry. He worked previously at the local Union Carbide plant. Speaking quickly to not exceed his allotted 3 minutes, he offered data and presented a failure mode analysis diagram. Another speaker questioned the CSB’s assessment of corrosive agents in the tank responsible for the chemical release. Another wondered about the relevance of the chemical analysis conducted by OSHA. She asked what the CSB knew about original analysis conducted by other government agencies. There was earning for data about the chemical mixtures to which the residents had been exposed.

Pam Nixon and Maya Nye, veterans of the struggle to address West Virginia’s “chemical valley,” spoke during the public comment period. They questioned the depth with which the CSB assessed the root cause of the incident, in particular, regulatory failures that allowed it to happen. There was dismay that the agency did not reiterate its previous recommendation for a chemical release prevention program. It was a recommendation made by the CSB following the 2008 explosion at the Bayer CropScience plant—another facility in the state’s “chemical valley.” The CSB recommendation is now more than five years old. Despite early progress toward a mandate for a chemical release prevention reprogram, industry opponents and their allied lawmakers put the brakes on it. It lost the momentum it once had. Residents wondered “what’s the harm if the CSB repeats a previously made recommendation?”

Board member Engler tried to reassure the audience, saying that the original recommendation remains open. It remains part of the outcome of the Bayer CropScience investigation. Residents believe, however, that having the CSB reiterate the recommendation could help to jump start action on the chemical release prevention program. Residents were looking for an ally. A government agency that would use its power to help the community secure a needed reform. No one explained the CSB’s reason for not restating the recommendation? More of the same: questions to agencies without clear answers.

The CSB made its Freedom Industries’ report available to the public a few hours earlier in the day. I was impressed by how quickly the residents studied the 134 page document. “Did you consider this?” residents asked and “why did you write that?” Despite having only a short time to read it, residents came prepared with thoughtful and technical questions.

But the CSB’s format wasn’t set-up for residents to get answers to their questions. The public comment period seemed perfunctory. The 3-minute time limit per speaker was confining. Yet residents continued to provide feedback. I waited to see if the board members would shift gears. Would they answer the questions posed by residents? Would they pitch questions back to the investigators for responses?  I didn’t see it. It was a missed opportunity to provide clarity and build public confidence in the CSB.

By this point in the public meeting, it was clear the board members were ready to stamp FINAL on the Freedom Industries’ investigation report. So why invite the public to provide feedback when you don’t intend to use it to inform your report? Residents remarked that it didn’t seem that their comment mattered to the agency.

The CSB members proceeded to approve the report and recommendations. However, chair Vanessa Sutherland offered a consolation to the public. She invited them to submit their comments and documents to After reviewing the submissions, the agency would possibly issue an addendum to the report.

But was that offer sincere?  It didn’t seem so to me. 48 hours hardly seemed like enough time to study the report—a document that had only been made public a few hours earlier in the day. When exactly would they have time to read the report and write feedback?

I guess improving public confidence was not part of the CSB’s agenda. That was a missed opportunity.






About the Author:

Celeste Monforton, DrPH, MPH
Celeste Monforton is a fellow in the Collegium Ramazzini; a lecturer at Texas State University; and professorial lecturer at the Milken Institute School of Public Health at George Washington University. She receives funding from the Public Welfare Foundation.


  1. Phil Price October 5, 2016 at 7:45 pm - Reply

    I reviewed the CSB’s Report & testified at the meeting. Astoundingly poor job by CSB – wouldn’t pass “Incident Investigation 101”.
    “MCHM corroded a hole in the tank” – none of the compounds listed as Spill are Bronsted acids strong enough.
    “38 Tons spilled” – this number came from the convicted criminal spillers; never mass-balance verified.
    “38 Tons went out a 0.5” hole in 12 hours – but the calculation is secret.
    NO definitive analysis of the spilled material!
    The Tox work was all done on the wrong material.
    etc., etc.

  2. Richard Rosera October 6, 2016 at 2:12 am - Reply

    Celeste, your remarks about the meeting & format for these public CSB meetings is spot on. I sent the following in an e-mail to Hillary Cohen of the CSB on 10/4/16, with a copy to Maya Nye & Ken Ward. So far, no response.

    Thanks for getting the Livestream broadcast of the Freedom Industries Public Meeting going. I was particularly interested in the comments of local citizens, who obviously took a very knowledgable interest in the report. Please pass this e-mail along to anybody at the CSB who might be interested or able to address the observations & questions I have.

    I realize that comments have technically closed, but I wanted to (at least) point out a problem with a footnote reference. On p. 19 of the report, footnote 56 (for Dow Propylene Glycol Phenyl Ether SDS) is correct, but footnote 57 (for Dow Di-propylene Glycol Phenyl Ether SDS) is incorrect, actually being identical to footnote 56. I am also troubled by the following unfootnoted & unexplained statement on p. 19 of the report:
    Freedom also removed any sodium hydroxide as part of the PPH, stripped formulation process.

    Philip Price, in his comments during the Freedom Industries Public Meeting, indicated that hydrochloric acid was mixed into Crude MCHM (or perhaps into the “finished product”, ShurFlot 944, or the Dow PPH Glycol Ether or Di-PPH Glycol Ether) by Freedom Industries employees. How & where was this done? What was the source of the sodium hydroxide, which is not mentioned as an ingredient in any material in the report? Hydrochloric acid is well known for pitting corrosion in steel, and it would at least be worth elaborating on this as part of the report. I am also somewhat mystified by the lack of explanation in the report for the terminology “PPH, Stripped” – this implies that something is removed by physical means, like filtration, settling or evaporation. Addition of hydrochloric acid is chemical neutralization, not “stripping”. If something was actually “stripped”, it would be worthwhile to elaborate this – was it done at the Freedom Industries site, or somewhere else? What was done as part of this process?

    Note that Dow Chemical supplies at several grades of Di-propylene Glycol Phenyl Ether (see, for example:
    Dowanol DiPPH Glycol Ether (
    Dowanol DiEPH (

    What grade(s) of Dow Chemical PPH & DiPPH were being used by Freedom Industries, and how were they processed & handled?

    With best regards for the investigation work of the CSB,

    Richard Rosera
    Rosearray EHS Services LLC

  3. Phil Price October 12, 2016 at 8:04 pm - Reply

    Based from testimony from a Freedom employee, they used a “mixing skid” connected directly to the 20′ tank. They were introducing CONCENTRATED hydrochloric acid to neutralize the 5% caustic coming in with the PPh from Dow. Solids would precipitate (never analyzed); these were removed, along with water (source?) directly at the tank. The whole process was “regulated” by measuring pH (of a non-aqueous, multi-phase system?!). So, the “spill material” was [Crude MCHM + PPh + HCl – water – reaction solids]. Thus, all of the toxicology work was done on the wrong (not spill) material. This information was available to the CSB – they chose to ignore it. It is certain that the spill contained more than the 6 components listed in the CSB Report. Their GC/MS work on spill material was terribly deficient. Without the use of CI, exact mass, & different chromatography, it is certain that: they will not even see many components & many components will give unidentifiable EI spectra.

    • Richard Rosera October 12, 2016 at 11:17 pm - Reply

      Phil, your description of the process certainly sounds like a “can of worms” that deserved much more than the scant mention in the CSB report that Freedom “removed any sodium hydroxide as part of the PPH, Stripped formulation process”. I would like to know more about the details of the process, as you understand it from the testimony of the Freedom Industries employee (or is this testimony available somewhere online?). For instance, how were the solids removed (e.g., from the “mixing skid” or the 20′ tank)? I haven’t seen a Dow SDS for PPH or Di-PPH which identified caustic as an ingredient, so what grades of these materials were being used by Freedom Industries? Perhaps we can dialog directly via my e-mail ( Also, I hope that you submitted your comments directly to the CSB (as they invited you to do), and that you have the time to phone into the CSB Public Meeting next week (October 20), to amplify your concerns.

  4. Phil Price October 20, 2016 at 7:44 pm - Reply

    The CSB seems committed to shoving forward (as finished!) their current Investigation Report. I review for several international journals… it trivially would not meet the requirements to be published. Factual errors abound. Footnote 120 is incorrect information (check Google). Footnote 5 relates to analyses of the spill material. I have reviewed data supplied by OSHA, and referenced in the report. It seems to be data for analyses of air sampling cartridges. There is no analysis available for a bulk analysis of liquid-phase spilled material! The OSHA lab analyses were amateurish, and would not be capable of producing interpretable data for the saturated organic acids, ethers, alcohols, and other spill components.
    As an INVESTIGATION, it fails to:
    — identify what was spilled
    — verify how much was spilled via material balance
    — determine when the spill began
    — document how much human exposure there was
    — document how much contamination there was (soil, etc.)

    Based on the 10/20/16 CSB meeting, they seem more focused on closing out investigations than on doing quality scientific work. Written comments, suggestions, and offers to coach their investigation staff have been (so far) ignored. Finally, the recommendations on page 113 of the report are vague, and clearly written to not offend the WV DEP, local water utility, or any government agency.

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