Along with its final report on the incident, the CSB released a 15-minute safety video, “No Escape: Dangers of Confined Spaces,” which includes a detailed animation depicting the horrible tragedy that unfolded inside the mountain tunnel at Xcel’s Cabin Creek plant on October 2, 2007.
The CSB investigation determined that while companies are required to perform a hazard analysis prior to issuing permits for work in confined spaces, regulatory standards pertaining to the use of flammables within confined spaces are inadequate.
At a press conference announcing the report findings, board member Mark Griffon said, “Other OSHA regulations on confined and enclosed spaces - for example in the maritime industry and other sectors - prohibit work in such confined spaces above a specific percentage of the LEL [lower explosive limit], often 10 percent. We are recommending that OSHA adopt such enforceable limits for all industry.”
The CSB recommended that OSHA amend its permit-required confined space rule for general industry to prohibit entry and occupancy if the atmosphere exceeds a specified low percentage of the LEL. CSB called on OSHA to establish a maximum percentage substantially below the lower explosive limit for any given flammable for safe entry and occupancy while working.
Additionally, the CSB made recommendations to nine other entities. These included:
- The state implement an accredited firefighter certification program for technical rescue with specialty areas, including confined space rescue. Though the first rescue personnel arrived at the site promptly, and while the trapped workers were conscious and in contact with personnel via radios, they were not equipped or trained to enter and fight the deadly fire that raged within the tunnel.
- The Colorado Public Utilities Commission (PUC) require regulated utilities to adopt provisions for selecting contractors based on safety performance measures and qualifications. The board noted that Xcel selected RPI despite the fact that the painting contractor had the lowest possible safety rating (zero) among competing contractors.
- The PUC require utilities to investigate all incidents resulting in death, serious injury or significant property damage and submit and make public written findings and recommendations within one year of the accident.
- Numerous recommendations were made to RPI Coating Inc., Santa Fe Springs, Calif., the industrial painting contractor hired by Xcel Energy, particularly aimed at revising its confined space entry program and guidance.
Citing a formal Letter of Admonishment sent to the Xcel CEO in late August, Wark said, “The lack of cooperation and efforts by Xcel to impede our investigation are unprecedented. Mr. Griffon and I join our chairman in criticizing these actions in the strongest terms.”
The letter, signed by CSB Chairperson Rafael Moure-Eraso, states Xcel Energy did not fully comply with CSB requests for documents or answers to questions in formal interrogatories. This required the CSB to seek assistance from the U.S. Attorney’s office in Denver, resulting in delays to the investigation and additional costs to taxpayers. In May, Xcel took the extraordinary and unprecedented step of going to federal court seeking to block release of the CSB report and the safety video. The court sided with the CSB in favor of release.
The CSB noted that Xcel was given an advanced draft copy of the report in April for review for accuracy and for confidential business information, in accordance with CSB review protocols. According to the federal agency, Xcel never responded, but in August 2010, contrary to the conditions of confidentiality attached to receiving the preliminary copy, Xcel released it to a news organization.
The letter from Moure to Xcel’s CEO continues, “In light of this disappointing pattern of corporate conduct, I am writing you directly to ensure that you are personally aware of the actions taken by Xcel to delay the CSB investigation, block publication of the CSB final report, and distort the conclusions of the investigation by releasing an unauthorized draft copy of the CSB report. The CSB will issue a formal recommendation that Xcel shareholders be directly notified by management of the significant findings and recommendations of the CSB report, and of the actions Xcel management intends to take to implement needed safety improvements.
The letter concludes, “In the wake of the corporate responsibility concerns raised by the Big Branch Mine accident in West Virginia and the disaster in the Gulf of Mexico, I strongly urge Xcel to renew its focus on safety and to swiftly implement the CSB’s recommendations.”