[June 25, 2014: Updated below]
Seven workers were fatally injured in April 2010 from an explosion and fire at a Tesoro petroleum refinery in Washington State. They were: Daniel J. Aldridge, 50; Matthew C. Bowen, 31; Darrin J. Hoines, 43; Matt Gumbel, 34; Lew Charles Janz, 41; Kathryn Powell, 29; and Donna Van Dreumel, 36. You won’t find their names listed, however, in the official investigation report prepared by the US Chemical Safety Board (CSB).
Earlier this week, TPH contributor Lizzie Grossman reported on the CSB’s recent public meeting at which it released a draft of its investigation into the Tesoro disaster. She summarized the CSB’s preliminary findings, and the reaction from family members of the deceased and their co-workers on their near four-year wait to receive the CSB’s final report.
In previous posts for TPH, Lizzie followed closely the events related to the 2010 Deepwater Horizon rig explosion, and reported ultimately on the National Commission’s detailed findings. As we chatted this week about the CSB’s Tesoro report, Lizzie remarked on a difference she noticed between the two reports: the names of the victims. Where the CSB’s report excluded the names of the workers fatally injured by the event, the Deepwater Horizon report was dedicated to the eleven workers killed in the explosion. Each was listed in the front of the report.
I’m someone who thinks there are important reasons to mention, at a minimum, the victims’ names in worker-fatality investigation reports. At the most fundamental level, the reports prepared by government agencies are an historical records of the event. Years down the road, when local news stories have long disappeared from the Web, reports with the victims’ names are memorialized and not forgotten.
Some years back, I met a young woman who was doing research in the library of the Mine Safety and Health Academy (MSHA) in Beckley, WV. She came from a long history of coal miners, and sadly, the widows and orphans left behind by deadly coal-mine hazards. The young woman was spending time in the agency’s archive hoping to find the investigation report of the incident that killed her great grandfather. (I remember, in particular, that she called him her “Paw Paw.”)
The MSHA Academy’s collection includes accident investigation reports prepared by the former US Bureau of Mines (BOM), an Interior Department agency established in 1910. This young woman was searching this part of MSHA’s amazing collection of documents. The only concrete piece of information the young woman had was the year her Paw Paw was killed. She didn’t know whether the coal mine was in West Virginia or Kentucky, and she didn’t know the nature of the incident (e.g., a coal dust explosion or a roof fall.) Combing through the accident reports---and there were many of them---she eventually found the one involving her grandfather. His name was right there in the report. It describe what he and his co-workers (who were also named) had done that day, and how the incident played out. She reacted as if the report was an important family treasure.
In conversing with the staff in MSHA’s library, I learned this: Family members, like this young woman, are some of the most frequent users of MSHA's collection of fatality reports. The MSHA library staff understand that many children are shielded from the details of their father’s death. When they become adults, some of them have a deep need to understand what happened to him. For those families, they are unable to share the story with the next generation if they don’t have those details.
(The library staff explained a couple of historical exceptions to listing the victims’ names. In some southern states, for example, it wasn’t uncommon for prison labor to be used to fill mining jobs. Prisoners who were killed on the job were not listed in the BOM's reports. In addition, children who worked in the mines were often not listed in a company’s payroll records, and often were not even tallied in fatality counts. )
Fatality investigation reports involving mine workers prepared by the BOM, and now, the Labor Department’s MSHA, have a long history of including the victims’ names. Not so at the CSB.
The agency’s spokesperson, Hillary Cohen, gave several explanations for their policy. The reasons include: following the model of the National Transportation Safety Board; avoiding placing blame; deferring to other agencies to provide the victims’ names; protecting the victim’s privacy; and being concerned about the reaction of the victims’ families.
Others see it differently.
“The names of workers killed on-the-job is a very important part of a fatality investigation report, and photos of the victims are even better,” Peter Dooley remarked to me. Dooley was with the United Autoworkers International Union for 20 years and involved in dozens of fatality investigations. “I believe it makes the tragedy much more real and relevant to people reading the report. It has much more impact from an educational and prevention aspect.” He added: “And, written fatality reports are the best educational tools we have for workers.”
From my own experience working at MSHA, I know that safety trainers use the agency’s fatality investigation reports in their lessons. Making the fatal incident “real and relevant” as Dooley suggests is why mine safety trainers use them.
The nation’s largest organization made up of family members who’ve had a loved one die from a work-related injury or illness has an opinion, too. The group spends hundreds of hours each year trying to find the names of worker-fatality victims. They post as many names as they can find on their website. “We feel strongly that the worker deserves to be recognized as the person he or she was, and not to be just a statistic,” Deb Koehler-Fergen told me. Her son, Travis, was fatally injured in February 2007 while employed at Boyd Gaming’s Orleans Hotel and Casino. Fergen conducts these resource-intensive searches because OSHA does not release the names in a timely, transparent manner. In contrast, MSHA promptly does so as soon as the victim's name is confirmed (e.g., here) and long before its investigation is complete.
Tammy Miser who founded United Support and Memorial for Workplace Fatalities (USMWF), added this: “An investigation report is very personal for a family who has lost someone in such a sudden and tragic way. To a grieving family it is the last thing done in their loved one's name. It is just plain disrespectful and insensitive to not include the names.” Miser’s brother, Shawn Boone, was fatally burned in an aluminum dust explosion at a Hayes Lemmerz plant in Indiana.
I recognize that government agencies with responsibility for conducting fatality investigations have a primary objective: to identify the circumstances that led to the loss of life. In the case of the CSB, it is also to make recommendations to relevant organizations to address those circumstances and prevent them from occurring again.
I believe that including the victims’ names in the CSB's reports is appropriate and would be meaningful. Acknowledging the victims by name is a good place to start.
[June 25, 2014: The CSB's final report of the Tesoro investigation was released in May 2014. It includes a dedication to the seven workers killed in the explosion and fire.]
Very interesting article, Celeste, that has provoked a lot of discussion within the CSB. The original policy dates all the back to 1998 and the establishment of the agency. However, we will give it a second look in light of your article and the practices of various other agencies and organizations.
Thanks Daniel. I look forward to hearing the conclusions of those discussions.
In case anyone missed that first-person collective pronoun, Daniel Horowitz is the Managing Director of the U.S. Chemical Safety and Hazard Investigation Board, on K Street.
Tammy and Peter (both of whom I have the priveledge of knowing) have it right. As Stalin said, "if I kill your family, it's a tragedy, if I kill 20 million, it's a statistic". Our loved ones are not numbers and they are not statistics, they are who we come from, the links from our present to our past. We don't grieve over numbers, give us the names.
Does OSHA have anything like the MSHA library with names of fatalities of workplace accidents and investigation reports? Letters are sent to the next of kin with copies of the citations, if any. But I believe the reports are destroyed five years after the case is closed.
OSHA does not have an archive, on-line or otherwise, of inspection information on each fatality. (OSHA does not produce investigation reports like MSHA.) OSHA does a post-fatality inspection. If someone wanted a "report" of the inspection, they'd have to FOIA OSHA for the case file. Those records are maintained by the area office that conducted the inspection.