Document 5Q1mpLr9MN2pzOjreEzJe12J

' - ' 'ftftV- comsmtB m mm ?ou cs m w a d f x p o s u ? k iw COBKECTIQB WITH TEE I.PAIT OF A GASOLIME ?TO AGF. i2 0 *<s -i TAlgOF CCWTIHrBTAL OIL COMPAHY, A? AT TESIA , KW METICO ii The clinical Information on these cases of load poisoning <o vas such as to indicate at the outset that the exposure bad been very severe *\/i he man vho died worked for less than a day before 1 he became acutely ill. Apparently his illness developed steadily ^ in severity until his death, -his could only have occurred as the 1 ^ result of gr-oss contact of the skin with tetraethyl lead, or as ii yr the result of the inhalation of high concentrations of tetraethyl i Xs* \)^r hilieead vapor in tho air.) -ho latter, no doubt, represented the true q5 S| ss1it>uation. Additional infemation on the men indicated that they had teen exposed sasevhat to triethyl lead compounds. This, hov3^ * V~evc:'^ need not have been severe, and under the conditions that are i i known to have existed, it could not have been a significant factor * 4 in tho induction of cases of poisoning. AA The severity of the lead exposure has been confirmed by * <?$A . 4 3, => --ci ^ t.2 'o ! ^ z_J *. the analytical data obtained on the urine and blood of several of the exposed men. These data are attached hereto, without additional ccessent. The source of the exposure is evident from the analytical IM* results cm the sludge, the scale, and tho ololh that was placed over tho only opening in the tank during a period of aeration. These "also are attached * >r -1 The organic lead content of the sludge vas high, - much 4^ ^higher, in fact than such sludges generally S. larger proportion of the organic lead in the sludge vas tetraethyl lead. Whether this vaa there as tetraethyl lead prior to the pro longed steaming of the tank cannot he ascertained, hut there are at least tvo possibilities. This tank ms a blending tank at one time, (a) It may. have had Ethyl Fluid introduced into it in such . a manner that the latter settled to the bottom of the tank and then ;' later seeped through into the space beneath the tank, (b) Or there may have been a considerable amount of organic lead salts in the sludge, and these may have been converted In part to tetraethyl lead by the steaming process* In any case tetraethyl lead vas there and this vas vaporized into the air by the steam and partly removed from the tank and partly deposited on the vails of the tank by condensation. In no other vay Is it possible to explain the presence of tetraethyl lead In appreciable concentration in the cample of scale removed from the valla of this tank, (cf. the tetra ethyl lead content of the scale). The result on the soil sample taken from beneath the tank is of no value in the reconstruction of the conditions within the tank, since the organic lead content was too low to have specific significance The significance of the results on the piece of cloth is fairly clear, despite the fact that the character of the lead com pound deposited ih the fabric vaa not determined. Probably moat of the lead in the air that passed through the cloth failed to be trapped by the cloth. Certainly this vas the case if this lead vas in the fora of vaporized tetraethyl lead. At all events the presence of lead in appreciable concentration in the air escaping from the tank has been demonstrated. The nature and tho`actual severity of the lead exposure of K f 0021400 3. the vorlaaen cannot b determined with precision. However, It cannot be said that there are an; nt-v or hitherto unanticipated factors that need to be taken Into account to explain this case. It was merely one of the series of extraordinarily dangerous tanks that has case to our attention. It is precisely this set of conditions that the tank-cleaning regulations are designed to deal vith. (Th application of these regulations did protect th cleaning personnel in this case*} Our. safety personnel must accept the fact that such conditions are destined to occur from time to time* and that gaso line storage tanks in general must be dealt vith on the assumption that such conditions may be encountered without warning or fore-- knowledge thereof. Despite th proved efficacy of the present regulations, if followed, in warding off danger under the conditions that existed in this tank, this incident may be regarded as an indication of the need for a device that may warn safety engineers of the existence of high ' concentrations of tetraethyl lead vapor in the air within tanks. Every effort will be made to develop such a device. Certain ideas have been advanced in this'direction and will be explored. However, it seems inadvisable at this time to acquaint field safety personnel with this possibility, since to do so might suggest that there is a technical inadequacy in our present procedure, and that no human fault could be blamed for this episode. The facta are to the contrary Tills unhappy affair was the direct result of a mistake In judgment, and a failure to follow verbal and written instructions. Our efforts in the development of a technical device of th type referred to, should not be permitted to take th burden of responsibility for . sound judgment from the shoulders of safety personnel, but rather to 0021401 supplement euch Judgment by technical data when it is possible to <2 so* Signed * r'ob'ci"t A ' ^c'hoo $ . l"-1, Medical Director' 0021402 5F % TAHK rEPAtniKG ACCXDHHT - COHTIllETAh OIL COMPANY AT-ITSXA> KEW MEXICO This tank was cleaned by aa contractor for . . the Continental Oil Company on November 27$ 1944 - November 29, 1944, and observed by Mr. Eenington, Ethyl Corporation safety representative * According to the management and Mr . Leaington all safety precautions were observed in the cleaning operations, in cluding complete changes of clothing, air-line masks, gloves and boots. Baths were taken by all workmen at noon and in the evening. Four men entered the tank in the cleaning operations and apparently the entile procedure was regular and according to safety regulations As evidence of this is the fact that only on of the men who helped with the tank cleaning developed any signs of illness, and that these occurred in connection with the repair work in which he assisted. The sludge was put in a pit located about twelve feet from the manhole, but as the work progressed, it was found necessary to dig a long trench to hold the sludge as the fluid portion did not drain readily into the ground due to the type of soil. This sludge remained uncovered for two days and subsequently a question arose as to the possibility that vapors from this source had entered the tank, thereby providing the exposure experienced by the repair men. This, obviously, is a most unlikely explanation of the : latter exposure. The sludge was not covered immediately because of shortage of help. The tank was steamed on the nights of November 29 and J , and December 2 and during th day ad night of December 5. Wet steam KT 0021403 ';b Crj at&am vos not avatlablS"<^Skl9 fact accounted for presence of about /llr :.' gallon# ofaqueous condensate In the ... . pools at various low spot# :OV#vf^M bottom when It was c&cj :or concrete. Sills vater was drained through a hole marie In the bottom of the tlBk.At the edge, as there was no water draw-on . c'Mr&^&W&'- I he tank remained: a#,-above until December 9, five days after the last steaming* whan the concrete bottom was poured, 'here v g s some question as to Whether a new steel bottom was to be installed or a layer of eonorete poured over the leaky bottom vith .ho idea of putting a metal bottom over the concrete i&*er. ih;n, by the way* would create a situation that would make it impossible to clean the bottom. Hr* Lenington inionaed the superintendent that if welding or Other hot work was to be done on tho bottom, it would have to be sand blasted and a side sheet removed, ihis vas con sidered too expulsive an undertaking, .he cupcrinicndcnt slated that Mr. Lenlngtoa approved the pouring of the concrete without apeeiSir precautions after tho thorough steaming and tooting for vapors* and declared it safe from that standpoint. Mr. lenington left for another- tank cleaning and later in the week went to Dallas to help Mr. Jeppe with the army school O being conducted there at the time. He was finishing there and on *--I CM hla way back to Amarillo When the report on the trouble at Artesia O O' was received. Ho other gaiety representative of the Corporation was present. Mr. Lenington# by the way, told me he had discussed if this particular tank and the pouring of the concrete on Thursday* I believe, et Dallas* with Mr. Ball who, so Lenington reports, said ho could eee nothing wrong with the procedure. The Continental Oil Company finally decided to employ 7. concrete on the bottom, and Mr * v&a given the contract. Five da^e had elapsed since the steaming, hut the refinery safety : man made three different tests on the tank and reported it gas free for open working and safe from the viewpoint of explosive mixtures. The contractor had a total of (13) men working for him* This number includes six Mexicans At some time during the day all of these men with the exception of one were In the tank. Some, however, were inside only momsntarilly, helping shift the trough or doing other work for a short time. The group of Mexicans spent their time in end out - at tines shovelling gravel and operating the concrete mixer. The actual working arrangement consisted of a small motor generator outside the tank for current for the light, and a email concrete mixer set up on blocks at the manhole, with a trough about six feet in length extending through the manhole into the tank. The concrete was dumped into the trough and moved along into the tank from the outside and then distributed on the inside as the bottom vac laid. who became violently ill'and succumbed, was the worker who followed the edge of the concrete, pushing, pulling and levelling it about the bottom and, as-1 understand, worked very hard. Others in the tonic moved about to and from the manhole. 0021405 By noon good progress had. been made af ter approximately four* hours of work in the tank. Mr. fttk felt weak and unsteady, but continued to work the remainder of the day. He complained to ) Mr. boon, *ke vaen*t feeling too good." Mr. another workman, became somewhat ill at noon and during the after noon worked outside of the tank. The other men worked as usual throughout the afternoon in and out of the tank. By evening 8j $ of cho tank bottcw had boon installed. Frc what I could learn no skin contact vaa made with ey portion of the inside of the tank. As the work progressed more and more of it vas done on top of the concrete vlth the exception of Mr. who vorkJd on the tank floor part of the tine. After finishing vork in the evening the ami vent to their honest, sane living twenty miles away la the town of K&ggermaa* Kev Mexico* The Mexicans lived nearby Artesia and in the surrounding country* TAKE DATA MMMM* NMWM Tank was blending tank #15 This tank is a small round top tank of Xo,tuo-hbl. capa city approximately sixty feet in diameter. There is a manhole opening near the bottom S3 inches in diameter and a vent on the roof 4 inches in diameter and a gauge hatch approximately 6 inches in diameter. On the teak directly opposite fro the manhole there were two openings about 6 inches from the floor - on inch and the other a 6-inch opening. These were the gasoline line openings and the linos were disconnected and blanked off. There was no manhole opening in the roof. The above were the only openings for ventilation into the tank and no side sheet was removed during the pouring of the concrete which v&s approximately 80# depleted* leaving about ** cubic yards still to be poured to complete the job. Through one of the small gasoline line openings at the bottom of the tank & compressed air hose was introduced and it supplied air from the compressor In another part of the refinery and was in operation while the men worked. ^ Kt 0021406 'If: 9. Relative to the bottom the superintendent of the refinery, . the contractor end Mr* Lcnington all state that it had no large : holes or openings in it. The contractor saw a few (three or four) holes the also of a pencil, but it would be rather difficult to see seme openings as the underlying soil would be the same color, and there might have been many fine holes. The bottom was springy when walked on which would allow settling when heavy cone rote was applied It is possible, of course, that there were larger holes than those described, and it is possible that sludge v&s present in considerable quantity under the tank on the ground. The charac ter of the soil, as mentioned elsewhere, was such th&t it v&s not readily penetrated by the sludge and therefore the absence of wetness around the edges of the tank, on the outside, does not : prove that there was not a considerable quantity of material under the tank. There was, in fact, a spot of wetness, about six by twelve inches on one side of the tank As to spiking of this tank in the past there is no history. It is an old tank, in service a number of years and addi tional lead may have been introduced directly Into the tank at sometime or other. The superintendont said it had never been done to his knowledge. However, in recent years, there have been three superintendents in charge of this refinery. Pe* Possible Source of %ad There was seas question at the outset as to load being the causative factor In these cases because of the rapidity of the onset of symptoms. However, as the illness progressed, it was apparent that it vac lead intoxication and an attempt vao made to K F 0021407 10* find th source of lead* Th bot tea of th tank was fowflf th covered and could not be seen but Jtr* Gillespie, th refinery superintendent * Hr. HHH* th contractor, and Hr. Leningtcn said there vere no large holes in the bottea. Mr. gUFaoid he s&v three or four small holes about the else of a lead pencil1 Hr* Gillespie said it vould hold a voter bottom of four to six inches for a couple of months but since the soil allows poor absorption and drainage as observed in the sludge pit, it vould be possible for fluid to pocket beneath the bottom. Around th edge of the tank in only one place vac there any significant vetting of the soil from the leaky hot testa. However, the interval of five days between the hot steaming and the concreting could allow vaporisation of the contents below the bottom. Cn the other hand, one might expect some gasoline vapor to be in the tank also but it tested gas free or within safe limits before work was begun. This could be explained by the water bottom : which the superintendent said was always kept in the tank because of the-leaky bottom so gasoline may have been kept out of the area under the tank sufficiently to give one this picture. The bottom In this tank was springy when walked on and th heavy concrete on th bottom may have bom a factor in pushing up any trapped below through the holes remaining in th floor ahead of the concrete. -j . In light of th fact that seme of th men in the tank complained of irritated eyes and ^running noses," I tried to find i' ' a source of dry triethyl salts* This vould mainly have to com from the idee, since the bottom was wet or damp. From previous findings cn sides of tanks I questioned this, but thought the air bloving from the hose into the tank may possibly have set up circular A'F 0021408 u* 7' * motion loosening up some dust from the sides to account for the . above symptoms, ; In checking into the sir line bloving into the tank it vas turned on vith the valve half opened as no one seemed to know vhere it vas set during the vork in the tank* In a short tiara air vas moving out of the manhole* and Trees the outside* vapor could he seen casing out of the vents on top---possibly from the moisture from the concrete. A piece of cloth vas obtained at the store and fastened over the manhole and allowed to remain there three and a half hours vith the air valve half open. This vas removed and folded to keep the exposed part together and placed Immediately in a paper bag for analysis* A control piece of the same cloth vaa kept. This would only disclose case lead vapor in the tank* but when done most of the floor vas covered. A sample of the sludge from the tank vaa obtained from the sludge pit* and a cample of scale from th side vail of the tank I*. J. Schradin January 25* 1$$5 0021409 I Semples o f u rin e and blood re ce ive d from men In v o lv e d In cem enting t o tic , In tank f o r the C o n tin e n ta l O il Company, .{D r. fc h ra d in ) A rte e l , JSev M exico. emples Pported t .12-50-44 r/i ?9 ?a I M *Ho* <5: *S? a 0Mo 1 as .- ** HM HV- V -r J4ar 4.aT* 45* . 4B- - Jsr S* &% |?SMo 11 Ch OS 1 e\ ar* vo VO VO *1 t+4y JW vr -4 VO &* 8cO+' w *-* o i gH $ Ct 4-- HCy*** u V4 0o0 a 00 *ct?s a5 > oo tr f IEo*M4 tt I I VCO\ cJS\ <7^ UV&CD-i >3 H> CU M s\> oHJJ} VfD *to sr r*-f2 Cl-u es Hr** 3 O' Of o 0* fO Vf5 {SO o<*-s> <5 V*tMt'*,,f.`- f(*fB?isi ts MO oo. 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