Document gE5N1RY04pKvmO12jLrL2D5dJ

CCI DMMirr.rr.HR..jE...PWA.O..FK..K&Jeoahmnlteexhyssaa(i2) Hr. J. J. Frey H. Taylor - Wilmington, N.C. Tank Cleaning Incident Hew York Eastern Region September 20, 19H8 Ve riave just new road a copy of FT. E* 0* Jones letter of August 26th v,lth reference to the Wilmington, North Carolina tank cleaning incident. Hie facts presented in this letter are substantially true. Havrever, we would like to make a few comments which may threw cone additional light on the entire affair and give a little clearer picture. . In Paragraph 2, on Page 1, Ur* Jones comments on Hr. Mercer's failure to arrive in time to observe the first entry in the tank. Mr. Mercer only received the notice (direct from the Cape Fear Terminal, and not from this office as indicated) late on the day of June 1S>, and the job was slightly over 200 miles sway from his home, lie arrived on the job on the afternoon of June 16th. We fail to see where there is ary room for criticism here. There lias been a direct contradiction in the stories of Ur. Mercer and Mr. L* E. 'Williams. Mr. Jones comments on tire fact that Mr. Williams* story is corroborated by the story of Mr. Nichols, the foreman. He goes on to say - "Nevertheless, we are accepting Mr. Mercer*s story as the correct one." I would like to add that the conversation held between Mr. Baldwin and Ur. George Smith, another foreman for the sane company, corroborates Mr. Mercer's story and convinces us that his is tire truthful one. 2, 3,In Paragraph. on Page Ur. Jones comments on the fact that Mr. Baldwin took samples from only one tank. There was not time to take the additional samples, so he instructed Mr. Mercer to take samples from the other tanks. This was done the following day* In Paragraph ii, on Page 3* Mr. Jones comments on the fact that all communications were carried on between the Southern and Eastern Regional Offices, and directly between these offices and Dr. Kehoe. This was naturally done because of the nature of the situation and the need for prompt action. V.re might add that we went out of our way, at all '.- V' :*- . . .V y - . #2 :.; v Mr. J* J* Frey September 20, 19U8 times, to keep Mr Jones advised on every move and every development \7e certainly take serious exception at the last paragraph on Page 3 which reads - "A careful examination of all the evidence in this case leads us to believe that most of the difficulty resulted from a misinterpretation on the part of the Eastern Region personnel of the so-called modified tank cleaning policy, a copy of -which is attached hereto*" The accident occurred because of one thing, and one thing only A man of long experience in tank cleaning, who was thoroughly familiar with our rules and regulations, as well as the hazards involved, failed to wear a mask* This man's experience and knowledge of our regulations is attested to by the written statements of Dr* Kitzmiller, Mr* R. L* Jordan, and others* The accident could only have been averted by our man constantly acting as a "watch dog" to make certain that this man did not take off his mask 17e later learned that he had done so on previous occasions, but we had no way of suspecting that this was a fact* Our local representative, Mr* Mercer, was convinced that this vras a capable crew; that they knew the rules and regulations and would abide by them, and acting on his interpretation of the modified tank cleaning program, lie returned home for the weekend and to take care of some other commitments* Yre feel confident that his interpretation of the modified tank cleaning program, as well as the interpretation of Mr. Baldwin and myself, are similar to those held by other Regions We certainly have gone out of our tray to adhere to these regulations and were of the opinion that we were so doing# The Mew York Safety Staff has received complete reports of all of our tank cleaning activities and should have been fully aware of the manner in which we operated over a period of years# Having heard nothing to the contrary from them, we naturally assumed that our method of operation, which they were constantly checking, was the proper one# On Page U, reference is made again that Mr. Mercer was not present when the work began at the Cape Fear TemLnal, nor was he present for the first entry at the Carolina Terminal* As we have explained, late notice was responsible for the first* Mr* Mercer was present when work began at the Cape Fear Terminal, as is indicated in his report, and he was satisfied that the equipment, the ability and the knowledge of the entire crew and all other factors tending towards safe operation, was such that he could safely leave the job* He had no reason to believe from his own observations or from reports received from other sources about this crew that they would violate our rules and regulations, which they under stood so thoroughly as indicated in Dr* Kitzmillers report# RE 0006380 kr# ,,,, . septonbi^'20, 1 & 8 / I believe tills report, possibly unintentionally, pate / both Mr* hercer and the Eastern Regional Management in an unfavorable light, T*iiich is entirely unjustified Furthermore, it makes no re commendations to correot a repetition of such an incident except to increase our attendance at future tank cleanings ue believe this matter is of sufficient magnitude and represents such a large item of expense to tire Corporation that ire should have a meeting of the minds to determine exactly h m this opera tion can best be iiandled and how far ire want to go in giving precedence to tank cleanings over all other work For this reason, I would appre ciate an opportunity for Jim Baldwin and I to discuss this with you and Harry iCaley in the very near future* I certainly think the matter is even serious enough to warrant a discussion with all of the Operations Managers so that tire Sales Department can determine the safest way of handling our tank cleaning program compatible with our budget limitations and the necessity for doing other important work* Very truly yours, I&TlQ m.a. m c i jt 0 0 0 6 0 3 1 cot Dr. E. A. Kehoe (2) Mr. J. P. Farnham Mr- H. W. Kaley Mr. J. J. Frey E. 0. Jones Wilmington, N. C., tank cleaning accident New York New York August 26, 1943 This memorandum is for the purpose of placing on the record a complete summary of the unfortunate tank cleaning tragedy which occurred recently at Wilmington, Morth Carolina. For your information and file, I am at taching several pertinent documents although the complete file in the Safety Department contains many more letters, reports, and so on, and will be available for reference at any time. During the week commencing June 13, 1948, the Eastern Region received notification of a series of tank cleanings to be carried out in Wilmington, Horth Carolina. Our Mr. F. Y. Mercer, whose headquarters are in Charlotte, North Carolina, was assigned to take care of the job. Despite the fact that notice was received on June 15th, Mr. Mercer did not arrive in time to see the first entry on the job. He did, however, see the first tank through to completion and he reports that all Ethyl precautions were followed. Work on the first tank was completed June 18th. The contract undertaken by Tank Cleaners, Inc., Jacksonville, Florida, called for the cleaning of three tanks at the Cape Fear Terminal and eight additional tanks at the Carolina Terminal, both in Wilmington and separated by something less than a mile. It is probable that the fatal lead exposure occurred at this latter terminal during the cleaning of the first three tanks, designated as numbers 1, 2, and A. Since the incident occurred, we have carefully investigated all possible angles, and it should be stated at the beginning that there is a complete contradiction between Mr. Mercer and Mr. L. E. Williams, General Manager of the contracting firm. The story of Mr. Lynch Nichol, who was Mr. Williams* foreman on the job, corroborates in most major details the statement signed by Williams. Nevertheless, we are accepting Mr. Mercer's story as the correct one. Mr. Nichol was not present at the conversation between L. E. Williams and Mercer during which Mercer stated that all precautions should be used during the cleaning of the tanks at the Carolina Terminal. According to Mercer the contractor's crew, consisting of Mr. Lynch Nichol (the foreman) end two negro workers moved the scene of their operations f r a R n ^ w i p e Fear Carolina Terminal on Friday, June 18th. Mr. Mercer says that he was with the erew and that the last part of Friday afternoon, June 18th, was spent pumping the accumulated water from the bottom of tank number 1. No history T, J. J. Frey -2- Subject* Wilmington, H. C. accident* August 26, 194S of any of the tanks at the Carolina Terminal was known to our representative, to the terminal management, or to the contractor, except for the fact that the tanks had been empty and unused for approximately five years. (It has oince been established that the tanks are owned by a Mr. 8am Brockwell of Wilmington, Worth Carolina, and are leased to the Cape Fear Terminal, which apparently is controlled by the Pure Oil Company. It was the Pure Oil Company which executed the contract for the tank cleaning at both the Cape Fear and Carolina terminals. It has also been established that tanks 1, 2, 3, 4, $, and A were used at some time or other in gasoline service.) Mercer says that Williams, the general manager of the contracting firm, asked his advice about the use of protective equipment in the cleaning of the Carolina Terminal*s tanks. Mercer said that inasmuch as no history of the tanks m s available it must be presumed that they had at one time been in leaded gasoline service and that all precautions should be taken. Mercer states that Williams agreed to the suggestion and said that he (Williams) would see that proper precautions were taken. On Saturday morning, June 19th, Mercer called at the Carolina Terminal and met Lynch Hichol, the foreman, after which he (Mercer) went to the Cape Fear Termin al to diseuse the condition of tank number 211 which had been completed the preceding day. Mercer then left for his home in Charlotte stating that he would return the following Tuesday evening to check the Job. Subsequent questioning of Mercer brings out a. significant fact. During the conversation with Nichol on Saturday morning at the Carolina Terminal, Mercer made no effort whatever to check the tank cleaning operation although at that time it had been in progress for approximately two hours. He knew that L. . Williams had left for Jackson ville earlier that morning but he did not make any effort to determine whether or not the suggestions given to Williams on Friday afternoon had been passed along to the foreman, Hichol. According to the subsequent stories of the tank cleaning crew, they were working in tank number 1 without protective equipment at the time that Mercer and Hichol conversed "in front of the terminal** on Sat urday morning. If our man had walked only a few yards to examine the progress of the work, there is reason to believe that the entire tragic incident might have been avoided. It has been found that tanks 1, 2, and A were cleaned on Saturday, June 19th, end on Monday, June 21st. Ho worK was done on Tuesday, June 22nd. It is quite certain that no respirator equipment was worn during the cleaning of these three tanks. On Tuesday, one of the negro workmen, complained of ill ness sad a local n e g ^ ^ M ^ ^ ^ e e o m m e n d e d an appendectomy. refused to submit to the operation had received permission to return to Jacksonville on the bus. On June 23rd, who had seen Dr. John H. Mitchell of Jacksonville in the meantime, was admitted to Brewster Hospital in Jacksonville where his condi tion became progressively worse and eventually resulted in. his death at 3*35 a .a. Saturday, June 26th. It has since been established that died of acute lead intoxication._^sWedne sd&y, June 23rd, George Smith, who nad replaced Hichol as foreman, and ^ J H ^ ( t h e second negro m emberof the original crew) worked in tank number 3 withprotective equipment. f l j H B became 111 end w&s sent to Jacksonville by bus Wednesday night and arrived Thursday evening. He also eon- eultedDr. Mitchell* (Our records do not show whether Smith, at this point, knew of load intoxication.) V B B K illness became acute on Sunday morning K 00G6G83 lMr. J. J. Frey - 3- Subject Wilmington, N. C., accident Au.gu.et 26, 1943 and he was admitted at 11 a.m. to Brewster Hoepital, The subsequent clinical record indicates that ^ p f t . a l e o suffered from acute lead intoxication but that be will recover. Mercer returned to Wilmington late Tuesday afternoon, where he met the foreman Hichol, and the two men spent considerable time together Tuesday evening. Hichol was dissatisfied with the job and he and Mercer met George Smith, who had bean sent up to take 8 ichoice place. The three man dined together. It is significant that at no time during the course of Tuesday evening did Mercer inquire of Hichol as to the progress of the job or as to whether or not his recommendations had been fully carried out, even though he knew that Hichol was preparing to leave. As a matter of fact, by the time Mercer got to the job the following morning, Hichol had already left. As soon as news of the serious illness of was received at the Hew York regional office, Mr. Taylor sent Mr. Baldwin to Wilmington to assist in the investigation. Little or nothing of significance developed as a result of this trip. Baldwin arranged to secure a Lead-in-Air Analyser and although it could have been presumed that exposure occurred in one of three tanks -- numbers 1, 2, and A -- Baldwin only sampled the atmosphere in tank number 1. Samples were aleo taken through the airline hose and within the fire wall of tank number 3 Hone of the readings are significant. Mr. Shank, of our Southern Region, has held separate interviews with Mr. Lynch Hichol (who is now located in Dellas, Texas) and with Mr. L. . Tilllame (of Tank Cleaners, Inc., Jacksonville, Florida) Their stories are essenti ally corroborative. While in Jacksonville Dr. Kitsmiller interviewed Mr. Hichol in the presence of Mr. L. E. Williams, and their stories are the same in all essentia^detail^as the ones told to Mr. Shank later. Dr. Kitssiller interviewed but it is believed that the accuracy of his state ments cannot be given any weight because of the fact that he was apprehensive and ill at the t i m e ^ H ^ g a s ^ a l s o quite frightened by the illness and death of his associate, stated that during the course of Saturday and Monday he entered the tanks for ten to fifteen minute periods at intervals of about an hour without an airline mask. All of the communications during the course of this incident were carried on directly between the Southern and Eastern Regional Offices, and directly be tween these two offices and Dr. Kehoe in Cincinnati. As will be brought out later, ve believe that future incidents of this kind should be handled by the Hew York Safety staff directly with the regions and with Dr. Kehoe, since this procedure will permit crossing of the regional lines during any necessary investigation end will make available the somewhat broader experience of our administrative group. Both regions cooperated excellently throughout. A careful examination of all the evidence in this case leads us to believe that most of the difficulty resulted from a misinterpretation, on the part of the Eastern Region personnel, of the so-called modified tank cleaning policy, a copy of which is attached hereto. This policy has been in effect since July 6, 1942, and we had no reason to believe until now that it was being irr. ** J ' Fry *4 eabjsct Wilmington, N. C., accident. August 26, 1948 misinterpreted. In examination of Section I of this policy entitled Observe the Cleaning of ell Large Tanks states, among other things, that All tanks of over 1,000 barrels should be observed if at all possible. While the policy permits the observer to leave the job from time to time during its progress to do other nearby duties, he is required to be there when work begins and during any critical stages. Our representative was not present when work began at the Cape Fear Terminal part of the job, nor was he present when the first entry was made at the Carolina Terminal. On Saturday, June 19th, he failed to check the progress of the job or to assure himself that his instructions to L. E. Williams had been passed along to the foreman, Michol. There is nothing in the record to indicate that it would not have been possible for all tanks in the Carolina Terminal group to be observed. Mercer left the job to return home for the week-end and spent Monday end Tuesday making calls at certain district offices. None of these calls has been established as being so important as to require Mercer* 6 presence at that particular time. It is now learned that the Eastern Regional Office has consistently misinter preted our modified tank cleaning policy and has tended to treat any group of tanks, such as the ones involved in this particular contract, as one tank. This region claims that it did not believe that the intention of the policy was to consider each tank as a separate entity, and it seems that the use of the phrase, critical stages, has not been made clear. We have no doubt whatever that the region and the representative fully believe in the importance of safety but we cannot help but draw the conclusion that the spirit of the modified tank cleaning policy as well as its letter has been badly misread. It is also estab lished that the Eastern Regional management does not agree with our interpreta tion of the policy and feels that it cannot be followed as written without uneconomical operation. In order to clarify these misunderstandings end to make sure that Management wishes this policy to be pursued in the future, we are arranging a meeting be tween the Sales Management, Dr. Kehoe, and representatives of this office to discuss the entire safety policy. This meeting is proposed for the very near future. If, in fact, the modified tank cleaning policy is badly written, at least part of the responsibility falls on the Mew York safety office. Steps are being taken to correct the wording and a new bulletin will be issued as soon after the above mentioned meeting as is possible. In the meantime, we have circulated the field requesting cooperation so far as attendance at large tank cleanings is concerned. Even admitting the possibility that the wording of the policy covering this situation is capable of some misinterpretation, it is our considered opinion that the Ethyl representative on this job showed poor judg ment in several ways, or a lack of interest in seeing to it that the instruc tions left with the responsible head of the tank cleaning contracting firm were put into execution. As the result of a hearing before the Florida Industrial Commission on August 10, 1948, certain awards were granted to the survivors Rhyl Corporation, at this writing, has not been made a party to an^xegalaction. f/f 0006G35 T*. f--- f"V*> r/' *4 Gf?c c* = , *v*** &< f~n o -4- r, .~-4' o IhV *** + ft O* C IX In addition to the "Memorandum on Modified lknk Cleaning Program" and F. Y. Mercer's interview report dated June 18, 1948, copies of which are attached hereto, the following correspondence is attached to Mr. Jones' memorandum of august 26th addressed to Mr. J. J. *eys F. I. Mercer to H. A. Taylor; August 20, 1948. L. Shank to M. A. Taylor, E. 0. Jon.ee, Dr. R. A. Kehoe, E. K.. Locher, and H. K. Ball; July 30, 1948 Dr. K. V. Kitmiller "Memorandum, Tank Cleaning Incident, Cape Fear ier&intxia, Wilmington, North Carolina." F. Y. Mercer to M. A. Taylor;; July 8, 194S. AL 1^0 0U0bG8i>