06/24/2013 01:36 pm ET Updated Aug 24, 2013

Remembering West, Texas: Lessons From a Tragedy

The blasts at the two chemical plants in Louisiana a day apart on June 13 and June 14 brought back to memory the explosion in West, Texas approximately two months earlier on April 17.

A total of three people and more than 100 were injured in the two Louisiana blasts but there was apparently little collateral damage to the surrounding neighborhoods. In contrast, the explosion at the West Fertilizer Company killed 15 (most of whom were fire fighters and first responders), injured at least 200 more, damaged 350 homes - destroying more than 50, devastated entire city blocks, and did extensive damage to the town's intermediate school and high school.

All three of these events are tragedies. The West, Texas event was a tragedy of almost epic proportion because of its far-reaching and direct impact upon an entire community. Yet, it received only modest attention in the mainstream press at the time of its occurrence and subsequently.

In his comments at the memorial service for the victims of the West Texas fertilizer plant explosion, President Obama reassured the citizens of West that "You are not forgotten. We're Americans too, and we stand with you, and we do not forget."

The president is absolutely correct and one of the best ways to ensure that "we do not forget" is to make the lessons learned from West enduring ones. These lessons relate to: media coverage, self-reporting, regulatory oversight, work place safety, zoning and community safety, accident investigation, and disaster recovery.

The West Texas explosion coincided with the bombings at the Boston Marathon. The media obsessed over the Boston event in its 24x7 coverage for a lengthy period of time. The attention it paid to the West Texas event came and went almost as quickly as the explosion itself.

Writing about this in an opinion piece for the Washington Post, Mike Elk, a labor reporter, commented, "The networks seemed to decide covering two big stories was covering one too many ... The media's neglect has greatly increased the danger that the explosion will quickly be forgotten..."

Elk went on to state that he, and other reporters who had covered the Upper Big Branch explosion that killed 29 miners in West Virginia in 2010, feared that "once again knowledge of why a massive workplace disaster occurred- knowledge that could save lives in the future - will be kept out of the public discourse because the media simply won't cover it." West Lesson Number 1: The lack of appropriate and ongoing media coverage decrease the potential for public concern and corrective action.

The West explosion was caused by ammonium nitrate. Fertilizer plants are required to report to the Department of Homeland Security (DHS) if they have more than 400 pounds of ammonium nitrate in storage.

According to reports, records show that in 2012 the West Fertilizer Company (The Company or Company) had 270 tons on hand. That's 1,350 times the amount that should have triggered DHS reporting and oversight.

The company, however, never submitted a report regarding this to DHS. Self-reporting might work in a gentleperson's sport like golf. It rarely does so in the competitive business world. West Lesson Number 2: Self-reporting is an ineffective method for managing the risks related to hazardous materials.

A variety of regulators are charged with oversight of the Company. Federal regulators in addition to DHS, include the Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), and the Pipeline and Hazardous Materials Safety Administration. State agencies include: the Texas Commission on Environmental Quality, the state chemist's office and the state health services department.

Overlapping and potentially conflicting jurisdictions can lead to many eyes but little accountability. West Lesson Number 3: A patchwork quilt does not provide a systematic framework for regulatory oversight.

The Occupational Safety and Health Administration (OSHA) reports that more than 4600 workers were killed on the job in 2011. OSHA is a small agency with approximately 2,200 inspectors (in its federal and state workforce) responsible for the health and safety of 130 million workers, at more than 8 million worksites across the country.

According to the AFL-CIO, "Federal OSHA can inspect workplaces on average once every 131 years; the state OSHA plans can inspect them once every 76 years." OSHA made its last inspection visit to the West Chemical & Fertilizer Company as the business was known at that time in 1985. The Company was issued a $30 fine at that time for serious violation for storage of anhydrous ammonia." West Lesson Number 4: Inspections do not guarantee safety. An almost 30 year gap without an inspection, however, definitely does not promote work place safety.

The fact that the homes and schools of the community of West Texas were so close to the fertilizer plant significantly exacerbated the scope and nature of the devastation. Federal and state regulators do not control this. Zoning is the province of local planning boards.

As Kelly Harragan, Director of the Environmental Law Clinic at the University of Texas noted in an article posted by Terrence Henry for StateImpact Texas (a collaboration of local public radio stations KUT Austin, KUHF Houston and NPR), "Regardless of the cause of the West Explosion, there's one thing that could've been prevented: the plant's proximity to homes and schools, which were built after the plant." West Lesson Number 5: Location matters. There should be a sufficient protective distance between a regulated industrial facility and community residences and buildings.

The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) and the Texas State Fire Marshall's Office (SFMO) announced the official findings from their scene investigation on May 16. (The ATF took jurisdiction because it viewed this as a "criminal investigation". The STMO had its lead because it is required to do so when fire fighters die in the line of duty.).

Both agencies ruled the cause of the fire as "undetermined." They eliminated the following causes: rekindling of an earlier fire, spontaneous ignition, 480 volt electrical system, anhydrous ammonia, ammonium nitrate, smoking and weather. Causes that could not be eliminated were: 120 volt electrical system, a golf cart, and an intentionally set fire. (One of the first responders has been charged in a separate criminal investigation with possessing pipe bomb making material).

While the scene investigation was inconclusive, the reaction of the Chemical Safety Board (CSB), the national agency created in 1998 to do root cause investigations on chemical accidents, was not. On May 17, CSB Chairman, Dr. Rafael Moure-Eraso sent a letter to Senate Environment and Public Works Committee Chair Barbara Boxer (D-CA) expressing frustration and concern about the "unprecedented delay and harmful delay" in granting members of the CSB investigative team access to the site. According to the CSB chair, its staff was not given access to the site by the ATF until after the ATF had significantly altered it and "removed almost all relevant physical evidence."

This jurisdictional dispute and the lack of inter-agency communications and cooperation should be unacceptable at any time. It is especially so after a tragedy of this magnitude. West Texas Lesson 6: The territorial imperative can restrict the nature of an investigative inquiry and how a problem is defined can dictate and compromise its findings.

On June 10, the Federal Emergency Management Agency (FEMA) which had provided $7 million in aid and low interest loans along with the Small Business Administration to West residents, advised Texas Governor Rick Perry in letter that it would not make a "major disaster declaration" for West. Such a declaration would have provided additional financial assistance to help the town to rebuild and for crisis counseling and other services. Reports indicate that it is not unusual for FEMA to turn down assistance requests that are not related to "natural" disasters. West Texas Lesson 7: Disasters are not created or treated equally in terms of their consequences or commitments.

In conclusion, these are some of the lessons that must be learned from West. It and they should not be forgotten.

Senator Boxer has called for an oversight hearing on June 27 to discover what happened in West. We need that hearing and to heed these lessons.

Their importance for America and Americans is highlighted by the fact, as Danielle Brian noted in her Huffington Post blog, that according to Reuters at last 800,000 people across the United States live near hundreds of sites that store large amounts of ammonium nitrate. Hundreds of schools, 20 hospitals and 13 churches also sit near sites. Twelve ammonium nitrate facilities have 10,000 or more people living within a mile of them.

These are disasters waiting to happen. They can be avoided if we remember the tragedy at West, Texas.