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Technological Hazard – Lab Error | Chemical Warfare Agent (Sarin): Dugway Proving Ground, Utah

2017/06/26

SARIN, LABORATORY ERRORS: DEPARTMENT OF DEFENSE INVESTIGATION REPORT
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Published Date: 2017-06-25 19:35:30
Subject: PRO/AH/EDR> Sarin, laboratory errors: DOD investigation report
Archive Number: 20170625.5127661

Date: Thu 22 Jun 2017
Source: Stars and Stripes [edited]

The same Army laboratory that mishandled anthrax in 2015 leading to a nationwide scare might also have lost a small amount of the chemical sarin, the Pentagon’s inspector general has found.

In a report released this month [June 2017], the inspector general for the Department of Defense found officials at the Army’s Dugway Proving Ground in Utah and a contractor that facility was using to care for chemicals did not properly inventory its sarin, a nerve agent that can be fatal to humans if they come into contact with it.

Dugway stored its sarin in a 2-container system. The sarin was stored in a primary container, which is then stored inside a secondary container. But officials only checked the secondary containers when doing inventory and did not check inside the primary container, so they did not know whether all the sarin was still in the containers, the inspector general found.

“Therefore, custodians cannot identify and account for leaks, evaporation, or theft that may have occurred,” the inspector general found. “Furthermore, Dugway officials did not immediately notify the chemical materials accountability officer of a 1.5-milliliter shortage of…sarin identified during a 19 Apr 2016 inventory nor did they properly document the results of that inventory,” the investigation found.

Dugway and its contractor also used different methods to seal the containers, the inspector general found.

“Dugway used stainless steel cylinders and ammunition cans sealed with tamper evident seals; and the contractor used resealable plastic containers sealed with tape, which provides no assurance that only authorized personnel had access,” the investigation found.

It would be difficult to tell whether sarin was removed from the facility or it evaporated, due to the amount that was reported missing and how it reacts with the environment, said Dan Kaszeta, a former Army chemical weapons specialist and now the managing director of Strongpoint Security, a chemical weapons consultancy based in the U.K.

“1.5 [milliliters] is actually rather a small amount,” Kaszeta said. “Yes, it could kill somebody, but sarin evaporates very quickly and also degrades very quickly.” It would not last long if it got out of one of the containment jars, he said.

That amount is small enough that it could be within the margin of error for measuring it, depending on what technique was used, Kaszeta said.

Bruce Anderson, a spokesman for the inspector general’s office, said the investigation recommended a new inventory of all the chemicals at Dugway be completed to establish a new system to better track dangerous substances.

“We found conditions that increased the risk that chemical agent operations are not conducted in a safe, secure and reliable manner,” Anderson said. “We believe that the Army should address the increased risk by quickly implementing corrective actions.”

Dugway is the same facility that was the source of a nationwide scare in 2015 after it was reported the facility had inadvertently shipped hundreds of samples of live anthrax to medical labs in all 50 states and 9 other countries when the samples were supposed to be inactive. The top officer at Dugway at the time, then-Colonel William King, was issued a career-ending reprimand following the incident.

[Byline: Tara Copp]

Communicated by:
ProMED-mail
<promed@promedmail.org>

[A milliliter is a very small amount and is likely due to evaporation. However, this is the same lab that shipped out live anthrax samples to diagnostic labs. Hence, there may be larger issues here than a tiny amount of chemical missing (which is likely due to evaporation). The larger issue here is the lack of uniformity in how the Army handles things, and how a contractor handles things.

It seems there should have been a Standard Operating Procedure (SOP) in place that specified some details such as:
-how often the levels of the chemicals should be checked, and was that to include primary and secondary containers?
-what the canisters were to be sealed with?
-how many people should be on an inspection team?
-what are the procedures in the event of an exposure?
-where this information was to be noted and how often?
-what kind of tape for resealing the containers should be used?
-what kind of training and how often should the training be performed and by whom?
-where is the documentation for that training kept?

There are likely other things the SOP should have contained, but from this article, it appears there was a lack of:
-communication
-training
-specificity regarding training and inspection

One wonders whether these things were spelled out for a contractor or any other inspector of the containers?

This is the 2nd type of general failure at this facility the Inspector General has investigated. These issues all need correcting. The correction of these events is paramount to keeping people at the facility safe, as well as the safety of lab personnel who may receive samples (such as the anthrax samples), or the surrounding communities if a mishap were larger than a few milliliters of a evaporated chemical.

If these things had been documented or tracked more closely if they were known issues, then it would be a clearer situation to understand if the tiny amount missing is from evaporation (which is likely) or from theft or mishandling. – Mod.TG

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/8040.]

See Also

2016
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Anthrax – USA (04): laboratory errors, GAO investigation report 20160929.4524933
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Source:
A ProMED-mail post
ProMED-mail is a program of the International Society for Infectious Diseases


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