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Shell Canada, Code 6 Review
Incident date: June 20
th,2003
Review Date: July 29
th, 2003

Response Review Members: Tom Cooper (Chair), Brian Hatfield, Tom Boone, Mark Wetering & Hank Bonnet.



Background and Sequence of Events:

Several odor complaints were received by Shell complaining of sulpher like smell. These were received from Corunna. The first complaint was at 15:25. Shell investigated and noted that there was a problem with an incinerator showing high So2 levels.

At 16:15 the SLEA monitor showed traces of So2.
At 16:45 the So2 peaked on the monitor.
At 17:04, Shell initiated a code 8 which they upgraded to a code 6 in area 2 at 17:07.
At 17:09, Shell requested a notification to residents by use of the “one call” system.
At 17:19 the sirens were sounded in the Reserve and Corunna and the “one call” was initiated at 17:20.
Shell faxed dispatch at 17:22.
At 17:35, Shell requests an “All Clear” and announced on radio that the All Clear had been given.
At 17:50, So2 levels were recorded at 405 ppb. Shell commenced contacting plants north of Lasalle Road due to the north wind and advised them of complaints. It was felt that due to the north wind, part of the problem was north of Shell. Shell commenced testing in the area until 18:25 when the SLEA monitor revealed a normal So2 reading.
At 18:37, St.Clair FD were prepared to terminate the code 6 and sound the “All Clear” which they did at 18:45. Shell faxed the all clear and update at 18:56
 

It was noted that there was a “brownish haze” coming from north of the refinery (19:22) and also complaints were received from north of the plant.
 

Analysis:
Having noted the above events, the review team compared actions with the protocol outlined in the manual and several items were raised.
 

1) OPP seemed confused about their role in traffic isolation.
2) Dow erected a roadblock at their gate area which was not in accordance with protocol.
3) It appears the Mobile Command Post did not respond.
4) Pagers were not activated with the Shelter in place or the all clear.
5) It appears Industry is not included on the “One Call” system
6) The shelter in place was not relayed over the CVECO radio.

 

Conclusions:

  • Shell followed the prescribed protocol, with one exception, They announced over the radio that the all clear had been given, and this was incorrect. It had only been requested and St.Clair FD were not prepared to do so at the time (17:35).

  • OPP and Sarnia Police should review their roles in a code 6.as confusion was noted in respect to positioning re road blocks.

  • Dow should not have erected road block at their location as this caused problems with responding Shell personnel.

  • The Command Post did not respond as required by code 6 protocol.

  • Dispatch did not activate pagers with the shelter in place or all clear.

  • Industry should be added to the one call system for area 2.

  Conclusions and Action Items:

1) Shell to review requesting of all clear and insure all personnel are aware that they can only request the lifting of a code, only the municipal Incident Commander can lift it and sound the all clear.
ACTION ITEM: H.Bonnet
 

2) OPP AND Sarnia Police to review their roles in a code 6 and retrain where necessary.
ACTION ITEM: M.Sumner & P.Futers
 

3) Dow to review code 6 protocol with personnel and eliminate any “unwritten” agreements to erect barricades.
ACTION ITEM: D.Martin
 

4) Command Post protocol to be reviewed and training initiated where required.
ACTION ITEM: C.Gardner
 

5) Industry to be added ( if possible) to the Corunna One Call System.
ACTION ITEM: T.Boon
 

6) Dispatch protocols re: alerting pagers with shelter in place orders and all clears should be reviewed with 911 operators.
ACTION ITEM: C.Gardner.