The East St. Louis Para-Nitroaniline Spill - A Case Study in the Cascading Effects of a Single Exposure Incident

On the Saturday of Labor Day weekend 2008, eight individuals were handling what they believed to be a relatively non-toxic product, para-nitroaniline (PNA); a spill occurred, covering them in the bright yellow powder.  Because of the low level of concern, the workers did not undergo proper decontamination or seek immediate medical attention; they cross contaminated the office and break rooms as well as their vehicles and homes.  Later that evening, as the effects of methemoglobinemia began to manifest, they went to five different emergency rooms in the metro St. Louis area.  This initiated a cascade of events leading to closure of three emergency rooms from contamination fears.  Initially, misinformation abounded regarding virtually all details of the incident.  As more information became available, CTEH was mobilized to re-open two emergency rooms, and subsequently guided the cleanup efforts at workers’ homes and the spill site. The facility’s manager was contaminated and unable to be onsite during the initial site assessment and formation of an action plan, further complicating the incident.  The subsequent OSHA investigation resulted in 21 willful violations and a 1.2 million dollar fine.  This presentation discusses the events leading up to the crisis, the efforts to re-open two emergency rooms, and the cleanup of the site and worker’s homes.  Additionally, the presentation will focus on the cause of the incident and how it could have been prevented, mitigation of the contamination, the roles of the cleanup contractor and responsible party, pre-planning for such events, and the subsequent OSHA investigation.