A dangerous carbon-monoxide leak triggers questions about safety, emergency response
On Monday, Nov. 18, Montezuma Creek Elementary School students, staff and faculty began arriving for the beginning of another day. It was 28 degrees outside. Winter had arrived at the remote southern Utah town on the Navajo Nation. Children streamed through the doors to warm classrooms on the east side of the building. They put away their light jackets, organized their desks and soon followed their teachers and the other children, an estimated 280 people by that time, to a brief assembly in the gymnasium on the other side of the building.
The large room also serves as a lunchroom and auditorium. Behind an elevated stage is the mechanical room where two gas-fired, 300-gallon water heaters are located. No one realized that the heavy-gauge, 4.25-inch exhaust pipe to one of the water heaters was uncoupled and releasing carbon monoxide into the mechanical room, and then out into the school building each time the water heater ignited.
There were no CO monitors in the school. The State of Utah does not require them in school buildings.
A statement posted on the San Juan County School District web site describes in simple terms what happened next: “… The gas spread throughout the school creating an extremely unsafe environment.”
Carbon monoxide, a by-product of fossil fuel combustion, is an odorless and colorless gas that can cause illness and death. Heavier than oxygen, it lies closer to the ground, floor or surface where it is being emitted and will build up in sealed or enclosed spaces. It is taken up by red blood cells more rapidly than oxygen and then essentially blocks oxygen from entering the cells.
The assembly lasted 15 minutes. Students were dismissed to their classrooms where, during the next 40 minutes, they began complaining that they felt sleepy and dizzy and their arms and legs hurt. Teachers, too, began experiencing headaches and dizziness.
Calls by teachers and staff to the administration desk alerted school officials that something was definitely wrong.
Principal Boyd Silversmith said that he and his staff consulted the emergency plan, which indicated the symptoms could be the result of a toxic atmosphere. Doors and windows were opened to aerate the building.
“It was probably about 40 minutes until we evacuated the school,” he told the Free Press. “We dialed 911 at around 9 o’clock.”
“My own grandson collapsed,” recounted a staff member the next day at the Aneth chapter house. “I told the receptionist when I dialed 911 that our children are going down. We need help!”
She was still shaking as she remembered the incident. “I can’t take a breath,” she said.
Airlifted to Salt Lake
Doug Wright, San Juan County School District Superintendent, said that after the initial calls, one teacher, reading-instruction coach Connie Todachinnie, went to the mechanical room, located between the administration offices and the gym, because the maintenance man did not answer his phone. She was exposed to a high level of the gas and was one of 43 victims transported to area hospitals.
The Deseret News reported two days later that Todachinnie said, “Once I was outside the building I just sat against the brick wall and tried to breathe. I could see what was going on, I could hear what was going on, but I couldn’t move.”
Todachinnie, the most seriously injured, was airlifted to Southwest Memorial Hospital in Cortez and was airlifted from there to LDS Hospital in Salt Lake City, where she was treated in a hyperbaric chamber.
Upon her release she told the Deseret News, “ ‘It kind of all went so fast and so slow at the same time. First, one boy felt aches and wouldn’t get up off the floor. Then a girl in another classroom collapsed. Soon everyone was feeling ill.’”
It is hard to put exact times on decisions and events at the school because “time just goes as you are dealing with the situation,” Wright added.
The 911 system in the Utah Navajo Strip is directly linked to the San Juan County Sheriff ’s Office in Monticello, Utah, 61 miles north of the school. By the time the call was made to that location, other cell-phone users were dialing 911, which connected them to emergency-response units and medical facilities in Cortez, a couple of hours from the school; the hospital in Blanding, about 45 minutes away; and the Northern Navajo Medical Center in Shiprock, N.M., an hour distant.
The Bluff Fire Department, only 19 minutes west of the site, was able to respond quickly.
But the Utah Navajo Health Clinic, a few hundred yards from the school, provided teams of doctors and nurses within minutes of the call. They treated children and adults on the playground, prioritizing who would need medical transport first and who could be transferred to Whitehorse High School less than a mile away.
Word spread swiftly that something was wrong. Parents attest to how traumatic it was to learn that something was happening at the school and then arrive at the scene to see the area filled with the flashing lights and sirens of emergency vehicles – and, worse, children wrapped in white sheets lying outside on the ground.
Wright said school officials asked the Utah Navajo Health Clinic to bring blankets for the children who were lying down on the playground, “because we were afraid of shock during that hour and it was still cold outside. Instead of blankets the clinic brought a box of white sheets, I guess because it was all they had. We wrapped them in the sheets, but kept their heads out so we could observe them and make certain they were breathing.”
Darlene Begay, mother of two children at the school, heard about the incident from a relative who called her at the Red Mesa Clinic, 26 miles south, where she works. Her relative asked her what had happened at the school, saying, “There’s a lot of cops and emergency vehicles and kids outside.” Begay promptly left work and drove to the school. “The kids were under white sheets that look like accidents on the road and that’s what scared people,” she said.
Fifteen to 18 ambulances arrived from regional medical facilities to transport the victims to hospitals. Others, cleared to be taken to Whitehorse High School, were checked again for latent symptoms and released to their parents or guardians later in the day.
“I was told to go to the Blanding hospital,” added Begay. When she arrived there, she said, “My son was scared and crying; my daughter was throwing up. She kept falling asleep there until they put oxygen on her. At 5 p.m. we were released.”
After the evacuation the Bluff Fire Department and a team from Resolute Energy used company equipment to sweep the school for gas fumes.
Leonard Lee, compression foreman for Resolute Oil, said, “We responded to the call that came into my office at 9:30. We have all the equipment. We can detect anything associated with gas.”
Lee said Resolute’s team first checked the gas pipelines near the elementary school. “There were no readings outside the buildings, but inside the readings were over 300 parts per million and one spot was 379. It was out of balance and that’s when it gets dangerous.”
Levels higher than 50-100 ppm are considered hazardous to human health.
Lee said the team then conducted a sweep of the building to make sure no one was left behind. “Our main goal was to get everyone out of the building,” he said.
Simultaneously, other energy companies located in the Aneth-Montezuma Creek area showed up to help. C.J. Woodie, company safety officer for Navajo Nation Oil and Gas and subsidiary Running Horse Pipeline, was delivering a contribution check for the school’s celebration of Native American Week. He arrived during the emergency and found first responders there.
Lynette Willie, public-information officer for Navajo Nation Oil and Gas, explained that Woodie had a breathing apparatus and gas-detection equipment in his vehicle, and dispatched the Running Horse Pipeline emergency-response team. “However, the school verified they had sufficient first responders. RHP’s team was on standby if further assistance was needed.”
By nightfall, all students were accounted for, but parents were still wondering why they had not been notified directly about what had happened.
“The school was evacuated and that’s why I figure I never got a call,” said Begay. “By 6 in the evening I still hadn’t heard anything from the school. I was angry. We have to have policies. I am sure there were a lot of parents needed calling.”
Principal Silverman explained that the school has been encouraging parents to enter their cell numbers in the Celly System – a cross-platform tool designed and used by schools for communication with parents. It is a dedicated application that can instantly share group messages and alerts, privately and securely.
But because only 12 families had entered their cell phones in the system at the time of the CO leak, it was only through private messaging that parents learned about the evacuation of the elementary school.
By Tuesday morning, Nov. 19, the building had been given the all-clear for safe reentry and families were told the students could return.
Word spread via social networks during the day that the community would be allowed to speak at the regularly scheduled Aneth Chapter meeting that night. More than 70 people came, including the San Juan County School Board, officials with the San Juan County, Utah, emergency-response teams and various oil-and-gas-company community liaisons.
The agenda for the regularly scheduled chapter meeting was abandoned by Chapter President Darrell Williams when it became apparent in the packed meeting hall that the statements of the people involved in the incident needed to be heard and recorded.
After introductory explanations from Silverman, Superintendent Wright spoke.
“What happened to cause the uncoupling on the water heater is speculation until the investigation led by the Utah State Risk Management is done,” he said, adding that it appears to have happened between Saturday evening and Monday morning.
He said the CO reading taken by Resolute and the Bluff Fire Department was 300 ppm – a potentially lethal level.
“Students have suffered. They were treated by medical professionals, not the school, and San Juan County School District will pick up any medical costs associated with this gas leak,” Wright said, advising parents to send the bills to the school district. He further explained that the State of Utah does not require schools to install CO monitors. In fact, none were in place in any of the schools in San Juan County. Wright said the district was supportive of families that chose not to return to school yet because their children were not ready. “San Juan County School District is providing mental-health workers at the school to help,” he said.
When the audience members began to speak, they clearly identified a feeling that the community lacks an adequate emergency- response plan, and 911/alert system.
A woman who works at San Juan College in Farmington, N.M., said she was flabbergasted when she heard the news. “Several times we said, ‘Let’s see it,’ [an Emergency Response Plan] and nobody responds. Honestly, emergency management shouldn’t be a learning process. If we had an emergency management team it would reduce the normal anger and confusion that’s inside our mind.”
‘Afraid to go back’
The chapter has been trying to organize an alert system for a long time, said Chapter Vice President Bill Todachennie, but nobody wants to volunteer. He asked for a show of hands for volunteers and a few people responded. President Williams added that the chapter’s emergency plan has not been implemented. It is under judicial review because of the many different entities in the community and the nature of the businesses that are affected by the plan.
Some citizens asked how a defective pipe could go undetected in the school.
“One of my grandsons went to the hospital,” said Andrew Tso of Cahone Mesa, one of many angry and frightened family members who spoke at the meeting. “He’s vulnerable. There was red around his eyes. What kind of boiler-maker expert works in our school? You have to have these checked in winter and summer, seasonally. I say this as a grandfather. I am glad our children survived.
“San Juan County commissioners say it’s not their fault. I don’t know if that’s true. Kenneth Maryboy should be responding to our school, looking out for our schools so that nothing like this happens again.
“My grandson was afraid to go back to school. We told him he had to go back today. Is the school cleaned out, brushed out for the students? Do this for them. We put them there to learn!”
Wright explained that CO gas is inert and does not embed in surfaces and that there was none in the school when the decision to re-open was made.
“The school district provides trained, licensed maintenance personnel,” Wright further explained. “The equipment is regularly maintained and inspected. The water heaters are two years old. The one that came uncoupled was inspected earlier this year, 2013. It passed inspection,” he said.
Responding to concerns about cleansing the school, Wright also said there had been a blessing at the school early that morning and another for the children at noon. “We want you to know that for any religious belief within the community that wants to be expressed in order to cleanse the school, we will break state law and grant that permission.”
Another concern was the lack of CO detectors.
“I do not want to send our kids to this dangerous environment again,” elder Joe Ben stated. “There are funds available for this! There should be alarms! Those will tell us. Our children should not be the bell-ringers to tell us something is wrong! We want our children to be healthy as they learn. We want all pipes inspected and those worn out to be replaced and an alarm system in place now.”
Wright assured the people that the malfunctioning water heater has been disconnected and will be removed and replaced when the investigation is finished. The decision to return to the building was made by experts.
Late in the meeting, after many people had left, Tso made a motion directed to Kenneth Maryboy, the Aneth Chapter council delegate, as well as the San Juan County School Board, Diné Education Department, Navajo Nation administration at Window Rock, county commissioners, San Juan County 911 and the Utah State Department of Education.
The motion directed that a written incident report be turned in to the chapter in one month; that CO monitors be installed in all the San Juan County schools; and that a working 911 system be put in place for the community. The motion passed 56-0.
A sustainable 911 system
Just four weeks before the CO leak at the school, the 22nd Navajo Nation Council passed legislation authorizing the Navajo Nation Telecommunications Regulatory Commission to implement and manage a 911 emergency-response system within the nation.
“We need this legislation to lay the foundation to build a sustainable 911 system. We are losing lives without it,” said legislation sponsor Walter Phelps (delegate representing Cameron, Coalmine Canyon, Leupp, Tolani Lake, Tsidi To ii), in a press release from the council. “Emergency response is a major challenge for our isolated Navajo communities.”
In the release, the regulatory commission’s acting executive director, Brian Tagaban, said the legislation would require the Navajo Nation to comply with the guidelines of each funding source. As a sovereign nation, it will be able to design and plan the 911 system guidelines and regulations.
“Developing this system is a lengthy process, and unfortunately I don’t see any other agency or department taking on this authority,” said Tagaban.
“We will now be in the position where the Navajo Nation can make a 911 system a reality by designating jurisdiction, developing a service plan, and obtaining eligibility for funding.”
In an email to the Free Press, Phelps explained that the “plan evolved from an unfortunate incident that involved the loss of one of our elders from the Black Falls area. The majority of Navajo Nation’s ability to access and utilize 911 is limited. The bill I sponsored is an enabling legislation designating the Navajo Telecommunications Commission to begin establishing protocols and all necessary certifications thru the FCC.”
Since wireless phones are mobile, they are not associated with one fixed location or address. While the location of the cell site closest to the 911 caller may provide a general indication of the caller’s location, that information is not usually specific enough for rescue personnel to deliver assistance to the caller quickly.
But according to a Navajo Nation Telecommunications Communications Notice of Inquiry from November 2012, “When an emergency call is received from a wireline or wireless telephone on the Navajo Nation, it is received on an administrative telephone line where additional information is unavailable, such as identity and address.”
Mark Lillemon, safety manager at Resolute Energy, agrees that the community is always better working collectively. “Along with other oil and gas companies, other entities and the Navajo Nation, it is in the best interest of everybody,” he said in a telephone interview.
“We have the detection instruments and emergency procedures in place. We could provide personnel and assistance at the emergency sites with instrumentation and offer direction and management as well, as it happened at the school. We can look at establishing the best resources while improving our own capabilities.
“We are proud of our involvement and the help that our employees gave to the school.”
Running Horse Pipeline is also ready to train community volunteers in emergency procedures.
“Each year we provide emergency-response training to community members from the Navajo chapters located along Running Horse Pipeline,” said Willie. “In addition, we have purchased specialized gas monitors for first responders in San Juan County so they would be prepared to help in the event of a pipeline emergency.”
Carbon-monoxide monitors have been installed at Montezuma Creek Elementary and Whitehorse High and have been ordered for the other schools, and legislation requiring monitors is being considered for the state, said Wright a few days after the gas leak.
“We just want to thank everybody who helped, including the emergency-response teams from surrounding communities, the oil and gas companies, and Maryboy Welding and Construction Company [of Montezuma Creek], who brought oxygen to the scene,” Wright said.
“We did not want to learn this type of lesson from our students. I hope the change in requirement affects more than just our local schools.
“Hopefully children and teachers in schools across the nation will benefit from this incident.”