Human error caused a fatal accident at an Aberdeen Proving Ground ammunition plant but better communication of safety information might have prevented the flash fire.
Those are the findings of an Army review of last winter's accident that killed two civilian workers, according to documents obtained by The Evening Sun through a Freedom of Information Act request.
The March 15 accident, the most serious at the proving ground involving ammunition in about 40 years, occurred when the workers used an improper method to prepare a tank round for a test, the investigators say.
Their review, conducted over the past seven months, found numerous safety deficiencies and infractions at the proving ground and similar Army test centers elsewhere. The review faulted the management of the ammunition plants and complained of inadequate safety inspections, equipment and training, among other things.
The Army investigation also revealed that the accident "may have been avoided" had proving ground officials been told about a similar but less serious accident six months earlier at an Army ammunition plant in Milan, Tenn.
One senior proving ground official told investigators that the "deplorable lack of communication in the [Army] safety community" was the "root cause" of the proving ground accident.
The official's name was censored in the review, which consisted of three separate reports containing about 600 pages.
As a result of the accident, the Army has changed the way its units exchange safety information.
The Army also is spending more than $2 million to improve safety at the proving ground, said Col. Roy E. Fouch, commander of the Army Combat Systems Test Activity. Similar improvements are planned at sister weapons-testing centers at the Army's Yuma Proving Ground in Arizona, Jefferson Proving Ground in Indiana and Dugway Proving Ground in Utah.
The two workers killed at the proving ground were participating in tests on a new lightweight gun being developed for a Marine Corps armored vehicle.
Norman L. Barcase, 40, of Abingdon, and John Zielenski, 41, of Aberdeen, were "uploading," or adding more propellent, to a standard 105mm tank round as part of a stress test of the gun.
Investigators say Barcase, who had 16 years' experience as a civilian ammunition worker, was using a pneumatic wrench to reassemble the 45-pound round. Heat generated by the use of the tool caused the propellent to ignite, shattering the steel cartridge case and killing the men instantly.
Zielenski, a 21-year military veteran who had 15 months' experience as a civilian ammunition worker, was steadying the cartridge as Barcase attempted to re-insert the primer assembly, investigators say.
Use of the air wrench was authorized when workers were taking apart such a round, the Army says, but re-assembly should have been done by hand.
Investigators found both workers culpable, the documents say, although Barcase was determined to have been the one using the air wrench against written guidelines and despite a supervisor's order. Investigators also say at least one other worker saw the men using the air wrench minutes before the accident.
Blame for the accident cannot rest solely with Barcase because a written policy at the time of the blast specified that any ammunition worker could call a halt to any operation for safety reasons, investigators say.
In a letter last week to the victims' families, Fouch said the workers' "good intentions to process the rounds a little faster proved to be disastrous."
Goldie Barcase, Norman Barcase's mother, reacted with disbelief when told that the Army documents say her son had not followed safety procedures. In an interview with The Evening Sun, she said her son respected the dangers of his job and had received awards for efficiency. Taeko Zielenski, the wife of the other victim, declined comment.
Fouch, whose unit operates seven major ammunition facilities at the proving ground, also wrote: "This tragic accident has caused us all to emphasize ways to enhance further the safety of all explosive operations."
Among steps taken as a result:
* All operations that involve similar insertion of primer assemblies remain suspended. Future operations will be performed by remote control, with workers shielded by protective barriers.
* All air wrenches have been removed from ammunition facilities.
* Video and audio monitors are being installed at all plants so supervisors can continuously observe workers. Monitors might have prevented the March accident, Fouch said.
* Flaws have been corrected in the dissemination of accident information among Army units. Such flaws became apparent when proving ground officials learned they had not been informed of the September 1990 accident at the Milan Army Ammunition Plant.
* High-speed sprinkler systems are being installed in all ammunition facilities at the proving ground.
* Daily safety briefings, written safety procedures and signs specifying safety procedures have been improved and updated.