This is the OSHA session. People who have been coming to AECOM for years may remember we used to do a split session with NIOSH. We actually did talk to NIOSH about that this year, but they did something else. So we have an hour at which we're going to present two different things. One, an overview of OSHA ergonomics activities over the last close to 40 years with some important lessons for employers around what OSHA was successful at doing. And then a second presentation about one of the more interesting recent clusters of deaths, several clusters of deaths over a few years from a Fortune 1000, global Fortune 1000 company, where we have some really interesting lessons around employer responsibility and willingness to change behaviors. Obviously OSHA perspectives on all of these things, ergonomics, and death investigations differ from the regulatory and enforcement side than from the ownership, operations, and ability to change things side. But the first presentation, Dr. Liz Bonson has been at OSHA now for about two years, had come to OSHA from the Railroad Retirement Board where she had been the chief medical officer. She had worked at the Harborview Clinic, worked for Concentra, had done some other stuff before, has both done preventive medicine and occupational medicine. And Dr. Bonson. Is it echoey or is it okay? It's okay? Okay. Hello everybody. Yeah, so I'm Liz and yeah, I've been at OSHA for a couple years now and got kind of roped into the ergo crew, which has been a lot of fun, learned a lot. So just quick disclaimer. So opinions here are mine, not OSHA's. I do not speak for OSHA. Any mention of trade names or any like visual representations are not endorsed by the U.S. government. Materials only for info purposes and no conflicts of interest to disclose for myself and the tagged images are generated by AI. And so just wanted to take a quick look back at OSHA's work in ergo. We'll look at kind of the inspections over the years and look at a few of the specific ergo citations that we've issued and then take a quick look ahead. And so obviously, you know, going back to the 1700s, there's been some equating of MSDs with work, but it wasn't really until kind of the 70s and 80s that sort of an epi focus came onto that correlation and the work relatedness of these conditions began appearing in the literature. We got our first official ergo complaint in 1979 from the Amalgamated Clothing and Textile Workers Union. We started to issue a couple of citations around that time as well. In the kind of mid 80s, there was a citation given to one of the meat packing companies and it came with a pretty big fine for that time, $4 million. And so the meat packing industry asked us for some guidance and so we did publish those guidelines for them in 1988. A few years later, the AFL-CIO and about 30 unions requested that we do an emergency temporary standard for ergo. The Secretary of Labor at the time said, no, we'll do some other stuff. And so in 1993, 1992, we gave advance notice of proposed rulemaking for ergo standard. The next several years were full of discussion. I think we got something like 15,000 comments on our proposed standard that we had to respond to. There were months of public hearings. I read somewhere there was 18,000 pages of transcripts from 714 witnesses. So it was a very discussed standard. But in November of 2000, we were actually able to publish that ergo standard. Very exciting. But within the life of a dragonfly, it was gone. And under the Congressional Review Act of 1996, it was rescinded and then signed by the then President. And not only was it rescinded, but that also prohibited us from issuing a substantially similar standard in the future. In lieu of the standard, the administration at that time decided to establish the National Advisory Committee on Ergonomics instead. And so when we don't have a specific standard with mandatory regulatory text, then we do have the option of using the General Duty Clause. And we can cite a company for a hazard under that 5A1 citation. And so to do that, we have to hit kind of four major points. We have to document that there's a recognized hazard in that industry. We have to document that there were workers exposed to that hazard. We have to document that that hazard has or could potentially cause serious harm. And we have to show that there's an economically feasible abatement method. When we can't quite hit those four points and cite a company, we do have the alternative of issuing a hazard alert letter, which basically just lets them know that we saw some issues, maybe gives them some ideas for things that they could change in the future, different ways that they could protect their workers a little bit better. And then it kind of gives us an opportunity to maybe follow up with that company in the future and see if they've had an opportunity to change any of their activities. So taking a look back at our ergo inspections, kind of starting when that standard got rescinded. So the blue lines, well, for context, so we do about 35,000 to 40,000 inspections a year. Just varies. COVID obviously kind of affected that as well. But you can see, so the blue line, that's the number of ergo inspections that we've done over the years. And so 2003 was kind of our big year, over 1,200 ergo inspections. Haven't quite hit those numbers since that time. The pink lines, you can see, those are the inspections where we issued a hazard alert letter. And so usually about 10 to 20% of the companies that we inspect, there's stuff going on and we issue that hazard alert letter. And then the little green boxes at the bottom, those are the number of ergo citations that we've issued over the years. So again, 2003 was kind of our big year. There were 12 citations issued. Over the years, it's kind of fluctuated, but you can see, especially in the past few years up till 2021, we had not issued too many ergo citations. And so what I did was kind of when I got to OSHA, looked at the last 10 ergo citations that we had issued kind of prior to my arrival. And it was in a variety of industries, as we sort of expect, you know, animal processing, warehousing, manufacturing, hospitals. And so they looked for kind of the main ergonomic issues, excessive force, excessive weight, repetitive motion, awkward postures, inadequate recovery times. And then they did, you know, obviously in the hospital situations, they were looking at patient transfers. And so one of the inspections that we did in a hospital was in a bariatric inpatient unit. And so when our field officer walked around, they noted that folks were doing manual transfers of these bariatric patients. And so that was obviously a little bit concerning. When they interviewed some of the nurses and nursing assistants, they said that there weren't enough of the lifts, patient lifts, to be used all the time, and that they didn't always have the proper, you know, additional equipment like the slings that were sometimes missing. And so oftentimes what they would do would be gather five to 10 nurses, nursing assistants, security folks, to help transfer these patients. And then so obviously that was pretty concerning. The way that we could kind of document the different parts of the citation then is obviously there was that observed hazard. We look at the OSHA 300 logs, and we can see that there were workers who were exposed to this hazard. You know, they document the folks who were, you know, transferring patients and suffered an injury, you know, usually back or shoulder, but a variety were documented there. There was the potential of serious harm. You know, one person was out for 180 days after a shoulder injury. Another person was out of work for about 100 days after a back injury. And so obviously these were serious injuries that the folks had suffered. And then there was feasible abatement because they could, you know, get some more lifts. They could get some, you know, the proper equipment for those lifts. And, you know, that's within the economic feasibility for the hospital. And so, yeah, so they get a citation from us. But not always just enough for us to walk around and look and say, oh, there's obviously a hazard. Sometimes we actually have to measure it. And so these are some of the tools that we've used in our ergo inspections. The RNLE is kind of a favorite. Been around for a long time, well established in the literature, fairly easy for our folks to do when they go on site for inspections. And obviously we see a lot of back injuries. Also use the ACGIH hand activity level, RULA, job strain index, and then, yeah, kind of observation only for the patient transfer ones. Let's see here. And so one of the other citations that was, that we issued was for a grocery warehouse. And so they were a distribution facility, supplied retail grocery stores. And so when our field officers went on site, they looked at the OSHA 300 log and they noted that, you know, the vast majority of the injuries that were logged were these selectors. And so what the selectors do is after everything's brought in on pallets, they go through and they pick pieces and put them onto another pallet and then wrap that pallet with plastic wrap, take it to the loading dock and ship it off to the grocery store. They found that, I mean, they were having to lift these 53 pound kind of water packages. Oftentimes there wasn't handles on there. They were just trying to grab it kind of with their, you know, gross strength of their hands. They often had to do these kind of long reaches for those to kind of pull them out closer to them. They had to do this up to nine picks a minute. And so they were working quickly. They were doing this heavy work, awkward postures. And I think the ergonomist calculated they were moving 10 tons a day per worker. So it was pretty intense work. And again, what we saw in the OSHA 300 logs is that these folks were sustaining injuries, severity of injury. There were a couple of folks who ended up having to have back surgeries. And when we do these inspections, then we often have an ergonomist help us with kind of the feasible abatements. And so whether it's, you know, moving things a little bit closer or opening up, you know, the areas that the person can walk around and pick up something up from the backside so they're not doing that awkward reaching, having things potentially packaged in smaller boxes or with, you know, hand grips, things like that, that will all help to make this a more reasonable work for these workers and hopefully fewer injuries. Let's see here. And so then just a quick look at national trends. So the Bureau of Labor Statistics publishes data on MSDs. And so they do it a few different ways. So this here is the total number of MSD cases. Originally, they were only publishing the data for cases with days away from work. So theoretically, the more serious injuries. And so what we can see is that healthcare is winning, unfortunately, have been since 2011. But the good thing is in most industries, overall, the number of MSD cases are decreasing, except for in transportation and warehousing. But again, this is the gross number of cases. It's not a rate. And so that's something to think about. Just this past year, they actually started publishing both the data for the cases with the days away from work, but also the days, the cases with days on either restricted work or transferred work, basically light duty. And so we're getting a little bit more of a complete picture now of the folks who are injured by MSDs at work. Pretty much we were getting half the picture before. And so again, you can see healthcare is winning, but transportation and warehousing is just behind. And so then we can look at the incidence rate of these MSD cases as well. And here we can see that actually transportation and warehousing is winning. And when we look at, you know, everybody is actually coming down over time, which is good, but we can see that that decreases less in transportation and warehousing and wholesale trade. So again, just kind of trying to see what those high risk industries are that we should be focusing on. And then again, this past year, when we were able to look at both the cases that had days away from work and the cases that had light duty, we saw that transportation and warehousing pulled way, way ahead. So yeah, so looking ahead at what we're doing at OSHA with ergo, you know, we're trying to find some more ergo assessment tools. There's certainly more and more out there. There's some with, you know, the wearables. There's different things with, you know, kind of learned technology. Some of those, you know, aren't very well established in the literature yet, but they're getting there. Some are expensive, so that can be a limitation for us, but we're working on it. What we have noticed in these cases is, you know, not only are we seeing a lot of MSDs, but we're also seeing some issues with medical mismanagement of the patients and so, of the workers, and so perhaps they're not receiving the appropriate medical attention that they should be, even when they start having medical issues. We're also seeing some issues with record keeping and so finding that some of the workers that should be on the OSHA 300 log and meet those criteria perhaps don't quite make it on there, and so perhaps their rates are a little bit, are underestimating their actual injuries at work. And then, again, because of the, you know, the high numbers that we've seen in the BLS numbers for MSDs and warehousing, that's become one of our national emphasis programs, and that allows us to kind of focus our attention on those higher risk industries. You know, we look at other safety hazards in there as well, but we also get to focus on ergo, which is good. All right, so we can maybe save questions for the end. I think Dr. Hodgson, do you want to? And so, this is Dr. Hodgson. Everybody knows him, but yeah, he hired me onto OSHA, but he's been around for a long time, had a long, esteemed career at the VA, and then spent a lot of time at OSHA doing some really great things, but he's, yeah. Thanks, Liz. So, actually, for people who don't know, I retired two weeks ago, so I'm not, and there will be adequate time to ask, to discuss the ergo stuff that Liz Bronson just discussed, and there are actually some really interesting things we could talk about if people want. I can't tell whether there were questions there. The second presentation, you know, in the past, these OSHA sessions have usually presented a few outbreak investigations that had some broader implications, and what I'd like to do now is present two clusters that involve deaths in a PFAS manufacturing facility. People have rotated through the office or have worked at OSHA know that any of our investigations are, often get to be quite complex, and in this case, the Salt Lake health response team, several industrial hygienists from Region 4 from Alabama, and three medical, three medical occupational medicine residents who have worked at OSHA, three medical occupational medicine residents who rotated through and were involved in these, including one of the other staff who has, meanwhile, gone on to private practice, so I'm listing those. I have a disclaimer. I have some, I get some money for talks from QIAGEN around TB, but I don't have any other disclaimers, and I no longer have to do the agency disclaimer because I'm not OSHA anymore, so that led to a comment some time ago that maybe this was Hodgson unleashed, and so we could have a conversation about the limitations of OSHA citations and OSHA inspections in general, and I think that is a worthwhile discussion because people have, often have the wrong impression of what OSHA can do and should do, but so what I'm hoping to do, and I'm hearing a lot of echo, is, oh yeah, okay. I'd like to present these two clusters of deaths related to manufacturing, discuss and remind kind of delayed onset pulmonary disease, review some of the literature on PFAS manufacturing and some of the chemical hazards related to thermal degradation, and then think about the elements of the general duty clause that people kind of, sorry, go with. So, a manufacturer, Fortune 1000 Global Company, multiple sites around the world with about 400 employees in Alabama making a broad range of fluoropolymers that include traditional poly and perfluoroalkyl substances, and we know those as Teflon and R-22 and others. The Alabama plant has about 400 employees all the time. When they did turnarounds, when they interrupted production for whatever reason, often the number of individuals would increase to double that. So, depending on what the process was, they would have lots more people. People who haven't thought about TFE production and haven't dealt with the Kirk-Omer Encyclopedia of Chemical Processes, who has, may not know much of this. I certainly didn't, and it turns out that most of the interesting chemical and toxicologic information that we had to dig out is covered by trade secret provisions. So, I can't actually talk about the interesting issues like one of the byproducts, well, PFIB we'll get to in a minute, but yes, one of the interesting byproducts on polyfluoroisobutylene was actually under consideration as a chemical warfare agent because it's got one of the lowest ACGIH sealing limits known to man. So we think that less than a minute of exposure will in fact lead to bad lung disease. But very complex chemical processes and trying to figure out without a lot of support from the industry what had actually happened took several chemical engineers, lots of site visits, and then understanding and synthesizing the information from about 10,000 documents that were released to OSHA without a label. That led to some trouble, given that we are always under a six-month deadline to issue a citation. And then for people who don't remember, you know, we issue our citations and then we go into the legal discovery phase. And that can be a very tedious way of trying to find out what really happens. The bottom line for this was, we know that there were some byproducts, PFIB, hexafluorochlorobutylene, carbon monoxide, hydrofluoric acid, although probably only with a half-life of milliseconds, hydrochloric acid, and others. We also know that there were lots of things added as drying agents to clean out. So, sulfuric acid, methanol, and a bunch of terpenes that were removed. This is just a photograph of the overall thing. It's very hard to trace the piping diagram, the abstracted piping diagram, and combine that with the chemical processes. And as you then try and pull information from the chemical mass balance equations, together with the piping diagram, and plot where what could have happened, you know, at the end you'll see we don't really know who was exposed to what. And we think there may have been two different classes of agents, but we still don't know for sure. So, the timeline of these two events, just to give people a sense of how long this all takes. In October of 2019, there was a first incident during a turnaround. The usual turnarounds at this plant involve cleaning out reactor vessels. As you synthesize chemicals, often there is residual. At some point, that residual clogs up both the reactor vessels and the piping. So, you have to isolate reactor vessels, clean them out in some way, and then take them back online. When that is happening, often companies do other things. So, they'll replace piping. And in the first incident, there was a turnaround cleaning out stuff in this M1, M2 process, but also other piping replacement. And when the company did that, often they would have direct reading instruments around, and there would be some tracing of stuff. And we were told that the ... Actually, that's the next slide. So, the turnaround involved a number of contractors, including fire watch and rigging and crane operators as they were floating pipe around the facility. We got involved sometime later ... Actually, no, I can't ... If I ... I forgot to check whether ... If I can highlight something. So, the 10-11-2019 was the first event. OSHA opened its inspection the same day we got notified, 12-16-2019. You see that there's more than a month of delay there. We know that of the five people, all were seen within 24 hours at an emergency room. Two were hospitalized at some point, but more than 24 hours after the incident. And so, the employer didn't have to report that to OSHA. Of the two people who were hospitalized, one survived for two months, a few months of ECMO, and then after discharge awaiting lung transplant, died of COVID. The other one died directly. So, OSHA issued its citation within six months of that, so sometime in early 2020. And while we were in negotiations with the employer on July 2nd of 2021, so well into the negotiations process, OSHA was notified by an uninvolved party that a similar phenomenon had happened. And there it turned out that three workers during a routine turnaround had been hospitalized, again, two, three, and four days after the incident. And in that case, two of the three eventually died. In March of 2022, so almost two years after the first incident, the employer settled the first case. And a few months later, late that year, settled the second case. So, what actually happened? So, we know that there was planned maintenance with a crane operator and riggers to assist with moving materials. There was fire watch needed because there was welding. Sorry, I thought somebody was waving their hand, but I see it's just fanning themselves. Sorry. I need my cataracts removed. So, there was hot work, so welding and requiring a fire watch. And because of the process, this is a sophisticated manufacturer with very complex process safety guidance, and people who have dealt with a PSM standard know there is all kinds of documentation that is required as you do that. They had a zone defined by a berm within which everybody had to wear respiratory protection. Obviously, magically, whatever chemical wafts through the air, you know, is automatically blocked at the end of that zone. And the primary protection was, you know, looking at wind direction. If the primary wind direction was, you know, to the south, people on the north didn't have to do anything. So, around 1130 in the morning, one of the direct reading instruments documented excursion beyond the lower explosive limit. LALs just tells you that there's probably some VOC around. It wasn't clear what that was, but in the pipe section that was being removed at the time, there was reason to believe that R-22 and TFE might still have been there. Some people, and this was part of the expert arguments later on, some people argued that there were other residual byproducts still in that pipe, but because there was no direct sampling on the part of the employer, it's impossible to say what that was. After work, people started, oh, at 420, there was a second so-called slight peak with that time labeled halogenated gas. We think it was the same thing. And again, R-22, HFP, or TFE, and we couldn't find out more from the employer. Five cases worked outside of this zone. One was a crane operator who sometimes went into the zone but carefully put on his air purifying respirator when he crossed the berm. Employee one developed symptoms. They were lower chest symptoms, coughing, chest tightness, pleuritic stuff, was hospitalized. Several, about two weeks in, was bronchoscoped. There was reactive bronchial and pulmonary parenchymal damage. Eventually wound up intubated and died 65 days after the incident. The second employee, also a smoker, developed dyspnea and pleuritic pain. Hospitalized on day three, was intubated, ECMOed on day 10, and discharged about two and a half months later after transfer to a third hospital. Was discharged awaiting lung transplant, developed COVID, and died. And the third employee who had developed was hospitalized. Sorry, the other three young men were not formally hospitalized, were discharged from the ER, wound up with some dyspnea, and at three months, showed some minor lung function abnormalities. An effort to track them down afterwards failed. There are some limits to when OSHA can call people back, and at some point we just run out of time and energy. As we talked about a minute ago, we had issued our citation when in July of 2021, a second incident happened. This time, the thinking is that it wasn't around moving pipe, but that it was directly related to the process of taking towers offline and back online. And so as you think about what happens in a chemical, in a manufacturing plant, you know, there are piping diagrams, and when you want to isolate a reactor vessel, you put in flanges, and you then clean out that reactor vessel, and then you have to take that reactor vessel back online. In this case, there were two parallel processes, an older and a newer one, and so they only cleaned out one reactor vessel at a time so that they could continue the overall manufacturing. So just a description of the steps. The critical issue is that they isolated this one vessel, cleaned it out, flushed it repeatedly until they were pretty sure that the water was clean, and then purged that vessel to make sure there was nothing else in it, and then introduced gas from downstream from the reactor process back into the reactor vessel to fill that up so that they didn't contaminate the process flow. And once, and as they were doing that, they vented that reactor vessel to the air. So what used to be downstream now winds up back upstream, and then they closed the bypass valve and took the whole thing back online. So a description of the processes of what actually happened. We could go through those in detail. The bottom line was we found several times where people could have been exposed to a combination of agents, but again, because we don't really know what's where in the piping, and the chemical engineers couldn't agree, I can't say for sure that this is PFIB or HFCB or some other product. The employees all donned air purifying respirators with both acid and VOC cartridges. So they fitted their hoses and then left. They spent about an hour, we think, without respiratory protection at that site. Where they were wearing respirators, they were wearing air purifying respirators. In one of the many of those 10,000 documents, it turned out that the employer had assumed that people would be wearing self-contained breathing apparatus because they had a sense that PFIB and HFCB were byproducts of the reaction vessel, and somebody forgot to look at their PSM documents. We never did find out how that could happen. So, on a brief listing of... Actually, I can't read that far. Right, the three employees and their symptoms. The... Actually, let me skip this for now. The three employees, the first, again... Well, of importance, both clusters had primarily lower pulmonary symptoms. So chest tightness, some coughing, pleuritic pain, none of them described wheezing or a productive cough. Early on, one of them had mucosal irritation consistent with sulfuric acid exposure, but that was the only hint of upper airways stuff. A 45-year-old non-smoker presented two days later with pleuritic pain, oxygen desaturation, oxygen desaturation, admitted to one hospital, wound up showing, you know, ground glass opacities that worsened and was intubated, bronchoscoped with normal airways, but clearly the chest CT showed not just the original ground glass appearances, but bronchiectasis and lung destruction, and he eventually developed complications and was made DNR when, because he was too sick, couldn't be... The hospital decided it couldn't deal with the lung transplant issues. It's a whole complicated workers' conversation we could have under which conditions is someone too sick to agree to the things that they need to do to be eligible for lung transplantation under workers' compensation. That's something that's a big issue right now in the silicosis outbreaks. Not one we'll be talking about here, but that's come up. The second employee, it all ended well for him. He developed symptoms almost 24 hours after exposure. Again, pleuritic pain presented with some desaturation, was hospitalized for a while, I think 12 days, was discharged, wound up improving slowly, and at seven months had no evidence of either symptoms or real pulmonary disease. He did have a mildly decreased FEC, but he was obese, and we attributed it to that, and he has continued to do well. And the third developed symptoms a full 24 hours later. Symptoms progressed. He was hospitalized. He was discharged after about 10 days on a steroid taper, but promptly was readmitted with O2 desaturation and wound up almost three months later dying in the same way. So what do we know about these exposures? What do we know about Teflon and R22? So from what I can tell, the first discussion of any of this occurred in 1951 when Harris documented what we have all come to think of, and every occupational medicine resident learns as polymer fume fever. And we recognize the fume fevers described in cotton dust. We've thought about those as a typical presentation of an endotoxin-release-like syndrome with feverishness, a delayed onset, but no abnormalities on chest X-ray as one of the important distinctions between the fume fevers and others. But in fact, we know that even with Teflon, there was delayed onset pulmonary edema with radiographic abnormalities within 10 years of that polymer fume fever description. And as you look through the world of PFAS manufacturing documentation, the EPA that did its acute exposure guidelines and has that available online, ATSDR NIOSH and the ACJH documentation, we recognize that in addition to the polymer fume fever, there is well-described multiple, on multiple occasions, pulmonary edema with infiltrates and X-ray evidence, ARDS, and death. And that's been around for years, including with these kinds of delayed onset that we saw in the second case. What is that from? Fluoroalkanes. We think that the upper respiratory tract is protected. Maybe that's why they don't do anything. On the other hand, many of those products are just not water-soluble. Remember, that's why all of the fluoride-based, waterproofing materials are so useful. They just don't mix with water. And so all of these products, we think, make it much farther down into the lungs. The process, we think they should be amenable to N-acetylcysteine. In fact, all three of the second cluster got N-acetylcysteine within 48 hours, but not acutely. None of the first five got NAC. Two of three deaths is, you know, similar to two of five deaths. We don't think NAC, given late, had any benefits. So, perfluoroisobutylene, chemical warfare agent, a number of exposures, great animal data showing that it's bad for you, and the ACGH TLV, the ceiling is 10 parts per billion. Hexafluorocytobutene, also a byproduct of Teflon, Teflon thermal degradation. And again, it too does bad things to rat lungs. There are no actual data on humans. So, do we know what was really there? We know that there are some differences between these two incidents. So, the latency to onset of symptoms, three to five hours in the first one, versus 24 hours in the second one, that's a striking change. And the polymer fume fevers, when you look at the Teflon, people have said, oh, four to six hours. So we're not sure whether this is the usual issue of, if you have a cluster, you see things earlier because people talk, or whether this is really a different set of exposures. Three to five hours versus greater than 24 hours is a big enough difference that we think there may well have been different chemicals involved, but we don't know. We know in incident A, there were documented exposures. We have no idea what happened in incident B. We do know that incident B wound up draining the drying of that tower involving sulfuric acid, so when that runs to a sump, it gets released. People noticed upper airways irritation. Could there be chemical reactivity of the sulfuric acid with other stuff that's going on that was coming out of the other end? We just don't know what those were. So OSHA did issue a bunch of citations for both the first and the second. They were really pretty similar. General duty clause, is there a known hazard? Clearly, PFA is manufacturing. It's known to be serious. OSHA's actually pretty loose about the serious definition. The field operations manual says, if you lose a day of work, OSHA thinks that's a serious problem. So death clearly meets that standard. That people were exposed, we could argue that. The employer had a hard time arguing back, and was there feasible abatement? So what does feasible abatement require? So part of the settlement agreement was that the employer would actually rely on SCBA and not air purifying respirators. They would do exposure monitoring. So we don't yet know how detailed that exposure monitoring was. And when we turn our lawyers loose to negotiate with the lawyers for the employer, often things don't get noted that concretely. We do have the ability to go back at some point. And we will then see whether the employer has figured out what the chemical releases are. There was also a HazCom citation. So the workers really didn't know what they were exposed to. So when they showed up in the emergency department, they didn't think to say, oh, I was exposed to Teflon combustion byproducts. And every ER doc knows to think about that. They wouldn't think about just a chemical manufacturing facility. So training, appropriate training on hazards was part of the abatement. Process safety, I just mentioned some of the issues. And there was a respiratory protection citation because the employer hadn't done appropriate risk assessment. So thinking through where what exposures occurred would have been important. Yeah, and there's a list of references for people who want to follow up on that. And yeah, thanks. So Liz, if you want to come back up here. And if people have questions for either of the panelists, go on back. Sure, this is, ah, it's on. Hi, Francesca Littow Ford. Can you talk about, I'm not sure if you can talk on behalf of OSHA, but also on behalf of yourselves, thoughts on exoskeletons for reducing the risk of ergonomic or work-related musculoskeletal disorders? Do you want to do that? You don't have a strong opinion. I don't have a strong opinion, I mean, I'm a habit. So first of all, one of the big questions right now is does it count as PPE or engineering controls? And there are different OSHA standards that pertain. The industry in which they occur, they're used, plays a huge role. And so what's the detailed question about exoskeletons? Oh, so I'm over here. I was just wondering if there was anything one could look at to learn, you know, are these considered a good idea? You know, again, just thinking about where they fit. Go for it. So it's a really hot, complicated topic in the, and Liz goes to the Applied Ergonomics Conference and is far more suitable to answer that question. Yeah. Yeah, so, I mean, I think there's so many, yeah, there's so much coming out about it. I think one of the things is that workers aren't always super keen to use it. And at least in our inspections, there's been some concern about, you know, what the employer is going to, you know, if they're gonna start using those to measure productivity and those sorts of things as well. And so even though sometimes we think of the exoskeleton as something that's gonna protect the worker, the workers are sometimes a little bit hesitant. But yeah, there's a lot of different ones coming out, but they're still relatively new. And so, I don't know, I think we're still finding out how useful they're gonna be. So check with the military is what we heard. Kathy Fagan, former OSHA medical officer. Great presentations. I have one quick question for each of you. Liz, can you talk a little more about the Warehouse NEP, National Emphasis Program? That's great. You know, I'm glad that OSHA is doing that. Can you give everybody a little quick, what's an NEP and how is this one gonna work? Yeah, and so basically it allows us to focus on specific industries. And so I believe they actually make a list then of the different employers within that kind of NAICS code, and then we can kind of randomly choose some of those to go and do actual inspections there. And so it just helps us kind of focus our resources because our resources are limited. And so, yeah, like I said, I mean, they're focusing on ergo, but they're also focusing a lot on other safety hazards, and so it's a good thing. Thanks, and a quick question for Michael. Does that company have an OEM medical director? And what do the local docs do with this? You know, did they seek out any OEM guidance? You know, how can we as OEM docs help in this situation? So, from what I can tell, they do not have a corporate medical director. They did hire, when this went to litigation, they did hire an academic group to help them think about this from the defense side. But I talked to the colleague who was there, you know, whom they labeled as their expert, and they clearly did not tell him everything that he wanted to know. And as you, you know, OSHA litigation, administrative law processes are no different from other legal processes. It didn't come to depositions. So, to my knowledge, they do not have a corporate medical director. They did not have standing relationships with the two hospitals in that city. The second case, the second cluster, did lead to NAC administration after the emergency room, both emergency rooms, called the local poison control center. But that was because people knew what was going on, and the workers told their physicians about the first cluster. And that is part of the goal of the HazCom citation abatement to make sure workers know what they're exposed to and what they should be telling their physicians when they see someone. Was that? Okay, next. This is for Dr. Bunsen about the ergonomics injuries. So, I think, you know, ergonomics injuries are a vast, you know, group of injuries. And when we're talking about musculoskeletal injuries, it's perhaps more than any other injury category or reflection of the different realities for different workers based on socioeconomic status in this country. So, people like us, for example, you know, the slightest low back pain, we get a standing desk. But for millions of low-wage workers, undocumented workers, you know, it's a different reality. And so, you know, for those of us who have worked clinically with those populations, warehouse workers, poultry workers, meatpacking workers especially, we know a couple of things. One thing is the incidence of musculoskeletal injuries virtually 100% in some of these plants. And I'm not exaggerating. Number two, only a tiny minority of those workers actually come to us. The vast majority are dealt with internally with constant job rotation, job restrictions that are technically recordable but are not recorded. They're dealt with internally. And they're not rotated in order to alleviate the injury. They're rotated in order to maintain minimal functionality of the worker. So, given that, in terms of enforcement, I mean, knowing that Congress has imposed extreme restrictions on OSHA in terms of funding, in terms of inspection capacity, and given also that OSHA fines are almost always in the thousands or tens of thousands, very rarely in the hundreds of thousands for willful repeat injuries. I mean, that's very rare. And given that these injuries are part of the business model, essentially, for the largest poultry and meatpacking corporations, what are the trends, if any, of OSHA criminally prosecuting the executives of these companies like we have done, like DOJ has done with pharmaceutical companies and medical device companies over the past 20 or 30 years, where you've seen huge settlements, sometimes in the billions, not altering behavior, but criminal prosecution under things like the Park Doctrine or other legal precedents, leading to changes in company policy? I mean, is there anything that OSHA can do on that front? I'm going to let Dr. Hodge say, because there's a — I'm no longer employed by OSHA. So you're free to talk. Right. Whereby, in all fairness, one has to be careful talking about these things to not step on toes in ways that is premature. So OSHA has been doing ergonomics work now with renewed interest. You may have noticed that between 2017 and 2020, there were no 5A1 citations for ergonomics for people who saw loses, who paid attention to that slide. And over the last few years, there's been a fair amount of interest in that. And I think it is known, widely known, that OSHA has inspected a number of large warehouses systematically in response to complaints that came in and used both basic and pretty sophisticated traditional ergonomics assessments to document the hazard. The litigation process is often quite tedious. But when OSHA cites an employer, it takes the employer to court, not the individual workers. Right now, those are the citations were all issued against individual sites, not against the corporate headquarters. There are, to my knowledge, the pharmaceutical stuff took a long time to build. I don't think we're at that point yet. Thank you. So this is Scott Walsh. So, Dr. Hodgin, good to see you again. It was fun working with you on these two cases. The two things I wanted to bring to attention from this and then one question for you related actually to the last question was that this was originally a VPP site before the first incident, which I thought was something that might be useful for the crowd to know and that you think that they would have had more of this info beforehand. The second part is that learning about the chemicals from this when we're talking about the medical management of chemical and biological casualties course, they brought these up as examples of things to be protected against and we've learned from these cases that the protection we use is also inadequate. So it was useful seeing that there. So I wanted to make sure you got that feedback because the military does use that as a teaching example, strangely, although a poor one. And then the question I had was related to a similar thing is what sort of updates could there be to the OSHA citation process and fines because as I believe we've discussed before, those established in the 70s as a set rate that's not scalable doesn't seem to have the impact we want. So where do you see changes in that legislation going or what changes should be made to make the citations actually have a bite? I didn't understand the last thing. Oh, sorry. What changes would you see to the citation process and the penalties for the citations to actually make them have the effect they're desired? First of all, I had forgotten about the VPP site. There are, you know, VPP, the VPP, the institution of VPP around the country is a, has often been thought of as a get out of jail free card by many and we have, you know, I am now biased because, you know, the OSHA inspection process, the complaint driven process generally doesn't focus on the high performing proactive employers. And yet there are quite a number of VPP sites that wind up with interesting problems. And we, you know, the lining out problem in noise exposure where corporations set up systematic ways of hiding hearing loss. Or we were in a shipyard a while ago where, you know, one of the early approaches to athletic trainers and onsite physical therapy was clearly set up to hide injury. And the prior, you know, that question about MSDs and prevalence, yes, this is a huge issue and how do we move the country to a different place given that social security disability is a huge problem when people, when employers don't respect the limits of the human body. So kind of the whole warehousing, meat packing, shouldn't we really be pushing all those undocumented workers back to Mexico or Nicaragua after they can't do their work anymore? That's one. What changes should be made to the legislative process? So the laws that govern workplace health and safety in this country are, from what I can tell, the least effective in the developed world. We forget that that kind of social legislation was originally set up by Bismarck as defense against the communists and socialists in the 1870s. And over the 100 years that I know the history in this country, we have, you know, started out with good intents, but in fact the administrative law process has consistently tightened those requirements and made it ever harder for OSHA to actually promulgate standards. Take the ergo standard story that Liz kind of summarized there. So now we have to do economic feasible abatement. In my prior life at the VA, we worked on safe patient handling and the VA developed what is now internationally the standard of care for manual handling. The huge economic benefits that the VA program could document, in part through its own data and through the Stanford data, were based in great part on benefits to patient falls reduction. And OSHA can't take credit for that. So OSHA can't use those economic justifications and it wouldn't work for OSHA to try and promulgate an ergo standard for healthcare because it knows it couldn't meet our economic feasibility criteria. So I don't think there is a legislative solution to OSHA. I think it has to happen through some different route. I think the idea of prosecuting the C-suite is a fabulous idea. The question of whether we can change the culture in this country to look at collaborative work rather than the adversarial processes that we have. Some people may remember the Joseph Stiglitz editorial in the Washington Post, I think last week, where he lays out the difference between the freedom to do, the freedom to act, and the freedom from harm as Isaiah Berlin's philosophical, the contrast in freedoms in, you know, this gets into political philosophy. I don't think our laws are going to let that change. I think we do have to have a different strategy, but I don't think it's going to be the administrative state. So it sounds like you think it would have to be an economic argument showing a benefit to them or potentially the prosecutorial, one of those two. So I actually don't think those are going to work. I think there has to be a culture change so that people want to do right by other people. People who have lived in small towns, whether it's, you know, in Connecticut small towns of 2,000 people where I spent many years or in rural Michigan where I spent my summers, the culture there is fundamentally different from the culture that rules between the C-suite and working people. And I don't think we can get back to, you know, the culture of the U.S. as a virtual society without changing the way we treat other people. How we get there, I don't know. But it's not, I don't think, I don't see much hope for OSHA. Somebody said I should end on a positive note. So I think, you know, $175,000 penalty isn't a big deal. We'll see what happens with ERGO. It's taken years to get to that point with ERGO. OSHA is very slow. What's that line from Shakespeare? The mills of God grind slowly, but they grind exceedingly small. There we go. Thank you.

OSHA activities

ergonomics

workplace safety

musculoskeletal injuries

exoskeletons

safety regulations

enforcement measures

worker health

penalty structure

C-suite accountability

organizational culture