I wasn’t in the room, but watching the webcast I could feel the public’s lingering dissatisfaction and distrust. It was last week’s (Sept. 28) public meeting held by the Chemical Safety Board on its investigation into the 10,000 gallons of a toxic soup that poured in January 2014 into the Elk River in Charleston, WV. The river is the water source for residents of the city and surrounding communities. 300,000 residents were affected by the disaster. They did not have safe tap water for drinking, cooking, or bathing. Some still have no confidence that the water is safe to use.

Headlines about the January 2014 included:

• “Thousands without water after spill in West Virginia” (The New York Times)
• “Chemical Spill Fouls Water in West Virginia” (The New York Times)
• “Spill Contaminates Water Near West Virginia Capital” (Wall Street Journal)
• “Chemical Leak Causes Water Emergency In West Virginia” (National Public Radio)

Immediately thereafter, residents wanted answers to their questions about the chemicals in their water supply. But the answers didn’t come, and what they did hear were confusing, conflicting, and perplexing explanations. As the days went on, residents’ distrust of government officials grew, including of health officials from the CDC and its National Center for Environmental Health. The public received mixed messages and contradictory statements, such as

The water’s safe to drink, but pregnant women should drink bottled water.

The initial suspect chemical was as 4-methylcyclohexane methanol (MCHM), but further investigation revealed a mixture of toxic substances including dipropylene glycol phenyl ether and propylene glycol phenyl ether. Officials could not tell residents how the chemicals would affect their health in the short or long term because there was (and remains) scant toxicological data. Few people had confidence in the information provided by the company that caused the disaster (Freedom Industries) or the manufacturer of the chemicals (Eastman Chemical Company.)

With that as the backdrop—distrust, no confidence, skepticism—the U.S. Chemical Safety and Hazard Investigation Board (CSB) conducted its investigation of the chemical release and resulting contamination of the region’s drinking water supply. The CSB’s meeting last week was its way to share with the public the agency’s findings.

I watched the meeting via webcast. I wondered if the agency had a plan to build public confidence, to engage and listen genuinely to the residents, to show respect for the community’s expertise, to detour if need be from the game plan, and to set their agency apart as one that would answer questions clearly. The CSB’s report acknowledged the failures by local, state, and federal governments in communicating effectively with the community. Reading the CSB’s acknowledgement, I was eager to see if that lesson would be reflected in the agency’s own approach at their public meeting.

It didn’t seem so. The CSB followed its typical format for public meetings. I’ve heard colleagues refer to the events as dog-and-pony-shows. The evening event began with presentations by the investigation team, followed by Q&A between the four board members and the team. It seemed prescribed—a set-up to pave an easy path to the end of the meeting when board members would vote to approve the report and three recommendations. The public comment period began one hour into the meeting.  As it progressed, the phrase “missed opportunity” kept coming to mind.

Some of the residents were (or had become) experts on the disaster. One concerned citizen has a PhD in chemistry. He worked previously at the local Union Carbide plant. Speaking quickly to not exceed his allotted 3 minutes, he offered data and presented a failure mode analysis diagram. Another speaker questioned the CSB’s assessment of corrosive agents in the tank responsible for the chemical release. Another wondered about the relevance of the chemical analysis conducted by OSHA. She asked what the CSB knew about original analysis conducted by other government agencies. There was earning for data about the chemical mixtures to which the residents had been exposed.

Pam Nixon and Maya Nye, veterans of the struggle to address West Virginia’s “chemical valley,” spoke during the public comment period. They questioned the depth with which the CSB assessed the root cause of the incident, in particular, regulatory failures that allowed it to happen. There was dismay that the agency did not reiterate its previous recommendation for a chemical release prevention program. It was a recommendation made by the CSB following the 2008 explosion at the Bayer CropScience plant—another facility in the state’s “chemical valley.” The CSB recommendation is now more than five years old. Despite early progress toward a mandate for a chemical release prevention reprogram, industry opponents and their allied lawmakers put the brakes on it. It lost the momentum it once had. Residents wondered “what’s the harm if the CSB repeats a previously made recommendation?”

Board member Engler tried to reassure the audience, saying that the original recommendation remains open. It remains part of the outcome of the Bayer CropScience investigation. Residents believe, however, that having the CSB reiterate the recommendation could help to jump start action on the chemical release prevention program. Residents were looking for an ally. A government agency that would use its power to help the community secure a needed reform. No one explained the CSB’s reason for not restating the recommendation? More of the same: questions to agencies without clear answers.

The CSB made its Freedom Industries’ report available to the public a few hours earlier in the day. I was impressed by how quickly the residents studied the 134 page document. “Did you consider this?” residents asked and “why did you write that?” Despite having only a short time to read it, residents came prepared with thoughtful and technical questions.

But the CSB’s format wasn’t set-up for residents to get answers to their questions. The public comment period seemed perfunctory. The 3-minute time limit per speaker was confining. Yet residents continued to provide feedback. I waited to see if the board members would shift gears. Would they answer the questions posed by residents? Would they pitch questions back to the investigators for responses?  I didn’t see it. It was a missed opportunity to provide clarity and build public confidence in the CSB.

By this point in the public meeting, it was clear the board members were ready to stamp FINAL on the Freedom Industries’ investigation report. So why invite the public to provide feedback when you don’t intend to use it to inform your report? Residents remarked that it didn’t seem that their comment mattered to the agency.

The CSB members proceeded to approve the report and recommendations. However, chair Vanessa Sutherland offered a consolation to the public. She invited them to submit their comments and documents to public@csb.org. After reviewing the submissions, the agency would possibly issue an addendum to the report.

But was that offer sincere?  It didn’t seem so to me. 48 hours hardly seemed like enough time to study the report—a document that had only been made public a few hours earlier in the day. When exactly would they have time to read the report and write feedback?

I guess improving public confidence was not part of the CSB’s agenda. That was a missed opportunity.