Sustained Outrage

What’s really in our drinking water?


Gazette photo by Lawrence Pierce

In the wake of the January chemical spill on the Elk River, West Virginians have been lectured a time or two by water company representatives and state officials who tout how much they say is done to protect our drinking water from contamination. One of the refrains is to remind us how many chemicals water utilities have to test the water for before they pump it to our homes and businesses.

The state Division of Homeland Security and Emergency Management helpfully posted a list of these chemicals on its website here.  And during one recent public meeting in Huntington, West Virginia American Water President Jeff McIntyre explained:

… That West Virginia American Water keeps in line with standards set forth in state and federal regulations, noting that the federal Safe Drinking Water Act requires monitor and control for 100 different parameters and there are more than 85,000 chemicals that are regulated through the Toxic Substance Control Act of 1976.

First, it’s worth noting — as has been reported many times before — that terribly few of those 85,000 chemicals that Mr. McIntyre talked about being “regulated” by TSCA have actually had complete safety testing.  As Jennifer Sass, a Ph.D. scientist with the Natural Resources Defense Council, testified to Congress last month:

… In the nearly forty years of TSCA, EPA has required a full set of testing on only a few hundred chemicals of the 62,000 grandfathered under the law in 1976.

Sass went on to explain how the Elk River chemical spill highlighted these concerns:

The leaking of 4-methylcyclohexanemethanol (MCHM) and other chemicals into the Elk River in West Virginia brought home – literally into people’s homes – some of the ways that timely access to updated and accurate information is a basic requirement for both informing and protecting the public. The Elk River spill presented an acute situation: the public drinking water supply for thousands of people was suddenly contaminated with a chemical about which virtually nothing was known, other than it smelled and tasted so badly that people found the water undrinkable in many cases. Contamination of a tap water supply – and of course the water was being used for drinking, cooking, bathing, laundry and other uses leading to direct skin contact and consumption – is one of the starkest situations any community may face. It was surprising to many people – and wholly unacceptable – that thousands of gallons of a hazardous chemical could be stored and spill upstream of a drinking water intake – and that there was essentially no useful information available for the public, drinking water system operators, state or federal public health officials, or medical professionals and first responders, as to the safety or potential health and environmental effects of the substance.

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CDC’s face in W.Va. water crisis resigns


Gazette photo by Lawrence Pierce

Readers who followed the continuing water crisis in West Virginia may remember the face of the federal official standing at Gov. Earl Ray Tomblin’s podium in the photo above. Or maybe we should say the former federal official — because Dr. Tanja Popovic has apparently resigned her post as director of the U.S. Center for Disease Control’s National Center for Environmental Health.

And the stories about her resignation are certainly interesting … here’s one from The National Journal:

The head of a federal agency that investigates health problems linked to toxic-waste sites has stepped down after a clash with former Marines who believe their families were harmed by poisoned drinking water at Camp Lejeune.

Tanja Popovic’s sudden resignation followed a tumultuous seven weeks as acting director of the Agency for Toxic Substances and Disease Registry, a division of the Centers for Disease Control and Prevention, during which she assured West Virginia residents that their water was safe to drink after a toxic chemical spill in January, questioned the need for a study of cancers that may be linked to Camp Lejeune’s tainted water, and sent scolding emails to aides of lawmakers on Capitol Hill.

The story continues:

Popovic also had some tense email exchanges with the leader of a group advocating for victims of Camp Lejeune’s contamination, former Marine Master Sgt. Jerry Ensminger, in which she accused Ensminger and his colleagues of sending messages that contained “disrespectful, condescending, and even offensive content.”

“I take attacks on my professional and personal integrity very seriously,” Popovic wrote to Ensminger on March 12, “and I am profoundly saddened to see that you will stop at nothing.”

The friction culminated in a meeting on Capitol Hill last week between staff of lawmakers concerned about Popovic’s handling of Camp Lejeune issues and congressional liaisons for Popovic’s division, the CDC, and the Department of Health and Human Services, which oversees both agencies. That meeting included aides to the two senators from North Carolina, where Camp Lejeune is located, as well as Rep. John Dingell, D-Mich., author of the federal law that established the agency Popovic ran.

The next business day, Popovic’s resignation was announced in an email to top managers at the CDC, headquartered in Atlanta.

And then there’s this part of the story, which will sound familiar to West Virginians who recall how hard it was to get the CDC to talk about what was going on in West Virginia back in early January:

A spokeswoman for the CDC, Bernadette Burden, said she could only confirm that Popovic’s tenure as acting director of the agency began on Jan. 26 and ended Monday. “It’s a personnel matter,” Burden said, so no information about the resignation would be discussed.

Reached at her home in Stone Mountain, Ga., the scientist who worked for the federal government for 25 years declined to comment. “I would not like to make any comments, thank you,” Popovic said before hanging up.

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We’re still waiting for the likely signing by Gov. Earl Ray Tomblin of SB 373, the legislation that grew out of last month’s Elk River chemical spill.

In the last few days of the session, we wrote about what was going on with a provision of the bill to require further state study of the U.S. Chemical Safety Board’s recommendation for a new West Virginia chemical accident prevention program. The program, as outlined by the CSB after two different fatal chemical plant accidents in the Kanawha Valley (see here and here), Kanawha-Charleston Health Department officials would run the program under existing legal authority of the state Department of Health and Human Resources.

As written, SB 373 mentions the CSB recommendation as among the things that a new Public Water Supply System Commission must consider, saying the commission must conduct:

A review and consideration of the recommendations of the U. S. Chemical Safety and Hazard and Investigation Board after its investigation of the Bayer CropScience incident of 2008.

I was thinking about this language — merely mandating that someone in West Virginia actually take a closer look at the CSB’s recommendation, not that they actually do anything to implement it — as I read a new court filing from the state DHHR. The filing came earlier this week, in response to a citizen legal action about the Elk River spill, seeking to have the state Supreme Court force DHHR and the state Department of Environmental Protection to do their jobs more effectively.

DHHR lawyers seem more than a little upset that the citizens who filed this legal action — citing the wording of a Gazette headline — alleged that the DHHR and other top state officials have basically “ignored” the CSB recommendation. Here’s what DHHR lawyers wrote:

Petitioners blame the DHHR respondents for ‘ignoring recommendations from the Chemical Safety Board in 2011 regarding the potential prevention of future chemical incidents following the tragic 2008 chemical explosion in South Charleston. Petitioners cite a January 2014 newspaper article for the proposition that “the secretary of the DHHR reported that neither it, nor DEP, would follow the CSB recommendation … That article reports that the then-DHHR Secretary, Michael Lewis, stated to the CSB that his agency did not ‘have the expertise in-house to draft the appropriate legislation that would be needed to develop the type of program suggested in your report.’

As the statement from former Secretary Lewis shows, the decision to implement the CSB recommendations was not solely within the DHHR Respondents’ discretion, as Petitioners  suggested, but would have instead required legislative action. In fact, following the CSB recommendations, DHHR continued efforts to implement the recommended chemical safety measures. For example, on April 12, 2013, an email from then-DHHR Secretary Rocco Fucillo recognized that DHHR and [DEP] had engaged in ‘considerable discussion about the logistics and feasibility of establishing such a program.’

Then-Secretary Fucillo explained that ‘since DHHR has neither the capacity, resources, nor expertise to undertake such a program, and because several other state, federal and local agencies are also recommended to take action (and in fact have some responsibility in this area), we believe the appropriate course of action would be a legislative study on the need for a program of this nature. Attached to the email was a draft resolution that DHHR intended to introduce during the 2014 legislative session.’

And here’s the kicker:

…It is thus a gross mischaracterization for Petitioners to suggest that the DHHR Respondents — professionals who diligently advocate for the health and well-being of West Virginians — would “ignore” any safety recommendation from federal regulators.

OK. First of all, the 2008 explosion that led to the CSB recommendation happened in Institute, not South Charleston.

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What happened to the Chemical Safety Board plan?


Photo by Tom Hindman, Charleston Daily Mail, via Associated Press

UPDATED: Read to the end for important update, with amendment planned to put CSB language back in the bill.

In the early days of West Virginia’s ongoing water crisis, one of the stories we focused on at the Gazette was this:

Three years ago this month, a team of federal experts urged the state of West Virginia to help the Kanawha Valley create a new program to prevent hazardous chemical accidents.

The U.S. Chemical Safety Board recommended the step after its extensive investigation of the August 2008 explosion and fire that killed two workers at the Bayer CropScience plant in Institute.

Since then, the proposal has gone nowhere. The state Department of Health and Human Resources hasn’t stepped in to provide the legal authority the Kanawha-Charleston Health Department needs to start such a program. And Kanawha County officials never funded the plan, and seldom mention that the CSB recommendation was even made.

Now, with more than 300,000 residents across the Kanawha Valley without usable water following a chemical accident at Freedom Industries on the Elk River, some local officials say it’s time for action.

“We’d had their recommendation on the books for several years now,” said Dr. Rahul Gupta, director of the local health department. “This gives us another opportunity to look at what they recommended.”

As Dr. Gupta predicted, the Freedom Industries chemical spill — contaminating water supplies for 300,000 West Virginians — provided state and local leaders another chance to focus on the CSB’s recommendation. And there’s been some talk about it, including some discussion that Delegate Stephen Skinner, D-Jefferson, would introduce a bill to require implementation of the board’s proposal.

But it appears that things are really going nowhere with this issue. That’s despite the fact that during its marathon meeting Sunday night and into Monday morning, the House Judiciary Committee appeared to have approved an amendment that included language regarding the CSB’s recommendations. The Daily Mail’s Dave Boucher mentioned this action in a blog post describing the committee’s maneuvering on the bill:

The committee created the Public Water System Study Commission, an entity that will consider the reports that come our in connection the leak and whether additional changes to the law are needed. The commission is also supposed to consider recommendations from the Chemical Safety Board’s other trips to West Virginia.

When you look at the version of SB 373 that moved out of Judiciary, though, the section about the water system study commission — W.Va. Code 22-31-12 — the Chemical Safety Board isn’t mentioned. Of course, that means that the language wasn’t considered by the House Finance Committee, and isn’t in the version of the bill that is up for debate today on the House floor.

I’ve posted here a .pdf file containing all of the amendments considered by the Judiciary Committee on Sunday and Monday. If you scroll to page 24, you’ll see the amendment from Delegate Mark Hunt, D-Kanawha, proposing the water system study commission. You can see at the bottom of the page that this amendment was adopted, right? But there’s nothing listed there about the Chemical Safety Board, or about this new commission considering the CSB’s recommendations.

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DEP increases estimate of chemical tank numbers

Coal Water Pollution

Readers who are closely following the continuing West Virginia water crisis may recall that three weeks ago, Department of Environmental Protection Secretary Randy Huffman gave a congressional committee some preliminary figures about the numbers of above-ground chemical storage tanks located near drinking water supplies around the state:

This investigation is still in its early stages, but so far, it has yielded an estimate of about 600 facilities housing approximately 3500 tanks across the State. Further investigation has determined that more than 100 of these – with as many as 1000 ASTs – may exist within an area that could impact a public drinking water source.

We’ve been trying for a while to get a list of those tanks, and this morning DEP officials finally provided it. Turns out their continuing investigation has found even more chemical storage tanks located in the “zone of critical concern” near drinking water intakes around West Virginia. Here’s what DEP spokesman Tom Aluise told us in an e-mail message:

Our investigation into the number of Above Ground Storage Tanks (ASTs) in the state is ongoing, but has yielded a preliminary number of just over 100 facilities with ASTs that may sit in a Zone of Critical Concern (ZCC), meaning there is potential to impact a public water drinking source. Those 100-plus facilities have what we’ve estimated to be roughly 1,600 ASTs. We have inspectors in the process of visiting each of the 100-plus facilities to verify the number of ASTs at each site, as well as the contents contained in the ASTs.

I’ve posted copies of two lists provided by DEP. This one contains the facilities covered by “individual” water pollution permits and this one contains the facilities that — like Freedom Industries — are covered by the less-detailed and rigorous “general” permits.

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What else could pollute Charleston’s water?

freedom aerial

Photo by Commercial Photography Services of West Virginia, via U.S. Chemical Safety Board.

Since the Jan. 9 chemical spill, lots of West Virginians have been asking some pretty good questions about the vulnerability of our drinking water supplies:  Why are facilities like Freedom Industries allowed to be located immediately upstream from drinking water intakes? What other similar sites present risks of contamination? What can be done to minimize or eliminate these risks?

A new report out this morning from the consulting firm Downstream Strategies tries to start digging into these sorts of questions.  The report is called Potential Significant Contaminant Sources above West Virginia American Water’s Charleston Intake: A Preliminary Assessment and is online here.

Among other things, the report identifies 61 potential significant contaminant sources, or PSCSs, which is nearly a dozen more than were counted in a decade-old report on the Elk River water supply from the state Department of Health and Human Resources.  Downstream Strategies explains in its report:

The largest numbers of PSCSs are identified as car dealerships (10 sites), gas stations (7 sites), permitted discharge pipes (5 sites), repair shops (4 sites), and auto repair shops (4 sites).

Notable PSCSs identified by WVBPH include the Freedom Industries site, a school bus parking and refueling facility with an aboveground storage tank, and a concrete facility with three readily visible aboveground storage tanks.

Downstream Strategies goes on to explain:

Additional research has identified other potential sites of interest within the ZCC that deserve additional scrutiny: an industrial park just downstream from the Freedom site and clusters of commercial and industrial buildings on both sides of the Elk River near the intake.

A water resources permit query identified 15 NPDES permits, two underground injection control permits, and one “no exposure” permit within the ZCC. These permits did not correlate well with the PSCSs identified by WVBPH.

The NPDES permits included three individual and 12 general permits, in addition to the general permits issued for home aeration units and construction sites that were omitted from the analysis. If the Legislature were to require individual NPDES permits within ZCCs, this new requirement would apply to these 12 identified general permits as well as to the home aeration units and construction sites omitted from this analysis.

Three facilities outside of the ZCC were identified for additional investigation. These sites include Yeager Airport, which is located immediately adjacent to the ZCC; what appears to be a propane facility located less than one mile upstream from the ZCC; and a compressor station and extraction plant located just upstream from Clendenin.

The report also says:

While this report focuses on the PSCSs and water resources permits above WVAW’s Elk River intake, the circumstances that led to contamination of the Elk River are examples of what could happen to many communities if they do not engage in proper planning and if regulatory agencies do not provide proper oversight. In some cases, tighter regulations are also warranted. Populations in Morgantown, Huntington, and cities and towns across the state are at risk if PSCSs are not accurately identified, and if risks from these sites are not managed.


                                                                                                    Photo from U.S. CSB animation.

For folks in West Virginia who have a new-found interest in chemical safety in the wake of the Elk River chemical spill, the latest report from the U.S. Chemical Safety Board is worth a read. Here’s part of the press release issued today by the CSB:

The April 2010 fatal explosion and fire at the Tesoro refinery in Anacortes, Washington was caused by damage to the heat exchanger, a mechanism known as “high temperature hydrogen attack” or HTHA, which severely cracked and weakened carbon steel tubing leading to a rupture, according to a CSB draft report released today. The draft report makes far-reaching recommendations to the federal Environmental Protection Agency and the Governor and State Legislature of the State of Washington to more rigorously protect workers and communities from potentially catastrophic chemical releases …

“Seven lives were tragically lost at the Tesoro refinery in 2010,” said Dr. Rafael Moure-Eraso, CSB chairperson. “I believe the draft report does an outstanding job of tracing this complex accident to its roots: a deficient refinery safety culture, weak industry standards for safeguarding equipment, and a regulatory system that too often emphasizes activities rather than outcomes. The report is a clarion call for refinery safety reform.”

Using sophisticated computer models, the investigation found the industry-wide method used to predict the risk of HTHA damage to be inaccurate, with equipment failures occurring under conditions the deemed to be safe from HTHA. It cited deficiencies in the company’s safety culture that led to a “complacent” attitude toward flammable leaks and occasional fires. Investigators also determined that during the unit startup, Tesoro did not correct the history of hazardous conditions or limit the number of people involved in the hazardous non-routine startup of the heat exchangers. But because of the reoccurring leaks and the need to manually open a series of long-winded valves that required over one hundred turns by hand to fully open, a supervisor requested five additional workers to help. All seven lost their lives as a result of the blast.

CSB Chairman Rafael Moure-Eraso said:

The accident at Tesoro could have been prevented had the company applied inherent safety principles and used HTHA resistant construction materials to prevent the heat exchanger cracking. This accident is very similar to the one that occurred at the Chevron refinery in Richmond, California in August 2012, where corrosion of piping went undetected for decades until it ruptured, endangering the lives of 19 workers caught in a vapor cloud and sending 15,000 community members to the hospital. Companies must do a better job of preventing refinery accidents, which occur all too frequently.

Regarding the U.S. EPA, the CSB report recommended:

Revise the Chemical Accident Prevention Provisions under 40 CFR Part 68 to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. Until this revision is in effect, develop guidance and enforce the use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards through the Clean Air Act’s General Duty Clause.

West Virginians may recall that the issue of industry not focusing on “inherently safer” designs and technology was discussed for many years regarding the former Union Carbide (now Bayer CropScience) plant in Institute and its now-dismantled stockpile of the deadly chemical methyl isocyanate, or MIC.  And, we’re coming up on the two-year anniversary of a National Academy of Sciences report that noted the lack of focus by industry on the concept of inherently safer practices:

Key obstacles to their use include lack of familiarity with the tools among chemical process industry decision makers and the fear that the methods are either too simplistic or too costly to use … The use of these techniques could benefit not only the communities at risk from safety breaches, but also the industries themselves, as decision making techniques can help with the identification of profitable safety solutions that otherwise could be overlooked.

Did Freedom Industries have to report the spill?


Gazette photo by Chip Ellis

As hundreds of thousands of West Virginians across a nine-county region wait for word on when they can resume using the water at their homes, folks have a flurry of other questions — not only about how to rid their homes of this “Crude MCHM” stuff, but also about what could have happened at Freedom Industries to cause this spill, and whether the company acted quickly enough in trying to deal with it.

One thing that’s come up is whether state or federal laws require Freedom Industries to report the spill to state or local authorities. The Daily Mail, for example, had a story today that told us:

The company responsible for a chemical leak that continues to force 300,000 West Virginians from using their tap water broke the law.

Which law, exactly, is still under investigation.

But state officials don’t believe Freedom Industries was required to follow a state law requiring industrial facilities to report an emergency within 15 minutes.

“I think the loophole, if you will, that this facility fell into is because it was not a hazardous material, it flew under the radar,” said Secretary Randy Huffman, head of the state Department of Environmental Protection.

The story focused on the reporting requirements written into West Virginia law at the behest of then-Gov. Joe Manchin following the Sago Mine Disaster and the Aracoma Mine fire.

That’s all well and good. But there really shouldn’t be much question of whether Freedom Industries was required to report this spill to the state DEP. Just look at the stormwater permit the agency issued for the facility. It’s really pretty clear. Look on page 43 under “immediate reporting”:

a) The permittee shall report any noncompliance which may endanger health or the environment immediately after becoming aware of the circumstances by using the Agency’s designated spill alert telephone number. A written submission shall be provided within five (5) days of the time the permittee becomes aware of the circumstances. The written submission shall contain a description of the noncompliance and its cause; the period of noncompliance, including exact dates and times, and if the noncompliance has not been corrected, the anticipated time it is expected to continue; and steps taken or planned to reduce, eliminate, and prevent recurrence of the noncompliance.

(b) The following shall also be reported immediately:

(1) Any unanticipated bypass which exceeds any effluent limitation in the permit;

(2) Any upset which exceeds any effluent limitation in the permit; and

(3) Violation of a maximum daily discharge limitation for any of the pollutants listed by the Director in the permit to be reported immediately. This list shall include any toxic pollutant or hazardous substance, or any pollutant specifically identified as the method to control a toxic pollutant or hazardous substance.

 c) The Director may waive the written report on a case-by-case basis if the oral report has been received in accordance with the above.

d) Compliance with the requirements of IV.2 of this section, shall not relieve a person of compliance with Title 47, Series 11, Section 2.

CSB proposes refinery safety overhaul


In a draft report released to the public today, the U.S. Chemical Safety Board is urging an overhaul of the way refineries are regulated in California, calling on officials to replace the current patchwork of rules with a more rigorous, performance-based regulatory regime. The proposal, similar to those successfully adopted in the United Kingdom, Norway and Australia, is known as the “safety case” system and could serve as a model for U.S.-wide safety reforms.

The draft report is the second part of three in the CSB’s investigation of the August 2012 process fire in the crude unit at the Chevron refinery in Richmond, California. That fire endangered 19 workers and sent more than 15,000 residents to the hospital for medical attention. CSB Chairman Rafael Moure-Eraso said:

After exhaustively analyzing the facts, the CSB investigation team found many ways that major refinery accidents like the Chevron fire could be made less likely by improving regulations.

Refinery safety rules need to focus on driving down risk to the lowest practicable level, rather than completing required paperwork. Companies, workers, and communities will all benefit from a rigorous system like the safety case.

I believe California could serve as a model for the nation by adopting this system. We applaud the work of the Governor’s Interagency Task Force for their proactive approach and highly positive recommendations to protect worker and public safety in California. I have great confidence that California will embrace the recommendations in our draft report and carry them forward to implement policy change.

The CSB’s press release explains:

As detailed in the CSB draft report, the safety case regime requires companies to demonstrate to refinery industry regulators – through a written “safety case report” – how major hazards are to be controlled and risks reduced to “as low as reasonably practicable,” or ALARP. The CSB report notes that the safety case is more than a written document; rather, it represents a fundamental change by shifting the responsibility for continuous reductions in major accident risks from regulators to the company.

To ensure that a facility’s safety goals and programs are accomplished, a safety case report generated by the company is rigorously reviewed, audited, and enforced by highly trained regulatory inspectors, whose technical training and experience are on par with the personnel employed by the companies they oversee, the draft report says.

The draft report comes about four months after the CSB released an “interim report” that found Chevron  repeatedly failed over a ten-year period to apply inherently safer design principles and upgrade piping in its crude oil processing unit, which was extremely corroded and ultimately ruptured on August 6, 2012.

The interim report identified missed opportunities on the part of Chevron to apply inherently safer piping design through the use of more corrosion-resistant metal alloys. The interim report also found a failure by Chevron to identify and evaluate damage mechanism hazards, which if acted upon, would likely have identified the possibility of a catastrophic sulfidation corrosion-related piping failure. There are currently no federal or state regulatory requirements to apply these important preventative measures. The investigation team concluded that enhanced regulatory oversight with greater worker involvement and public participation are needed to improve petroleum refinery safety.

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There’s a new study out today that might be of interest to West Virginians who follow the debate over the boom in natural gas drilling in our state’s Marcellus Shale region. Here’s the press release from The Endocrine Society:

A controversial oil and natural gas drilling technique called hydraulic fracturing, or fracking, uses many chemicals that can disrupt the body’s hormones, according to new research accepted for publication in The Endocrine Society’s journal Endocrinology.

Endocrine-disrupting chemicals, or EDCs, are substances that can interfere with the normal functioning of the endocrine system. EDCs can be found in manufactured products as well as certain foods, air, water and soil. Research has linked EDC exposure to infertility, cancer and birth defects.

… The study examined 12 suspected or known endocrine-disrupting chemicals used in natural gas operations and measured their ability to mimic or block the effect of the body’s male and female reproductive hormones. To gauge endocrine-disrupting activity from natural gas operations, researchers took surface and ground water samples from sites with drilling spills or accidents in a drilling-dense area of Garfield County, CO – an area with more than 10,000 active natural gas wells – and from drilling-sparse control sites without spills in Garfield County as well as Boone County, MO.

The water samples from drilling sites had higher levels of EDC activity that could interfere with the body’s response to androgens, a class of hormones that includes testosterone, as well as the reproductive hormone estrogen. Drilling site water samples had moderate to high levels of EDC activity, and samples from the Colorado River – the drainage basin for the natural gas drilling sites – had moderate levels. In comparison, little activity was measured in the water samples from the sites with little drilling.

Here’s a link to the study, and a link to criticism of the study from the industry group Energy in Depth, which says, among other things:

The study focuses on water samples from five areas in Garfield County, Colo., that are known to have had “a spill or incident related to natural gas drilling processes” within the past six years. These data are compared against a small number of samples from “drilling sparse locations” in the same county and a “drilling absent location in Boone County.” That’s Boone County, Missouri, by the way.

We all know spills are bad and can cause problems, so what exactly did they expect to find?  If this were about advancing the state of knowledge about the risks of development, the study would have focused on areas with oil and gas development where no known incidents had occurred. That might actually tell us something relevant about safety, since it would help determine if there are any unknown impacts that we should take care to safeguard against.

Instead, they investigated a known problem area and declared it a problem area. Real cutting edge stuff.