Two years after an explosion at a crucial Army factory that is the country's largest producer of small-caliber ammunition, the true cause of Lawrence Bass Jr.'s death remains unclear.
Bass, a long-time employee, followed explosives-handling procedures later deemed to be poorly written. He worked for a defense contractor anxious to slash costs on a government contract it had underbid.
The ammunition plant run by that contractor suffers from a worker safety record far worse than its peers. The facility on the outskirts of Kansas City, Missouri, is "still making ammunition the old-fashioned way," according to the Congressional testimony of a three-star general.
The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) ruled the April 11, 2017, explosion at the Lake City Army Ammunition Plant was accidental, but subsequent investigations found a series of safety concerns that may have caused the blast.
The Occupational Safety and Health Administration later uncovered a second, unreported explosion. The agency eventually levied significant fines after its initial inquiry morphed into three separate investigations, according to documents obtained by Guns & America.
Today, there are lingering questions: Should the plant have been using a different, safer manufacturing process? Did cost-cutting measures at the company endanger workers?
The Army, which owns the Lake City facility, and Northrop Grumman, which runs the ammunition plant, declined interview requests for this story.
Neither the Army nor the ATF has provided even a redacted version of their separate investigations more than six months after Guns & America filed requests under the Freedom of Information Act.
Meanwhile, the massive Lake City production contract is being rebid, which means 2,000 employees could soon be working for their fourth corporate boardroom in five years.
When a soldier, sailor, airman or marine fired a bullet from a rifle or machine gun anytime between World War II and the present day, there's a good chance that bullet came from Lake City's sprawling facility in suburban Kansas City.
The plant, which produces as many as 2 billion rounds per year, is the primary provider of small-caliber ammunition for the military (a version of this round is also sold to the public). The common 5.56 mm round fired by M16 rifles and M4 carbines is produced at the plant. So are 7.62 mm and .50-caliber rounds typically used in light and heavy machine guns.
"Making ammunition is dangerous work," plant commander Lt. Col. Eric Dennis said at a press conference following the 2017 explosion. "Our employees risk their lives to protect our men and women in uniform."
The Lake City facility does have a history of catastrophic incidents: Workers were also killed or injured by explosions in 1981, 1990, 1991 and 2011.
But the industry overall is no more dangerous than other manufacturing jobs. And some common vocations lead to far more injuries than working at an ammunition plant. Nursing home employees, firefighters and public transportation workers were at least 10 times more likely to suffer injuries in 2016, according to data compiled by the Bureau of Labor Statistics.
The data, calculated in what is known as a DART score, represents the rate at which workers suffer on-the-job injuries requiring them to miss work or perform alternate duties.
During the five years preceding the fatal 2017 explosion, the Lake City facility's DART score was about 3.5 times higher than the DART average at ammunition factories considered by OSHA to be peer facilities, according to records obtained via the Freedom of Information Act.
The highest of those years by far was 2014, which happened to be the first full year of operation under a problematic contract that would throw the company managing the plant into financial turmoil.
Orbital ATK, the defense contractor that ran the Lake City facility from 2000 until it was bought last year by Northrop Grumman, stunned investors on Aug. 10, 2016, when it announced it wouldn't be able to file its quarterly earnings report on time.
Corporate officials said they'd uncovered accounting problems and would need to refile earnings reports dating back months.
Orbital ATK stock plummeted more than 20%. Institutional investors such as a St. Louis construction laborers' union quickly filed a class-action lawsuit alleging the company fraudulently hid the fact it was losing hundreds of millions of dollars on its massive, multi-year Army contract.
In a 2016 conference call with financial analysts, Orbital ATK officials said they made "vigorous and sustained efforts to achieve productivity improvements" but had achieved only "one-half to two-thirds" of the cuts necessary to break even on the deal.
The company eventually said it expected to lose $373 million on the contract.
"The magnitude of the expected [loss] is surprisingly large," wrote one Wells Fargo analyst, "considering that most of the [expenses] for this work are fixed-price metals."
As the lawsuit pointed out, profit on the new contract "was dependent upon achieving hundreds of millions in cost savings that had never been achievable in the company's long history of manufacturing ammunition."
Workers at the Lake City facility, many of whom had complained for years about layoffs and declining wages under Orbital ATK, voted to unionize weeks after work began under the new contract in 2013.
Orbital officials denied the fraud allegations but acknowledged the company had filed incorrect financial data. The Securities and Exchange Commission opened a non-public investigation into the matter, according to the company's corporate filings.
The company blamed the errors on "inappropriate behaviors" and "suppression of information … due to pressure to achieve cost savings" by workers in the department that oversaw the Lake City contract.
Former plant manager Kent Holiday, however, pinned blame on a software system that he said made it harder to track costs.
"When the new system came on [in 2013 or 2014] we struggled mightily and worked for years to get the cost properly shown," Holiday told Guns & America. "Unfortunately, all our diligence either didn't pay off or there was a bug in the software … we thought we were doing OK. Obviously we weren't."
Holiday, who managed the plant for five years until he was let go about three months before the explosion, also defended the company's safety protocols.
"We always took safety as priority one," he said. "In fact, I think we did things to improve safety even while we were cutting costs."
As an example, Holiday said the company installed new robotic machines that kept workers in one section of the plant from having to pack materials by hand.
In January, Orbital ATK, now a subsidiary of Northrop Grumman, agreed to settle the investor lawsuit for $108 million.
While the company dealt with fallout from its financial misdeeds on Wall Street, at least one worker at Lake City was pushing for safety improvements.
Kristina Sevy arrived at the facility in 2015 and soon identified problems with some of the plant's standard operating procedures (SOP).
The procedures provide employees with written step-by-step instructions on how to do their jobs and are important in any manufacturing facility. They were especially important on "the hill," where Sevy worked as a chemical engineer.
Buildings on the hill are situated far away from other parts of the 3,900-acre plant because they house primer mix production, a particularly dangerous phase of the manufacturing process.
Primer is the explosive that ignites the smokeless gunpowder, which then forces a bullet down the barrel of a gun. Some of the primer manufacturing processes at Lake City are directed via remote control, but others are handled by experienced workers known as explosive mixers.
As she would later tell investigators, Sevy found some of the primer procedures did not properly explain each step required to complete a task.
Tetrazene, the compound that would ultimately explode and kill Bass while injuring four other workers, was one focus of Sevy's concern.
Freshly-made tetrazene is too wet to be used in primer mix, so workers dried the compound in a metal vacuum chamber until it reached a consistency somewhere between cake batter and silly putty.
The drying took about three hours but was an inexact science, partially because the building where it was manufactured was not climate-controlled. If a batch was found to be too dry, workers would rinse it with water and put it back in the vacuum chamber and try again.
That could be problematic because as tetrazene dries it becomes volatile and more dangerous. At the Lake City facility, workers wanted to keep the moisture content above 15% for safety reasons but below 35% to maintain quality control.
Sevy declined to be interviewed for this story, but transcripts of her conversations with investigators indicate she changed the SOP so that dry tetrazene would be discarded and disposed, instead of rehydrated and reused.
"That was the safest thing to do rather than try to rehandle it," she told OSHA investigators.
Explosives mixers also handled tetrazene without knowing its moisture content, Sevy said. Each batch was tested in an on-site lab, but the results took hours and sometimes were not available until the next day.
Sevy found a machine that could analyze the moisture content in just 15 minutes. She spent months pushing her supervisors to purchase the device and it was finally installed in late 2016 as part of a project to replace the vacuum receiver used to dry the tetrazene.
Four months later, Bass was killed when a batch of tetrazene exploded as he removed it from the new vacuum receiver. Bass did not know the tetrazene's moisture content because the batch had not been checked by either the laboratory or the new moisture analyzer, investigators would later learn.
Procedures for the new machine had not been finalized before the explosion, Sevy and another worker told investigators.
Sevy said Bass, one of the most experienced workers on the hill, had done nothing wrong.
He "wasn't doing anything that they hadn't done for the last 30 years," she told investigators.
OSHA investigators opened their inquiry the day of the explosion and brought in a team from Salt Lake City, Utah, to assist with the complicated investigation.
The agency soon found evidence that workers on the hill were also improperly exposed to lead dust. One investigation became two.
Weeks after the explosion, someone sent OSHA an anonymous complaint. Attached was an internal company letter from December 2016 that outlined some of the risks remaining under the new tetrazene manufacturing process. "There is no immediate feedback mechanism for moisture content," it said. "Which means we risk over-drying the high explosives."
Many of OSHA's questions revolved around a small spatula Bass, 55, had been using to break up the tetrazene when it exploded.
Something as simple as friction or static electricity can ignite tetrazene, so workers had to be careful when touching the explosive. But the company didn't know whether the spatula was made with conductive material, or even where it came from. OSHA found that workers manufacturing the dangerous explosive had been using the spatula for at least 15 years.
It wasn't mentioned in the SOPs for that stage of the manufacturing process.
In August 2017, OSHA got another anonymous complaint from the Lake City facility. This time they were told about a new explosion in the production room of lead styphnate — another compound used in primer mix — that happened in July.
Nobody was injured in the smaller explosion, which records alternately refer to as an "exothermic event." OSHA opened a third investigation.
The agency eventually cited Orbital ATK for 11 serious safety violations and one safety violation classified as "other."
OSHA proposed fines totaling nearly $150,000 — just under the maximum amount allowed by law. Orbital ATK contested virtually all of the agency's findings and OSHA reduced the severity of some of the citations.
The company eventually agreed to pay about $103,000.
Perhaps more importantly, Orbital ATK overhauled its tetrazene manufacturing process.
Speaking to investigators in July 2017, three months after the explosion, Sevy said the company stopped drying tetrazene and was instead "de-watering" the explosive, similar to the process used by a private company in Lewiston, Idaho.
The company's new target moisture content was 26%, Sevy said, well above the 15% used before the explosion.
The new method would take longer — think of drying pants on a clothesline instead of in a dryer — but eliminated some of the risks that the tetrazene would become volatile.
Sevy also said workers were no longer allowed to handle tetrazene until its moisture content had been tested.
Northrop Grumman, which now owns Orbital ATK, declined to say whether the Lake City facility made those changes permanent or adopted any other worker safety measures after the fatal explosion.
"We are committed to maintaining a safe workplace for our employees," company spokesman Whitney Watson said in a statement. "Lake City Army Ammunition Plant has played a vital role in our nation's security for more than 78 years and we look forward to continuing to support the men and women who serve our country."
The Army's Joint Munitions Command, which controls the Lake City facility, also declined to say whether any worker safety improvements were made after the explosion.
Orbital ATK would ultimately estimate it lost about $65 million due to production delays after the explosion. The company also told the Army it wants an early release from the Lake City contract, which is now set to expire in 2020.
The Army rebid the contract in December 2018, although it is not clear how many companies Northrop Grumman will be competing against. The Army has said it will announce the winner this fall.
KERA is part of Guns & America, a national reporting collaborative of 10 public media newsrooms focusing attention on the role of guns in American life. You can find more Guns & America coverage here, and learn more about the collaboration here.