Last week, the Chemical Safety Board released its draft report on its investigation into a spate of three accidents over January 22-23, 2010, at a DuPont plant in Belle, West Virginia. The three incidents involved releases of of methyl chloride, fuming sulfuric acid (oleum), and phosgene; plant worker Carl Daniel Fish was sprayed on the chest and face with phosgene and died the next day. The report is 172 pages long and I haven’t read beyond the executive summary, but here are CSB’s bullet points on the root causes:
Methyl chloride incident (January 22, 2010, 5:02 AM)
- DuPont management … approved a design for the rupture disc alarm system that lacked sufficient reliability to advise operators of a flammable methyl chloride release. (Jyllian notes: The plant released 2,000 lbs of methyl chloride over five days before the leak was identified.)
Oleum release incident (January 23, 2010, 7:40 AM)
- Corrosion under the insulation caused a small leak in the oleum pipe.
Phosgene incident (January 23, 2010, 1:45 PM)
- DuPont’s phosgene hazard awareness program was deficient in ensuring that operating personnel were aware of the hazards associated with trapping liquid phosgene in transfer hoses.
- DuPont relied on a maintenance software program that was subject to changes without authorization or review and did not automatically initiate a change-out of phosgene hoses at the prescribed interval, nor did they provide a back-up process to ensure timely change-out of aging hoses.
- DuPont Belle’s near-miss reporting process was not rigorous enough to ensure that the near failure of a similar phosgene transfer hose, just hours prior to the exposure incident would be immediately brought to the attention of plant supervisors and managers.
- DuPont lacked a dedicated radio/telephone system and emergency notification process to convey the nature of an emergency at the Belle plant, thereby restricting the ability of personnel to provide timely and quality information to emergency responders.
Here’s CSB’s animation of the phosgene release:
Ken Ward Jr covers the chemical industry for West Virginia’s Charleston Gazette and attended last week’s press conference–here are his stories so far on the draft report:
- CSB: DuPont needs to ‘re-examine’ safety practices
- Phosgene leak could have crossed river, CSB says (a similar post appears on the paper’s “Sustained Outrage” blog)
- More from the CSB’s DuPont press conference
- DuPont responds to Chemical Safety Board report
- CSB: DuPont ignored safer phosgene plans
The DuPont plant is in the same area as the Bayer CropScience plant where two workers were killed in an explosion and fire in 2008. After the Bayer CropScience incident, CSB recommended that local authorities develop a regional chemical plant safety program. Ward also reports that little progress has been made on implementing such a program.
CSB will accept public comments on the draft DuPont report until 5 p.m. on Aug. 22. “Following the close of the public comment period, the draft report may be modified based on comments received and other staff investigative activities. A final report will then be presented to the Board for its consideration and final vote. Only after the report is approved by the Board will the investigation into the three incidents at the DuPont facility be considered closed,” says a notice in the Federal Register.