The U.S. Chemical Safety and Hazard Investigation Board (CSB) this week released a final report on its investigation of three incidents that occurred at the Honeywell International, Inc., plant in Baton Rouge, Louisiana, in 2003. Each involved toxic releases and, in one case, the death of a worker.

The CSB report pointed to management system deficiencies at the plant that were common to all three incidents. The company's hazard analyses did not provide an adequate review of all equipment, procedures and likely accident scenarios, the report said, noting that potentially dangerous "non-routine" situations at the plant were not always recognized as such.

The board also concluded work practices at the plant did not always strictly follow written operating procedures.

"These incidents at the Honeywell Baton Rouge facility in the summer of 2003 should not have happened and would not have happened had better procedures, hazard analyses and design of critical equipment been put in place at the plant," said board chairwoman Carolyn Merritt.