Report cites unsafe equipment, failure to investigate near misses
The U.S. Chemical Safety Board (CSB) today released its final report on a series of three accidents that occurred over a 33-hour period on January 22 and 23, 2010, at the DuPont Corporation’s Belle, West Virginia, chemical manufacturing plant – including a fatal release of deadly phosgene gas, which was used as a chemical weapon in World War One.
The Board voted 4-1 to approve the report following an extensive public comment period initiated with the release of a draft report on July 7, 2011, in Charleston, West Virginia. In the final report, the Board took into consideration all of the comments filed by industry stakeholders, members of the public and other interested parties, some of which resulted in factual corrections or language changes to the draft report.
CSB Chairperson Rafael Moure-Eraso said, “We thank those individuals, companies and agencies who helpfully commented on our report. Our final report shows in detail how a series of preventable safety shortcomings -- including failure to maintain the mechanical integrity of a critical phosgene hose -- led to the accidents. That this happened at a company with DuPont’s reputation for safety should indicate the need for every chemical plant to redouble their efforts to analyze potential hazards and take steps to prevent tragedy.”
The CSB also released a safety video today entitled “Fatal Exposure: Tragedy at DuPont,” based on the investigation, which features an animation depicting the sequence of events leading to the death of a worker when a phosgene hose suddenly burst. The video also explains the causes of two other toxic chemical releases detailed in the report and features comments by Board Member John Bresland, CSB Investigation Team Lead Johnnie Banks and Investigator Lucy Tyler.
The report makes numerous safety recommendations. Among them, DuPont was urged to enclose all of its phosgene production and storage areas so that any releases of phosgene will be contained. (The Belle facility subsequently announced it was ceasing phosgene usage in 2011, and had no plans to resume use.)
The CSB recommended that the Occupational Safety and Health Administration (OSHA) revise the General Industry Standard for Compressed Gases to be at least as effective as the relevant National Fire Protection Association (NFPA) Code 55 (the Compressed Gases and Cryogenics Fluids Code). This would require secondary enclosures for highly toxic gases such as phosgene and provide for ventilation and treatment systems, interlocked failsafe shutdown valves, gas detection and alarm systems, piping system components, and similar layers of protection.
DuPont’s Belle facility occupies more than 700 acres along the Kanawha River, eight miles east of Charleston, the state capital. The plant produces a variety of specialty chemicals.
The series of accidents began on January 22, 2010, when an alarm sounded leading operators to discover that 2,000 pounds of methyl chloride, a toxic and extremely flammable gas, had been leaking unnoticed into the atmosphere for five days. The next morning, workers discovered a leak in a pipe carrying oleum, producing a fuming cloud of sulfur trioxide. The phosgene release occurred later that day, and the exposed worker died the next evening in a Charleston hospital.
Noting the company started as a gunpowder manufacturer in 1802, and became a major chemical producer within 100 years, Dr. Moure-Eraso said, “DuPont has had a stated focus on accident prevention since its early days. Over the years, DuPont management worked to drive the injury rate down to zero through improved safety practices.”
Dr. Moure-Eraso continued, “DuPont became recognized across industry as a safety innovator and leader. We at the CSB were therefore quite surprised and alarmed to learn that the DuPont Belle plant had not just one but three accidents that occurred over a 33-hour period in January 2010.”
CSB board member and former chairman John Bresland noted the CSB finding that the phosgene hose that burst in front of a worker was supposed to be changed out at least once a month. But the hose that failed had been in service for seven months. Furthermore, the CSB found the type of hose involved in the accident was susceptible to corrosion from phosgene.
Team Lead Johnnie Banks said, “Documents obtained during the CSB investigation showed that as far back as 1987, DuPont officials realized the hazards of using braided stainless steel hoses lined with Teflon, or polytetrafluoroethylene (PTFE). An expert employed at DuPont recommended the use of hoses lined with Monel, a metal alloy used in corrosive applications. The DuPont official stated: ‘Admittedly, the Monel hose will cost more than its stainless counterpart. However, with proper construction and design so that stresses are minimized…useful life should be much greater than 3 months. Costs will be less in the long run and safety will also be improved.’”