CSB Investigation: DuPont guilty safety deficiencies

CSB Investigation: DuPont guilty of safety deficiencies

3:52 PM, 8th July 2011
CSB Investigation: DuPont guilty of safety deficiencies
Rafael Moure-Eraso, Chairman, CSB.

CHARLESTON, WEST VIRGINIA: A series of preventable safety shortcomings - including failure to maintain the mechanical integrity of a critical phosgene hose - led to a string of three serious 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, according to the draft report of the US Chemical Safety Board (CSB). In one of the accidents, a worker died following exposure to phosgene, a gas used as a chemical weapon in World War I.

The CSB investigation found common deficiencies in DuPont Belle plant management systems springing from all three accidents: Maintenance and inspections, alarm recognition and management, accident investigation, emergency response and communications and hazard recognition.

For DuPont’s Belle facility, 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 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 the sulfur trioxide. The phosgene release occurred later that day and the exposed worker died the next day in a hospital.  

“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. We at the CSB were therefore quite surprised and alarmed to learn that DuPont had not just one but three accidents that occurred over a 33-hour period in January 2010,” said Rafael Moure-Eraso, Chairman, CSB.

Member John Bresland noted the CSB finding that the phosgene hose that burst in front of a worker was supposed to be changed 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.

“Documents suggested that in 1987, DuPont officials realized the hazards of using the braided stainless steel hoses lined with Teflon or PTFE. An expert employed at DuPont recommended the use of hoses lined with Monel, a strong metal alloy used in highly corrosive conditions,” said Johnnie Banks, Team Lead, CSB.

But the DuPont managment did not implement the Monel hose recommendation at that time. Internal DuPont documents indicated that in the 1980’s, company officials  considered increasing the safety of the area of the plant where phosgene is handled by enclosing the area and venting the enclosure through a scrubber system to destroy any toxic phosgene gas before it entered the atmosphere. However, the documents show the company calculated the benefit ratio of potential lives saved compared to the cost and decided not to make the safety improvements.

CSB Team Lead Banks said, “The CSB found that each incident was preceded by an event or multiple events that triggered internal incident investigations by DuPont, which then issued recommendations and corrective actions. But this activity was not sufficient to prevent the accidents from recurring.”

The CSB draft report recommended that the DuPont Belle facility revise its near-miss reporting and investigation policy. It also recommends the Belle plant to ensure its computer systems provide timely updates on scheduling maintenance for phosgene hoses.

The CSB recommended that DuPont Corporation require all phosgene production and storage areas have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers and automated audible alarms for highly toxic gases.

The draft report recommends that industry-organizations such as the Compressed Gas Association (CGA) and the American Chemistry Council (ACC) adopt the more stringent guidelines for the safe handling of phosgene and other highly toxic gases.   The report recommends the Occupational Safety and Health Administration (OSHA) update its compressed gas safety standard to include modern safeguards for toxic gases such as phosgene.

(C) WOC News




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