Accident: DuPont Corporation Toxic Chemical Releases
Location: Location: Belle, WV
Accident Occured On: 01/23/2010 | Final Report Released On: 09/20/2011
Accident Type: Release
Investigation Status: The CSB's final report was approved on September 20, 2011.
On January 23, there was a release of highly toxic phosgene, exposing a veteran operator at the DuPont facility in Belle, West Virginia and resulting in his death one day later. DuPont officials told the CSB that a braided steel hose connected to a one-ton capacity phosgene tank suddenly ruptured, releasing phosgene into the air. An operator who was exposed to the chemical was transported to the hospital, where he died the following day. The phosgene release followed two other accidents at the same plant in the same week, including an ongoing release of chloromethane from the plant’s F3455 unit, which went undetected for several days, and a release from a spent sulfuric acid unit. The plant announced over the weekend that it would be shutting down a number of process units immediately for safety checks. The CSB is also investiating a November 2010 accident at the Dupont facility outside Buffalo, NY, that fatally injured one worker.
Revise the Phosgene Safe Practice Guidelines Manual to
Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to include specific requirements for storing and handling highly toxic compressed gas, including enclosure ventilation and alarm requirements at least as protective as Section 7.9, Toxic and Highly Toxic Gases and NFPA 55, Compressed Gases and Cryogenics Fluids Code.
Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to incorporate by reference CGA E-9, Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service.
Improve the existing maintenance management by
Revise the facility emergency response protocol to require that a responsible and accountable DuPont employee always be available (all shifts, all days) to provide timely and accurate information to the Kanawha County Emergency Ambulance Authority (KCEAA) and Metro 9-1-1 dispatchers.
Revise the near-miss reporting and investigation policy and implement a program that includes the following at a minimum:
Revise safeguards for phosgene handling at all DuPont facilities by
Review all DuPont units that produce and handle phosgene that, at a minimum, observe and document site-specific practices for engineering controls, construction materials, PPE, procedures, maintenance, emergency response, and release detection and alarms, and use information from external sources to develop and implement consistent company-wide policies for the safe production and handling of phosgene.
For each DuPont facility that uses, but does not manufacture, phosgene onsite:
Commission an audit in consultation with operations personnel to establish and identify the conditions that cause nuisance alarms at all DuPont facilities. Establish and implement a corporate alarm management program as part of the DuPont PSM Program, including measures to prevent nuisance alarms and other malfunctions in those systems. Include initial and refresher training as an integral part of this effort.
Revise the DuPont PSM standard to require confirmation that all safety alarms/interlocks are in proper working order (e.g., not in an active alarm state) prior to the start-up of all Higher-Hazard Process facilities.
Reevaluate and clarify the DuPont corporate MOC policies to ensure that staff can properly identify and use the distinctions between subtle and full changes and train appropriate personnel how to properly apply the distinctions on any changes in the policy.
Revise OSHA 29 CFR 1910.101, General Industry Standard for Compressed Gases, to require facilities that handle toxic and highly toxic materials in compressed gas cylinders to incorporate provisions that are at least as effective as the 2010 edition of Section 7.9, Toxic and Highly Toxic Gases, in National Fire Protection Association (NFPA) 55, Compressed Gases and Cryogenic Fluids Code, including enclosures, ventilation and treatment systems, interlocked fail-safe shutdown valves, gas detection and alarm systems, piping system components, and similarly relevant layers of protection.
Take sustained measures to minimize the exposure of hazards to workers handling highly toxic gases from cylinders and associated regulators, gages, hoses, and appliances. Ensure that OSHA managers, compliance officers, equivalent state OSHA plan personnel, and regulated parties conform, under the Process Safety Management Standard (29 CFR 1910.119) Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) provisions, to industry practices at least as effective as the following: