DuPont La Porte Facility Toxic Chemical Release

Final Reports

FINAL REPORT: Final DuPont LaPorte Investigation

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Recommendations

DuPont LaPorte, Texas Chemical Facility
2015-01-I-TX-1

Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a comprehensive

engineering analysis of the manufacturing building and the discharge of pressure relief systems with toxic

chemical scenarios to assess potential inherently safer design options. At a minimum, evaluate the use of

an open building structure, and the direction of toxic chemical leaks and the discharge of pressure relief

systems with toxic chemical scenarios to a destruction system. Implement inherently safer design

principles to the greatest extent feasible and effectively apply the hierarchy of controls such that neither

workers nor the public are harmed from potential highly toxic chemical releases. Detail the analysis,

findings, and corrective actions in a written report and make this report available to DuPont La Porte

employees, their representatives, and the CSB.

Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendations Status Change Summary

2015-01-I-TX-2

Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a robust

engineering evaluation of the manufacturing building and the dilution air ventilation system that includes

the implementation of corrective action(s) to the greatest extent feasible in order to ensure a safe

environment for all workers. Develop a documented design basis for the manufacturing building and the

air dilution ventilation system that identifies effective controls for highly toxic, asphyxiation, and

flammability hazards and implement these controls to the greatest extent feasible. Address nonroutine

operations and emergency response activities in the design basis. The design basis for the manufacturing

building and the dilution air ventilation system must use the hierarchy of controls and inherently safer

design principles to the greatest extent feasible.

Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendations Status Change Summary

2015-01-I-TX-3

Prior to resuming manufacturing operations, ensure all Insecticides Business Unit (IBU) pressure relief

systems are routed to a safe location and effectively apply the hierarchy of controls to protect workers and

the public. Commission a pressure relief device analysis, consistent with API Standard 521 and the

ASME Code, including a field review. Include an evaluation of relief system discharge location to ensure

that relief systems are discharged to a safe location that will prevent toxic exposure, flammability, or

asphyxiation hazards in order to ensure public and worker health and safety to the greatest extent feasible.

Include an evaluation of relief scenarios consistent with API Standard 521.

Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendations Status Change Summary

2015-01-I-TX-4

Develop and implement an expedited schedule to perform more robust process hazard analyses (PHAs)

consistent with R1, R2, and R3 for all units within the Insecticides Business Unit (IBU). At a minimum,

the PHAs must effectively identify and control the hazards referenced in this document utilizing the

hierarchy of controls. The PHA schedule must be prioritized based on anticipated risks to the public and

workers in order to ensure that the highest risk areas receive priority consideration. At a minimum, the

more robust PHAs must be consistent with the approach applied to post-incident reviews described above

in paragraph 10.

Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendations Status Change Summary

2015-01-I-TX-5

Work together with the International Chemical Workers Union Council of the United Food and

Commercial Workers (ICWUC/UFCW) Local 900C and the ICWUC/UFCW staff (at the request of the

local) to develop and implement a plan to ensure active participation of the workforce and their

representatives in the implementation of Recommendations R1 through R4. In addition, provide a copy

of DuPont’s integrated plan for restart to La Porte workers and their local union representatives.

Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendations Status Change Summary

2015-01-I-TX-6

Make publicly available (on a website) a summary of the DuPont November 15, 2014 incident

investigation report, the integrated plan for restart, and actions to be taken for the implementation of

Recommendations R1 through R5. This website must be periodically updated to accurately reflect the

integrated plan for restart and implementation of Recommendations R1 through R5.

Status: Closed - Acceptable Action

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

Recommendations Status Change Summary
2015-01-I-TX-8
Work together with emergency response team (ERT) member companies (DuPont, Chemours, Kuraray, and Invista), the International Chemical Workers Union Council of the United Food and Commercial Workers (ICWUC/UFCW) Local 900C, and the ICWUC/UFCW staff (if requested by the Local 900C) to update the DuPont La Porte emergency response plan. The emergency response program should ensure that periodic exercises or drills are performed on new procedures developed to address key lessons to strengthen ERT capabilities. The emergency response program should address the following:

Preidentifying unit experts as technical support personnel and ensuring that backup capability is available in the event the primary technical support personnel become unavailable. (Section 4.2: Process Coordinator Was Missing)

Clearly detailing in plant emergency procedures the alerting and notification protocols for different types of plant emergencies. Provide initial training to new plant personnel and periodic training to all plant personnel on these emergency communication procedures. These procedures should also include guidance for emergency responders when there is insufficient initial information to effectively assess the nature of the problem and the level of ERT resources required. (Section 4.3.1: Call for ERT Response)

Developing and applying regular maintenance schedules for emergency response vehicles consistent with the National Fire Protection Association’s Standard for the Inspection, Maintenance, Testing, and Retirement of In-Service Emergency Vehicles (NFPA 1911), which requires weekly visual and operational checks of emergency vehicles and has example checklists to use when performing preventive maintenance on emergency vehicles. (Section 4.3.2: ERT Mini-Pumper Truck Not Operational)

Ensuring that ERTs have reliable means to characterize hazardous atmospheres, for example equipment that monitors toxicity, explosivity, and oxygen levels. Additionally, ensure that ERT members know where the equipment is stored, can access it, and are trained on its proper use. (Section 4.4.1: Entry into Potentially Explosive Atmosphere)

Evaluating high-hazard areas, including PSM covered processes, to determine whether detectors and alarms are necessary to identify chemical releases (or other types of emergencies). Additionally, consider equipping high-hazard areas with surveillance technology to identify personnel in the field. (Section 4.4.2: No Technology to Locate Missing Workers)

Developing and implementing written policy and procedures to update emergency response plan documents when hazards are identified. For example, personnel can identify these types of hazards in process hazard analyses, facility siting studies, management of change reviews, and incident investigations. Changes to emergency planning documents should be effectively communicated to the site ERT as soon as possible after identifying the hazard. (Section 4.4.3: Unrecognized Manufacturing Building Collapse Hazard)

Ensuring that emergency response planning accounts for difficulties in conducting response efforts, including (1) maps included in emergency response plans to show the layout of buildings containing hazardous chemicals, for use by emergency responders and to aid evacuation and rescue efforts; (2) coordination of periodic (at least annual) site tours for plant and external emergency responders; (3) training emergency responders to help ensure familiarity with facility access points, hazards, emergency response issues, and site or facility layout; and (4) building teamwork by having members (from the different companies) of the ERT field train (by conducting drills) together when practicable. (Section 4.5: Difficulties Navigating Manufacturing Building)

Assigning knowledgeable personnel the responsibility to analyze process data to assess the source, scope, and magnitude of any incident. (Section 4.6: No Analysis of Process Data to Identify Source of Leak)

Training emergency response team members to (1) physically designate the hot zone; (2) communicate the location of the hot zone and entry control points to all personnel assisting with the emergency response, including operations personnel; and (3) control entry and exit points of the hot zone. (Section 4.7: Inadequate Control of Hot Zone)

Addressing in the emergency response plan how to characterize (including size, concentration, location, and direction of release) hazardous chemical releases and providing guidance on how and where people should take protective action (e.g., sheltering-in-place) in the event of a chemical release. (Section 4.8.1: Release Modeling)

Developing a procedure in the emergency response plan to effectively monitor for hazardous gases along the fence line at chemical facilities during the release to help workers understand and clearly communicate the extent of a release. (Section 4.8.4: Air Monitoring)

In addition, provide a copy of the emergency response plan to the Emergency Response Team and their local union representatives.
Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendation Status Change
International Chemical Workers Union Council (ICWUC) of the United Food and Commercial Workers (UFCW) and Local 900C

2015-01-I-TX-7

Work together with DuPont to develop and implement a plan to ensure active participation of the

workforce and their representatives in the implementation of Recommendations R1 through R4.

Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendations Status Change Summary

2015-01-I-TX-9

Work together with DuPont to develop and implement the emergency response plan described in Recommendation R8 (2015-01-I-TX-R8).

Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendation Status Change