The U.S. Chemical Safety Board, releasing a video depicting a deadly chemical leak at a DuPont plant in Belle, West Virginia last year, said the final investigation report should remind every manufacturer to make safety a priority.
The report formalizes conclusions the CSB had made public in July: An ineffective alarm system, maintenance deficiencies and an inadequate emergency response system led to three chemical leaks within 33 hours in January 2010.
Each leak was preceded by an incident that triggered an internal investigation and a corrective-action plan, the report said, “but this activity was not sufficient to prevent the accidents from recurring.”
The CSB said DuPont could have prevented the death of 58-year-old Carl Fish if it had built an enclosure around tanks of phosgene. Fish was taking readings when a hose failed, spraying his chest and face.
Phosgene was used as a chemical weapon during World War I and today is used as a building block in synthesis of pharmaceuticals and other organic compounds.
The report says workers were supposed to replace hoses on the phosgene tanks once a month, but the one that broke had been in service for seven months.
DuPont had also known since 1987 that the braided stainless steel hose, lined with Teflon, was susceptible to corrosion, said team leader Johnnie Banks. A worker recommended a different, more expensive kind of hose, he said, but the switch was never made.
DuPont has removed all phosgene from the plant since the accident and taken a series of corrective actions, including an operations safety review and improvement of its maintenance and inspection system for hoses.
Chemical Safety Board: http://www.csb.gov/