Document 8R7eQ4yNDngDQEoNNmwZp7L7k

FILE NAME DuPont DUP DATE 2011 July DOC DUP179 DOCUMENT DESCRIPTION Draft of Investigation Report - U.S. Chemical Safety and Hazard Investigation Board RE E.I. DuPont de Nemours & Co. Inc. STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD oe: te U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD INVESTIGATION REPORT Draft Report for Public Comment E.I. DUPONT DE NEMOURS & CO INC BELLE WEST VIRGINIA METHYL CHLORIDE RELEASE JANUARY 22 2010 OLEUM RELEASE JANUARY 23 2010 REPORT NO 2010-6-1 JULY 2011 PHOSGENE RELEASE JANUARY 23 2010 One Fatality One Confirmed Exposure One Possible Exposure KEY ISSUES MECHANICAL INTEGRITY ALARM MANAGEMENT OPERATING PROCEDURES COMPANY EMERGENCY RESPONSE & NOTIFICATION STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. D_raft Report for Public Comment July 2011 CONTENTS 1.1 1.2 1.3 Background Background . 12 Investigative Process meee 14 E.I. DuPont de Nemours & Co. Inc. occ cccesssscsssseceesceanseciseseeeeserereteeeeereeereenensnasiee 15 1.3.1 - 1.3.2 Company History 1515 DuPont Business Areas and Corporate Management cece ....... tsee. eeie. seee: eesec eese. aeee 15 1.4 DuPont Belle Plant 19 2,0 2.1 METHYL CHLORIDE RELEASE JANUARY 22 2010 cicosess tenes ceteris 21 Background ee 2.1.1 Methyl Chloride 22 22 2.2 Incident Description2323 2.2.1 2.2.2 ECF Sensor Alarm .....24 Odor Detection Considerations .. .24 2.2.3 Incident Response 2525 2.2.4 Community Impact2828 2.3 Incident Analysis Analysis 2828 2.3.1 Mechanical Integrity Integrity -sssnsssneunnpeninninninntninninnnninnnn 28 inne 2.3.2 Design and Maintenance of Rupture Discs ........ .30 - 2.3.3 Previous Incidents of Rupture Discs Bursting . cee eee .31 eee 2.3.4 2.3.5 Management of Technology and Subtle Change . essen 33 F3455 Unit Turnaround 20.0 3434 2.4 2.5 2,3,6 Second Process Safety Management Aud nesses . i 3t 7 .37 Key Findings ... 38 Root Causes . 38 3.1 Background Background .... 39 3.2 Incident Description ..... 39 3.2.1 Incident Response 41 ii STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 3.3.1 3.3.2 3.3.3 3.3.4 3.3.5 3.3.6 Reconstructive Analysis .......ccccccccceccseceeecseseeceecseeeecaeeevseessevavsenseersesevavenssarerstetaseesens 42 Pipe Testing and Analysis 44 Previous Incident Investigation ccc cccccscccccsesccesecescescececeecoeseaestsescreeseeseaeestetseseesees PM Program Recommendation from 2009 Incident 0.0... cenc ee ceee ere cree.46 Mechanical Integrity oo... ee cece eeneeeeecaene cess ceeenerieceer bop ci tna cieessasnacsnteeaecseness 46 Heat Tracing Design ..........cccccccceccsesstessesesseseveaseenes .47 3.5 Root Causes . ee ce esse ceeeseeccse ceesntaneeneees 48 4.0 4.2 4.3 PHOSGENE RELEASE JANUARY 23 2010 .... Background Background .... 4.1.1 Phosgene .. 4.1.2 Phosgenc Stainless Steel Hose Transfer Operation 4.1.3 Phosgene Highly Toxic Material Guardian Committcc * Incident Descr ccci ceesep ececcest eeerenssi eneeneno ensernen reenies 4.2.1 Community Impact 0... ccc scncnceteneeeeereesneeseneeneeeseasesenesesssasaseanepecerecensiesceeeataeneees Incident Analysis 0... cece .60 cee 4.3.1 4.3.2 Hose Failure Analysis ..t. enses teen . . 6 . 0 Effect of Plastic Adhesive Tape 4.3.3 4.3.4 4.3.5 4.3.6 Hose Degradation eects Issu cersesesasc sesesceneeves nsneareesee Hose Change Frequency ........ ce eee rene ccesenecneresseeenesseesneseesersesenss SAP Work Process ..... Near Phosgene Incident ..... 4.3.7 Mechanical Integrity oo... cece cee ecceseeeseeeeaeeeeneseeneeteees 4.3.8 Flex Hose Materials of Construction 0.2.0.0... cc cece ecsecee nes eseeceteassesesecn eases seeseeneateeas 4.3.8 routine Job Planning . cece eeere tere nee cere neceeeeeeenenenssseeeseetenetseeetarieaetenees Process Hazard Analysis Analysis ccceecssecccecseeneseseencseeneeresrsnsccsessacesesnesessaneesenssseeeranconenseneeeaseneacons 4.6 4.7 4.8 . 4.5.1 4.5.2 Unit Second PSM Audit cece cecene rece seeeeessssannese revere enertcniseesseseseaneenenes 2006 Phosgene Committee Audit 00. ccc ccc ce eseceeseerteeresesnerannenteets 79 Standards and Guid.e.lci ccnce c s cecscenseenee .80 .80 Key FindingsFind ene eenesseus sci sesesresecessaacn sanessenerensageg ngnanecsansausnas esentaesgnesiens 86 Root Causes ....cccccccccccccccsececcecccaceusccetescceseceusevecensaescenssaususuaesesenseccseuesasssacecaetecseecuieessererse:seaseceaeennes 87 111 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment .July 2011 .88 5.0.1 Additional DuPont Inci teend se ee rerene ene tenn nen s vencaesnt ease sees s cee .90 .90 Management Systems oo... tcc ceeecsirsesieseeeneneseescencerenseneneersentcnsatineseeussenenecessiserceneasncsseinirsne .91 5.I.l Knowledge Management ... ec eseeceteseeeserseeteeeeenneteeenersoees .91 5.1.2 Hierarchy of Controls oo... cee eee .93 .93 ese neces 6.0 6.1 6.2 6.3 7.0 .97 Occupational Safety and Health Administration OSHA .97 6.1.1 6.1.2 Process Safety Management Program ...........ccccc eee eect tctenene creer anaes eeeietateeesarsetescaeren 97 Compressed Gases eccccereesssssceseecesseenesnscaseneeeneaesnissecessnececenssrnenesersseeninanersensnageag 99 6.1.3 Inspection History .... .... 100 Environmental Protection Agency . cee ceceiesesseee tenes cesses renee ee renee tieieniese esses caeenen sees 101 State Hazardous Chemical Release Prevention Prosg sc cr seceeseenea neeetreeem eeteerens 103 105 REFERENCES REFERENCES 113 APPENDIX A THREE EVENT LOGIC TREE 115 APPENDIX B HISTORICAL AND EVENT TIMELINE cecccecseersereer erences 120 .. 121 124 APPENDIX E HAZARD ANALYSIS FOR PHOSGENE USE AT BELLE 130 eee APPENDIX F HARD PIPE TO FLEXIBLE HOSE TRANSITION CORRESPONDENCE 130 APPENDIX G PHA RECOMMENDATION DELAY LETTER . iv STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 List of Figures Figure 1. DuPont Belle WV facility on the Kanawha River EPA 197 enti3 ett 19 Figure 2. Simplified thermal oxidizer and rupture disc block flow diagram cece cea ceeceeceeenecnesenetreseesret entrees Figure 3. inch NPS drain pipe and rupture disc 0... eee esesees ese ceneesenerntenerteencenneceees 24 Figure 4. Rupture disc piping and vent pipeline to atmosphere on roof . .... 27 Figure 5. Rupture disc burst sensor incident 29 Figure 6. New rupture .31 disc occ .31 Figure 7. Process data showing sudden pressure decrease when rupture disc burst eee .. 36 Figure 8. Photo of the position of the inch sample line which had not yet been replaced Figure 9. The pitting phenomena observed in the small initial hole of the oleum sample line wall 42 Figure 10. The large hole eroded from the outside on the oleum sample line 43 eee Figure 11. Photo showing the orientation ofthe small hole to the main hole ccc eeeneeeeenee 44 Figure 12. Phosgene shed and full F and empty MT cylinder locations on day of incident to esc not scale ees 50 tes eessessucesscessouessesniqsiietsenieerecsessnesneseeesvecsesesecsacesenuicanctancaeeeetaetestsy betters Figure 13. SafeAir Phosgene Dosimeter Badge 54 Figure 14. The distinct effect of the clear plastic adhesive tag on the corrosion of the stainless steel overbraid ... ......62 Figure 15. Damaged hillside phosgene hose removed from phosgene cylinder The plastic adhesive tag that covered the damaged section fell off during the hose decontamination procedure .66 Figure 16. Flex hose comparison photographs top to bottom ruptured riverside hose flow restricted hillside hose a new hose with attached ID tag cceueersisetaveviteusitseitisavassisiemasreiievenaseititiecseseseeseees 71 Figure 17. Hierarchy of Controls .......... 93 Figure 18. The hose and piping system that supplicd phosgene for the release oo. eee eeees eects 124 Figure 19. ALOHA estimate of phosgenc concentrations with MARPLOT GIS overlay .scccecseceeseeeeese 128 List of Tables Table 1. Previous rupture disc events in the F3455 unit cece eee eente ieee 3333 Table2. Phosgene hose change frequency oo... sreseseess seen 64 sees ertennecnanrcenneeneertencereccanctensreteeceesctinaas Table 3. Flexible hoses for phosgenc service as listed in the DuPont P3H Standard Flexible Chemical Hose for Highly Toxic Services68 Table 4. Preliminary Risk Assessment by DuPont Engineering 1988 Appendix E ..... 75 Table 5. PHA enclosure recommendation delays timeline ........... cc ee teen esee tet tneneea settee 78 Table 6. Sum of Belle plant retirements and new hires from 2005 to 2009 .92 .92 Table 7. DuPont Belle covered chemicals and threshold quantities vccceustitssasiesesesesneesieeeseesecesseeess 102 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 List of Acronyms and Abbreviations ACC ALOHA CFR | C CMMS CO CSB DCS DMA DMS ECF FRC EPA GIS H~ I KCEAA KPEPC LDAR MM MOC NDE NIMS NIOSH NOAA NPS OSHA OTPT PHA ppm psig PSM PTFE American Chemistry Council Area Locations of Hazardous Atmospheres Code of Federal Regulations Chlorine Computerized Maintenance Management System Carbon Monoxide U.S. Chemical Safety and Hazard Investigation Board distributed control system dimethylaminc dimethylaminc dimethylsulfate dimethylsulfate ethyl chloroformate flame resistant clothing U.S. Environmental Protection Agency Graphical Information System hydrochloric acid Kanawha County Emergency Ambulance Authority Kanawha County Emergency Planning Committee Leak Detection and Repair million old notation style Management of Change destructive examination National Incident Management System National Institute for Occupational Safety and Health National Oceanic and Atmospheric Administration nominal pipe size U.S. Department of Labor Occupational Safety and Health Administration Oleum Tower Pump Tank Process Hazard Analysis parts per million pound per square inch gauge OSHA Process Safety Management Standard 29 CFR 1910.119 polytetrafluoroethyplolyteetraflnuoroetehylene E. STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 RMP RQ SAP SAR SCBA SLM SOPS TQ VOC Risk Management Plan reportable quantity System Application & Products Spent Acid Recovery Unit contained breathing apparatus Small Lots Manufacturing Unit Standard Operating Procedures threshold quantity weighted average volatile organic compounds vii STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Draft Report for Public Comment July 2011 Executive Summary On January 22 and 23 2010 three separate incidents at the DuPont plant in Belle WV involving releases of methyl chloride oleum and phosgene triggered notification of outside emergency response agencies The incident involving the release of phosgene gas led to the fatal exposure of a worker performing routine duties in an area where phosgene cylinders were stored and used Operators discovered the first incident the release of methyl chloride the morning of January 22 2010 when an alarm sounded on the plant's distributed control system monitor They confirmed that a release had occurred and that methyl chloride was venting to the atmosphere Managers assessing the release . estimated that more than 2,000 pounds of methyl chloride might have been released over the preceding 5 days The oleum release the second incident occurred on the morning of January 23 2010. Workers discovered a leak in an overhead oleum sample pipe that was allowing a fuming cloud of oleum to escape to the atmosphere The plant fire brigade was called and after donning the appropriate personal protective equipment closed a valve that stopped the leak about an hour after it was discovered No injuries occurred but the plant called the Belle Volunteer Fire Department to assist The third incident a phosgene releasc occurred later that same day when a hosc used to transfer phosgene from a ton cylinder to a process catastrophically failed and sprayed a worker in the face while checking exposed he was the weight of the phosgene cylinder The employee who was alone when was assisted by workers who immediately responded to his call for help Initial assessments by the plant's occupational health nurse indicated that the worker showed no symptoms of exposure prior to transport to the hospital for observation and treatment A delayed onset of symptoms consistent with information in phosgene exposure literature occurred after his arrival at the hospital and his condition deteriorated over the next day He died from his exposure the next night STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. = Draft Report for Public Comment July 2011 Communication related to emergency notification and response was an issue in two of the incidents and was addressed in conducting the investigation At the request of the Board the U.S. Chemical Safety and Hazard Investigation Board CSB investigation team examined all three incidents at Belle due to the severity and potential for even greater consequences and to examine how and why they could occur at a DuPont facility DuPont retains stature as an industry leader in the advancement of health and safety practices and develops sound respected and widely used safe practice guidance With such a reputation the CSB was interested in examining the conditions at the Belle facility that led to a declinc in adherence to the higher standard of performance that the corporation historically held The CSB incident investigation determined root and contributing causes for each of the three incidents An overall analysis revealed common deficiencics in the following management systems e Maintenance and inspections e Alarm recognition and management Incident investigation e Emergency response and communications fi Hazard recognition The CSB found that each incident was preceded by an event or multiple events that triggered internal incident investigations by DuPont which investigated all of these precursor events and issued recommendations and corrective actions Despite investigating these preceding events the recommendations and corrective actions did not prevent the occurrence of similar events Because of recent changes to the Kanawha County Metro 9-1-1 response policies and procedures that could lead to delays in treatment for future incidents the CSB investigators also examined concerns STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. _Draft Report for Public Comment July 2011 raised by the emergency response organizations These concerns included the timeliness and quality of information provided to dispatchers and EMS personnel who responded to two of the incidents and mirrored issues identified in the CSB Bayer CropScience August 2008 incident investigation ' The CSB identified the following root causes Methyl Chloride Incident January 22 2010 5:02 AM DuPont management following their Management of Change process approved a design for the rupture disc alarm system that lacked sufficient reliability to advise operators of a flammable methyl chloride release Oleum Release Incident January 23 2010 7:40 AM Corrosion under the insulation caused a small leak in the oleum pipe Phosgene Incident January 23 2010 1:45 PM DuPont's phosgenc hazard awareness program was deficient in ensuring that operating personnel ~ were aware of the hazards associated with trapping liquid phosgene in transfer hoses DuPont relied on a maintenance software program that was subject to changes without authorization or review and did not automatically initiate a change of phosgene hoses at the prescribed interval nor did they provide a back process to ensure timely change of aging hoscs DuPont Belle's miss reporting process was not rigorous enough to ensure that the near failure of a similar phosgene transfer hose just hours prior to the exposure incident would be immediately brought to the attention of plant supervisors and managers . 2008-1 Bayer CropScience 10 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. D_raft Report for Public Comment July 2011 e DuPont lacked a dedicated telephone system and emergency notification process to convey the nature of an emergency at the Belle plant thereby restricting the ability of personnel to provide timely and quality information to emergency responders The CSB makes recommendations to ie Occupational Safety and Health Administration OSHA e DuPont Belle WV plant E.J. DuPont de Nemours & Co. Inc. e Compressed Gas Association of America CGA e American Chemistry Council ACC Phosgene Pancl 11 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 1.0 Introduction 1.1 Background At 5:02 a.m. on Friday January 22 2010 a release of methyl chloride activated an alarm in the F3455 unit control room signaling the first of three incidents that would occur over the next 33 hours at the DuPont Belle WV facility No injuries were associated with this incident but the release went undetected for as long as 5 days DuPont estimates that more than 2,000 pounds of methyl chloride released to the atmosphere At 7:55 a.m. on Saturday January 23 2010 a contractor reported seeing a fuming plume on a inch diameter sample pipe in the Spent Acid Recovery SAR unit Operations personnel confirmed that oleum was leaking thus a fumc alert was activated for the entire Belle plant Plant fire brigade members responded to the release and closed valves that stopped the leak at about 8:26 a.m. after which the all clear was sounded The third incident occurred just 6 hours later At approximately 1:45 p.m. an operator walked into the phosgene cylinder storage area in the Small Lots Manufacturing unit and was sprayed in the face and upper torso with phosgene a when flexible hose suddenly ruptured The worker called for assistance and immediately went to his aid His personal dosimeter indicated that he had been exposed to a significant dose of phosgene but he did not exhibit immediate signs of breathing problems About 3 hours after arriving at the hospital his condition deteriorated and he died the following night No injuries occurred as a result of the first two releases but communication to Metro 9-1-1 dispatchers regarding the nature of the each relcscon Saturday became an issue incident CSB investigators examined how information related to the incidents was conveyed to Metro 9-1-1 dispatchers The CSB also interviewed Kanawha County Ambulance Authority KCEAA Kanawha Emergency Planning Committee KPEPC and Metro 9-1-1 representatives to assess each incident and determine if STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 actions could be taken to improve communication methods to prevent recurrence of the issues brought to the attention of county officials During the Saturday afternoon call for assistance from DuPont Metro 9- 1-1 dispatchers were not provided with sufficient information regarding the nature of the emergency and the chemicals involved to adequately inform the responding EMS personnel Many of those interviewed were familiar with the role of the CSB having participated in conferences and interviews as part of the CSBs investigation of the August 2008 Bayer CropScience incident in attempts to address similar emergency response and notification issues . Because of recurring communication problems associated with emergency responses to chemical plants in the Kanawha Valley responding medical units have established a practice of not immediately going onto a property that has called for assistance Instead EMS personnel respond to a staging area as far as a mile away where they remain until they receive more detailed information regarding regarding the material involved and whether the victim has been or will need to be decontaminated prior to transport to a hospital This practice was developed by the emergency response organizations duc to information that was sometimes so imprecise that EMS personnel could not ensure that they or their equipment would not be contaminated by a hazardous chemical as a result of transporting an exposed victim In examining the activities of employees involved in the response the CSB learned that two other DuPont employecs were also possibly exposed to phosgene One coworker noticed that his dosimeter was discolored indicating exposure after he transported the victim part of the way to the plant medical center in a company truck He transferred the victim to the care of a supervisor who completed the trip to the medical center with the victim The second exposure occurred when a worker unaware of the phosgene relcasc went into the area of the phosgene shed and noticed an odor that he had never smelled before Unsure of what the odor was he left the arca and joined his workers in the control room STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 1.2 Investigative Process The CSB began monitoring and continued to track information related to the chemical release incidents at the DuPont Belle WV facility that were reported to the media and the National Response Center NRC throughout the weckend of January 22 and 23 2010. On January 25 2010 the CSB board deployed an investigation team Because of the number and potential for more severe consequences at the DuPont Bellc plant over this day period the CSB launched an investigation determine the root and contributing causes and to issue recommendations to help prevent similar occurrences Although the consequences of the first two incidents were not as severe as the third the CSB decided that since the three incidents occurred in less than 2 days including one that led to a fatality all three would be investigated to determinc any common causes The investigative team arrived at the Belle Plant on January 26 2010 and met with Occupational Safety and Health Administration OSHA inspectors U.S. Environmental Protection Agency EPA officials and DuPont representatives to explain the CSBs authority and purpose for conducting the investigation The CSB investigation team remained onsite for 2 weeks and made subsequent visits to Belle conduct independent investigations of each of the three DuPont Belle WV facility incidents During its investigations CSB investigators e Interviewed plant personnel emergency responders plant supervisors and managers and corporate personnel * Coordinated the examination removal and storage of physical evidence Requested and reviewed relevant documentation e Reviewed technical and industry guidance standards and regulations e Discussed emergency response issues with the Kanawha Emergency Planning Committee KPEPC Kanawha County Emergency Ambulance Authority KCEAA and Metro 9-1-1 dispatch center officials 14 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 Entered into joint testing protocol agreements with DuPont OSHA and the EPA ' Obscrved metallurgical testing of the oleum sample line e Observed metallurgical testing of the phosgene stainless steel overbraid hose and ' Observed analytical testing and analysis of the polytetrafluoroethylene PTFE inner core of the transfer hoses involved in the phosgene release 1.3 E.I. DuPont de Nemours & Co. Inc. 1.3.1 Company History E.1 DuPont de Nemours and Company named after its French founder Eleuth^reIr^'n^'deu Pont was established in 1802 as a gunpowder manufacturing company on the Brandywine River in Wilmington DE DuPont grew as a manufacturer of gunpowder and explosives in the United States and a century later in 1902 transitioned into a science chemical company DuPont established Experimental Station the first industrial laboratory where researchers and scientists began work on nitrocellulose chemistry and smokeless powders to improve military rifles for the World War 1 effort By the 1920s DuPont purchased several chemical companies and focused on polymers which led to the discovery of neoprene synthetic rubbers polyester and nylon by 1935. Many of these products were in demand during the Second World War Further work with plastics and fibers led to the development of Teflon Lucite Nomex and Mylar in the 1950s DuPont also introduced a number of inorganic insecticides and fungicides such as Lannate methomyl and Telvarfiwhich eventually led to the establishment of its agricultural products business By the 1980s DuPont had grown to almost 100 major businesses selling a wide range of materials such as textiles agricultural chemicals pctrocumand biomedical products 1.3.2 DuPont Business Areas and Corporate Management DuPont headquartered in Wilmington DE has 58,000 employees in more than 80 countries The company offers a broad range of products for industry and consumer use including pesticides STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. D_ raft Report for Public Comment July 2011 electronics apparel and biomedical supplies Five business platforms comprise the DuPont organization Agriculture and Nutrition Coatings and Color Technologies Performance Materials Electronics and Communications and Safety and Protection Within each business platform are strategic business areas focusing on the production sale and distribution of products and services related to each marketing area The Crop Protection business arca a segment of the Agriculture and Nutrition platform is responsible for the development manufacture and sale offungicides herbicides insecticides and seed treatments globally The agriculture industry uses DuPont Crop Protection products on a variety of crops worldwide including cotton soybeans fruits and vegetables The F3455 and Small Lots Manufacturing SLM units at the Bcllc Plant manufacture intermediate chemicals for their Crop Protection products In 2009 the Agriculture and Nutrition platform had the most sales of any business arca at 8.3 billion A member Board of Directors including the chairperson and CEO manage DuPont Executive committees made up of board members and representatives from DuPont businesses oversee areas such as environmental policy corporate governance strategic direction and auditing In 2010 DuPont had global sales of 31.5 billion and ranked as the largest chemical company in profits and second in revenues in the world 1.3.3 Safety at DuPont | Concern for safety and health at DuPont became a part of the company's structure in 1805 due to the hazards of gunpowder and explosives production The early corporate safety program was rooted in process safety concepts more than a century before governing safety regulations existed Practices such as 2 Pioneer bred Crop Protection Nutrition and Jealth Electronics and Communications Performance Coatings Performance Polymers Protection Technologies Building Innovations Sustainable Solutions Chemicals and Fluoroproducts Titanium Technologies and Applied Biosciences 16 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 safe siting of buildings explosion venting concepts incident investigation processes and emergency response were implemented in the DuPont gunpowder mills throughout the 19th century The company continued to focus on health and safety to improve safety performance and in 1915 created the company's first corporate safety division which was responsible for technical training safety inspections project design reviews and the purchase of safety equipment According to DuPont incident records the safety division participation in facility operations decreased incident rates throughout the company As a result individual sites established specific safety groups in the 1930s Hazard elimination was recognized as a priority above education and personal protection Klein 2009 1.3.3.1 Early Process Safety Program The release of highly toxic methyl isocyanate MIC at the Union Carbide Corp. in Bhopal India resulted in nearly 3,800 immediate deaths and 16,000 are estimated to have since died as a result of exposure while in excess of 100,000 still report associated illnesses In response to the Union Carbide incident chemical companies industry associations and government agencies directed efforts to decrease process safety risks which eventually led to the establishment of the OSHA Process Safety Management PSM Standard 29 CFR 1910.119 and the creation of the CSB as part of the Clean Air Act amendment of 1990 Prior to establishing the OSHA PSM Standard DuPont was practicing many process safety concepts at its facilities as part of the DuPont Process Hazards Management PHM Program After a serious 1965 incident in Louisville KY caused 12 fatalitics the company directed all sites to perform hazard reviews to evaluate the safety of site processes which eventually became a corporate Process Hazards Review PHR program The PHR was intended to prevent serious process incidents and cach site handling hazardous substances had to have a PHM program The Bhopal incident contributed to an increase in DuPont's focus on process hazards management particularly in the manufacture of MIC DuPont developed an inherently safer method of manufacturing 17 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 and handling MIC that eliminated MIC bulk storage as it relied on producing and directly consuming MIC The company also created the Highly Toxic Materials HTM Subcommittee to review the global management of toxic chemicals In 1985 HTM became a corporate guideline and a separate subcommittee was established to focus on cach of the 15 highly hazardous materials identified within the company DuPont continued to refine its PHM program eventually developing professional guidance for process safety and OSHA PSM rulemaking Mottle et al 1995 1.3.3.2 Zero Incident Goal DuPont introduced the zero incident goal in the early 1900s as a management directive to drive injury rates down to zero through continuous improvement of safety practices The zero concept became a corc strategy as the company grew and accepted the philosophy that all injuries occupational illnesses and environmental incidents were deemed preventable and that the goal for all was zero DuPont became recognized throughout industry as a safety innovator and leader The company offers services as a safety resource for other corporations to evaluate and improve workplace safety which include methodologics and technical training to manage and improve employee and contractor health and safety performance as well as process safety improvements 18 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 1.4 DuPont Belle Plant Figure 1. DuPont Belle WV facility on the Kanawha River EPA 1973 The DuPont Belle plant is located in Belle WV about 8 miles east of Charleston the state capital The plant occupies about 723 acres along the Kanawha River and sits in an industrial commercial and residential use arca The plant was established in the West Virginia coal country as part of a World WarI effort to produce ammonia In the carly 1920s DuPont spent 27 millionon a highly complex production facility with atmospheric compressors capable of producing 25 tons of ammonia per day Belle's pressure ammonia technology yielded a host of collateral benefits Methanol was initially manufactured on a small scale and then rapidly expanded to 1 million gallons a year By 1935. Belle had 3 Equivalent to 332 million in 2010 according to the Bureau of Labor Statistics Inflation Calculator 19 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours Co. _ Draft Report for Public Comment July 2011 become DuPont's largest facility with more than 80 different chemical products which included the first synthetic urca used in fertilizers and plastics In 1939 DuPont began producing nylon chemical . intermediates at Belle and by 1944 the plant was producing 30 million pounds of synthetic polymers polymers per new ycar Expansion of nitrogen and nylon intermediate production at Belle continued after the war and product lines were introduced regularly In 1969 Belle began producing the fungicide Benlate Currently the DuPont Belle Plant produces a variety of organic chemicals and agricultural intermediates and products According to company documents the plant had the best safety record of any DuPont production facility prior to the incidents of January 22 and 23.9 In January 2010 the DuPont Belle Plant employed approximately 440 and had seven primary operating divisions occupying a acre manufacturing area nearly 1 mile long The operated SAR unit is owned by Lucite International and operated by DuPont employees The Belle facility is also the site of the newly constructed Kureha unit owned by the Kureha Corp. of Japan which is operated by Kureha employees on DuPont's Belle site The Kureha production unit uses glycolic acid produced by DuPont as a feedstock for polyglycolic acid a specialty plastic The DuPont Belle plant holds a Resource Conservation and Recovery Act RCRA Part B Treatment and Storage Permit for onsite handling of waste materials in addition to a permitted drum storage facility onsite The Belle plant participates in a Community Action Council CAC aimed at addressing citizen concerns regarding site safety health and environmental performance The council is comprised of citizens from neighboring communities and representatives from the industrial facilities in the region A www.2.dupont.com/heritage S DuPont Belle Plant Information Sheet 20 STAFF DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD - _ E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 2.0 Methyl Chloride Release January 22 2010 2.1 Background The Belle plant's F3455 unit manufactures the intermediate F3455 a chemical that is shipped to another DuPont facility to make the herbicide Velpar Due to the exothermic reaction in the first reactor dissolved methyl chloride vaporizes and normally exits through the reactor vent line along with carbon dioxide nitrogen and trace amounts of dimethylamine DMA vapor through a process scrubber and then to a thermal oxidizer for emission control To protect against damage to the scrubber if excessive a pressures occur a piping connection upstream of the vent line is routed to rupture disc that will burst- and allow for venting outside on the roof of the building which occupies two reactors Figure 2 However due to a lack of safety considerations during installation a inch weep hole was placed on the vent line inside the building As a result dangerous chemicals vent inside the building if the rupture disk bursts Unaware that the rupture disc had blown during a nitrogen purge activity before the reactor startup plant personnel proceeded with the normal production run For nearly 5 days methyl chloride vapor passed through the blown rupture disc and escapedinto the operation building and outside atmosphere On the fifth day the methyl chloride vapors interfered with the chemical sensor configured to detect ethyl chloroformate ECF which alerted the workers 6 A thermal oxidizeris a process unit for air pollution controlin many chemical plants that decomposes hazardous gases at a high temperature and releases them into the atmosphere In process vent lines that lead to the atmosphere protection must be installed to prevent prevent ambient moisture -- from rain or other elements -- from collecting within the vent line One such protection is a weep hole whichis a small hole drilled into a vent line that allows drainage 21 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. E.I. DuPont Nemours & Co. _ Draft Report for Public Comment July 2011 at 7 Vent to Atmosphere on Roof Weep Hole on 3 Floor I Rupture disk set at 15 psig pone To Thermal Oxidizer af Buikfing + ~ Scrubber RX +1 vk et RX 2 ? Lf ; To Treatment System Tank Car Figure 2. Simplified oxidizer and rupture disc block flow diagram 2.1.1 Methyl Chloride Methyl chloride also called chloromethane or monochloromethane is a colorless gas with a faint sweet odor at low concentrations The odor may not be noticeable and cannot be relied upon as warning of concentrations that are dangerous to health Methyl chloride is extremely flammable has a potent 8 The odor threshold or concentration of methyl chloride detectible by most humans varies between 10 and 250 ; ppm http://www.oxy.com/Our http://www.oxy.com/Ourhttp://www.oxy.com/Our Documents chloride 20Chloride 20Handbook 20Handbook .pdf 11/2009 22 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.1 DuPont de Nemours & Co. TO Draft Report for Public Comment July 2011 narcotic effect similar to trichloromethanc also known as chloroform and is listed as a Group 3 carcinogen by the International Agency for Research on Cancer IARC The OSHA hour time- weighted average TWA concentration is 100 ppm and the National Institute of Occupational Safety and Health -designated Immediately Dangerous to Life and Health IDLH concentration is 2,000 ppm Symptoms of methyl chloride exposure include dizziness confusion and nausea and at higher concentrations extreme nervousness trembling and possible loss consciousness High concentrations or long exposure time can be fatal The gas is also heavier than air and therefore settles close to the ground 2.2 Incident Description The F3455 process was in the first series of batch runs following an extended maintenance outage from September 12 2009 through January 17 2010. The release is thought to have initiated on January 17 during the first batch run in the unit and continued until discovered on January 22 the release rate may have been sporadic throughout this period On January 22 2010 an air monitor alarm on the process control monitor alerted plant operating personnel of a chemical release while they were adding DMA to the reactor The sensor for this alarm located on the third floor of the F3455 building is calibrated to activate when it detects ECF at 0.5 ppm | The methyl chloride vapors interfered with the ECF sensors on the third floor and activated the alarm The distributed control system DCS recorded the alarm at 5:02 a.m. and responding operators saw a 10 Substances the IARC lists as Group 3 carcinogens are mixtures or agents for which evidence of carcinogenicity in humans is inadequate and limited in experimental animals 11 Dimethylamine DMA is a toxic and extremely flammable colorless product with a fishy or ammonia odor DMA attacks the respiratory system and irritates eyes and skin and at higher concentrations can cause pulmonary cdema The OSHA hour TWA is 10 ppm and the NIOSH IDLH is 500 ppm Humans can deteci DMA odors at 0.34 ppm Sittig 2008 DMA is a heavier than air vapor and settles close the ground 23 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. TO Draft Report for Public Comment July 2011 diffused fog and liquid puddle near a inch nominal pipe size NPS drain pipe referred to as a weep hole Figure 3 This connection was associated with a thermal oxidizer vent stack which vents to the atmosphere on the roof of the building under normal operation Operators notified the board operator 5:19 a.m. when they found the source of the release Figure 3. inch NPS drain pipe and rupture disc 2.2.1 The ECF ECF Sensor Alarm sensor was chlorine detecting not ECF The ECF sensor is responsive to chemicals composed of chlorine i.e. chloroformate ECF and chloride On the fifth day the chlorides present in the relcase were of sufficient concentration near the ECF sensor to activate the alarm 2.2.2 Odor Detection Considerations The methyl chloride DMA and HCl mixture is extremely odorous however due to the nature of the F3455 process operating personnel would have had to be in the area of the inch weep hole at the time of the releasc to see or smell the leak 24 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 Methyl chloride libcrated during this phase of the reaction would have likely taken the normal route to the thermal oxidizer piping where it would have been consumed and vented to the atmosphere unnoticed vent releases products of the reaction into the room only if the pressure inside the pipe is greater than the pressure in the room The rupture disc piping was routed to the atmosphere above the roof of the building which would have provided an outlet path for the methyl chloride vapor where it would have dissipated and dispersed without notice - The day before the leak was discovered a crew performed a leak detection and repair LDAR inspection on the third floor of the building near the location of the releasc The volatile organic compounds VOC electronic monitor was calibrated to detect methyl chloride ECF DMA and methanol Although an area within 12 inches of the weep hole for the rupture disc was checked for leaks with the device it did not detect any VOCs 2.2.3 Incident Response In response to the ECF alarm operators took a VOC analyzer to search for the source of the vapor and immediately smelled an offensive odor on the third floor of the building They observed steam fumes near the vent pipe and dripping liquid accumulating in a puddle on the floor both clear indications that the rupture disc had burst Figure 4 The operators left the process area ciosed all valves leading to the vent line and cooled the reactors to stop the process At about 9:30 a.m. maintenance mechanics replaced the rupture disc and burst sensor 12 The Clean Air Act requires refineries and chemical plants to develop and implement a LDAR program to control fugitive emissions Fugitive emissions occur from leaks on valves pumps compressors pressure relief valves flanges connectors and other piping components 25 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 After receiving confirmation of the release the board operator notified the process supervisor who then calculated the estimated duration and magnitude of the release After performing these calculations the | supervisor notified the plant manager the safety health and environmental SHE manager the area and the unit technology leader and advised them that the release may have been ongoing for the manager entire run of 9 batches which took place over 5 days DuPont estimated that approximately 2,000,, pounds of methyl chloride werc likely released the atmosphere During the initial phases of the DuPont incident investigation employees discovered that the burst sensor on the rupture disc had started alarming 5 days prior to the incident Due to its history of unreliability operators likely became desensitized to the alarm indicating that the rupture disk had burst This was the first incident in this sequence of events that led to a safety pause at the plant 13 DuPont in its final investigation report determined that 2,045 pounds of methyl chloride and 25 pounds of HCI released to the atmosphere as a result of this incident 14 A is a structured work stoppage that the plant manager initiates to engage the entire work force with safety pause awareness of hazards providing safety education and addressing past incidents A tshaefeotbyjpecatuisveeswaos f iinnictrieaatseidnagt the Belle facility on Saturday January 23 2010 because of the incidents at the F3455 and SAR Units 26 STAFF DRAFT " SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 Figure 4. Rupture disc piping and vent pipeline to atmosphere on roof 27 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Once it determined that the release quantity was in excess of the CERCLA reportable quantity RQ of 100 pounds,,scompliance with Comprehensive Environmental Response Compensation and Liability Act CERCLA of 1980 DuPont reported the release of methyl chloride to the NRC DuPont also reported the release to the WV State Department of Homeland Security Emergency Operations Center who then notified the U.S. Coast Guard Kanawha County Metro 9-1-1 was not informed of the release until 2:00 p.m. on January 22 2010 nine hours after discovery 2.2.4 Community Impact DuPont estimated that between January 17 and 22 2010 2,045 pounds of methyl chloride 25 pounds of hydrogen chloride and trace amounts of DMA released to the atmosphere through a vent line on the roof . of the F3455 building No monitoring information was available to determine the concentrations of chemicals released to the atmosphere through the vent line If monitoring information had been recorded a more accurate estimate of chemical concentration would have provided data related to when the release first started and the potential for site impact No workers at the facility reported any symptoms from methyl chloride or any of the other toxic chemicals either during or after the release DuPont did not receive any odor complaints from the community 2.3 Incident Analysis 2.3.1 Mechanical Integrity Rupture discs are overpressure protection devices used in processes operating above ambient pressure They are intended to prevent equipment damage including catastrophic failure Without them a process upset can cause unsafe levels of pressure in a system and cause an overpressure incident Since these devices activate only when a system has had an overpressure event it is imperative that their activation be 15 Under CERCLA operators of facilities and vessels are required to immediately report releases above the EPA RQ to the NRC 28 - STAFF DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 20112011 discovered In this application it releases hazardous chemicals to the atmosphere One approach to assist carly detection is to evaluate the alarm management process and where appropriate adjust process to parameters so that an alarm will activate prior to the disc actually bursting Another strategy is evaluate the process and eliminate the conditions that are causing the pressure to rise to levels that would cause the disc to burst Regardless once systems have been selected the configuration should be reviewed by a team including process cngineers control engineers and operations managers Lees 2005 Thin Plastic Membrane Figure 5. Rupture disc burst sensor incident DuPont Belle used a burst sensor intended to notify the board operator that the rupture disk Figure 5 activated A burst sensor is a thin plastic membrane with embedded wires installed on top of the rupture disc Small electrical current passes through the wires If the rupture disc activates it breaks the membrane and embedded wires and triggering the alarm The CSB learned that the rupture discs and sensors associated with this system were historically problematic The burst sensor involved in the January 22 2010 incident had been replaced many times 29 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. _ Draft Report for Public Comment July 2011 because it was not reliable Initially the sensor was operated sending signals to a remote receiver in the control room rather than to the process control monitor However operators found that the battery life on the sensor was short consequently they received frequent falsc or nuisance alarms According to Management of Change MOC documentation ... the burst sensor was in and out of alarm every 3 minutes When the batteries failed the transmitter sent an alarm to the remote receiver to notify the operators This device displayed the same alarm text as when the sensor detected a burst rupture disc Because the batteries nccded frequent replacing and because the operators had to wait for an electrician to change the batteries the false alarms became a nuisance Battery life however was not the only reported shortcoming of burst scnsors Operators told CSB investigators that burst scnsors were so delicate that they could sometimes tear during the installation and that liquid condensation on top of the sensors sometimes caused them to fail and trigger a false alarm An improved burst sensor indicator was installed on the DCS while the unit was down for maintenance just before the incident Operators indicated they were not retrained to respond to the more reliable burst sensor alarm and still considered it a nuisance 2.3.2 Design and Maintenance of Rupture Discs The rupture disc involved in the incident was a inch diameter graphite rupture disc designed to rupture at 15 psig and mounted in neoprene casing Figure 6 While the rupture disc is on a preventive maintenance PM schedule the annual frequency was so infrequent that the disc is only replaced when it . has activated or when it is removed for certain processes Operators told CSB investigators that once removed the rupture discs intact or compromised are thrown away and are replaced with new ones 30 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 Even without a burst sensor all overpressure protection devices including rupture discs should.bc routinely checked on an effective PM schedule as a layer of protection Figure 6. New rupture disc 2.3.3 Previous Incidents of Rupture Discs Bursting Since 2005 the rupture disc on the F3455 unit vent line had experienced nine recorded activations On April 11 2006 the rupture disc activated three times DuPont determined that the disc was most likely experiencing thermal or hydraulic shock Thermal shock would occur from boiling reactor vapor mixing 16 BS Safety Systems Inc Special Applications and Preventive Maintenance Catalog 77-1007 Section B. / STAFF DRAFT " SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. _Draft Report for Public Comment July 2011 with cool liquid on the disc due to its close proximity to the reactor hydraulic shock would occur from any sloshing in the line upstream of the disc This recurring problem was remedied by moving the rupture disc a greater distance away from these units and eventually to the third floor of the building toward the extreme end of the vent line An incident in May 2006 helps illustrate how the January 22 2010 relcasc could have gone undetected for 5 days On May 6 2006 a rupture disc activation went unnoticed for 48 hours Although operators complained about strong odors in the F3455 building they never considered the rupture disc as the source The operators and supervisory staff identified multiple locations where fugitive emissions could have been producing the offensive smell Eventually when a new batch of F3455 was started an operator near the vent line observed fuming by the rupture disc which indicated that it was the odor source Pipe blockage at the unit was the most commonly reported cause of a premature rupture disc activation as shown in Table 1. The F3455 process creates various solids in the vent and process lines which eventually block flow increasing the pressure in the system Once the blockage is melted by the process temperature or forced through the line due to the increased pressure the resulting pressure spike activates the rupture disc 32 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Previous Rupture Disc Incidents Date Cause 05/20/05 | Unknown 05/31/05 | Pressure Control Issues 04/11/06 | Hydraulic Shock,,7 05/06/06 | Blockage 06/16/06 | Unknown 05/30/07 | Ruptured during Water Cleaning 06/12/07 | Blockage 04/15/08 | Blockage 02/24/09 | Blockage Table 1. Previous rupture disc events in the F3455 unit 2.3.4 | Management of Technology and Subtle Change Within DuPont Management of Change MOC procedures are defined at a corporate level and adopted according to each site's procedures At the corporate level the PSM Standard defines two types of MOC technology MOC and subtle changes MOC is defined as a change in hazards of materials including the introduction of chemicals a change in equipment design basis or a change to the process design basis Subtle changes are defined as any change within the documented process technology that is not a replacement in kind The corporate PSM Standard gives subtle changes special attention when used in high hazard processes such as the F3455 and SLM units at the Belle facility The corporate PSM Standard states subtlc changes in the field can and have led to catastrophic events However even with this knowledge the MOC team at Belle incorrectly categorized the burst sensor installation as a subtle change 17 This incident was actually three incidents over a short period The rupture disc was discovered ruptured and replaced three times before the unit was shut down for further investigation 18 This incident went undiscovered for 48 hours 19 The corporate DuPont PSM Standard defines replacement in kind as the replacement of an instrument or electrical piping or other process equipment component with an identical part or an approved equivalent part that is specified by the applicable DuPont Engineering standard 33 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 At the Belle site the standard operating procedures SOPs do not distinguish between MOC subtle changes and MOC The MOC package documentation however shows that subtle often referred to as minor changes are not subjected to the same depth review as a MOC When the MOC is marked as a subtle change the level of safety review is at the discretion of the MOC team leader The MOC package that first installed the rupture disc burst sensor.was sensor.was marked as a subtle change and included a what if review that stated What if you get a false positive indication indicating failed disc but not actually failed Not a safety issue Shut down and investigate This type of review did not go deep enough to confirm that false positives could lead to a nuisance alarm A nuisance alarm can create risk by desensitizing operators to a hazard and be more detrimental than the absence of the alarm In the MOC section marked Reason for this Type of Safety Review the response by the MOC team leader was Minor Change The MOC package that converted the burst sensor from powered to a supplied power device was also marked as a subtle change Again the MOC team leader recorded in the documentation that a What If review was appropriate for the mentioned sic change The MOC did not address the operators battery related concerns for the burst sensor or how to train the board operator to no longer treat the burst sensor alarm as a positive Because MOC packages deemed subtle are not given the same level of review as MOC packages the subtle change MOC packages did not identify or prevent the potential causes of this incident 2.3.5 F3455 Unit Turnaround On June 6 2009 nearly 2 years after installing the battery operated transmitter DuPont attempted to climinate the false alarms caused by low batteries by wiring the transmitter to a standard electrical circuit The unit was shut down during a maintenance turnaround that lasted from September 12 2009 through January 17 2010 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 During the shutdown there was significant maintenance activity including work that by its nature triggered alarms but that did not require response from the operators because there were no live process streams that would initiate an actual alarm DCS data recorded during the shutdown indicated that the pressure in the reactor system increased slowly from December 18 2009 to December 20 2009 when it excccded the rupture disc rating Figure 7 The source of the pressure was a nitrogen valve on a level indicator that slowly leaked nitrogen into the system The rupture disc burst and the burst sensor triggered an alarm as it should have Under normal operating conditions the operators would have investigated to understand acknowledge and correct the alarm condition However extensive maintenance work was still underway in the unit thus the operators did not address the alarm as they would have under normal operation 20 The level instrument measures the difference between the pressure in the vapor space inside the top of the reactor and the pressure under the liquid at the bottom of the reactor Based on the pressure difference the control computer calculates the amount of liquid in the reactor The nitrogen provides a chemical barrier between the reactor liquid and the level instrument 35 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours Co. Draft Report for Public Comment July 2011 14 12 10 Presure a 0 12/18/09 12:00 : AM = 12/18/09 12:00 = 12/19/09 12:00 PM AM = 12/19/09 12:00 PM = 12/20/09 12:00 = 12/20/09 12:00 AM PM 12/21/09 12:00 AM = 12/21/09 12:00 PM . Time Figure 7. Process data showing sudden pressure decrease when rupture disc burst . The operators did not address the alarm when it triggered in December because they knew that work in the area would cause nuisance alarms however when the ECF alarm activated on January 22 2010 operators responded The board operator in the F3455 control room investigated and observed that the original alarm from December 21 2009 was still displayed as the first item on the alarm screen was not acknowledged because they had become accustomed to the operated transmitter causing the 21 nuisance alarm condition 21 Under normal operating conditions when an alarm point activates it will remain in an activated state until the alarm condition is cleared and acknowledged 36 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD ; E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 2.3.6 Second Process Safety Management Audit In 2007 an audit team of engineers and safety and health experts from other DuPont facilities conducted a day second audit22 of the Crop Protection business at Belle which included the F3455 and SLM units The member team audited the units against PSM focus areas such as subtle change pre- startup safety reviews PSSRs training process hazard analysis PHA mechanical integrity and during process technology While auditing the F3455 unit and a review of site and area management practices the team noted the many active alarms in the unit control room the control system is not engineered to eliminate alarms from idled and secure process equipment and as a result the contribution to nuisance alarms is unknown The audit team recommended that Belle evaluate the control system and develop an engineered solution to reduce the number of active alarms and establish a policy reflective of improvements to safely manage operations with active alarms During another review of SOPs and work site practices the team noted that the Crop Protection procedure for operating with active alarms did not effectively address alarm activations from idle equipment The current situation can lead to human factors errors such as failing to recognize an alarm and misidentifying misidentifying an alan~-mThe team recommended that Belle conduct an engineering evaluation to determine changes that could separate alarms on active processes from those associated with shutdown equipment so that operators could readily identify abnormal process conditions Both recommendations added to a corrective action tracking plan were completed in fourth quarter 2008 months beyond the original target completion dates Despite these recommendations F3455 unit personnel continued to restart the unit while the alarm was activated failing to recognize the impact of the burst sensor alarm 22 A second audit is an independent assessment of PSM systems performed against the requirements of the DuPorit corporate PSM standard 37 _ STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 2.4 1. Key Findings The rupture disc alarm system being monitored by a powered transmitter with batteries requiring almost monthly replacement was designated as criticalequipment by DuPont DuPont ran the equipment with an unreliable battery powered transmitter for 18 months before executing a MOC package to convert to a wired power supply Operators expected maintenance work to trigger alarms but planning and communication were insufficient to distinguish which alarms needed immediate attention during the turnaround and after work was completed Despite repeated incidents of rupture discs bursting DuPont did not adequately address the cause to prevent rccurrence The alarm from the transmitter did not distinguish between a condition that required immediate attention ruptured disc burst and a lower priority condition such as failed batteries Operators became desensitized to the rupture disc burst alarm on their computer screens 2.5 Root Causes DuPont's MOC process approved a design for the rupture disc alarm system that lacked sufficient reliability for minimizing the release of methyl chloride DuPont did not resolve the nuisance alarm condition in a timely manner despite various safety 2. reviews 23 critical is defined in DuPont SHE standards S21A and S24 A as components equipment or systems whose failure could cause allow or contribute to process incidents that result in death or serious injuries significant . property damage or significant environmental impact STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 3.0 Oleum Release January 23 2010 3.1 Background Lucite International owns the sulfuric acid recovery unit on DuPont's Belle plant property and DuPont employees operated the equipment The SAR unit produced oleum which is a solution of sulfur trioxide dissolved in sulfuric acid As the sulfuric acid is consumed the sulfur trioxide converts to sulfuric acid The process unit adjacent to the SAR unit used the oleum to produce methacrylic acid an ingredient for acrylic polymers and then returned the spent oleum to the SAR unit The SAR unit burned off the impurities from the spent oleum and used the remaining sulfur compounds to produce clean oleum As a result of an unrelated earlier inspection the U.S. EPA ordered the Belle facility to upgrade . emissions monitoring equipment or improve abatement capacity in the SAR Unit As part of a consent decree with the U.S. EPA issued on April 24 2009 Lucite International chose to permanently shut down the plant The complete and final shutdown of the SAR was concluded in March 2010 3.2 Incident Description On January 23 2010 at about 7:40 a.m. contract personnel working near the SAR unit saw an unusual cloud in the vicinity of the oleum tower and reported a fume release to the board operator The contractors estimated the release to be about midway along the length of inch diameter insulated pipe between the Oleumi Tower Pump Tank OTPT and a sample station Figure 8 The board operator asked the plant operator to go to the arca of the reported leak to determine the nature of the relcase The plant operator confirmed that a leak had developed on the sample piping between the OTPT and the sample station and alerted other workers in the vicinity to move to a safe area Based on the information the plant operator 39 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 provided at about 7:45 a.m. the board operator notified the main gate guard who then activated fume 24 alert to notify the facility of the release Figure 8. Photo of the position of the inch sample line which had not yet been replaced 21 Each plant in the facility has a determined unique number of rings that identify it in case of a release or emergency 40 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 A cloud of steam and sulfuric acid mist from this release is reported to have traveled in a westerly direction and dissipated in an adjacent operating unit A concrete dike surrounding the OTPT contained liquid from the leak There were no reports of exposure to any DuPont or contract employees or the public | 3.2.1 Incident Response When the plant activates a fume alert a klaxon bcll notifies plant personnel of the location of the incident This action also initiated a response by plant fire brigade personnel who went to the facility's fire station to obtain the plant fire engine and personal protective equipment PPE necessary to respond to the incident At about the same time the fume alert was sounded the gate guard called Metro 9-1-1 The shift supervisor radioed the gate guard to notify the Belle Volunteer Fire Department which then dispatched three engines to the plant Two of the engines staged outside the plant's gate while the third went into the plant to stand by if needed DuPont fire brigade members arrived at the site of the release and set up a water fog spray from the DuPont fire engine and an oscillating water spray from a nearby hydrant for about an hour After donning an acid suit and contained breathing apparatus SCBA one responder entered the arca and closed a valve which stopped the release at about 8:09 a.m. The gate guard sounded the all clear at about 8:27 a.m. Calculations estimate that 22 pounds of 20 percent oleum was released during the incident 25 20 percent oleum has an acid content that is 20 percent greater than pure sulfuric acid 41 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 3.3 Incident Analysis 3.3.1 Reconstructive Analysis . CSB investigators documented the analysis of the oleum sample line to determine the incident cause which was conducted by an independent metallurgical lab Caused by an unknown defect oleum corroded through a small scction of the pipe involved in the release on January 23 2010. Starting as a pitting phenomena and finishing slightly larger than a pin hole the corrosion penetrated the insulated stainless steel sample pipe Figure 9 Outside Figure 9. The pitting phenomena observed in the small initial hole of the oleum sample line wall Once oleum was present on the exterior of the oleum pipe it readily corroded the insulation and steam tracing line and then created a leak in the steam tracing causing the steam and oleum to mix This reaction created a strong solution of sulfuric acid that rapidly and effectively corroded the stainless steel sample line exterior until a second larger hole developed at a location near the original small leak The second hole clearly shows corrosion occurring from the outside Figure 10 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Figure 10. The large hole eroded from the outside on the oleum sample line When DuPont removed the soaked insulation and cover a large hole was visible the acid had also corroded a large amount of the steam tracing When the sample line was properly cleaned inspection revealed that the smaller hole was only a few inches away from the larger hole and after thorough examination metallurgists concluded that the small hole in the sample line initiated the oleum release Figure 11 26 Due to a delay in the decontamination of the oleum pipe for purposes of evidence preservation the size of the holes may have marginally increased from continued corrosion prior to examination 43 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 Figure 11. Photo showing the orientation of the small hole to the main hole 3.3.2 Pipe Testing and Analysis The oleum sample line was tested using gamma ray radiography ultrasonic thickness UT and metallographic analysis The metallographic analysis confirmed that the sample line was fabricated from 304L stainless steel one of the few metals approved by the DuPont Piping Standard for this oleum service The radiographic and UT testing showed that the pipe wall had suffered general thinning from corrosion which is expected in most piping applications involving corrosive materials The thinning rate can predict the service life of the pipe and in the case of pipes routing corrosive materials the expectation is that 44 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 roughly 1 to 2 mils will corrode per year UT testing and radiography revealed that general wall thinning of the sample linc was much less than the predicted 1 to 2 mils per year and showed much less thinning than expected for its lifetime This sample line had been in place for 19 years which is not unusual for this type of service Only one anomaly later deemed the initiator of this incident was found during the testing During visual inspection a small hole was discovered 90 off and a few inches from the large hole Under microscopic examination the shape of the small hole corrosion phenomenon could clearly be seen however its cxact cause is unknown One theory is that this small hole may have originated from some sort of manufacturing defect but the size and shape of the pitting phenomenon suggest that if this were a manufacturing defect the pitting would have occurred around the circumference of the pipe or along the longitudinal axis This particular phenomenon does not fall into any easily defined defects Due to the small size of this pitting it is unlikely that routine destruction examination NDE techniques would have identified this defect 3.3.3 Previous Incident Investigation On January 27 2009 almost a year to the day prior to the incident a leak developed in the Oleum Tower circulation piping Although the amount estimated to have been rclcased was greater than the January 23 2010 release 40 pounds vs. 22 pounds supervisors deemed the situation unnecessary for an emergency shutdown and activation of a fume alert 27 A mil is a unit of measure equal to thousandth of an inch i.e. 1/1000 in 45 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 The cmergency response for the 2009 incident was inconsistent with that taken in 2010. Unlike in 2010 in 2009 a hot line announcement informed plant personnel of the incident In the incident investigation report for the 2010 incident no mention is made of criteria that would provide guidance for the appropriate response or what distinguished the two events 3.3.4 PM Program Recommendation from 2009 Incident The internal DuPont investigation identified the following key factor in the 2009 incident Pipe in acid service tends to have very localized areas of corrosion that can be easily missed while performing thickness checks These areas are often the result of welds the heat affected area of welds and disruptions or turbulence in the acid flow Although DuPont realized that certain wall thinning in acid service could go undetected one recommendation from this investigation was to incorporate all piping in olcum service into a PM schedule however this recommendation was not completed prior to the January 2010 incident Moreover the sample line involved in the January 2010 incident was not included in the PM schedule An interview with one of the engineers responsible for arranging for this equipment to be included in the PM schedule revealed that the oversight occurred due to poor communication between DuPont and the contractors hired to perform the PM inspections 3.3.5 Mechanical Integrity The piping material 304L stainless steel is acceptable to carry this concentration of oleum The expected rate of wall thinning would project the lifetime of the pipe to be approximately 40 years and this pipe had 28 A hot line announcement involves notification to a determined list of operating and supervisory personnel who are all informed of an incident at the facility with one call 46 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 been in service for only 19 ycars While the pipe was within the design specifications DuPont failed to address the corrosion issues associated with acid service 3.3.6 Heat Tracing Design The oleum sample line is traced29 with a steam tracing line comprised of " copper tubing strapped to the outside of the sample line The steam in the copper tracing line heats the sample line to prevent the olcum inside from freezing Steam tracing however can create hot spots and often does not create even heat distribution throughout its length A preferred method to heat piping in oleum service is clectric tracing which can be easily controlled and prevents hot spots through even heat distribution Dillon 1997 As described in the Analysis Section steam tracing played a significant role in the failure of the sample piping Once the olcum escaped containment the copper tracing corroded away The oleum and steam then mixed and the resulting extremely corrosive sulfuric acid created the larger holc If an clectric tracing line had been used as DuPont suggests for these conditions the large hole would not have formed reducing the magnitude of this incident 3.4 Key Findings 1. An internal DuPont investigation report from a prior oleum leak recommended including all piping in a PM thickness monitoring program The CSB found no evidence that the piping in the January 23 2010 incident was included in the program 2. The general wall thinning rate estimate for the oleum service was conservative However highly localized corrosion attack cannot be predicted by this method 20 The protection of a liquid pipe against freezing by installing heat tubing or heating cable around or along the pipe 47 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 | 3.5 Root Causes 1. Corrosion caused a small leak in the oleum pipe under the insulation 4.0 Phosgene Release January 23 2010 4.1 Background 4.1.1 Phosgene Phosgene in liquid and gaseous forms is colorless and highly toxic and has a characteristic odor of freshly cut hay or grass with a boiling point of 8 C 47 F and is liquid in cold weather gas in warmer weather At room temperature phosgene is a dense gas that is heavier than air Phosgene is manufactured through the reaction of carbon monoxide and chlorine and is used widely in industry as a chemical intermediate for isocyanate insecticides polymers and pharmaceuticals Inhalation is the primary route of exposure to phosgene The OSHA hour TWA PEL for phosgene is 0.1 ppm the NIOSH IDLH concentration is 2 ppm The odor thresholdr,,anges between 0.4 and 1.0 ppm which is higher than the OSHA PEL therefore odor is not a reliable detection method for phosgene as injury may occur before the odor becomes prominent Phosgene gas may irritate skin and eyes upon contact at lower concentrations Liquid phosgene contact with skin can also cause severe chemical burns at higher doses 30 The NIOSH- and recommended TWA concentrations are also 0.1 ppm for phosgene 31 An odor threshold is the lowest airborne concentration that can be detected by a population of individuals The range of detection varies among individuals 48 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 Phosgene inhalation can result in two mechanisms of injury to the respiratory tract both of which can result in pulmonary edema at high concentrations Inhaled phosgene slowly undergoes hydrolysis and forms HCl which results in upper respiratory irritation and burning sensations cough and chest oppressions Symptoms may not appear until several hours after exposure Phosgene also reacts with proteins in the pulmonary bronchioles and alveoli disrupting the blood barrier in the lungs and resulting in increased lung fluid Pulmonary edema can be present in victims as long as 40 hours after exposure and may last days depending on the concentration and duration of the exposure 4.1.2 Phosgene Stainless Steel Hose Transfer Operation The Small Lots Manufacturing Unit SLM runs on a campaign basis and is divided into two processes the front end and back cnd The front end process makes five isocyanate intermediate products Phosgene used to produce the five intermediate products is fed to a process from ton cylinders stored in , the phosgene shed at the SLM unit The phosgene cylinder storage shed is a covered partially walled structure where the phosgene transfer and storage operations occur Figure 12 All equipment used for th^sepurposes is in or around the shed The shed contains no mechanical ventilation or exhaust systems | to control phosgene lcaks only natural ventilation flowing through the shed wall opening from the atmosphere 32 Pulmonary edema which occurs when fluid accumulates in the lungs leads to impaired gas exchange and may cause respiratory failure It is due to either failure of the heart to remove fluid from the lung circulation cardiogenic pulmonary edema or direct injury to the lung parenchyma noncardiogenic pulmonary edema 33 The front end of the SLM unit manufactures several types of isocyanate intermediates on a demand schedule 49 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 HILLSIDE INASSOND INASSOND . MONITOR MONITOR aareed 4lowes eet | |. PARTIAL CYLINDER - 0000 00 00000000 0000 0000 Expansion Akage e . _ | RIVERSIDE RIVERSIDE Figure 12. Phosgene shed and full F and empty MT cylinder locations on day of incident not to scale During normal operation two cylinders arc staged on weigh scales and each is connected to the process with two inch diameter by inch long PTFE 304 stainless steel overbraid hoses One hose transfers liquid phosgene to a stcam vaporizer and one provides psig nitrogen the cylinder The scales record the weight of the service cylinder and when the container is nearly empty an alarm notifics the board operator who then directs the plant opcrators to switch to a full cylinder This switch is completed by opening valves to the full cylinder and closing valves to the empty cylinder The hoses remain coupled in this operation and plant SOPs do not require enhanced PPE such as a fully encapsulated suit and breathing air Under normal operating conditions the process consumes two to three cylinders of phosgene per day 50 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. TO Draft Report for Public Comment July 2011 The SOPs do require operators to don encapsulated suit with supplied breathing air when they replace an empty cylinder with a full cylinder After clearing all phosgene from the stainless steel hose with a nitrogen purge under vacuum to a scrubber the hose is isolated from the vent piping and disconnected from the empty cylinder Operators then replace the empty cylinder on the scale a with full cylinder and connect the stainless steel hosc back to the new cylinder Maintenance mechanics replace stainless steel hoses in phosgene service when a work order is generated to change out the hoses The DuPont SOPs for the change frequency of the nitrogen and phosgene hoses directs replacement every 30 days Hose assemblies are fabricated by a number of manufacturers to DuPont's specifications for phosgene and nitrogen hoses and arrive assembled The hoses are stored in plastic bags in the maintenance shop Prior to connecting the hoses to the phosgene cylinders the maintenance mechanics install valves on either end of the hose Hoscs removed from scrvice are decontaminated in a water bath and then disposed _ 4.1.2.1 VanDeMark Chemical Inc. VanDeMark Chemical supplies phosgene to the Belle plant in ton cylinders VanDeMark located in Lockport NY is the only North American company that both produces and distributes phosgene They distribute phosgene and phosgene derivatives in ton cylinders Each VanDeMark cylinder is 87 percent full and contains 2,000 pounds of phosgene Each Department of Transportation cylinder has two valves with a seal plug screwed in the outlet covered by a flanged and gasketed bonnet to protect the valves and prevent leaks during transport The Belle plant receives phosgene cylinders via truck and 34 DuPont's former maintenance management process directed that hoses be changed every 2 months 51 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. _Draft Report for Public Comment July 2011 they are unloaded at the phosgene shed empty cylinders are loaded onto the truck and returned to VanDeMark 4.1.2.2 Use of Personal Protective Equipment PPE DuPont safety procedures include two levels of PPE required for work in the phosgene cylinder shed on the SLM unit based on the connection status of the phosgene cylinders When the phosgene cylinders are connected to the process and no breaks in the phosgene lines are occurring the standard required PPE for the SLM unit is a hard hat steel safety shoes safety glasses flame resistant clothing FRC and a ' phosgene indicator badge Work with this level of protection includes * entering the phosgene shed to check cylinder scale weights * opening and closing valves to switch from one cylinder to another and * operating the crane when loading and unloading full or empty cylinders in the phosgene shed The Belle Plant SOPs for disconnecting a phosgene cylinder require operators to wear a chemical suit gloves boots and hood with supplied breathing air in addition to the PPE listed above while performing the work During all phosgene cylinder line break operations another operator wearing standard PPE . stands outside the shed to monitor the breathing air supply of the operator performing the work At the time of the incident the employee fatally exposed to phosgene was wearing the standard PPE This met DuPont operating standards for the task he was performing because he was likely checking cylinder weights in preparation for switching to the partially filled riverside cylinder The Belle Plant PPE requirements and SLM unit procedures did not require him to don a chemical suit with supplied air during this activity 4.1.2.3 Phosgene Indicator Badge Belle Plant safety procedures require all personnel operators contractors managers and visitors in the SLM unit to sign a log sheet and obtain a phosgene indicator badge from the SLM control room prior to entry and to wear a phosgene indicator badge in their breathing zone Figure 13 Phosgene indicator STAFF - DRAFT SUBJECT TO CHANGE APPROVAL OR Report DISAPPROVAL E.I. DuPont de Nemours & Co. _ Draft for Public Comment BY THE BOARD July 2011 badges change color when exposed to phosgene and the color indicates the concentration 1 minute after exposure After 2 consecutive days of use personnel using badges must discard and replace their indicator badge to ensure accurate sensitivity Two types of phosgene indicator badges are available for use in the SLM unit For work tasks not involving supplied air personnel clip AirfiSystem phosgene badges Morphix Technologics to the collar or pocket of FRC near the breathing zone The badges change from white to pink or red to indicate dose concentration or duration of exposure In addition to badges the SafeAir system uses a color comparator wheel to detect exposure dose and the presence of phosgene between 0.9 and 100 min.36 35 The manufacturing specifications state that the maximum recommended sampling time for each badge is 3 days The Belle plant requires phosgene badges to be replaced after 2 days to ensure accurate detection and avoid discoloration or interference with other chemicals ppm exposure 36 Parts per million is is the concentration of a contaminantin air related to the through inhalation 48 ppm= 480 minutes of exposure at 0.1 ppm concentration time 53 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Figure 13. SafeAir Phosgene Dosimeter Badge37 For work tasks in the SLM unit requiring supplied air all personnel must wear a CheckAirfiphosgene badge inside the mask of their supplied air respirator The CheckAir detector Morphix Technologies detects exposure dose concentrations between 0.9 and 100 ppm The color comparator wheel for detecting exposure concentrations of the CheckAir CheckAir detectors differs from that of the SafeAir badges 4.1.2.4 Alarms The SLM unit has 12 phosgene sensors placed in and around it to continuously sample and record phosgene concentrations every 30 seconds concentrations of phosgene are detected via an electrochemical diffusion sensor within a range of 0.05 to 1 ppm One phosgene sensor is located in the phosgene shed six are in the SLM building and two are located outside the building Three sensors arc 37 The badge in Figure has a range of 0.5 to 450 ppm The SafeAir badge worn by the exposed employee had range of 0.9 to 100 ppm : STAFF - DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 on the fence line of the facility along the Kanawha River approximately 120 feet from the phosgene storage shed The analyzer readings are monitored by the DCS in the SLM control room and concentrations in excess of 0.05 set off audible and visual alarms at the board operator's operator's work stations Concentrations equal to or greater than 0.05 ppm set off a medium alarm and concentrations at or above 0.1 ppm set off a high- high alarm The CSB could find no evidence that audible or visual alarms were in service in the phosgene shed when the release occurred On the day of the incident the phosgene release activated alarms in the control room for 4 of the 12 analyzers in and around the SLM unit The phosgene analyzer in the shed recorded concentrations ranging from 0.04 to 1.0 ppm for approximately 50 minutes following the initial release Two of the three fence line monitors triggered alarms with the maximum recorded concentration of 0.27 ppm on a monitor located approximately 120 feet from the phosgene shed along the river Another monitor located on spill tank outside the SLM unit building also recorded a concentration of 0.04 around the time of the release All 12 phosgene analyzers chosen by DuPont have a maximum detectable concentration of 1 ppm The analyzers do not record actual values for concentrations in excess of 1 ppm therefore if phosgene concentrations exceeded the detection range at the analyzer sample point the values were only recorded as 1 ppm 4.1.3 Phosgene Highly Toxic Material Guardian Committee DuPont's Phosgene Highly Toxic Material Guardian Committee focuses on the safe management of phosgene at applicable DuPont facilitics DuPont has several guardian committees for HTMs used within the company Representatives known as phosgene guardians from all DuPont sites that produce or consume phosgene comprise the committee Managers from affected processcs corporate health and safety representatives engineers and industrial hygiene specialists also participate The Phosgene 55 55 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. D_raft Report for Public Comment July 2011 Guardian Committee holds meetings twice a year to share Icarnings and discuss phosgene handling issucs DuPont has an HTM manual for phosgene a company protocol that includes requirements and guidelines for the safe design and operation of processes that generate or use phosgene The primary purpose of the manual is to reduce the likelihood that phosgene could harm employees or the public The requirements of the manual are mandatory for all DuPont facilities with enough phosgene to impose a significant offsite hazard as determined by a chemical consequence analysis of offsite exposure Members of the Phosgene Committee conduct a second audit every 3 years of all facilities using phosgene against the requirements and guidelines set forth in the phosgene HTM manual The Phosgene HTM Committee audited the SLM unit at the Belle Plant in September 2006 the next audit was scheduled for January 25 2010 just two days after the phosgene release incident 4.2 Incident Description The third incident occurred on January 23 2010 between 1:45 and 2:00 p.m. in the SLM unit when the stainless steel braided transfer hose connected to a partially filled but not in service ton phosgene cylinder failed catastrophically This incident occurred in the phosgene shed When the release occurred an operator was in the phosgene shed inspecting the status of the hillsidephosgene cylinder as he anticipated the cylinder was nearly empty and would need to be switched He was sprayed across the chest and face with liquid phosgene remaining in the riverside hose from a previous transfer operation DuPont estimates that about 2 pounds of phosgene were released to the atmosphere when the hose failed The CSB concurs with this estimate and further calculated that the operator would have a received lethal dose of phosgene in less than a tenth of a second Appendix D 38 The cylinders are commonly referred to as the hillside or riverside cylinders based on their orientation in the phosgene shed relative to the hills north of the building and the Kanawha River to the south STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Immediately after the operator was sprayed he called for assistance on the SLM unit public address phone in the phosgene shed A worker who responded to the call for assistance noticed the victim's phosgene dosimeter badge Figure 13 was discolored indicating an exposure The worker directed the exposed worker to a plant truck to transport him to the plant's medical center for assessment and treatment As they drove to the medical center the two workers were met by the Shift Supervisor and the exposed worker was transferred to the shift supervisor's vehicle to complete the trip While en route to the plant's medical center the front gate guard was radioed and advised to call Metro 9-1-1 and request that an ambulance respond for a medical emergency The exposed worker while at the medical center waiting for the ambulance chose to wash his face and hands but there is no evidence or record that he was placed in a safety shower to wash off as instructed by the emergency procedures or that any decontamination activity took place beyond his washing his face and hands He was given a change of coveralls to put on in exchange for the work clothes he was wearing at the time of exposure The gate guard called Metro 9- 1-1 at 1:59 p.m. requesting transport for a medical emergency patient to the hospital The 9-1-1 dispatcher asked if there was a chemical release however the gate guard who was unaware of the situation responded that there was no release and that the response was for a medical emergency As part of the Metro 9-1-1 emergency response protocol the dispatcher asks for specific information to ensure that responders are as informed as possible prior to arrival at the scene At 2:03 p.m. an ambulance was dispatched from the Kanawha County Emergency Ambulance Authority KCEAA At 2:08 p.m. responding EMTs asked Metro dispatchers if more information was available about the victim When Metro called DuPont to get more information the line was busy EMTs also wanted to know if there was a chemical exposure but Metro 9-1-1 could not get that information from DuPont Six minutes later the EMTs arrived at the DuPont gates EMTs were directed to the DuPont medical center to meet the exposed worker As the EMTs gathered the worker for transport they were given a written phosgene treatment protocol intended to be used at the 57 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 hospital to provide treatment While the worker was being transferred to their care DuPont employees told the EMTs that the victim had been exposed to liquid phosgene The EMTs left the facility with the victim at 2:26 p.m. or 27 minutes after the first call to Metro 9-1-1 During transit and after arrival at the hospital at 2:34 p.m. the victim was lucid conscious and talking clearly to the emergency responders and attending physician Until the attending ER physician consulted the provided phosgene treatment protocol which advised hour monitoring for suspected phosgene exposures he considered sending the victim home based on his condition shortly after arriving at the hospital A baseline ray revealed no congestion in the victim's lungs At about 5:30 p.m. or almost 4 hours after exposure the operator's condition began to rapidly deteriorate Over the next 29 hours the victim received treatment from a variety of physicians but his condition failed to improve and he died at 9:27 p.m. on Sunday January 24 2010 incident KCEAA staff voiced concerns regarding the quality and timeliness of information DuPont provided to Metro 9-1-1 dispatchers and responding EMTs The concerns raised address the need to ensure that emergency responders and their equipment are not exposed to contaminants and that the victims they are assisting receive optimum care in transit for medical treatment A review of comparable responses by KCEAA EMTs in the region revealed that the response time to DuPont and from there to the hospital was not unduly delayed by the lack of information A sampling of similar emergency responses reveal an average response time from the initial call to Metro 9-1-1 until arrival at the hospital to be about 36 minutes Total elapsed time for the response time on the day of the exposure was 35 minutes Although the emergency response and transport of the victim was not delayed during this incident or the oleum release because of a lack of clear accurate information regarding the material involved response procedures have since been modified by the administrators of Metro 9-1-1 These modifications mandate that EMS units will not report directly to the site of an incident until clear information has been provided such that EMS personnel will not be at risk of unknown contaminants This change in response STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 hospital to provide treatment While the worker was being transferred to their care DuPont employees told the EMTs that the victim had been exposed to liquid phosgene * The EMTs left the facility with the victim at 2:26 p.m. or 27 minutes after the first call to Metro 9-1-1 During transit and after arrival at the hospital at 2:34 p.m. the victim was lucid conscious and talking clearly to the emergency responders and attending physician Until the attending ER physician consulted the provided phosgene treatment protocol which advised hour monitoring for suspected phosgene exposures he considered sending the victim home based on his condition shortly after arriving at the hospital A baseline ray revealed no congestion in the victim's lungs At about 5:30 p.m. or almost 4 hours after exposure the operator's condition began to rapidly deteriorate Over the next 29 hours the victim received treatment from a variety of physicians but his condition failed to improve and he died at 9:27 p.m. on Sunday January 24 2010 incident KCEAA staff voiced concerns regarding the quality and timeliness of information DuPont provided to Metro 9-1-1 dispatchers and responding EMTs The concerns raised address the need to ensure that emergency responders and their equipment are not exposed to contaminants and that the victims they are assisting receive optimum care in transit for medical treatment A review of comparable responses by KCEAA EMTs in the region revealed that the response time to DuPont and from there to the hospital was not unduly delayed by the lack of information A sampling of similar emergency responses reveal an average response time from the initial call to Metro 9-1-1 until arrival at the hospital to be about 36 minutes Total elapsed time for the response time on the day of the exposure was 35 minutes Although the emergency response and transport of the victim was not delayed during this incident or the oleum release because of a lack of clear accurate information regarding the material involved response procedures have since been modified by the administrators of Metro 9-1-1 These modifications mandate that EMS units will not report directly to the site of an incident until clear information has been provided such that EMS personnel will not be at risk of unknown contaminants This change in response STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. _ Draft Report for Public Comment July 2011 protocol was incorporated after several incidents in the Kanawha Valley The CSB considers the change in response protocol significant enough to define the cause and effect of the communication gap as a near miss Several key factors that contributed to poor communication included the absence of a process knowledgeable person who was assigned to convey information to the dispatchers and the lack of a direct line to the Metro 9-1-1 emergency operations center must be recognized and addressed One confirmed and one possible phosgene exposure to workers occurred after the initial release The first occurred when a worker responded to the call for assistance immediately after the phosgene hose ruptured As he drove the victim to the facility's medical building the worker's dosimeter badge became slightly discolored indicating a phosgene exposure A possible source of this exposure was phosgene vapor in the atmosphere as recorded on one of three fence line monitors about 120 feet from the shed along the river Another possible source was from the victim's clothing which may have been saturated with phosgene immediately after the release When interviewed this employee indicated that he was subjected to pulmonary function tests afterward and reported no signs of adverse effects A second possible exposure occurred when an employee working in the SLM unit went toward the phosgene shed shortly after the release He reported in an interview that as he got closer he noticed a smell that he had not encountered before or since He recalled that the odor was not strong or offensive as would be expected with ammonia chlorine but noticeably different from any odors he had smelled in the past Being unfamiliar with the characteristic fresh mown hay odor associated with phosgene he left the area Although the phosgene shed area has flashing lights to alert against entry into the area during cylinder changes there is no evidence that a fume medical or plant radio alert sounded at any time during this releasc cpisode to warn operators and maintenance personnel to avoid coming near the phosgene shed STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 4.2.1 Community Impact Two ofthethree fence line analyzers recorded a maximum concentration of 0.15 and 0.27 ppm phosgene indicating that phosgene concentrations had traveled offsite toward the Kanawha River However no member of the public reported phosgene exposure symptoms the day of the incident nor did the U.S. Coast Guard restrict river traffic or conduct air monitoring as it had a day prior as a result of the methyl chloride release 4.3 Incident Analysis 4.3.1 Hose Failure Analysis incident inspections of the stainless steel hoses used for the two phosgene cylinders connected to the process identified comparable degradation patterns Their failure was associated with corrosion that developed in approximately the same location on hoses used to transfer phosgene from the riverside and hillside cylinders Investigators found that while the majority of tags attached to the hoses to indicate the intended service were secured in place with plastic ties and metal clamps was normal manufacturer's tag was secured with clear plastic adhesive tape this tag applied by the manufacturer also provided identification information The corrosion identified on the two hoses associated with the hillside and riverside cylinders was localized under the area covered the clear plastic adhesive tape securing the tag The characteristics of the transfer hose consisting of a core constructed of permeable PTFE and braided 304- 39 ERPG value for phosgene is 0.20 ppm and at this concentration all could be exposed for up to one hour without experiencing or developing irreversible or other serious health effects or symptoms that could impair their abilities to take protective action AIIIA 2008 40 Witnesses could not provide an exact date that the hoses came into the facility with the tags affixed with adhesive tape 60 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 stainless steel provided a suitable environment under the adhesive tape for stress corrosion cracking SCC to occur In order to provide comparative data hoses from the hillside riverside and exemplars of similar age and new assembly were sent to an analytical lab for testing and analysis The tests established that all of the hoses were constructed with stainless steel and the construction material for the inner core of the hoses was PTFE as expected 4.3.2 Effect of Plastic Adhesive Tape The PTFE 304 stainless steel and the clear plastic adhesive tape contributed to the incident The PTFE inner core was permeable and susceptible to phosgene vapor diffusing through the hose The adhesive tape used to secure the tag contributed to the retention of phosgene gas on the exterior of the stainless steel overbraid The phosgene gas converted to HC1 and 304 stainless steel overbraid is subject to corrosive attack by HCl Since the clear plastic adhesive tag trapped the phosgene permeating through the PTFE inner core the resulting concentration of HCl was much higher under the tag than elsewhere on the hose Figure 14 61 OR DISAPPROVAL BY THE BOARD SUBJECT TO CHANGE APPROVAL July 2011 STAFFSTAFF DRAFT - Draft Report for Public Comment E.1 DuPont de Nemours Co. End of Cellophane Tag Rupture J Noticable Difference In Corrosion adhesive tag on the corrosion of the stainless steel 14. The distinct effect of the clear plastic Figure overbraid valves on the phosgene hose on the riverside Additionally at the time of the incident the isolation in the hose and pipe between the valves that isolated were closed which retained liquid phosgene cylinder of the stainless steel over braid coupled with the corrosion the cylinder from the process The heavy and thermal expansion of the isolated liquid phosgene caused length of time the hose had been in service worker this failure occurred the was exposed as he walked nearby the hose to fail catastrophically When to check on the status of the adjacent service cylinder cylinder 4.3.3 Degradation issues Hose plan for the hillside and riverside hoses prescribed a regular change Although the maintenance nor that change frequency was neither systematic schedule of 30 days for the hoses work orders show 62 APPROVAL OR DISAPPROVAL BY THE BOARD STAFF DRAFT - SUBJECT TODrCafHt AReNpoGrEt for Public Comment July 2011 E.I. E.I. DuPont de Nemours & Co. hoses were left in service from four to At least three times from 2006 to 2010 phosgene predictable seven months without being replaced 4.3.4 Hose Change Frequency halted so the plant can produce a material requiring the Several times each year the phosgene process is Table including all full or ton cylinders from the phosgene shed empty physical removal of phosgene when SLM did periods hoses in the SLM unit and the 2 shows the change frequency of the phosgene run was not used in the The most recent recorded instance where phosgene not processes using phosgene and November 2009 2 months prior to the incident Work orders for process was between September indicate that the stainless steel transfer hoses connected at the time of changing out the phosgene hoses months the incident had been in service for more than six This included a removal of the phosgene 2009 when the hoses could have been changed out system change out in September BOARD STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE July 2011 E.I. DuPont de Nemours & Co. Draft Report for Public Comment Hose Change Frequency | | Month Jul Phosgene Hoses Changed Phosgene Used Phosgene Used : Sea: Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Changed Changed Changed Changed ot Changed ; Changed Changed Phosgene Used Phosgene Used Phosgene Used Sd Phosgene Used Phosgene Used : Phosgene Used Phosgene Used oN Aug Sep Oct Changed Nov Changed , ae Dec Jan Feb Mar Apr May Jun Jul ee Changed Changed : <i) Phosgene Used Phosgene Used Phosgene Used Phosgene Used Phosgene Used Phosgene Used Phosgene Used Re Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Phosgene Used Phosgene Used Changed Changed : ; Phosgene Used Phosgene Used Phosgene Used Phosgene Used Changed Phosgene Used : Changed : Oct Nov Dec Jan Feb Mar Apr May 09 | Jun Jul Aug Phosgene Used Phosgene Used Phosgene Used Phosgene Used Phosgene Used . Phosgene Used Phosgene Used Sep Oct Nov Dec Jan ae Phosgene Used Table 2. Phosgene hose change frequency 64 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THEJuBlOy A20R1D1 E.I. DuPont de Nemours & Co. Draft Report for Public Comment was intended to be governed automatically by the Belle The CSB found that change frequency facility's SAP maintenance program Some supervisors also relied on the maintenance coordinator remembering to initiate the change 4.3.5 SAP Work Process module of SAP enterprise resource planning software to schedule DuPont uses the plant maintenance the change of phosgene hoses at determined 30 day intervals The SAP system is programmed to issue the work orders for hose replacement to prevent the release of phosgene thus maintaining accurate data in the SAP database is crucial to protect against phosgene exposure In late 2006 SAP data managing the change frequency of the phosgene hoses at the Belle facility changed were changed consequently SAP stopped automatically issuing work orders to change the hoses but personnel plant were unaware that SAP no longer automatically issued the work orders The CSB additional information regarding the change however DuPont could not determine who requested changed the SAP data why it was changed or when the change was executed No back layer of protection ensured that the hoses were changed at the determined frequency such as a weekly critical equipment maintenance check or an inspection tag With SAP no longer automatically issuing work hoses orders to change the the system did not trigger maintenance notifications to change out the hoses at assigned intervals maintenance of database software that allows data related to flows of money 41 Enterprise resource planning software is a type sales and marketing manufacturing and other resources in areas such as accounting supply chain management and project management to be recorded and accessed STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 4.3.6 Near Phosgene Incident On the morning of the phosgene incident operators asked maintenance personnel to replace the phosgene hose on the hillside cylinder because of a suspected flow restriction Although the cylinder was still about half full it was removed from service and replaced with the full riverside cylinder The hillside phosgene supply hose and valve assembly were removed and decontaminated in a water bath When the hose was removed from the water the clear adhesive ID tag had fallen off revealing a broken stainless steel braid and collapsed PTFE liner a possible cause of the flow restriction Figure 15 Figure 15. Damaged hillside phosgene hose removed from phosgene cylinder The plastic adhesive tag that covered the damaged section fell off during the hose decontamination procedure An operator stated during an interview that when he saw the physically defective section of the frayed hose he told his workers stressing that the hose was close to rupturing and that they were lucky to have found it and changed out the hose in time Unfortunately this discovery was not captured as a nearmiss since supervisors were not made aware of the issue 66 STAFF - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD DRAFT _ E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Operators told the CSB investigators that they had never seen a phosgene stainless steel hose braid corroded to the point of separation Although they were surprised and concerned about their finding they decided since supervisory staff does not work on weekends to wait to tell the supervisors about the discovery on Monday morning about 48 hours later Operators said that they expected that the supervisors would conduct a full investigation however since the incident occurred on a Saturday it was not investigated Had there been a system in place for operators to report miss incidents on weekends to supervisory staff the miss investigation may have been properly initiated prior to the fatal release 4.3.7 Mechanical Integrity | The DuPont P3H Standard lists acceptable construction materials for flexible hoses used in HTM service and recommends three different hoses acceptable for use with phosgene H2 H7 and H9 Table 3 67 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 Name DuPont P3H Standard Hoses for Phosgene Service Specifications H2 | Inner core material Reinforcement material Monelfi400 corrugated Monelfi400 overbraid End fitting material fitting connection method Monelfi400 SCH 80 | Welded full penetration | H7 Inner core material , _ Reinforcement material End fitting material fitting connection method Hastelloy C276 corrugated Monel 400 or Hastelloy C276 overbraid Hastelloy C276 stub ends Welded full penetration H9 | Inner core material Teflonfi42PTFE helical corrugated taped or extruded construction unpigmented or conductive Reinforcement material PVDF Kynarfidouble overbraid Monel 400 Hastelloy C276 or Teflonfiencapsulated End fitting material SS fitting connection method | Crimped or swaged Table 3. Flexible hoses for phosgene service as listed in the DuPont P3H Standard Flexible Chemical Hose for Highly Toxic Services The Bellc facility did not use any of the P3H specified hoses and configurations Instead the facility used a flexible hose made of a TeflonfiPTFE inner corc and a braided stainless steel reinforcement material even though stainless steel is not recommended for phosgenc service as it is susceptible to SCC from chlorides Phosgene which can readily react with air to produce chlorides can permeate PTFE directly exposing the stainless steel braid to chloride attack 12 Teflon is the registered trademark for PTFE 68 DISAPPROVAL STAFF - DRAFT SUBJECT TO CHANGE APPROVAL OR E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment BY THE BOARD July 2011 4.3.8 Flex Hose Materials of Construction The Belle facility deferred to corporate experts and the La Porte facility where flexible hoses were being used for phosgene service The discussions about flexible hoses began in 1987 when corporate experts suggested the use of Monel metal for both the hose core and hose overbraid since it resists chloride SCC However the La Porte plant asserted that its history with Moncl metal was less than desirable one correspondent noted The La Porte plant was considering testing overbraid covered Teflon hose because of discoloration and gradual deterioration of the Monel An expert from DuPont corporate told Belle that the discoloration was not a problem Reports from La Porte that Monel braided hoses were corroding phosgene service are not exactly true The hoses at that time were Teflon lined with a Monel outer overbraid Due to permeation of phosgene through Teflon the Monel was slightly attacked forming a green surface film known as a patina which is common to all copper alloys A Belle representative sent a questionnaire to La Porte in August 1987 to evaluate its hose program The questionnaire revealed that La Porte had been using PTFE stainless stccl hoses for the previous 3 to 4 years and that they were replaced every 3 months It reported that the majority of the hose failures were due to fatigue and that the facility was using stainless steel because it is not as susceptible to failure from 43 DuPont uses phosgene at five of its facilities including the one in La Porte TX 14 The Kynar hose was also not pursued due to conceived flexibility limitations $ Patina is a green film formed naturally on the surface of copper and copper metals and can most easily be observed on old pennies 69 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.1 DuPont de Nemours & Co. Draft Report for Public Comment July 2011 fatigue and bending stresses as are Monel and Kynar hoses After reading the questionnaire the corporate DuPont expert wrote I still believe that Monel is the best choice for material of construction for phosgene unloading hoses and definitely for the fittings I am surprised that La Porte is using Teflon hose with stainless overbraid since Teflon is known to bc permeable and the phosgene is known to attack the stainless The DuPont expert further stated Admittedly the Monel hose will cost more than its stainless counterpart However with proper construction and design so that stresses arc minimized life should be much greater than 3 months Costs will be less in the long run and safety will also be improved Correspondence or other records that would explain why the expert's recommendation went unheeded at La Porte and why the Belle staff decided to follow the La Porte approach was not discovered during the investigation However Belle decided to follow La Porte's example and adopted a hose design not recommended by their P3H Standard or by a DuPont corporate expert The phosgene hose replacement frequency at Belle is defined in DuPont's Phosgene Hose Assembly Procedure Due to the extremely hazardous nature of phosgene the hose assemblies are replaced every 2 months However the PM schedule in SAP is actually set to a replacement frequency of 30 days and this procedure does not effectively communicate to operators why these hoses must be replaced so frequently If left on too long the accepted corrosion condition poses a serious risk to the facility and the community 70 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Figure 16. Flex hose comparison photographs top to bottom ruptured riverside hose flow restricted hillside hose a new hose with attached ID tag 4.3.8 | routine Job Planning Operators told the CSB investigators about the difficulty in maintaining the required flow of phosgene from one of the two cylinders on the weigh scales the day prior to the exposure incident The phosgene flow from the cylinder to the process was inadequate thus they performed a routine operation to establish a steady flow of phosgence because they suspected a plugged hose or a malfunctioning automatic feed control valve To minimize disruption of the phosgene flow to the process operators switched to the riverside cylinder which operated as expected and supplied the normal flow rate Continuing throughout the day and into the next opcrators repeated switching to the riverside cylinder as the flow from the hillside cylinder became low enough to begin to affect the process When valves for each of the respective transfer hoses were closed liquid phosgene was not evacuated as stated in the SOP for switching from one cylinder to 71 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 another Since the operators were not fully aware of the hazards of thermal expansion liquid phosgene remained in the hoses as the cylinders were switched | The CSB investigators reviewed DCS flow and weight data and a observed distinct difference in the ability of the riverside cylinder to provide the needed flow rate of phosgene compared to the hillside cylinder this operation All of the DCS information the operators received as a result of the routine cylinder switching indicated that their actions were successfully maintaining the smooth operation of the unit The operators however were involved in routine operations by attempting to maintain steady operations as the SOPs did not address handling flow restriction In addition they were unaware of the threat of liquid thermal expansion developing as a result of switching the cylinders and not evacuating the hoses after each switch operation 4.4 Process Hazard Analysis A team conducted a Process Hazard Analysis PHA on the phosgene cylinder feed system and vaporizer as part of the Front End SLM Unit assessment in 1994 1999 2004 and 2009. The 2009 PHA team which included a senior process engineer two technical resources a mechanic and a front end operator all of whom were DuPont Belle employees reviewed subtle changes to the process and associated MOC documentation since the last PHA in 2004 previous phosgene relcase incidents and recommended corrective actions The PHA for the phosgenc system included the ton cylinders nitrogen pressuring 46 routine operations are characterized by infrequent practice routine operations can be both planned and scheduled or can occur without an opportunity to schedule them 72 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 system the vaporizer and all associated piping and controls The team used a Hazard and Operability HAZOP and What If methodologies for the review of process hazards and deviations The team recognized and assessed the potential for a phosgene rclcase from the cylinder transfer hoses but only if the hoses were incorrectly connected or inadvertently disconnected while the cylinder feed valve remained open They did not assess the potential for the hose to rupture due to thermal expansion of liquid phosgene even though the potential for liquid phosgene thermal expansion was cvaluated in other process equipment during the 2009 PHA None of the consequence scenarios the PHA team assessed involved failure of the phosgene transfer hose or the nitrogen flex hose When it evaluated the phosgene vaporizer the team considered corrosion potential when stainless steel is exposed to phosgene and water but did not apply those factors to the cylinder transfer hoses For the vaporizer the probability value assigned to the phosgene leak scenario was decreased by reliance on the PM program to detect corrosion The PHA team also noted that the slowly developing corrosion would decrease the probability of a leak because the corrosion would be noticeable during visual inspections If the PHA team assessed the thermal expansion and corrosion issues for the phosgene transfer hoses and applied the same conditions to decrease the probability as used for the vaporizer corrosion scenario the incident may still have occurred due to the team's reliance on the preventative maintenance program to reduce the hazard Unfortunately the slowly developing corrosion on the hose was not visible due to the location of the clear plastic adhesive tape and the PM program was not configured to ensure that the hoses were changed at the appropriate frequency 47 A systematic method in which process hazards and potential operating problems are identified using a series of guidewords to investigate process deviations CCPS 2008 48 A technique in which a team with process knowledge and experience examines possible process deviations or combinations of deviations than can result in an undesired consequence CCPS 2008 73 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD . E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 Phosgene permeation through PTFE resulted in leaks at Belle in the past however the PHA team did not consider this hazard for the phosgene cylinder hoses The CSB received documentation of all SLM PHA audits dating back to 1994. The 1999 PHA included two incidents in which phosgene likely permicated through PTFE conveyance equipment in other parts of the phosgene process Even with these previous incidents taken into consideration the PHA team still did not consider the potential for the phosgene cylinder hoses to result in a release under similar conditions 4.5 Audits 4.5.1 Unit Second PSM Audit In August 2007 a second audit team comprised of engineers and health and safety experts from other DuPont facilities audited the SLM unit against regulatory and company PSM requirements As in the F3455 unit audit the team focused on subtle change PSSRs training PHAS mechanical integrity and process technology The audit contained 64 findings observations 35 policy and 2 regulatory issues the Crop Protection business consisting of the F3455 and SLM units at Belle One regulatory issue noted for the SLM and F3455 units was timely initiation ofaccident investigations Auditors observed several instances where incident investigations were not started and communicated within the Belle Plant hour or the hour OSHA requirements The audit team recommended revising the Belle Plant Incident Investigation procedure and arca practices to ensure that plant personnel initiate investigations within 24 hours and no later than 48 hours following an incident According to the audit tracking plan the CSB investigators reviewed an assigned DuPont employee completed and closed the recommendation as of June 2009 ' However in the case of the hillside hose miss prior to the phosgene exposure Section 4.3.3 operators told the CSB investigators that they planned to communicate the miss to supervisors for investigation the following Monday however this would not have been within the Belle Plant required hour period The OSHA PSM Standard requires the employer to investigate cach incident which 74 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 resulted in or could reasonably have resulted in a catastrophic release of highly hazardous chemical in the workplace 1910.119 and that an incident investigation shall be initiated as promptly as possible 1910.119 Though supervisors are not typically present at the facility on weekends management and safety and health experts including the SLM Area Manager were at the Belle Plant the morning of Saturday January 23 2010 attending the safety pause meeting Had the incident been reported in a timely manner management on site could have immediately initiated an investigation 4.5.2 Site Phosgene Generation In 1988 DuPont engineers considered two options for using phosgene at the Belle facility in cylinders from an site provider or making phosgene site by constructing a phosgene generation plant To better understand the hazards involved in each design DuPont engineers conducted a risk assessment in which four cases were considered Table 4 Case 1. Operating with a liquid phosgene feed from cylinders Case 2. Vaporizing the feed from the cylinders Case 3. Installing a plant to make phosgene from CO and Cl Case 4. Enclosing the phosgenc plant in a fully contained building with an air scrubber After evaluating each case they estimated the risk of fatality as follows Case 1 Case 2 Case 3 Case 4 244 154 16.7 2.3 10.5 0.22 . 0.007 0.006 Table 4. Preliminary Risk Assessment by DuPont Engineering 1988 Appendix E While it was estimated that Case 4 would have the least amount of risk the assessment concluded Spending 2 MM for an enclosure to get from Casc 3 to Case 4 saves 14.4 lives per 10,000 years Almost all the improvement is in site risk Off risk STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 ~ of improvement is not significant This sets a value . life plus public outrage at 143 MM It may be that in the present circumstances the business can afford 2 MM for an enclosure howeveirn the long run can we afford to take such action which has such a small impact on safety and yet sets a precedent for all highly toxic material activities sic After the analysis construction on Casc 3 the open to atmosphere phosgenc generation plant began However the phosgene generation plant was abandoned construction and Case 2 is the current configuration at the Belle facility Documentation to support why the phosgene generation plant was abandoned was not provided The CSB obtained a proposal to DuPont by a party contractor to build the phosgene generation plant The | proposal for a plant as presented in Casc 3 estimated a cost of 830,000 dollars and stressed the contractor's history of building successful phosgene generation units DuPont decided not to act on this proposal Anecdotal evidence from CSB interviews pointed to corporate engineers deciding to not hire a third party and using DuPont resources to construct the phosgene generation unit However once the project was partially complete it was determined that the designed system would not work and the effort was abandoned DuPont made the decision to cancel plans for the enclosed phosgene generation unit but the potential for offsite impact still remained a concern and was identified in SLM Unit PHAS years later In 2004 Belle Plant personnel conducted a PHA on the SLM Unit and identified the nccd for a shed enclosure with a scrubber to mitigate or prevent the release of phosgene offsite The recommendation was formed as a result of a What if analysis performed during the PHA The PHA team listed two separate scenarios shed that could result in a plant or offsite consequence both recommending an enclosure to the . The original due date for the shed enclosure was scheduled for December 2005 but was extended A 76 DRAFT STAFF SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 PHA recommendation extension request letter was created to describe the need for an extension and was signed by SLM Unit Management The shed enclosure extension scheduled for December 2006 was not met and there were three subsequent extensions on the enclosure recommendation which remained incomplete on the day of the fatal phosgene release Table 5 77 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 PHA Enclosure Recommendation Delays _ Original Recommendation created in SLM 2004 PHA Provide appropriate mitigation to prevent multiple fatalities from the | Dec release of a 2000 lb phosgene cylinder Due Date Dec First Extension A COC12 generation system is currently being evaluated and if this was installed the shed enclosure may be designed differently to handle the appropriate chemicals New Due Date Dec May Second Extension Work to define the scope on this item is progressing but not yet complete We are evaluating potential lower cost alternatives to total shed enclosure Dec Third Extension the schedule indicates completion by August 2009. The holds on the capital project were due to uncertainty of the future of the facility and due to the cost of the project Dec Fourth Extension ... project to install a phosgene scrubber to address these recommendations an error in basic data was discovered This invalidated the original design basis for the scrubbing system and required a halt to the project activity New Due Date Nov SLM 2009 PHA Completed . , 32 Recommendations are made none of which capture the outstanding recommendation from the SLM 2004 PHA Nov Dec Fatal Phosgene Incident Occurs Table 5. PHA enclosure recommendatdeiloayns timeline 78 - STAFF DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 A year following the phosgene release incident DuPont announced that it would idle the storage and use of phosgene at the Belle site but did not state intensions for phosgene usage beyond 2011. The CSB requested documentation from DuPont that defines the status of the PHA recommendation for the shed enclosure as of the date of this report DuPont extended the PHA recommendation for the shed enclosure for November 2010 but the shed was not enclosed prior to the deadline and extended again until the end of 2011 4.5.3 2006 Phosgene Committee Audit 2006 In the Phosgene Guardian Committee audited against the DuPont Phosgene Highly Toxic Materials HTM Manual which included a review of the phosgenc cylinder cylinder storage shed the SLM production area and other areas of the Belle Plant Three audit team members from other DuPont sites visited the Belle facility to conduct field walkthroughs and hold discussions with process unit personnel The audit team divided the findings and recommendations from the audit into two categories policies and observations The policies were related to the requirements of the HTM manual and the observations were suggestions or preferred but not mandatory practices The team found no regulatory compliance deficiencies in the audit but did issue five policy recommendations and eight observations to the Belle Plant The policy findings applied to cquipment downstream of the phosgene cylinder feed system including a recommendation to add inspection plans for corrosion detection of the Teflon reactor piping The team found and noted as an observation that the hoses used on the phosgene feed system were not one of the three types of hoses recommended for phosgenc service by the DuPont P3H Standard but did not require the Belle facility to use the appropriate hoses The team also observed that liquid phosgene lines in the shed had moderate external corrosion and that significant moisture in the shed should be addressed to climinate future corrosion potential Because these items were observations the HTM manual did not require that DuPont develop an action plan to resolve 79 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 them The plant continued to use a hose for phosgene service that the company standard did not recommend SLM unit equipment selection practices did not align with the requirements and recommendations in the phosgene HTM manual The manual requires that Materials of construction must be selected properly to handle phosgene safely but only recommends against the use of nonmetals for piping valves and process equipment containing phosgene It further states Where small amounts of phosgene are present stainless steel lined with Teflon is commonly used without specifically quantifying an amount of phosgene where Teflon is acceptable In the SLM phosgene transfer system phosgene was continuously present in the PTFE hoses while the connected cylinder was feeding the process The HTM manual's design information section requires that special attention be given to the prevention of over pressuring those lines and vessels where liquid phosgene can be trapped between two isolation valves In the course of switching between cylinders on the morning of the phosgene incident SLM operators blocked in i.e. closed the valve on each end of the hose which trapped liquid phosgene between the partially filled riverside cylinder and the valve to the process The liquid phosgene trapped in the hose underwent thermal expansion rupturing the hose due to the overpressure of the line facilitated by the weakened and corroded stainless steel overbraid None of the SOPs for the SLM unit warned against blocking in liquid phosgene to prevent hose ruptures making operators less aware of the thermal expansion hazards of phosgene 4.6 Standards and Guidelines 4.6.1 DuPont Highly Toxic Materials Phosgene Manual The DuPont Highly Toxic Materials HTM Manual contains mandatory criteria for the storage handling maintenance and management of phosgene in quantities with the potential to cause offsite impact if released The page manual also includes mandatory practices for new and existing units or facilitics handling phosgene and company requirements and procedures related to first aid and medical 80 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 treatment MOC design information for new and existing phosgene equipment and PSM principles The Phosgene Guardian Committee reviews and revises the manual and the committee chairperson and Safety Health and Environmental SHE leader authorizes the revisions The Responsible Care Core Team reviews and approves all changes to mandatory requirements before issuing the revised manual The Plant or Unit Manager must authorize any deviation from the manual requirements before using an alternative practice The HTM Committee conducts a safety analysis to ensure that the alternate practice is acceptable before implementation 4.6.2 American Chemistry Council ACC Phosgene Safe Practice Guidelines Manufacturers and users of phosgene formed the Phosgene Panel in 1972 to share information about practices to safely produce handle and use phosgene throughout industry The Phosgenc Panel is part of the Chemical Products and Technology Division of the ACC an industry trade association for chemical companies its Chemical Products and Technology Division supports companies through continuous evaluation and communication improvements related to the safe use of hazardous chemicals Engineers health and safety experts and occupational health physicians from member companies participate on the panel which meets twice a year to share information and experiences related to handling phosgene The panel sponsors engineering studies and research to prevent phosgene incidents and has prepared manuals for phosgene safe practices and medical treatment information as a resource for ACC member companics The ACC Phosgene Panel compiles information from member companies into the Phosgene Safe Practice Guidelines Manual to provide general information to those that manufacture or handle phosgene The manual contains nine sections of phosgene safety information such as phosgene propertics design 49 In 2010 all U.S. phosgene manufacturers participated in the panel BASF Corp. Bayer Corp. Chemtura Dow Chemical DuPont Huntsman SABIC Innovative Plastics and VanDeMark Chemicals Inc. 81 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 information for phosgene process facilities transportation emergency planning first aid and medical treatment and training Phosgene panel members draft summaries of industry practices that they submit for review and approval by all members of the ACC Phosgene Panel prior to inclusion in the manual The panel periodically updates the manual and adds new and relevant practices identified by industry The ACC does not intend for the manual to be a training tool or be adopted as procedure it is to be referenced for general information regarding safe practices for phosgene storage and use The Design of Facilities section of the manual has several subsections pertaining to construction materials and layout of phosgene process equipment and facilities The section includes leak prevention information such as equipment inspections monitoring and alarms and describes the use of engineering controls and multiple layers of protection or barriers between phosgenc exposure hazards and personnel The section includes precautions with regards to piping and valves in phosgene service The manual states that users should pay particular attention to * protecting piping from pressurization duc to liquid phosgene trapped between closed valves * protecting dryphosgene dryphosgene systems from the intrusion of moisture which can react with phosgene and cause severe corrosion and failure and e inspecting and testing where stainless steel materials are used to detect the presence of stress corrosion cracking caused by exposure to chlorides The section also states that the use of metallic and metallic hoses for permanent or temporary piping systems may increase the opportunity for phosgene leakage and advises users to give duc consideration to Phosgene in the absence of water or moisture sometimes referred to as anhydrous 82 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 the design fabrication and testing of all components The manual also notes the potential permeability issuc with PTFE liners and states that these liners are typically used for phosgene service in wellventilated areas but docs not describe specifically what methods of ventilation are acceptable 4.6.3 National Fire Protection Association NFPA The NFPA 55 Compressed Gases and Cryogenic Fluids Code provides fundamental safeguards to users producers distributors and others who handle compressed gas cylinders The standard contains general requirements for storage occupancy and emergency response as well as provisions for specific chemicals or hazard classes as defined by the NFPA The current version of the CGA P standard references NFPA 55 in the Ventilation Storage and Site Criteria section for toxic and corrosive gases DuPont Belle's programs and practices related to the storage and handling of phosgenc cylinders does not align with the provisions set forth in NFPA 55 NFPA 55 defines phosgene as a highly toxic gas because it contains a lethal concentration LC50 equal to or less than 200 ppm in air when administered via inhalation for 1 hour The LC for phosgene is 5 ppm for 1 hour of exposure CGA 20 1995 NFPA 55 includes guidelines for controls in buildings that store compressed gas cylinders and classifies the phosgene shed structure as an indoor storage area because the walls comprise more than 25 percent of the shed perimeter Figure 12 Indoor storage for the use of highly toxic gases must have a gas cabinet exhausted enclosure or a gas room according to NFPA 55. Exhausted enclosures gas cabinets or gas rooms fully enclose cylinders and associated process equipment and are equipped with ventilation systems to capture and treat hazardous vapors The phosgene shed at Belle though considered indoor storage by NFPA did not contain a ventilation system instead DuPont relied on natural ventilation from the outside to decrease concentrations of phosgene which allowed phosgene vapors to travel downwind 51 LC is the lethal concentration for 50 percent of the exposed population 83 - STAFF DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD for E.I. DuPont de Nemours & Co. Draft Report Public Comment July 2011 potentially exposing other employees working outside Without exhausted cnclosures no barriers were present to prevent phosgene from exposing operators or traveling site The standard also includes guidance for alarms to warn personnel of potential releases from compressed gas cylinders and associated equipment The SLM unit at the Belle plant had alarms for phosgene releases that were activated manually by the control board operator upon notification from outside personnel or if a phosgene analyzer activated an alarm at the control board NFPA 55 guidance states that manual emergency alarms should be provided in the buildings that enclose cylinders and when activated should sound local alarms to alert occupants in the surrounding area The phosgene shed at Belle contains no alarms that can be activated locally Operators suspecting suspecting release are expected to communicate verbally with the control operator who then sounds an alarm In the absence of automatic alarm notifications personnel in the surrounding arca risk exposure as was the case on the day of the incident For gas detection systems the NFPA states that alarms should activate a local alarm that is both audible and visual In the phosgene shed the SLM building area and on the Belle Plant fence line the gas detection systems activate alarms only in the SLM control room if concentrations exceed the alarm set points The gas detectors do not locally sound or visually indicate the detection of a hazardous concentration to alert surrounding personnel 4.6.4 Compressed Gas Association CGA Standards for the Safe Handling of Cylinders The CGA is an industry association that represents manufacturers distributors suppliers and transporters of gases and cryogenic liquids It develops and promotes standards and practices for the industrial and medical gas industry with input from over 125 member companies Standards include technical specifications health and safety practices and training and educational materials The VanDeMark phosgene bulletin references the current CGA Standard Safe Handling of Compressed Gases in Containers P for the training and proper handling of phosgene cylinders The P Standard from 2008 includes safe practices related to the transportation identification and storage of compressed 84 TO STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E. DuPont Nemours & Co. Draft Report for Public Comment July 2011 gases and specific safe handling and storage rules for chemicals defined by hazard classcs Each chemical has an assigned hazard class based on its physical properties flammable asphyxiant oxidizer toxic corrosive and extreme cold The CGA lists phosgene as a primary toxic and secondary corrosive The toxic and corrosive gas section includes requirements for cylinder storage and ventilation emergency response and training OSHA adopted the 1965 version of the CGA P Standard under the requirements of the Compressed Gas Standard 29 CFR 1910.101 Under the OSHA Standard the plant handling and storage of compressed gas cylinders shall be in accordance with CGA P 1965 The current version of the CGA P standard includes a specific reference to Chapter 7 of NFPA 55 for the storage and handling of compressed gas cylinders with flammables but only contains basic requirements for the storage and handling of corrosives and toxics In CGA P Section 6.2.6 of Flammable Gases the standard includes NFPA 55 requirements such as separation distances flammable storage quantities and fire barriers However for toxics the P Standard states Storage of corrosive and toxic gases shall be in accordance with local and provincial building and fire prevention codes The standard also states toxics shall be filled and used only in adequately ventilated arcas or preferably outdoors or in exhausted enclosures but does not contain any specific provisions to achieve adequately ventilated areas such as the requirements set forth in NFPA Section 7.9 4.6.5 CGA Standards for PTFE Hoses In 2010 CGA published the fourth edition of Standard E Standard for Flexible PTFE Pigtails for Compressed Gas Service Section 1 of E states that the standard applies to hoses with a diameter of 0.25 inches or smaller and with a maximum allowable working pressure MAWP of at least 3,000 psi such as the hoses used at DuPont Section 2 of standard E states PTFElined pigtails are not suitable for use with poisonous toxic or pyrophoric gases because permeation of gas through the PTFE wall 52 Pigtails are hoses or flexible tubing used to transfer material from a compressed gas cylinder 85 TO STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 creates a potential hazard Since phosgene is toxic this standard rules out using PTFE hoses for phosgene Additionally Section 5 of Standard E defines the identifying information for hoses and rather than allowing tags with adhesive or shrink wrap as was the case with the DuPont hoses 9 states The markings shall be made on the end fitting collar separate band or other permanent location The hose supplier's practice of affixing adhesive tape on the hose itself did not align with the requirements in CGA E and enhanced the corrosion of the metal braid on the PTFE hoses at Belle However had DuPont followed this standard they should have considered another permeable hose material as CGA prohibits the use of PTFE hoses with permeable toxic gases such as phosgene The CGA 2008 P Standard does not specifically reference the prior revisions of the E standard Section 5.9 of P includes general requirements for container connections and states that Piping regulators and other apparatus should be kept air tight to prevent leakage The P Standard does not address materials of construction or permeability for cylinder discharge hoses in the standard's general requirements or the safe handling requirements by corrosive and toxic hazard class 4.7 Key Findings 1. An service phosgene transfer hose failed exposing a worker to a lethal dose of phosgene 2. DuPont did not follow its own standards for the change out of phosgene transfer hoses 3. DuPont engineers voiced concerns regarding the materials of construction for phosgene ~ hoses These concerns were not addressed 4. Liquid phosgene was not evacuated from the riverside hose as the SOPs indicate between transfers to the process from the ton cylinders 86 TO STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 _ 5. A similar hose failure almost occurred a few hours before the exposure of the worker but the miss did not prompt an investigation when operators observed the failure mode on the morning of the fatal release 6. The SAP maintenance program was altered so that a work order to change out the phosgene transfer hoses were no longer generated automatically Appendix C 7. one worker was confirmed to have been exposed to phosgene after the initial exposure while a second is thought to have been possibly exposed 8. Emergency responders did not receive timely and detailed information on how to adequately prepare to respond to the incident | 9. There was no audible or visual phosgene alarm indication in or around the phosgenc shed 10. The 2009 PHA did not address thermal expansion and corrosion potential for phosgene transfer hoses 11. Operators were unaware of the hazards of liquid phosgene thermal expansion training and procedures 12. No plant notification occurred in response to the exposure 4.8 Root Causes | 1. DuPont relied on a maintenance software program to initiate the automatic change of phosgenc hoses at the prescribed interval 2. DuPont did not provide a back method to ensure timely change of the hoses 3. A maintenance software program change was not documented or reviewed in accordance with the MOC process 87 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 4. No person with process knowledge was in place and assigned to convey timely and useful information to Metro 9-1-1 This responsibility was consigned to the gate guard 5. The Bellc Plant did not use the construction materials recommended by a corporate expert the P3H standard CGA or the HTM manual for phosgene hoses even though the 2006 second HTM audit recorded it as an observation 5.0 Three Incidents in 33 Hours Because two incidents occurred in a relatively short period on Saturday January 23 2010 after the oleum release had been secured the Plant Manager convened a mecting of supervisors and roughly 10 managers and supervisors assigned to the Belle Plant Crisis Committee to discuss and initiate a safety pause the intent of which was to evaluate what the managers had seen and take appropriate steps to ensure safe operation Approximately 10 managers are part of the Crisis Committee and after a debriefing other supervisors and managers were advised that a safety pausc would be conducted Where shut possible processes would be shut down to allow the discussion and in those plants that could not be down employees were expected to participate as best they could The Plant Manager assigned the Area Manager for the SLM and F3455 units who was part ofthe Belle Plant Crisis Committee to contact supervisors and managers and request that they come to the plant to participate in planning a plant safety pause These calls went out at about 11:00 a.m. and supervisors and managers started arriving at the plant at about noon At about 2:00 p.m. shortly after the planning for the safety pause began the group heard a radio call advising the plant of a medical emergency In response to the Plant Manager's inquiry it was learned a worker had been exposed to phosgene in the SLM unit making it the third incident in about 33 hours at the facility In a striking similarity of events and activitics after two release incidents at the Honeywell Baton Rouge facility in July 2003 upper management ordered the entire plant to shut down and review all facility 88 - STAFF DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD _ E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 operations prior to start During this safety stand down a third incident occurred where an employee was exposed to hydrofluoric acid during clean of an area in the plant The objective of both shutdowns in these cases was to get the attention of the workforce acknowledge that the occurrence of incidents was unacceptable and to recommit to the two companies respective core values of adhering to health and safety guidance One common element was that both companics initiated safety down activities after the string of incidents started in their respective plants Another common theme was the precursor or miss events preceding actual incidents At the Belle plant even on though investigations were conducted miss investigations were not immediately responded to weekends including the near catastrophic failure of a separate phosgene transfer only hours earlier Management at all levels are responsible for fostering an atmosphere of trust openness and encouragement of reporting misscs and incidents as failure to do so could result in reporting of miss events CCPS 1992 Despite these efforts to address the cause of the string of incidents at the Belle plants a fatal incident occurred The examination of corporate oversight of safety management systems and corporate safety culture has been conducted as part of another CSB investigation of the BP Texas City incident in 200554 and a blue ribbon panel of experts chaired by former Secretary of State James A. Baker was convened as the result of an urgent recommendation from that same investigation The Report of the BP U.S. Refineries Independent Safety Review Panel While not indicating that the safety culture was irretrievably broken at the Belle facility perhaps within the DuPont Corp. events before and after the string of incidents in late January 2010 suggest that the safety culture has shifted is not operating as it has 53 2003-13 Iloneywell Iloneywell 54 CSB 2005-04 2007 89 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 historically and could benefit from an extensive examination of all facets of the safety culture both within the facility and extending throughout the corporation 5.0.1 Additional DuPont Incidents About 8 months after the series of incidents at the Belle plant triggered this investigation another . significant release occurred At about 4:00 p.m. on September 21 2010 DuPont Belle plant personnel discovered a methanol leak in a heat exchanger in the methylamines production unit while conducting regular sampling of the plant's water effluent stream More than 160,000 pounds of methanol were estimated to have been released into the Kanawha River over a 24 hour period This incident occurred when pressure on the process side of a heat exchanger was increased to a pressure greater than the steam condensate side of the process After troubleshooting operators suspected a leak on the process side of the heat exchanger and increased steam pressure until samples of the cffluent stream confirmed that the lcak had stopped No employee or community injuries were recorded as a result of this release _ Almost three months after the methanol release on December 3 2010 at about 2:23 a.m. a fume alert was sounded in the amines unit at the DuPont Belle WV facility announcing a release of monomethylamine MMA The release occurred while two opcrators senior operator with 34 years of experience at DuPont and a junior operator with a little over one year's experience in the facilitywere obtaining a sample of MMA a from rail car One operator received 1st and 2nd degree chemical burns to his face and one inhaled some of the escaping MMA in addition to receiving 1st degree chemical burns to his face Both were transported to Charleston Area Medical Center for hour treatment and observation and were released the following day CSB investigators returned to the Belle facility to conduct an assessment of this incident In examining the equipment one area of concern was the design of the valves used to isolate the sampling apparatus As configured during the sampling operation only a single block valve isolated the process from the sample container This is in contrast to industry standards which suggest the use of double block valves 90 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_ raft Report for Public Comment July 2011 and bleed vents to allow assurance that the sample piping is clear of hazardous material prior to disconnecting About 10 pounds of MMA are estimated to have been released during this incident and no complaints were received from the community At DuPont's Yerkes facility in Tonawanda NY the CSB conducted an assessment of a hot work incident that caused a fatality to a welder and an injury to his supervisor on November 9 2010. This incident was under investigation as this report went to publication but preliminary assessments indicated that hot work inspections were less than adequate including a failure to check the atmosphere in a tank that normally processed flammable material but that had connecting piping that could route flammable vinyl fluoride into the tank The workers were assigned to make repairs to the tank but prior to commencing comencing their work there is no record of DuPont using a portable gas detector to ensure that the tank being worked on was free of flammable material 5.1 Management Systems 5.1.1 Knowledge Management DuPont employees told the CSB investigators that many very knowledgeable Belle plant operations and maintenance workers had recently retired or are approaching retirement age From 2005 to the end of 2009 82 Belle Plant employees retired and 14 resigned The total number of employees at the Belle plant has dropped 13 percent 55 people over the last 5 years A loss of specific knowledge or corporate memory fade has contributed several incidents in industry CCPS 1995 as new hires cannot replace years of experience thus companies must train and supervise new staff until they acquire job competencies to work safely Experienced maintenance mechanics and technicians have valuable hands experience and knowledge of equipment essential to the safe operation of plant processes A worker in the Belle maintenance department told the CSB investigators that they reported to four different maintenance site leaders over 91 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THEJBulOy A20R1D1 E.I. DuPont de Nemours & Co. Draft Report for Public Comment the last 5 years prior to the January 2010 incidents Other employees expressed concerns that new hires spent too little time learning from veteran employees The CSB investigators reviewed and compiled workforce data from DuPont Belle organization announcements between January 2005 and June 2010 which listed all new hires transfers resignations and retirements that affected the Belle workforce Over the 4 years there were 85 retirements totaling Among 2,572 years of experience with an average of 30 years of service per employee the 85 20 were from the maintenance department contributing to a loss of 713 total years of knowledge and experience Table 6 DuPont Belle Workforce 2005 to 2009 Retirements Years experience at Belle | Maintenance 20 Total 85 713 2,572 New hires Years experience at Belle Maintenance 10 0 0 Total 101 Table 6. Sum of Belle plant retirements and new hires from 2005 to 200955 In addition to the 85 retirements there were 14 resignations and 14 transfers to other sites The Belle plant hired 101 new employees over that year period and 8 DuPont employces transferred to Belle from other sites Though the overall proportion of new to departing employees has remained consistent a significant reduction of employees with an average of 30 years of experience working on the Belle site contributes to a loss of institutional and specific knowledge 55 This does not include interns ops special assignments or leaves of absence 92 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 In the case of Belle a significant population of employees is retiring with a great deal of process knowledge that is lost if not properly maintained This is an issue for industry in general as an entire generation of baby boomers approaches retirement In January 2011 DuPont announced plans to hire 150 employees at Belle over the next few years to compensate for the number of retiring workers 5.1.2 Hierarchy of Controls The Hierarchy of Controls is a method generally recognized and used by health and safety professionals to control workplace hazards The National Safety Council NSC developed the Hierarchy of Controls in the 1950s and Congress later adopted and enacted it into the Occupational Safety and Health Act of 1970 The Hierarchy of Controls Figure 17 demands the use of higher engineering and administrative controls to eliminate hazards When those operations are not feasible a PPE program must be implemented Figure 17. Hierarchy of Controls DuPont recognized the notion of eliminating hazards in the early 1900s as the preferred method beyond education and protection However operating procedures for the SLM phosgene cylinder feed system relied primarily on work practices and PPE to protect operators from the exposure hazards on the day of DRAFT STAFF - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD Comment July 2011 Report E.I. DuPont de Nemours & Co. Draft for Public the incident Other facilities within DuPont and in the chemical industry have engineering controls in place for similar phosgene cylinder operations 5.1.2.1 Design and Engineering Controls for Phosgene Cylinders In Geigy 1984 employees at the Corp. published a technical paper about the safe handling of phosgene in chemical processing specific to the operation of ton phosgene cylinders cylinders Alspach et al 1984 Geigy now part of BASF had a facility in Toms River NJ where two ton cylinders of phosgene fed a chemical process Similar to DuPont the cylinders connected to the process through PTFE hoses with a stainless steel overbraid induced with nitrogen to drive liquid from the cylinders At the Geigy plant a transparent isolation chamber enclosed the cylinder valve connections and operators opened and closed valves while standing outside the enclosure extending their arms though rubber arms and gloves that were part of enclosure The enclosure continuously vented to a caustic scrubber and acted as a barrier between the operator and any potential phosgene vapors present near the cylinders The phosgene area had phosgene analyzers to continuously monitor and alarm if concentrations exceeded a defined set point At high concentrations alarms would automatically alert the production building plant guards and adjacent roadways and buildings with flashing lights and audible warnings At the Belle facility phosgene rcadings on the analyzers activate alarms in the control room but DuPont relies on the operator to notify personnel in the unit and the rest of the plant By automating the phosgene analyzer alarm system to activate notifications plant Geigy eliminated the reliance on work practices to notify and protect personnel 5.1.2.2 Phosgene Handling at the DuPont Mobile AL Plant The DuPont Mobile plant in Mobile AL uses the same ton phosgene cylinders as Belle for its agricultural chemicals process The Mobile process has three cylinders on weigh scales transferred to the different process through similar PTFE flexible hoses with a stainless steel overbraid made by a 94 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 manufacturer The Mobile hoses are 18 inches shorter and have a greater maximum operating temperature and pressure than those used at Bellc A hose distributor supplies both hoses from the manufacturer to each site The phosgenc cylinders and weigh scales at the Mobile plant are housed in an enclosed room TheThe cylinder room vents to an emergency scrubber that pulls a slight negative pressure on the room and scrubs air before venting to the atmosphere The scrubber is designed to capture vapors from a release of an entire cylinder Operators at the Mobile plant enter the phosgene cylinder area under the same PPE requirements as Belle for isolating and changing cylinders hard hat steel shoes safety glasses and phosgene dosimeter However at Mobile to capture and scrub phosgene vapors in the event of a release the operator turns on the emergency scrubber and pump before entering the enclosure Like Belle Mobile has phosgene analyzers located in and around the unit to continuously monitor concentrations At Mobile alarms in the cylinder enclosure activate local audible alarms inside the enclosure and a flashing light outside to alert employees If no operators are present in the enclosure when the alarm activates the emergency vent scrubber automatically starts The Belle plant analyzer in the phosgene shed had no audible alarm to alert personnel in the area instead Belle plant procedures require the board operator to notify personnel of the release and only operators at the phosgene shed can activate the switch for the warning light The emergency scrub system and automated alarms at Mobile are examples of higher controls that protect workers from hazards Mobile has automated alarms where Belle relies on operator action to initiate alarms to warn personnel of a suspected or actual release Mobile implemented the scrubber system an example of an engineering control to manage the concentrations of phosgene in the cylinder enclosure in the event of a release The Belle plant phosgene shed design allows only for natural ventilation to carry unwashed phosgene gases that can potentially harm personnel in or around the shed and possibly enter the community STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_ raft Report for Public Comment July 2011 5.1.2.3 Safety in Design Issues Safety considerations in the equipment design stage eliminate the need for companies to retrofit existing existing process cquipment or implement administrative or PPE programs to protect workers and the environment In addition to the SLM unit the CSB also identified a lack of safety and health considerations during the design and construction phases of the F3455 and SAR units In the F3455 unit engineers did not design the control system alarms so that operators could distinguish between a failed battery and activation of a rupture disc burst sensor which resulted in nuisance alarms for the rupture disc on the methyl chloride vent linc Instead of addressing the reliability issues associated with the frequently failing scnsor management decided to wire the burst sensor to electric power so that low batteries were no longer causing frequent and false alarms However operators were not retrained to respond to the alarm causing them to disregard the alarm during the F3455 unit maintenance activity consequently the unit restarted with a failed rupture disc CSB investigators also noted safety in design issues with the presence of the weep hole on the methyl chloride vent line upstream of the rupture disc assembly DuPont engineering standards require that drainage holes be placed upstream of the relief devices on vent lines to allow for drainage and prevent liquid from lodging in the discharge side of the rupture disc However the location of the weep hole allowed toxic vapors from the methyl chloride vent line to enter the F3455 building where concentrations could accumulate to dangerous levels DuPont could have designed the vent line so that the weep hole would drain to the exterior of the facility where vapors would dissipate into the atmosphere in the event of a burst rupture disc In the SAR unit DuPont chose copper steam tracing to prevent the oleum sample line and other process lines from freezing even though steam tracing is not the preferred method for oleum service Dillon 1997 Steam tracing can create hot spots that result in an uneven heat distribution in the oleum sample line which accelerate corrosion The use of steam tracing in the SAR unit exacerbated the corrosion incident in the oleum sample line resulting in a significant release of oleum Had the SAR unit design 96 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_ raft Report for Public Comment July 2011 engineers called for electric tracing or replaced the steam tracing the larger hole in the sample line might not have formed 6.0 Regulatory Analysis 6.1 Occupational Safety and Health Administration OSHA 6.1.1 Process Safety Management Program The OSHA PSM Standard 29 CFR 1910.119 requires employers to minimize or prevent the consequence of catastrophic incidents involving highly hazardous chemicals by applying clements of the PSM regulation to covered processes PSM applies to processes using or producing any of the 137 listed toxic chemicals at or above threshold quantities and processes with flammable liquids or gases onsite in quantities of 10,000 pounds or more in one location The PSM Standard applies to the SLM and F3455 units because they contain listed toxic chemicals in excess of the threshold quantities TQ specified in the regulation A Process Hazard Analysis PHA is one of the 14 elements in the PSM Standard requiring the employer to assess all covered processes to identify evaluate and control hazards involved in the processes by using one or a combination of several methodologies listed in the regulation Furthermore the standard requires the PHA to address e the hazards of the process engineering and administrative controls applicable to the hazards and their interrelationships such as appropriate application of detection methodologies to provide early warning of releases | * consequences of failure of engineering and administrative controls 56 29 CFR 1910.119 97 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours Co. D_ raft Report for Public Comment July 2011 In the 2009 PHA for the SLM unit the team did not assess the potential for a phosgene release from a failed transfer hose duc to corrosion or thermal expansion but did consider these issues in process equipment downstream of the hoses The team identified engineering and administrative controls such as the PM system and adherence to SOPs to reduce the likelihood of a phosgene release from this equipment However the team did not assess the consequences caused by the preventative maintenance system failing to initiate hose replacements at the proper frequency In its 2009 PHA for the SLM unit an audit team did not address phosgene thermal expansion in the liquid transfer hose consequently in July | 2010 OSHA a issued serious violation to DuPont The PSM Standard also requires employers to conduct an MOC for all modifications to process chemicals technology equipment and procedures and changes to facilities that affect a covered process The procedures are mcant to address the following prior to the change The technical basis for the proposed change * Impact of change on safety and health e Modifications to operating procedures fi Necessary time period for the change Authorization requirements for the proposed change The MOC also requires that the employees in operations and maintenance affected by the change be informed of the change and trained prior to the start of that process Investigators found MOC program deficiencies for modifications made to critical equipment on both the F3455 and SLM units On the F3455 unit DuPont's MOC process approved a design for the rupture disc alarm system that lacked sufficient reliability to minimize the release of flammable methyl chloride The changed the rupture disc burst sensor on the methyl chloride vent line from battery power to electric 7 29 CFR 1910.119 98 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 to eliminate battery failure but failed to assess the reliability of the burst sensors individually The MOC purpose did not evaluate the basis of the modification to verify that it met the intended of process eliminating nuisance alarms caused by battery failure DuPont did not perform an MOC review for the changes to the maintenance system that handled the phosgene hose replacements on the SLM unit The modification made to the phosgenc hose replacement work orders kept the system from generating a new work order thus extending phosgene hose use beyond its planned service life DuPont stated that knowledge of the change was limited to only a few key SAP users but they lacked training necessary to recognize its impact on hose replacement frequency 6.1.2 Compressed Gases The OSHA Standard for Compressed Gascs 29 CFR 1910.101 applies to employers that handle store and use compressed gases in cylinders portable tanks or tank cars The standard includes requirements for cylinder inspections safety relicf devices storage and handling of compressed gas cylinders and requires employers to handle and store cylinders in accordance with CGA pamphlet P 1965 Safe Handling of Compressed Gases in Containers Regulation In the 41 years since OSHA adopted the reference standard as part of the Compressed Gas | CGA P has been revised 10 times The current 2008 version of the P Standard is more comprehensive than the adopted 1965 version The 1965 version does not list chemicals by hazard class and contains only specific safety information for flammable and poisonous gases The current version lists 82 chemicals that fall into the primary toxics category whereas the 1965 version lists only 13 poisonous gases as defined by the Interstate Commerce Commission ICC The 1965 standard contains the same general information as the current version but lacks the detailed guidance for facility siting 58 A regulatory body abolished in 1995 some of whose responsibilities were transferred to the Surface Transportation Board an agency within the U.S. Department of Transportation 99 OR DISAPPROVAL BY THE BOARD STAFF DRAFT - SUBJECT TO CHANGE APPROVAL July 2011 E.I. DuPont de Nemours & Co. Draft Report for Public Comment chemicals emergency response and safety information specific to various types of stored in compressed outdated gas cylinders The 1965 version includes obsolete and references and lacks references to to the establishment of OSHAOSHA With respect to applicable OSHA regulations regulations as it was published prior release investigation had OSHA adopted the current version of the the issues identified in the phosgene have been accountable for more phosgene storage engineering controls CGA P Standard DuPont would of NFPA 55 and other consensus standards referenced in the standard by the incorporation 6.1.3 Inspection History OSHA is authorized under the Occupational Safety and Health Act of 1970 to conduct workplace that employers are providing a safe and healthy work environment by complying inspections to ensure with standards issued by the agency A range of inspection categories establish a system of prioritics e Imminent Danger Catastrophes and Fatal Accidents e Complaints and Referrals e Programmed Inspections .. Follow Inspections reveals that three planned inspections were conducted at the Bellc A review of OSHA's inspection history unprogrammed facility in 1982 1984 and 1993 in addition to one inspection in 1981. Even from 1993 through 2010 two inspections in 1995 and one in though no planned inspections took place 2004 were the result of complaints all of which were closed OSHA cited DuPont for a serious violation of Section a of in a series of incident inspections not conducted for all sections of the Occupational Safety and Health Act alleging that inspections were worksite when an employer is being 59 An unprogrammed inspectaicocnicdaenntococrurrefaetrarael mAnpyloothyereermployer with workers on: the worksite is subject inspected because of a complaint to inspection 100 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. E.I. DuPont de Nemours Co. Draft Report for Public Comment July 2011 oleum piping based on prior leak incidents at the SAR unit Citations for numerous violations of the PSM60 Standard were also issued OSHA cited DuPont for serious violations including the company's failure to properly inspect piping used to transfer phosgene perform a thorough PHA for its phosgene operation and train workers on hazards associated with phosgene The OSHA PSM Standard 29 CFR 1910.119 requires employers to prevent or minimize the consequences of a catastrophic release of highly hazardous chemicals as well as flammable liquids and gases Phosgene and methyl chloride are listed chemicals and the SLM and F3455 units processed more than the TQ so the PSM Standard applied Proposed penalties for all violations totaled 43,000 6.2 Environmental Protection Agency The EPA Risk Management Program RMP regulation 40 CFR 68 mandated by Section 112 of the Clean Air Act Amendments of 1990 regulates regulates the use of highly hazardous chemicals at fixed facilities Its purpose is to prevent accidental offsite relcases of listed substances and ensure that a company and the community are able to respond effectively in the event of a release The regulation applies to facilities using or storing regulated substances exceeding the TQ specified in the EPA regulations Each covered process is required to be designated as one of three prevention program levels based on offsite consequence analyses incident history and PSM program applicability Program 1 is the lowest simplest management program ProgramProgram 2 is an intermediate management program with added elements and basic documentation requirements covered processes cannot be designated program 3 Program 2. Program is the highest management program most covered processes fall into with detailed record retention criteria and all Program 3 which requires a rigorous management program PSM program elements All PSM program activities and records are directly applicable to the Program 3 60 PSM is a regulation promulgated by OSHA A process is any acotfivHitHyCosr caosmdbeifnianteidobnyoO f aScH tiA vitainesd itnhcelEudPinAg any use storage manufacturing handling or the site movement 101 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD ; E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 regulatory activities and all RMP covered chemicals at the DuPont Belle plant fall into Program 3 requirements Table 7 Anhydrous Ammonia Phosgene Sulfur Trioxide ; Formaldehyde Oleum Methyl Chloroformate Flammables Flammables Dimethylamine Methylamine Methyl Ether Ethylamine 70 aqueous 10,000 500 10,000 15,000 10,000 5,000 : 10,000 10,000 * 10,000 10,000 Table 7. DuPont Belle covered chemicals and threshold quantities Each covered process must undergo a hazard assessment 40 CFR 68 Subpart B in which the owner is required to prepare a worst case release scenario and an alternative releasc scenario for each covered process Different analysis criteria apply based on whether the covered chemical is toxic or flammable The hazard assessment also requires inclusion of the five year accident history The results of the hazard assessment along with other pertinent information for each covered process must be submitted to the EPA The Risk Management Plan 40 CFR 68 Subpart G is submitted clectronically and must be periodically updated The DuPont Risk Management Plan submission for 2010 had no accident history to report In November 2003 the EPA Region III Chemical Accident Prevention Program Program audited the Belle facility to ensure compliance with the EPA RMP The EPA audited the million gallon ammonia storage tank Risk against the RMP requirements for Program Program 3 management programs and the Management Plan documentation DuPont submitted The audit covered all RMP elements and emergency response and site security The EPA audit report submitted to DuPont in December 2003 contained nodeficiencies or 102 CHANGE STAFF DRAFT - SUBJECT TO APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 recommendations for improvement The November 2003 RMP audit is the only one conducted at the Belle Plant prior to the January 2010 incidents 6.3 State Hazardous Chemical Release Prevention Program On January 20 2011 the CSBs Bayer CropScience CropScience investigation issued a recommendation to the Charleston Health Department to establish a Hazardous Chemical Release Prevention Program with the objective of enhancing the prevention of accidental releases of highly hazardous chemicals and optimizing responses in the event of their occurrence In light of its proximity in the Kanawha Valley the series of incidents at the DuPont Belle WV facility support the plant's inclusion in such a program The implementation of the new program would incorporate several key guidelines applicable to chemical plants operating in the Kanawha County The Belle facility is one of 13 facilities in the county that report EPA Risk Management Program covered chemicals assigned as Program level 3 that could fall under the auspices of the program The recommendation to the Charleston Health Department stated Specifically the Bayer report recommends that the Director of the Charleston Health Department establish a Hazardous Chemical Release Prevention Program to enhance the prevention of accidental releases ofhighly hazardous chemicals and optimize responses in the event of their occurrence In establishing the program study and evaluate the possible applicability ofthe experience ofsimilar programs in the country such as those summarized in Section 5.3 ofthis report As a minimum Q. Ensure that the new program 1. Implements an effective system ofindependent oversight and other services to enhance the prevention ofaccidental releases ofhighly hazardous chemicals 2. Facilitates the collaboration ofmultiple stakeholders in achieving common goals of chemical safety and STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.~ . DuPont de Nemours & Co. Draft Report for Public Comment July 2011 3. Increases the confidence of the community the workforce and the local authorities in the ability ofthe facility owners to prevent and respond to accidental releases ofhighly hazardous chemicals b Define the characteristics ofchemical facilities that would be covered by the new Program such as the hazards and potential risks of their chemicals andprocesses their quantities and similar relevantfactors c Ensure that coveredfacilities develop implement and submit for review and approval 1. Applicable hazard andprocess information and evaluations 2. Written safety plans with appropriate descriptions ofhazard controls safety culture and human factors programs with employee participation and consideration of the adoption ofinherently safer systems to reduce risks 3. Emergency response plans and 4. Performance indicators addressing the prevention ofchemical incidents d Ensure that the program has the right to evaluate the documents submitted by the covered facilities and to require modifications as necessary e Ensure that the program has entry to coveredfacilities and access to requisite information to conduct periodic audits ofsafety systems and investigations ofchemical releases Establish a system offees assessed on covered facilities sufficient to cover the oversight and related services to be provided to thefacilities including necessary technical and administrative personnel and g Consistent with applicable law ensure that the program provides reasonable public participation with the program staff in review offacility programs and access to 1. The materials submitted by coveredfacilities e.g. hazard evaluations safety plans emergency response plans 104 APPROVAL STAFF DRAFT - SUBJECT TO CHANGE OR DISAPPROVAL BY THE BOARD _ E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 2. The reviews conducted by program staffand the modifications triggered by those reviews 3. Records of audits and incident investigations conducted by the program 4. Performance indicator reports and data submitted by the facilities and 5. Other relevant information concerning the hazards and the control methods overseen by the program Ensure that the program will require a periodic review ofthe designated agency activities and issue a periodic public report ofits activities and recommended action items 61 2008-1 Bayer CropScience STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 7.0 Recommendations The CSB makes recommendations based on the findings and conclusions of its investigations Recommendations are made to parties that can effect change to prevent future incidents which may include the companies involved industry organizations responsible for developing good practice guidelines regulatory bodies and organizations that have the ability to broadly communicate lessons learned from the incident such as trade associations and labor unions Phosgene Exposure The Occupational Safety and Health Administration OSHA | 2010-06-1 Revise the OSHA 29 CFR 1910.101 General Industry Standardfor 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 failsafe shutdown valves gas detection and alarm systems piping system components and similarly relevant layers of protection 2010-06-1 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 106 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 1. NFPA 55 - Compressed Gases and Cryogenic Fluids Code 2010 2. CGA P Safe Handling of Compressed Gases in Containers 2008 3. CGA E Standardfor Flexible PTFE Pigtailsfor Compressed Gas Service 2010 4. ASME B31.3 Process Piping 2008 DuPont Belle Plant 2010-06 Improve the existing maintenance management by Supplementing the computerized system with sufficient redundancy to ensure tracking and timely scheduling of preventive maintenance for all critical equipment ~e Conducting Conducting Management of Change MOCs reviews for all changes to preventive maintenance orders for all critical equipment in the computerized maintenance management system 2010-06 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 9-11 dispatchers 2010-06 Revise the miss reporting and investigation policy and implement a program that includes the following at a minimum e Ensures employee participation in reporting investigating analyzing and recommending corrective actions as appropriate for all misscs and disruptions of normal opcrations 107 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 . Develops and encourage use of an anonymous electronic and hard copy miss reporting process for all DuPont Bellc site employees e Establishes roles and responsibilities for ownership management execution and resolution of recommendations from incident or miss investigations at the DuPont Belle facility Ensures that the miss investigation program requires prompt investigations as appropriate and that results are promptly circulated to well suited recipients throughout the DuPont Corporation Ensures that this program is operational at all times e.g. during night weekend and holiday shifts E.I. DuPont de Nemours and Co. Inc. 2010-06 Revise safeguards for phosgene handling at all DuPont facilities by . Requiring that all indoor phosgene production and storage areas as defined in NFPA 55 have secondary enclosures mechanical ventilation systems emergency phosgene scrubbers and automated audible alarms which are at a minimum consistent with the standards of NFPA 55 for highly toxic gases * Prohibiting the use of hoses with permeable cores and materials susceptible to chlorides corrosion for phosgene transfer * Conducting annual phosgenc hazard awareness training for all employces that handle phosgene including the hazards associated with thermal expansion of entrapped liquid phosgene in piping and equipment 108 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 2010-06 Conduct a review of all DuPont units that produce and handle phosgene At minimum this review shall observe and document specific practices for engineering controls materials of construction PPE procedures maintenance emergency response release detection and alarms and utilize information from sources outside of the company to develop and implement consistent company policies for the safe production and handling of phosgene 2010-06 For each DuPont facility that uses but does not manufacture phosgene site Conduct a risk assessment of manufacturing phosgene site against the current configuration Communicate the findings of each assessment to compile recommendations applicable to all DuPont phosgene delivery systems * Implement these recommendations Compressed Gas Association Inc. 2010-06-1 Revise CGA P Safe Handling of Compressed Gases in Containers to include specific requirements for the storage and handling of highly toxic compressed gass including enclosure ventilation and alarm requirements at least as protective as Section 7.9 Toxic and Highly Toxic . Gases NFPA 55 Compressed Gases and Cryogenics Fluids Code 2010-06 Revisc CGA P Safe Handling of Compressed Gases in Containers to incorporate by reference the CGA E Standard for Flexible PTFE Pigtails for Compressed Gas Service 109 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_ raft Report for Public Comment July 2011 American Chemistry Council Phosgene Panel 2010-06-1 Revise the Phosgene Safe Practice Guidelines Manual to incorporate the following Advise against the use of hoses for phosgene transfer that are constructed from permeable cores and materials subject to chlorides corrosion Include guidance for the immediate reporting and prompt investigation of all potential near miss releases of phosgene Methyl Chloride Release E.I. DuPont de Nemours and Co. Inc. 2010-06 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 2010-06 Revise the DuPont PSM standard to require confirmation that all safety interlocks arc in proper working order e.g. not in an active alarm state prior to the start of all Hazard Process facilities 2010-06 Recvaluate and clarify the DuPont corporate Management of Change MOC policies to ensure proper identification and use by staff of the distinctions between subtle and full changes and train 110 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 the appropriate personnel in the proper application of the distinctions and any changes in the policy 111 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 By the U.S. Chemical Safety and Hazard Investigation Board Dr. Rafacl Moure Chair John Bresland Member Mark Griffon Member William Wark Member Date of Board Approval William Wright Member 112 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment ; July 2011 References Alspach .; Bianchi R.J. Safe Handling ofPhosgene in Chemical Processing Operations Progress Vol 3 No. 1 January 1984 American Chemistry Council Phosgene Pancl Phosgene Safe Practice Guidelines Manual American Chemistry Council Washington DC 2006-2009 Center for Chemical Process Safety CCPS Guidelines for Hazard Evaluation Procedures American Institute of Chemical Engineers Center for Chemical Process Safety New York NY 1992 Center for Chemical Process Safety CCPS Guidelines for Safe Process Operations and Maintenance American Institute of Chemical Engineers Center for Chemical Process Safety New York NY 1995 Center for Chemical Process Safety CCPS Investigating Chemical Process Incidents American Institute of Chemical Engineers Center for Chemical Process Safety New York NY 1992 Collins et al Results From the US Industry Phosgene Surveillance The Diller Registry American College of Occupational and Environmental Medicine Article JOM201162 January 2011 Compressed Gas Association Inc. CGA Safe Handling of Compressed Gases in Containers P Eleventh Edition Compressed Gas Association Inc. Chantilly VA Compressed Gas Association Inc. CGA Standardfor Flexible PTFE Pigtails for Compressed Gas Service E Fourth Edition Compressed Gas Association Inc. Chantilly VA Dillon C.P. Materials Selector for Hazardous Chemicals Concentrated Sulfuric Acid and Oleum Vol 1 Materials Technology Institute ofthe Chemical Process Industries Inc. MTI St. Louis MO 1997 113 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 Klein J.A. Two Centuries ofProcess Safety at DuPont Process Safety Progress American Institute of Chemical Engineers March 2009. pp 114-122 Lees Frank P. Loss Prevention in the Process Industries 3rd ed Elsevier Butterworth Burlington MA 2005 Mottle W.J Long J.F Morrison D.E. Industrial Safety is Good Business John Wiley and Sons New York NY 1995 National Fire Protection Association NFPA 55 - Compressed Gases and Cryogenic Fluids Code National Fire Protection Association Quincy MA 2010 USGOV National Archives and Records Administration Archival Research Catalog ARC Identifier 5519.1 Series DOCUMERICA The Environmental Protection Agency's Program to Photographically Document Subjects ofEnvironmental Concern compiled 1972-1977 1972-1977 1972-1977 Sittig M. Handbook of Toxic and Hazardous Chemicals and Carcinogens 5th ed William Andrew Norwich New York NY 2005 U.S. Chemical Safety and Hazard Investigation Board Investigation Report Chlorine Release July 20 2003 Contaminated Antimony Pentachloride Exposure July 29 2003 Hydrogen Fluoride Release August 13 2003 Honeywell International Inc. No. 2003-13 2005 U.S. Chemical Safety and Hazard Investigation Board Investigation Report Pesticide Chemical _ Runaway Reaction Pressure Vessel Explosion Bayer CropScience LP August 28 2008 No. 2008-08 2011 114 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 Appendix A Three Event Logic Tree STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment _- July 2011 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 117 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 119 STAFF - DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Appendix B Historical and Event Timeline ROE ake f EAoBnt Meat Deas RB | SRAIRS Bets BRT AbaE tie Offener ; 0175902 0175902 sombrerons Be WP dopant ob 120 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 Appendix C SAP Program The DuPont Belle Plant uses the SAP R Plant Maintenance module to schedule preventive maintenance PM and repair work and track maintenance costs Many companies use a Computerized Maintenance Management System CMMS such as SAP Plant Maintenance for this purpose In particular companies use the CMMS to schedule PM to ensure that critical equipment will function properly This appendix gives additional detail on scheduling and completing PM jobs in SAP and why SAP failed to issue work orders to change the hoses PM keeps plant equipment functioning properly and to minimize the likelihood of a phosgene hose corroding and rupturing DuPont created a PM job in SAP to replace the hoses regularly The SAP Plant Maintenance module automatically schedules the job at the frequency DuPont designates In the SAP Plant Maintenance module DuPont created an equipment number for the physical equipment and an electronic document or maintenance plan to store all information about the job The maintenance plan is a complex form with many fields One field confirmation required can be clicked on or off If this button is off SAP schedules the first hose change job waits the specified time indicated in the interval field such as 30 days and then automatically schedules another hose change job Thus when the button is off by default SAP schedules hosc change every 30 days which for critical equipment subject to intermittent operation is usually the desired option CCPS 1995 If the button is on SAP requires that someone confirm that the hoses are changed Thus if the confirmationrequired button is on SAP schedules hose changes 30 days after the previous change but opens the possibility that no one will confirm the completion date in the system creating a scenario where SAP will not schedule the hose change at the determined interval 121 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Despite the computer and administrative controls that SAP and DuPont provided in late 2006 someone changed the confirmation field for the phosgene hoses from off to -or requiring confirmation These administrative controls highlight gaps that contributed to the fatality When an SAP user account is created access is provided according to the work role profile that DuPont establishes for the user Only certain users would have had access to change the data in the maintenance plan for the phosgenc hoses Programmers are super users who have higher level access than normal users and can write batch programs to change data forms and other SAP computer code that affects multiple pieces of equipment and multiple plant sites at once As an administrative control at DuPont programmers write computer . code in a development box to prevent creating problems in the SAP production box that normal users sandbox see When the programmer completes the code or downloads it to the the process owners test the change see that it performs as requested or if the change creates a problem After the process owners approve the change the programmer runs the code or downloads it to the production box and makes the actual change for regular users These computer controls help ensure the integrity of the production box for regular users but were not enough to prevent the Belle Plant fatality The CSB discovered evidence relevant to the SAP change e The SAP work role controls allow programmers process owners and specific Belle Plant employees to access the phosgene hose maintenance plan In 2005 the Belle Plant upgraded from SAP R to the newer SAP R partly because SAP R included the new PM module Converting from the previous CMMS to the SAP PM module was a large project that involved site personnel who verified the data in spreadsheets before contract SAP programmers uploaded the data into SAP 122 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. _Draft Report for Public Comment July 2011 Based on this evidence the most likely scenario is that a programmer accidentally changed the confirmation field for the phosgene hoses The change may have been an unintended effect of a valid change that DuPont requested or may have been an accidental change that went undetected 123 STAFF - DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Appendix D Phosgene Release Calculations DuPont initially estimated that 0.7 pounds of phosgene released from the riverside cylinder hose and associated valving at the time of the rupture After performing more detailed calculations DuPont revised the estimated release quantity to 2.0 pounds of phosgene The CSB performed calculations and modeled the release to verify the phosgene release quantity Process Equipment Figure 18 shows the hose and piping dimensions and the maximum amount of phosgene present in the piping system associated with the hose failure | Steelbase ot1hi.n0chpipe Figure 18. The hose and piping system that supplied phosgene for the release 1 Area of a circle -2 r or -2 = ft = ft 2 Volume of a cylinder is equal to the area of the circle multiplied by the length L ft ( L ft 3 To determine weight multiply by the density p ( ( L = p ft lbs fee = Ibs 124 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 The density of phofstgene = 87.55 given that the ambient temperature was 8 C Phosgene containedin the inch pipe D 1.05 in = 0.0875 ft L 16 in +22 +22 in= 38 in 3.17 ft Thus ( L 0.0875 87.5 = 1.67 lbs Phosgene contained in the inch pipe D = 0.622 in = 0.052 ft 3.5 = 10 = 0.83 ft Thus 2 = 0.052 * .83 = 87.5 0.154 lbs Phosgene contained in the inch valve D = 0.in0 = 05 .0522 ft length valve 5.5= 1.83 in 1/3 the full 1.83 in = 0.15f3t of the since it was closed Thus x 2 P 0.052 .153 87.5 = 0.028 lbs contained in the inch valve Phosgene = 1.05 in = 0.087f5t D 6.5= 2.17in 1/3 the full length of the valve since it was closed 2.17 in = 0.18f1t Thus TE 2 = 0.0875 .181 87.5 = 0.095 lbs Phosgene contained in the quarter inch four foot long hose 0.25 = 0.021 ft 48 = ft Thus 2 = 0.021 + * 0.=1 0.2 12 lbs The sum of phosgene in the system 1.67 + 0.154 + 0.028 + 0.095 + 0.12 = 2.067 lbs of phosgene released STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.~ . DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 Phosgene Dose Calculation Using the phosgene release quantity above the CSB calculated the approximate concentration of phosgene the fatally injured operator was exposed to Assuming the operator was three feet away from the release and the phosgene instantly vaporized in a spherical fashion from the point of release the operator would have received a lethal dose of phosgene in less than a tenth of a second This calculation will assume homogeneous concentration within the spherical phosgene gas cloud g Air molecular weight = 28.97 mol62 mol Phosgene molecular weight = 98.9161 mol Volume of a sphere with 3 ft radius = 1 = 113.1 ft3 453.593 g phosgene 1 mol phosgene gas 22.414 L phosgene gas6 2.067 lbs phosgene * * * 1 lb phosgene 98.9161 g phosgene 1 mol phosgene gas 1 ftphosgene gas * = 7.5 ftphosgene gas 28.3168 L phosgene gas 7.5 ft Phosgene concentration in the sphere uniform dispersion = 113.0973 ft = .0661 or 6.61 volume phosgene effectively = 6.63 mol phosgene Average total molecular weight of gas phosgene - air mix = ( 98.9161 mol phosgene * 6.63 + ( air 28.97 mol * 100 - 6.63 = 33.69 33.69 gas in the sphere Weight percent of phosgene = 6.63 mol phosgene 98.9161 g phosgene phosgene mol gas 33.6 gas 0.195 or 19.5 wt phosgene in the sphere or 195,000 ppm ppm * min Where a lethal dose is estimated to be 300 ppm * min Collins et al 2011 = 195,000 ppm 60 seconds * = minute 1 minute 0.09 seconds to recieve a lethal dose of phosgene 62 A mole mol of any substance has a mass g exactly equal to that substance's molecular mass Mol is a base unit in the International System of Units for the amount of substance 63 Ideal gas law STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours Co. Draft Report for Public Comment July 2011 Vapor Cloud Dispersion Modeling The CSB used the ALOHA Area Locations of Hazardous Atmospheres 5.4.1 program to model the - phosgene release based on the characteristics of the release and atmospheric conditions on the afternoon ofJanuary 23 2010. The National Occanic and Atmospheric Administration NOAA and the U.S. EPA developed ALOHA to estimate the threat zones associated with hazardous chemical relcases from toxic plumes fires and explosions The user inputs chemical property and weather information and the program generates a defined release scenario that shows the concentration of toxic gases within a radius of the release source The following assumptions were used to model the phosgene release in ALOHA Atmospheric and Environmental Conditions Atmospheric temperature 50 Wind speed calm 1.5 m Wind direction from the north Humidity 66 Cloud cover scattered Surrounding terrain urban - Release conditions - Chemical Phosgene Amount released 2 pounds Release type instantaneous Height of release 4 feet The ALOHA program generated a display of concentration threat zones over a distance downwind from the source of the release Using the U.S. EPA MARPLOT program threat zones arc displayed over a satellite map of the area using a graphical information system GIS interface Figure 19 127 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. = Draft Report for Public Comment July 2011 Figure 19. ALOHA estimate of phosgene concentrations with MARPLOT GIS overlay The ALOHA program estimated threat for three user selected phosgene concentrations e ppm IDLH 0.2 miles from release source e 0.5 ppm odor threshold and phosgene alarm set point 0.3 miles from release source * 0.2 ppm ERPG 0.4miles from release source 64 ERPG is the concentration to which all could be exposed for up to one hour without experiencing or developing irreversible or other serious health effects or symptoms that could impair their abilities to take protective action -- -- --20--08 128 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 The release estimates from the ALOHA program are based on the weather conditions recorded at the Charleston Yeager Airport around the time of the January 23 2010 phosgene release but may not accurately represent atmospheric conditions at the plant The ALOHA program also does not consider the topography or terrain surrounding the plant The fence line monitors south and southwest of the phosgene shed recorded phosgene concentrations between 0 and 0.27 ppm suggesting phosgene vapor may have traveled south of the DuPont Belle plant fence line toward the river The ALOHA threat overlay in Figure 19 displays a model of the worst case release conditions indicating IDLH concentrations of phosgene could have been present on the Kanawha River shortly after the release and lower concentrations could have traveled across the river There were no reports of odors or exposure symptoms from the community on the afternoon of the phosgene release incident 129 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Appendix E Hazard Analysis for Phosgene Use at Belle Documents in this appendix are redactedfor confidentiality by black and white out List of Acronyms Abbreviations and Terminology dia flashing IHI LD50 MM PHI ppm diameter instantly vaporizing liquid Individual Hazard Index 50 lethal dose million old notation style Process Hazard Index parts per million 130 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Lebed. RE REIEE, : E.DU PONT DE NEMOURS &COMPANY ORF ONES BELLE WEST VIRGINIA25015 : ASRICULTURALPRODUCTSCEPARTMENT HELLE FLANT 901 QU PONT AVEM June 2 1980 1 PRELIMINARY eferences attached teno PHOSCENE PLANT PRELIMINARY PHOSCENE PHOSCENE Dated May to BELLE HEVICEN ASSESSMENT PRELIMINARY RISK 19 1988 HEVICEN Dated 3 AttachedMeno QUI A GOOD RISK PRESMUTER e 3) AttachedAttached Memo, TUE DatedAprila3 1988 risk and proposedproposed phosgene supply References 2 and 3 question the operations # Bel e plant as a means means of directing resources towards cost effective improvements insafety Please advise the writer if you have comments or suggestions 131 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 132 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_ raft Report for Public Comment July 2011 133 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.1 DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 134 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. D_ raft Report for Public Comment July 2011 136 STAFF DRAFT - SUBJECT TO CHANGE, APPROVAL, OR DISAPPROVAL BY THE BOARD E.}. DuPont de Nemours & Co. Draft Report for Public Comment July 2041 137 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 138 E.I. DuPont STAF DRAFT BAMIZZNZ de HoxProbable ; - \ Qhadie::) BERMoite Offsite- Nemours& SUBJECT ae ae Rees - 8.00019 Co. TO eted considered by Riaht to Be nit: - Draft CHANGE sei? np: 3.000 gl: Report for APROVLPublic Be Coment OR DISAPROVL BY THE July 139 201 BOARD STAFF DRAFT - SUBJECT TO CHANGE, APPROVAL, OR DISAPPROVAL BY THE BOARD E.1. DuPont de Nemours & Co. D_raft Report for Public Comment Jul2y 011 140 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 141 STAFF DRAFT - SUBJECT TO CHANGE, APPROVAL, OR DISAPPROVAL BY THE BOARD E.1. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 142 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 143 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 ESGINEERING ESGINEERING DERAR ENVERS Bor LENG IS THEPHI A GOOD RISK PARAMETER PARAMETER : The ched note challenges theuse of Be a good parameter parameter for risk criteria Kazards Evaluation 4 criterion a sort of sophisticated sophisticated < Ilion per life saved saved chemicaland IMIs without inevitablyinevitably lead 144 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours Co. _ Draft Report for Public Comment July 2011 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 146 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 147 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 148 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 149 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 OU PONT RISK CRITERIA CRITERIA I havenot thought so much much aboutcriteria since I was responsiblu 1 target because that the fik to worked coat us reducing that we write notes notes for using numbers criteria we were neversole to banda gray which whichsatisfied our nane could stand all the improvement done improvement prevent damage plant environment andreduce prevent outrage both to We make whatever improvements someone judges to be appropriate and no more more 150 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 151 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _ Draft Report for Public Comment July 2011 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 153 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 Appendix F Hard Pipe to Flexible Hose Transition Correspondence Documents in this appendix are redactedfor confidentiality by black and white out List of Acronyms Abbreviations and Terminology AgProducts dry phosgene engg spec , ESD SS The Agricultural Products Department of DuPont liquid phosgene without any water also called anhydrous phosgene engineering specification Engineering Services Division of DuPont stainless steel STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 157 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 160 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 161 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 162 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. D_raft Report for Public Comment July 2011 163 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E. DuPont Nemours & Co. _ Draft Report for Public Comment July 2011 164 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. Draft Report for Public Comment July 2011 Appendix G PHA Recommendation Delay Letter Documents in this appendix are redactedfor confidentiality by black and white out List of Acronyms Abbreviations and Terminology COCL2 FEL PM Rec Rx Phosgene Front loading Preventive Maintenance Recommendation Reactor 165 - STAFF DRAFT SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD for E.I. DuPont de Nemours & Co. _Draft Report Public Comment July 2011 Area Reviewed SLMFront End Recommendation ID 8 21 _ Original Due Date 12/31/05 12/31/05 New Due Date 12/31/06 Original Complete Recommaepnpdraoptriioante ProvideProvide Building PA Recommendation . mitigation tomultiple fatalities fatalities from the releaseof 2000 L vaporizer cylindercylinder phosgenpehosgene 21. Provide mitigation to preventmultiplemultiple fatalities from phosgene tubefailurfaeilure phosgene relase as result of Hazard 8. Family from rupture ofRx2or Rx5 15. Multiplefatalitieson and site 21. Faiality from phosgenerelease Cleared for Release 166 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont Nemours & Co. D_raft Report for Public Comment July 2011 Cleared for Release 167 DISAPPROVAL - STAFF DRAFT SUBJECT TO CHANGE APPROVAL OR Comment E.J. DuPont Nemours & Co. _ Draft Report for Public BY THE BOARD July 2011 12/23/06 Date . | PHA Area Reviewed SLM General Building Year ofPHA 2004 Recommendation ID 8,15,218,15,21 oe Original Due Date 12/31/05 12/31/05 Extended Due Date 12/31/0162/31/06 New Due Date 12/31/08 Recommendation : Original Recommendation 3. Complete 2005Building Recommendation : 15. Provide appropriate phagene cylinder multiple mitigation to prevent prevent = fatalities from the release ofa 2000 we prevent mutinde 21. Provideappropriateabilisation abilisation to prevent Balines of tube vaporizer faline ; faline ce from phosgene release as result, Fatality phosgene Soma hiptare Multiple fatalities 2 Rx Rx as or from on and off site from large 21. phosgene Faiality from phosgenpehosgene release releaserelease release Deliciency Cleared for Release 168 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. Draft Report for Public Comment July 2011 169 Comment STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL E.I. DuPont de Nemours & Co. Draft Report for Public BY THE BOARD July 2011 Frea Date 12/3/08 Year PHA 2004 Recommendation 15 Original Due Date 12/3005 - OriginalOriginal Recommendation Provide of 2000ib phosgenecylinder mitigation to prevent masluple fatalities from the completion Why CanOriginal DueDas NotBe Meet TheThe pprojecrt oject is in FEL3 FEL3 and the schedule by August 09 Summary of Progress To Date completed Thecapital project mostofin 2003but was placedon hold Blackbelt again Blackbelt donein 2005. Thecapital project was in recurvated 20016 and on placed milectisinty was reactivated again in 2008. The holdsthecapitalproject were due to future of the facilityand duetto o cost ofthe project project ofthe Lauterien Mossures To Be Followed name why not None Nointerim measuns were identifiebyd the Blackbolt project "REM SABG 170 STAFF DRAFT " SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. TO Draft Report for Public Comment July 2011 Extended Due Dates : phosgene Cleared for Release 171 STAFF DRAFT - SUBJECT TO CHANGE APPROVAL OR DISAPPROVAL BY THE BOARD E.I. DuPont de Nemours & Co. _Draft Report for Public Comment July 2011 172