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FILE NAME DuPont DUP DATE 2011 July 7 DOC DUP180 DOCUMENT DESCRIPTION Transcript of U.S. Chemical Safety Board News Conference - DuPont Belle Plant Investigation Final Report U.S. CHEMICAL SAFETY BOARD NEWS CONFERENCE JULY 7 2011 CHARLESTON WV DU PONT BELLE PLANT INVESTIGATION FINAL REPORT RAFAEL MOURE CSB CHAIRPERSON JOHN BRESLAND BOARD MEMBER JOHNNIE BANKS LEAD INVESTIGATOR LUCY TYLER INVESTIGATOR DAVID CHICCA INVESTIGATOR MARC SAENZ INVESTIGATOR CHAIRMAN MOURE COMMENTS Welcome to this Chemical Safety Board news conference We are here this morning to release the draft report and safety recommendations of the CSB investigation of three accidents that occurred at the DuPont facility in Belle West Virginia on January 22nd and 2010. One of these accidents involved the fatal release of phosgene Today will be relcasing a computer animation depicting the fatal phosgene relcase - which -_ will be a part of the full safety video we will release when the report is ultimately approved DuPont started out as a gunpowder manufacturer in 1802. Within a hundred years it had evolved into a major chemical company DuPont has had a stated focus on accident prevention since its early days Over the years DuPont management worked to drive the injury rate at its facilities down to zero through improved safety practices The Company became recognized across industry as a safety innovator and leader We at the CSB were therefore quite surprised and alarmed to learn that DuPont had not just one but three preventable accidents that occurred over a 33 hour period in January 2010 - The first accident involved an ongoing release of methyl chloride from process ' equipment that went unnoticed for five days The following morning highly corrosive oleum was released through a hole in process . piping Then just six hours later a transfer hose ruptured releasing Phosgene Phosgene is an - extremely toxic chemical it was used as a chemical weapon in World War One The phosgene at DuPont sprayed the face and chest of a worker who died later in a hospital Our investigators will provide details about all three of these accidents along with key findings But first I would like to turn the podium over to CSB Board Member John Bresland Member Bresland was the CSB chair at the time of this series of accidents and became . thoroughly familiar with the investigation Comments concerning the draft report will be carefully considered following the public comment period after which Board Members will vote on the findings and recommendations The report is not final until the vote is taken MEMBER BRESLAND COMMENTS Thank you Chairman Moure As you mentioned given DuPont's reputation as a safety leader the Chemical Safety Board was especially concerned about this quick succession of three accidents Particularly distressing was the fatal release of highly toxic phosgene We found that a phosgene transfer hose was susceptible to failure We learned another phosgene hose had failed in a similar manner but was not investigated by DuPont that hose failed just hours before the fatal release Furthermore the the phosgene transfer hoses were supposed to be replaced at least once a month Our investigation found the hose that ruptured had not been replaced in seven months The CSB determined there were safer ways that DuPont could have run its phosgene + operation as putting it in an enclosure equipped with a ventilation system Documents we arc releasing today show that DuPont considered building such an enclosure in 1988 but then decided against it You will see in our findings that poor design and inadequate maintenance of a batteryoperated alarm system allowed for the methyl chloride release to go undetected for nearly five days And that a lack of preventive maintenance permitted corrosion in the oleum piping to go undetected as a larger hole grew prior to the release of the oleum These kinds of findings would cause us great concern in any chemical plant but particularly in DuPont with its historically strong work and safety culture In light of this I would hope that DuPont officials are reexamining the safety culture throughout the company - Thank you Mr. Chairman CHAIRMAN MOURE COMMENTS Thank you Member Bresland The CSB incident investigation determined root and contributing causes for each of the three incidents The CSB report proposes several recommendations to DuPont and others We will discuss those in a short while . Right now I will turn the time over to our team lead Johnnic Banks and the investigative team to discuss the findings from the report concerning the three accidents TEAM LEAD JOHNNIE BANKS Thank you Chairman Moure That a company like DuPont would have three accidents like this within 33 hours surprised and concerned our team Methyl chloride oleum and particularly phosgene of course procedures are potentially very hazardous chemicals and companies must have place to prevent their accidental release and processes in Investigators David Chicca Lucy Tyler Marc Saenz and I will now take you through the three incidents This will be a summary of the main points but we do call your attention to the full report which has many more details and also includes the documents that Member Bresland referred to concerning DuPont's consideration to improve the safety of the phosgene transfer area We'll discuss the two fatal accidents first then the phosgene accident which we will illustrate with a computer animation Mr. Chicca INVESTIGATOR DAVID CHICCA For those not familiar with it --- DuPont's Belle West Virginia facility produces a variety of chemicals and occupies more than 700 acres along the Kanawha River eight miles east of Charleston the state capital On January 17 2010 a production unit was started up after extended maintenance Methyl chloride produced in a reaction vessel flowed through a blown rupture disk and escaped from an improperly located drain hole inside the production unit building Rupture disks arc safety devices designed to burst and relieve pressure so that a vessel will not explode Operators were unaware that the rupture disk had failed during an earlier maintenance activity Methyl chloride 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 " It extremely flammable it has a potent narcotic effect similar to chloroform It is listed as a potential occupational carcinogen by the National Institute for Occupational Safety and Health NIOSH Symptoms of methyl chloride exposure include dizziness confusion and nausea and at High higher concentrations extreme nervousness trembling and possible loss of consciousness concentrations or long exposure time can be fatal Although no one reported acute affects from this release this was a serious release The hazardous gas vented indoors in an area not frequented by workers and there were no reports by plant employees or the community concerning the methyl chloride vapor escaping from the exterior vent line Five days after the methyl chloride production began on January 22nd an air monitor the alarm inside the building alerted personnel of methyl chloride had escaped release Approximately 2,000 pounds of When the rupture disc burst earlier an alarm was triggered But our investigation found that due to a history of false alarms operators came to view this alarm as a nuisance that could safely be ignored DuPont management had gone through whatis called a Management of Change process in approving a design for the rupture disc alarm system However we found that the alarm system lacked sufficient reliability to advise operators of a flammable methyl chloride release We found that in addition to the design review another root cause of the continued release was that DuPont did not resolve the nuisance alarm condition in a timely manner despite various safety reviews NowI will turn to Investigator Marc Saenz to discuss an incident involving yet another release of a toxic chemical not long aftethre methyl chloride release INVESTIGATOR MARCH SAENZ COMMENTS Thank you Investigator Chicca Oleum is a concentrated solution of sulfuric acid and sulfur trioxide Over time the oleum had corroded piping in the plant's spent acid recovery unit Caused by an unknown defect oleum corroded through a small section of the pipe involved in the release on January 23 2010. Starting as a pitting phenomenon it finished slightly larger than a pin hole The corrosion penetrated the insulated stainless steel sample pipe and an attached copper tube Steam from the attached copper tube mixed with the oleum and created a large hole in the pipe Oleum escaped through the hole and formed a vapor cloud Workers discovered the cloud shortly after 7 am on January 23rd Approximately 22 pounds of oleum were released _ 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 olcum tower pump tank captures liquid from the leak + 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 one responder entered the area 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. There were no reports of exposure to any DuPont or contract employees or the public We found that DuPont had a previous oleum leak resulting in a company recommendation to conduct regular maintenance inspections of all olcum piping But the CSB found this was not done - due to ineffective communications between DuPont and its inspection contractors Now Team Lead Investigator Johnnie Banks will discuss the fatal phosgene release TEAM LEAD INVESTIGATOR JOHNNIE BANKS This was of course the most serious accident of the three and resulted in the death of a worker It came just six hours after the oleum release As mentioned earlier ' It involved phosgene an industrial chemical so toxic it was used as a chemical weapon in World War One Phosgene severely damages lung tissue This can result in a deadly buildup of fluid in the lungs which may not appear until hours after exposure We will now play a CSB animation depicting the accident in the phosgene unit PLAY DVD OF CSB ANIMATION Text of Animation Narr The Belle plant's Small Lots Manufacturing unit purchased phosgene in one ton cylinders from an outside chemical company The plant used the phosgene to manufacture five different pesticide intermediates Narr The cylinders were stored in a one story partially structure called a phosgene shed which which was open to the atmosphere Narr During use the cylinders were connected to other equipment by flexible braided stainless steel hoses Inside each hose was a permeable liner made of Teflon or PTFE One hose used nitrogen to pressurize the cylinder pushing the liquid phosgene into the manufacturing process Narr An electronic scale recorded the weight of each cylinder and when it was nearly empty an alarm sounded in the control room An operator then closed valves to the empty cylinder and opened valves to a second full cylinder The stainless steel hoses to the empty container were purged of phosgene with nitrogen The empty cylinder was then replaced with a new one on the weigh scale Narr On the day prior to the fatal phosgene release operators were experiencing flow problems with one of the hoses and began switching between cylinders to avoid disruption to the chemical process In the course of switching cylinders the valve was closed on apartially full cylinder However the hose was not purged allowing pressure to build as the liquid phosgene inside warmed up Narr Sometime between 1:45 and 2:00 pm on January 23 a worker was inspecting one of the cylinders when the pressurized hose suddenly burst Narr He was sprayed across his chest and face with a lethal dose of phosgene Another worker was exposed to the deadly gas and a third was potentially exposed but neither reported any symptoms A total of two pounds of phosgene were released the atmosphere Small concentrations of the dangerous chemical were detected by monitors at the plant's fence line Narr The worker who had been sprayed with the poison called for help and was transported to a local hospital Four hours later the worker's condition began to deteriorate rapidly and despite medical treatment he died a day after the accident END ANIMATION HERE INVESTIGATOR BANKS CONTINUES The CSB found the permeability of the transfer hoses to phosgene was a key factor in the | accident During our investigation we found that the Teflon stainless steel hoses in use at the Belle plant are particularly susceptible to failure when using phosgene That is because the phosgene can sccp through the permeable Teflon lining and corrode the stainless steel We also learned that another phosgene hose nearly failed in the same manner and was discovered just hours before the fatal phosgene release but this did not prompt an investigation DuPont's standard operating procedure requires replacement of hoses in phosgenc service every thirty days However by the day of the accident January 23 2010 the phosgene hoses had not been changed in over seven months The software used to manage maintenance at the Belle plant had been modified and it no longer notified operators when to replace the hoses As a result the hoses remained in use much longer than the prescribed service life Documents obtained during the CSB investigation showed that as far back as 1987 DuPont officials realized the hazards of using the braided stainless steel hoses lined with Teflon or PTFE An expert employed at DuPont recommended the use of hoses made from Monel a strong metal alloy used in highly corrosive conditions The DuPont official stated Admittedly the Monel hose will cost more than its stainless counterpart However with proper construction and design so that stresses are minimized life should be much greater than 3 months Costs will be less in the long run and safety will also be improved But the CSB found that the Belle plant never followed the recommendation to install the safer Monel hoses NowI will ask Investigator Tyler to discuss DuPont's earlier consideration of enclosing the phosgene cylinder storage area INVESTIGATOR TYLER COMMENTS The CSB determined there are safer ways that DuPont could have run its phosgene operation For example phosgene cylinders should have been kept in an enclosure equipped with a ventilation system and a scrubber If the enclosure were designed for human entry workers should have been required to wear fully encapsulated protective equipment Documents from 1988 show that DuPont considered building such an enclosure but then decided against it One DuPont official wrote and I quote It may be that in the present circumstances the business can afford 2 million for an enclosure however in 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 DuPont decided not to enclose the phosgene unit at that time but the potential for a deadly release remained a concern The danger was noted in a 2004 process hazard analysis which recommended constructing an enclosure equipped with a scrubber Originally the enclosure was scheduled to be completed by December 2005 but the deadline was extended four times and still had not been met in January 2010 when the fatal phosgene release occurred Without an enclosure around the phosgene operation no barriers were present to prevent exposing operators or the community to deadly phosgene Investigator Banks TEAM LEAD INVESTIGATOR BANKS CONCLUDING REMARKS In our report we write that our overall analysis revealed common deficiencies in the following management systems at DuPont relating to all three accidents These were Maintenance and inspections Alarm recognition and management Incident investigation Emergency response and communications And hazard recognition The CSB found that each incident was preceded by an event or multiple events that triggered internal incident investigations by DuPont which then issued recommendations and corrective actions But this activity was not sufficient to prevent the accidents from recurring That concludes the presentation by our investigation team Member Bresland and Chairman Moure now will discuss the recommendations we have proposed in the draft report MEMBER BRESLAND COMMENTS Industry groups have established various good practices for the safe handling of phosgene and other highly toxic materials in compressed gas cylinders The CSB found that the most comprehensive guidelines are those set forth by the National Fire Protection Association or NFPA The CSB draft report recommends that industry organizations such as the Compressed Gas Association and the American Chemistry Council adopt the more stringent guidelines of the National Fire Protection Association for the safe handling of phosgene and other highly toxic gases The report also recommends that OSHA update its compressed gas safety standard to include modern safeguards for toxic gases These improved safeguards include : - Secondary enclosures for units using phosgene - Mechanical ventilation systems - Emergency phosgene scrubbers and '- Automated audible alarms Chairman Moure CHAIRMAN MOURE RECOMMENDATIONS COMMENTS As mentioned previously the CSB investigation team found that cach of the three serious incidents at DuPont's Belle plant was preceded by another event or series of events However these carly warnings and near misses did not result in action to prevent them from recurring Therefore the CSB investigation team recommended that the Dupont Belle facility revise its miss reporting and investigation policy to encourage anonymous reporting by all - employees so that problems can be addressed before they become serious There is a complete list of all the recommendations in the draft report Remember that the recommendations are not final until they are approved by the Board Members The report now is a publicly available document and we are inviting comment tragedies In summary let me say that the incidents at DuPont show that companies with regarded safety cultures can occur even at Safer management practices and proper attention to near misses are critical if the DuPont company is to maintain a higher standard of safety performance that the corporation has historically claimed Correction of common deficiencies of safety management systems found by the CSB investigation will help the company accomplish its goal of eliminating incidents Nationally adoption of the CSB recommendations by OSHA Compressed Gas Association and the American Chemistry Council would greatly increase the safe handling of toxic gases and will protect workers from the deadly exposures Thank you We will now be available to take questions Please state your name and news media affiliation 10