DuPont engineers didn't build a safety enclosure to prevent workers from breathing highly toxic gas at a West Virginia chemical plant because they believed the $2 million project would set a precedent for safeguarding other hazardous materials, a federal probe released Thursday said.
The U.S. Chemical Safety Board cited the company's 1988 cost-benefit analysis in a draft report on the causes of three leaks last year at a DuPont plant in Belle, near Charleston.
The board said the internal analysis concluded that if the phosgene enclosure were built there would be a risk of 2.3 on-site deaths every 10,000 years and that leaving the plant open to the atmosphere would result in a risk of 16.7 on-site deaths per 10,000 years. The company computed the "value of life plus public outrage at $143 million." The analysis added, according to the board, "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?"
In January 2010, a worker died after inhaling a lethal dose of phosgene, which was used as a chemical weapon during World War I and today is used as a building block in synthesis of pharmaceuticals and other organic compounds.
The board said 58-year-old Carl Fish likely wouldn't have died had the enclosure been built.
DuPont said in a statement that it doesn't put cost above safety, and it noted that all phosgene has been removed from the plant since the accident.
As for the cause of the accident, the board's report blamed an ineffective alarm system, maintenance deficiencies and an inadequate emergency response process.
DuPont said it already has taken a series of corrective actions, including performing an intensive operations safety review and improving its maintenance and inspection system for hoses.
The federal board's primary jurisdiction is to investigate serious chemical accidents and make recommendations involving hazardous releases to the air by fixed industrial facilities.
The leaks occurred over a 30-hour period. Fish was taking readings when a line failed. Investigators said he was sprayed across the chest and face with phosgene. They released a computer animation of how they believe it happened.
Other leaks at the Belle plant involved the release of 2,000 pounds of methyl chloride and 22 pounds of a sulfuric acid solution. Methyl chloride leaked for five days before being discovered.
Among the board's findings:
_ DuPont management approved a design for the rupture disc alarm system that lacked sufficient reliability to advise operators of a release of flammable methyl chloride.
_ Corrosion under the insulation caused a small leak in the oleum pipe.
_ DuPont relied on a maintenance software program that was subject to changes without authorization or review and did not automatically initiate a change-out of phosgene hoses at the prescribed interval, nor did they provide a backup process to ensure timely change-out of aging hoses.
_ DuPont lacked a dedicated radio/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.
DuPont is widely considered as having a strong commitment to safety, and because of that investigators were "surprised and alarmed" at the breakdowns at the Belle plant, CSB Chairman Rafael Moure-Eraso told reporters at a news conference held to discuss the report. Board member John Bresland said he hopes DuPont re-evaluates its safety culture across its company as a result of what happened.
The board made several recommendations for the company, the government and the industry.
It said the DuPont plant should supplement the computerized system with sufficient redundancy to ensure tracking and timely scheduling of preventive maintenance for all critical equipment and revise the facility emergency response protocol to require that a responsible and accountable DuPont employee always be available to provide timely and accurate information to emergency responders.
It also said DuPont should conduct annual phosgene hazard awareness training for all employees who handle phosgene. The board recommended that federal Occupational Safety and Health Administration regulations be revised to require facilities that handle toxic materials in compressed gas cylinders to incorporate provisions that are more effective.
"DuPont is committed to the long-term operation of the Belle plant," DuPont said. "We are hiring new employees, making capital investments in the site, and continuing to be actively involved in the local community. Safety is a core value at DuPont and is our most important priority."
Follow Harry R. Weber at http://www.facebook.com/HarryRWeberAP