Final Investigation Report: E.I

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Final Investigation Report: E.I Toxic Chemical Release at the U.S. Chemical Safety and DuPont La Porte Chemical Facility Hazard Investigation Board La Porte, Texas | Incident Date: November 15, 2014 | No. 2015-01-I-TX Investigation Report Published: June 2019 Investigation Report EY SSUES K I : • Emergency Planning and Response (Preparedness) • Implementation of Process Safety Management Systems • Assessment of Process Safety Culture FINAL COPY Toxic Chemical Release at the DuPont La Porte Chemical Facility U.S. Chemical Safety and Hazard Investigation Board La Porte, Texas | Incident Date: November 15, 2014 | No. 2015-01-I-TX The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The CSB is a scientific investigative organization, not an enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining accident causes, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other government agencies involved in chemical safety. More information about the CSB is available at www.csb.gov. The CSB makes public its actions and decisions through investigative publications, all of which may include safety recommendations when appropriate. Types of publications include: Investigation Reports: Formal, detailed reports on significant chemical incidents that include key findings, root causes, and safety recommendations Investigation Digests: Plain-language summaries of Investigation Reports Case Studies: Reports that examine fewer issues than Investigation Reports Safety Bulletins: Short publications typically focused on a single safety topic Hazard Investigations: Broader studies of significant chemical hazards Safety Videos: Videos that animate aspects of an incident or amplify CSB safety messages CSB products can be freely accessed at www.csb.gov or obtained by contacting: U.S. Chemical Safety and Hazard Investigation Board Office of Congressional, Public, and Board Affairs 1750 Pennsylvania Ave NW, Suite 910 Washington, DC 20006 (202) 261-7600 No part of the conclusions, findings, or recommendations of the Board relating to any accidental release or the investigation thereof shall be admitted as evidence or used in any action or suit for damages arising out of any matter mentioned in such report. See 42 U.S.C. § 7412(r)(6)(G). Page 2 FINAL COPY Toxic Chemical Release at the DuPont La Porte Chemical Facility U.S. Chemical Safety and Hazard Investigation Board La Porte, Texas | Incident Date: November 15, 2014 | No. 2015-01-I-TX TABLE OF CONTENTS 1 EXECUTIVE SUMMARY .......................................................................................................................................... 7 2 INCIDENT DESCRIPTION ...................................................................................................................................... 13 METHYL MERCAPTAN RELEASE ..................................................................................................................................... 14 EMERGENCY RESPONSE ............................................................................................................................................... 21 3 DELAYED AWARENESS OF TOXIC CHEMICAL RELEASE BY OPERATIONS ................................................................. 28 4 EMERGENCY RESPONSE OPERATIONS .................................................................................................................. 31 ERT BACKGROUND .................................................................................................................................................... 33 PROCESS COORDINATOR WAS MISSING ......................................................................................................................... 34 DELAY IN ERT READINESS TO SEARCH FOR MISSING WORKERS ........................................................................................... 38 4.3.1 Call for ERT Response ....................................................................................................................................... 38 4.3.2 ERT Mini‐Pumper Truck Not Operational ......................................................................................................... 39 THE SEARCH FOR MISSING WORKERS WAS HIGH RISK ...................................................................................................... 40 4.4.1 Entry into Potentially Explosive Atmosphere .................................................................................................... 41 4.4.2 No Technology to Locate Missing Workers ...................................................................................................... 43 4.4.3 Unrecognized Manufacturing Building Collapse Hazard .................................................................................. 43 DIFFICULTIES NAVIGATING MANUFACTURING BUILDING .................................................................................................... 44 NO ANALYSIS OF PROCESS DATA TO IDENTIFY SOURCE OF LEAK .......................................................................................... 47 INADEQUATE CREATION AND CONTROL OF HOT ZONE ....................................................................................................... 50 DEFICIENCIES IN EVALUATING RISK TO THE PUBLIC ............................................................................................................ 52 4.8.1 Release Modeling ............................................................................................................................................. 53 4.8.2 Physical Properties of Methyl Mercaptan ......................................................................................................... 56 4.8.3 Chemical Sensor Data ....................................................................................................................................... 58 4.8.4 Air Monitoring .................................................................................................................................................. 59 EMERGENCY RESPONSE CONCLUSIONS ........................................................................................................................... 60 5 DUPONT’S PROCESS SAFETY MANAGEMENT SYSTEM .......................................................................................... 61 OSHA ..................................................................................................................................................................... 62 5.1.1 The Process Safety Management Standard ...................................................................................................... 62 5.1.2 DuPont La Porte’s Implementation of PSM ...................................................................................................... 63 5.1.3 Recent Developments Affecting the PSM Standard .......................................................................................... 65 ENVIRONMENTAL PROTECTION AGENCY ......................................................................................................................... 65 5.2.1 Risk Management Plan Rule ............................................................................................................................. 65 5.2.2 DuPont La Porte’s Implementation of RMP ...................................................................................................... 67 5.2.3 Recent Developments Affecting the RMP Rule ................................................................................................. 68 AMERICAN CHEMISTRY COUNCIL ................................................................................................................................... 69 5.3.1 History of Responsible Care .............................................................................................................................. 70 5.3.2 Responsible Care Requirements ....................................................................................................................... 71 5.3.3 Responsible Care Conformance Audits ............................................................................................................. 73 Page 3 FINAL COPY Toxic Chemical Release at the DuPont La Porte Chemical Facility U.S. Chemical Safety and Hazard Investigation Board La Porte, Texas | Incident Date: November 15, 2014 | No. 2015-01-I-TX 5.3.4 Recent Developments in Responsible Care ....................................................................................................... 76 5.3.5 Responsible Care Improvement Opportunities ................................................................................................. 77 DUPONT’S DEVELOPMENT AND IMPLEMENTATION OF ITS PROCESS SAFETY MANAGEMENT SYSTEM .......................................... 80 5.4.1 Building a Safety Culture .................................................................................................................................. 82 5.4.2 Using the Process Safety Management and Risk Model .................................................................................. 92 DUPONT’S PROCESS SAFETY MANAGEMENT SYSTEM CONCLUSIONS .................................................................................... 94 6 PROCESS SAFETY MANAGEMENT
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