U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD INVESTIGATION REPORT Final Report E.I. DUPONT DE NEMOURS & CO., INC. BELLE, WEST VIRGINIA METHYL CHLORIDE RELEASE JANUARY 22, 2010 OLEUM RELEASE JANUARY 23, 2010 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 REPORT NO. 2010-6-I-WV SEPTEMBER 2011 E.I. DuPont de Nemours & Co. Final Report September 2011 CONTENTS 1.0 INTRODUCTION ......................................................................................................................... 13 1.1 Background .................................................................................................................................... 13 1.2 Investigative Process ...................................................................................................................... 14 1.3 E.I. DuPont de Nemours & Co., Inc. ............................................................................................. 16 1.3.1 Company History .............................................................................................................. 16 1.3.2 DuPont Business Areas and Corporate Management ....................................................... 16 1.3.3 Safety at DuPont ............................................................................................................... 17 1.4 DuPont Belle Plant ......................................................................................................................... 20 2.0 METHYL CHLORIDE RELEASE (JANUARY 22, 2010) .......................................................... 22 2.1 Background .................................................................................................................................... 22 2.1.1 Methyl Chloride ................................................................................................................ 23 2.2 Incident Description ....................................................................................................................... 24 2.2.1 ECF Sensor Alarm ............................................................................................................ 25 2.2.2 Odor Detection Considerations ......................................................................................... 25 2.2.3 Incident Response ............................................................................................................. 26 2.2.4 Community Impact ........................................................................................................... 29 2.3 Incident Analysis ........................................................................................................................... 29 2.3.1 Mechanical Integrity ......................................................................................................... 29 2.3.2 Design and Maintenance of Rupture Discs ....................................................................... 31 2.3.3 Previous Incidents of Rupture Discs Bursting .................................................................. 32 2.3.4 Management of Change--Technology and Subtle Change ............................................... 34 2.3.5 F3455 Unit Turnaround .................................................................................................... 35 2.3.6 Second-Party Process Safety Management Audit ............................................................. 38 2.4 Key Findings .................................................................................................................................. 39 2.5 Root Causes ................................................................................................................................... 39 3.0 OLEUM RELEASE (JANUARY 23, 2010) .................................................................................. 40 3.1 Background .................................................................................................................................... 40 3.2 Incident Description ....................................................................................................................... 40 3.2.1 Incident Response ............................................................................................................. 42 3.3 Incident Analysis ........................................................................................................................... 42 ii E.I. DuPont de Nemours & Co. Final Report September 2011 3.3.1 Reconstructive Analysis ................................................................................................... 42 3.3.2 Pipe Testing and Analysis ................................................................................................. 45 3.3.3 Previous Incident Investigation ......................................................................................... 46 3.3.4 PM Program Recommendation from 2009 Incident ......................................................... 47 3.3.5 Mechanical Integrity ......................................................................................................... 47 3.3.6 Heat Tracing Design ......................................................................................................... 48 3.4 Key Findings .................................................................................................................................. 48 3.5 Root Causes ................................................................................................................................... 49 4.0 PHOSGENE RELEASE (JANUARY 23, 2010) ........................................................................... 49 4.1 Background .................................................................................................................................... 49 4.1.1 Phosgene ........................................................................................................................... 49 4.1.2 Phosgene Stainless Steel Hose Transfer Operation .......................................................... 50 4.1.3 Phosgene Highly Toxic Material Guardian Committee .................................................... 56 4.2 Incident Description ....................................................................................................................... 57 4.2.1 Community Impact ........................................................................................................... 61 4.3 Incident Analysis ........................................................................................................................... 61 4.3.1 Hose Failure Analysis ....................................................................................................... 61 4.3.2 Effect of Plastic Adhesive Tape ........................................................................................ 62 4.3.3 Hose Degradation Issues ................................................................................................... 64 4.3.4 Hose Change-out Frequency ............................................................................................. 64 4.3.5 SAP Work Process ............................................................................................................ 66 4.3.6 Near-Miss Phosgene Incident ........................................................................................... 67 4.3.7 Mechanical Integrity ......................................................................................................... 68 4.3.8 Flex Hose Materials of Construction ................................................................................ 70 4.3.8 Non-routine Job Planning ................................................................................................. 72 4.4 Process Hazard Analysis ................................................................................................................ 73 4.5 Audits ............................................................................................................................................. 75 4.5.1 Unit Second-Party PSM Audit .......................................................................................... 75 4.5.2 2006 Phosgene Committee Audit ..................................................................................... 79 4.6 Standards and Guidelines ............................................................................................................... 80 4.7 Key Findings .................................................................................................................................. 86 4.8 Root Causes ................................................................................................................................... 87 iii E.I. DuPont de Nemours & Co. Final Report September 2011 5.0 THREE INCIDENTS IN 33 HOURS ............................................................................................ 88 5.0.1 Additional DuPont Incidents ............................................................................................. 90 5.1 Management Systems .................................................................................................................... 91 5.1.1 Knowledge Management .................................................................................................