A series of preventable safety shortcomings — including failure to maintain the mechanical integrity of a critical phosgene hose — led to a string of three serious accidents that occurred over a 33-hour period on January 22 and 23, 2010, at the DuPont Corporation’s Belle, West Virginia, chemical manufacturing plant, according to the draft report of the U.S. Chemical Safety Board (CSB) which was issued today. In one of the accidents, a worker died following exposure to phosgene, a gas used as a chemical weapon in World War I.

The report makes numerous safety recommendations. Among them, DuPont is urged to enclose all of its phosgene production and storage areas so that any releases of phosgene will be contained. The CSB recommends that the Occupational Safety and Health Administration (OSHA) update its compressed gas safety standard to include secondary enclosures for toxic gases such as phosgene.

 The draft report and recommendations remain subject to change and final approval by a vote of the presidentially-appointed board of the CSB.  That vote is expected to occur following a 45-day comment period which closes on August 22.

DuPont’s Belle facility occupies more than 700 acres along the Kanawha River, eight miles east of Charleston, the state capital.  The plant produces a variety of specialty chemicals.

The series of accidents began on January 22, 2010, when an alarm sounded leading operators to discover that 2,000 pounds of methyl chloride, a flammable gas, had been leaking unnoticed into the atmosphere for five days.  The next morning, workers discovered a leak in a pipe carrying oleum, producing a fuming cloud of the sulfur trioxide.  The phosgene release occurred later that day, and the exposed worker died the next day in a hospital.  
CSB Chairman Rafael Moure-Eraso said the three accidents particularly concerned CSB personnel given DuPont’s longstanding reputation for a commitment to safety.  Noting the company started as a gunpowder manufacturer in 1802, and became a major chemical producer within 100 years, Dr. Moure-Eraso said, “DuPont has had a stated focus on accident prevention since its early days. Over the years, DuPont management worked to drive the injury rate down to zero through improved safety practices.”

Dr. Moure-Eraso continued, “DuPont 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 accidents that occurred over a 33-hour period in January 2010. 

CSB board member and former chairman John Bresland also spoke at the news conference:  “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 examining the safety culture company-wide.”   

Member Bresland noted the CSB finding that the phosgene hose that burst in front of a worker was supposed to be changed out at least once a month.  But the hose that failed had been in service for seven months. Furthermore, the CSB found the type of hose involved in the accident was susceptible to corrosion from phosgene.

Team Lead Johnnie Banks said, “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 lined with 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…useful life should be much greater than 3 months. Costs will be less in the long run and safety will also be improved.’”

In fact, the Monel hose was never used.

Internal DuPont documents released with the CSB draft report indicate that in the 1980’s, company officials  considered increasing the safety of the area of the plant where phosgene is handled by enclosing the area and venting the enclosure through  a scrubber system to destroy any toxic phosgene gas before it entered the atmosphere. However, the documents show the company calculated the benefit ratio of potential lives saved compared to the cost and decided not to make the safety improvements. A DuPont employee  wrote in 1988,  “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?”

The need for an enclosure was reiterated in a 2004 process hazard analysis conducted by DuPont, but four extensions were granted by DuPont management between 2004 and 2009, and at the time of the January 2010 release, no safety enclosure or scrubber system had been constructed.   CSB investigators concluded that an enclosure, scrubber system, and routine requirement for protective breathing equipment before personnel entered the enclosure would have prevented any personnel exposures or injuries.

The CSB investigation found common deficiencies in DuPont Belle plant management systems springing from all three accidents:  Maintenance and inspections, alarm recognition and management, accident investigation, emergency response and communications, and hazard recognition.

CSB Team Lead Banks said, “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.”

The CSB draft report recommends that the DuPont Belle facility revise its near-miss reporting and investigation policy to emphasize anonymous participation by all employees so that minor problems can be addressed before they become serious. The CSB report also recommends the Belle plant ensure that its computer systems will provide effective scheduling of preventive maintenance to require, for example, that phosgene hoses get replaced on time.
 
The CSB draft recommends that the DuPont Corporation require all phosgene production and storage areas company-wide have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms, which are at a minimum consistent with the standards of the National Fire Protection Code 55 for highly toxic gases.

 Industry groups have established various good practices for the safe handling of phosgene and other highly toxic materials in compressed gas cylinders.  The draft report concluded that the most comprehensive guidelines are those set forth by the National Fire Protection Association, or NFPA. 
 
The draft report recommends that industry-organizations such as the Compressed Gas Association (CGA) and the American Chemistry Council (ACC) adopt the more stringent guidelines of the NFPA for the safe handling of phosgene and other highly toxic gases.  

The report recommends the Occupational Safety and Health Administration (OSHA) update its compressed gas safety standard to include modern safeguards for toxic gases such as phosgene.  These improved safeguards include: Secondary enclosures for units using phosgene, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms. 

Chairman Moure-Eraso said, “Adoption of the CSB recommendations by OSHA,  the Compressed Gas Association and the American Chemistry Council and, would greatly increase the safe handling of toxic gases  nationally, and will protect  workers from the deadly exposures.” 
 
     Dr. Moure-Eraso noted that he welcomes today’s release of the draft report and invites public comment on it.  “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.”

The video is entitled “Fire in the Valley,” a reference to the Kanawha River valley where numerous chemical facilities are located, including the Bayer plant that manufactures insecticides, near Charleston, West Virginia.
———–Ad———————
For easy to understand training programs on Hazardous Area Instrumentation, Safety Instrumented Systems, Gas Monitors and HAZOP, please click here
————————————
The video features a detailed computer animation showing how a series of errors and deficiencies during a lengthy startup process resulted in a runaway chemical reaction inside a residue treater pressure vessel. The CSB’s investigation found that operators were not adequately trained, new computer process equipment had not been fully checked out, and a critical safety interlock was bypassed to begin a chemical reaction.

Investigations Supervisor John Vorderbrueggen, P.E. discusses the CSB’s findings, “We found serious deficiencies in the company’s process safety management program. This resulted in a series of critical omissions during the startup that led to a runaway reaction and violent explosion.”
These events contributed to the over pressurization of the residue treater which ultimately exploded and careened into the methomyl pesticide manufacturing unit, leaving a huge fireball in its wake.  Pieces of the vessel struck a steel-mesh covering surrounding a large tank of methyl isocyanate, a highly toxic chemical of concern to residents of the valley since 1984 when an accidental release of MIC in Bhopal, India, killed thousands.
In the video, CSB Chairperson Rafael Moure-Eraso says, “The communities surrounding Bayer CropScience have been concerned for decades about the MIC stored there.  Its presence added even more gravity to the series of safety lapses the CSB investigation found to have preceded the tragedy.   And when the accident occurred, the company refused to give out critical information to responders and the public.”
Ultimately, 40,000 area residents were requested to shelter-in-place the night of the accident. The video features comments by county and state officials on the initial refusal of Bayer to provide information to Metro 911 emergency response operators as well as resident’s concerns about chemical plant safety in the area. “Fire in the Valley” also details the key CSB safety recommendation that Kanawha Valley county authorities emulate the regulatory regime of Contra Costa County, California. There, chemical process safety experts regularly inspect the multitude of facilities throughout the county in a program that is paid for by a proportional levy on the plants. The program’s director, Randy Sawyer, comments in the CSB video on the success of the program.
Chairperson Moure-Eraso concludes the video saying, “Good communications between chemical plants, responders, and community leaders can help assure the safety of workers and residents during an emergency. But preventing accidents requires companies to have effective process safety management programs. The fact that accidents continue to occur shows the need for improved inspections and oversight whether at the federal or local levels.”

Though the reactor core itself may not trigger a radioactive release as bad as Chernobyl, what about the spent fuel? Apparently there is enough spent fuel in the same facility that can be more dangerous than the reactor core itself.

Some more information about this hitherto unlooked at issue is given below in the Comments section on The Naked Capitalism blog.

The commenter quotes a research paper “Reducing the Hazards from Stored Spent Power-Reactor Fuel in the United States” which was submitted 2000; accepted for publication 2003, written by Robert Alvarez, Jan Beyea, Klaus Janberg, Jungmin Kang, Ed Lyman, Allison Macfarlane, Gordon Thompson, Frank N. von Hippel.

The authors state that “Because of the unavailability of off-site storage for spent power-reactor fuel, the NRC has allowed high-density storage of spent fuel in pools …virtually all U.S. spent-fuel pools have been re-racked to hold spent-fuel assemblies at densities that approach those in reactor cores. In order to prevent the spent fuel from going critical, the fuel assemblies are partitioned off from each other in metal boxes whose walls contain neutron-absorbing boron. It has been known for more than two decades that, in case of a loss of water in the pool, convective air cooling would be relatively ineffective in such a “dense-packed” pool. Spent fuel recently discharged from a reactor could heat up relatively rapidly to temperatures at which the zircaloy fuel cladding could catch fire and the fuel’s volatile fission products including 30-year half-life 137Cs, would be released. The fire could well spread to older spent fuel. The long-term land-contamination consequences of such an event could be significantly worse than those from Chernobyl”

Reader of this blog must be aware that the water in the spent fuel pools is quickly evaporating and the electric power outage implies that it would be difficult to cool these spent fuel boxes now. This is really alarming and should concern nuclear experts around the world.

Meanwhile, there were news reports online that said that a “Radioactive Plume” was rapidly spreading out from Fukushima and would soon reach America’s West Coast in a matter of hours. The level of radioactivity in the plume would however be much less and certainly below the “safe exposure” limits.

Meanwhile the Japanese government has denied that the explosion affected the actual reactor. Only the outer containment building was affected, the roof of which blew off. This is not good at all as this building is supposed to trap the radioactive material that may come out of the metallic containment vessel surrounding the reactor. One hopes that the actual reactor is in a safer condition than what appears. Radiation rates have increased significantly, with unconfirmed reports citing figures that the daily radiation in the area now equals the total radiation over a year!

The Tokyo Electric Power Company, that runs the plant says that four workers were injured in the explosion.

Other experts opine that since the reactor is a light water reactor,  a Chernobyly type incident cannot happen. This must be surely good news to everybody around the area. A loss of coolant may cause a temperature rise, but it will also decelerate the reaction, according to the expert.

More information is available at the link here (at the website of the Union of  Concerned Scientists).

Tokyo, March 12 update- Pressure at one of  the Daiichi reactors is continuing to rise, worrying the authorities. Reportedly radioactive steam from one reactor was vented out after evacuating residents in a 10 Km radius in Fukushima, about 170 miles north of Tokyo.

Tokyo, Mar 11, 2011- An earthquake of a very large magnitude (8.9 on the Richter scale) has caused massive damage at an oil refinery as well as a nuclear power plant. The Cosmo oil refinery, near the city of Ichihara, in Chiba prefecture experienced a massive blaze after the earthquake hit. You can see it in the video below.

According to reports, natural gas storage tanks were part of the blaze. It is still not clear if the fire is under control. Things are equally bad, if not worse at the  various Nuclear Power plants, where safety shutdown systems are automatically programmed to shut down the plants in case of an earthquake above a certain magnitude.  Residents near the Fukushima Daiichi Nuclear Power Plant, located about 170 miles north east of Tokyo, were reportedly evacuated after the cooling system failed, triggering a fear of a possible nuclear meltdown. If cooling water is unable to be pumped to the core, then it may cause the reactor to melt and carry over into a steel containment vessel, which also has an outer concrete containment chamber. So far no reports suggest that anything has come into the containment chambers.However this thought itself is scary as if something radioactive does escape, it can cause severe radiation damage to large parts of the countryside.

Meanwhile apparently Ms. Hillary Clinton, US Secretary of State has informed that the US Military has transported additional coolant to the facility and will extend its help as needed.

There are reports of a fire in the turbines of the Onagawa Nuclear Power plant, while another facility at the same site is having a “water leak”, which is not good news at all.

The unprecendented nuclear power shutdown means that large swathes of areas are without any electricity at all, making the disaster worse than it had to be. Though diesel backup power generators are on, they cannot substitute for all the load. The earthquake highlights the consequential accidents and damages that can occur due to a natural phenomenon such as an earthquake.

The incident also highlights that supposedly “clean” nuclear power has a very big disadvantage-the danger of a radiation leak after something like an earthquake. Environmentalists please note!

Meanwhile various news reports suggest that there could be various nuclear facilities in Japan which could have failures that have been unreported so far, which is cause for worry. This has caused the Japanese government to declare an “atomic emergency”, a scary word indeed, not only for the Japanese, but for all of us as well.