[ID] => 11294
[post_author] => 34
[post_date] => 2019-07-25 10:38:42
[post_date_gmt] => 2019-07-25 09:38:42
[post_content] => The US Chemical Safety Board (CSB) has identified several safety management shortcomings that led to a release of methyl mercaptan at DuPont’s plant in La Porte, Texas in November 2014 that killed four workers. As is often the case, there are numerous root causes but, CSB says, put together they indicate a flawed engineering design and a lack of adequate safeguards.
“Our investigation revealed a long chain of failures which resulted in this fatal event, including deferring much needed process improvements - improvements that could have prevented the toxic release,” says Dr Kristen Kulinowski, CSB’s interim executive.
The incident happened while plant personnel were trying to clear a blocked pipe outside the manufacturing building. They identified what they took to be an unrelated pressure problem within the building and two men went to drain liquid from piping. Unfortunately they found the cause of the pressure problem and nearly 24,000 lb (10.9 tonnes) of methyl mercaptan leaked from the piping, filling the building with toxic vapour. Both men died, as did two of four other workers who went into the building to help.
“Contributing to the severity of the incident were numerous safety management shortcomings, including deficiencies in formal process safety culture assessments, auditing and corrective actions, and troubleshooting operations,” says Tamara Qureshi, CSB’s lead investigator.
The Board identified weaknesses in the site’s safety management system, which failed to generate a strong safety culture. Its investigation report notes that, while DuPont had created its own corporate process safety management system, it was not effectively implemented at the La Port site; nor did the plant formally evaluate its process safety culture prior to the incident.
CSB’s report makes a number of other pertinent observations:
- The emergency response efforts at the La Porte facility were disorganised and placed operators, emergency responders and potentially the public at risk. “Chemical plants need a robust emergency response programme to mitigate emergencies and protect the health of workers, emergency responders and the public,” the report says.
- DuPont’s corporate process safety management system did not identify, prevent, or mitigate significant process safety deficiencies at the DuPont La Porte facility that contributed to the incident. “A company must effectively implement a process safety management system and its corresponding programmes to reap the accompanying process safety benefits.”
- The site’s bonus structure may have disincentivised workers from reporting injuries, incidents and near misses. “Ensuring that employees can report injuries or incidents in accordance with regulations, without fear of discrimination, retaliation, or other adverse consequence, is central to protecting worker safety and health, and aiding accident prevention,” CSB says.
CSB’s report makes a number of recommendations to the La Porte site, although it has closed since the incident. Rather worryingly, many of the recommendations relate to very basic issues, notably the lack of equipment and technology that should be available at any high-hazard site to help in preventing or dealing with a major incident.
CSB also recommended that the local branch of the International Chemical Workers Union Council work together with DuPont to develop and implement the recommended emergency response plan; this recommendation should be regarded as valid for any similar facility.
[post_title] => Investigation report: Weak at the needs
[post_status] => publish
[comment_status] => open
[ping_status] => open
[post_name] => investigation-report-weak-needs
[post_modified] => 2019-07-25 10:38:42
[post_modified_gmt] => 2019-07-25 09:38:42
[post_parent] => 0
[guid] => https://www.hcblive.com/?p=11294
[menu_order] => 0
[post_type] => post
[comment_count] => 0
[filter] => raw
Investigation report: Weak at the needs
The deaths of four workers at a DuPont plant in Texas in 2014 were down to poor design, poor planning and an inadequate safety culture