INCIDENT BACKGROUND

The DuPont Belle Plant specializes in many areas of chemical-related products and one of its expertise is the production of fertilizers. Phosgene is one of the chemicals used in the plant. It is a hazardous chemical that is commonly used to make plastics and fertilizers. Phosgene gained popularity during the World War I when it was used as a chemical weapon. It exists as gas at room temperature but phosgene is usually compressed to liquid in industries. Phosgene gas appear colourless or pale yellow and gives out a pleasant smell. Any contact of the chemical on human being either through respiratory tracts, touch, eye contact or ingestion can lead to fatality or serious internal damage.

SUMMARY/OVERVIEW

On January 23rd, 2010, at approximately 2.00pm, a fatal poisonous gas accident occurred at the Belle plant, a chemical manufacturing plant. The accident causes fatality of a worker following exposure to the poisonous gas called phosgene. Two other workers had been exposed to the poisonous gas but neither reported any symptoms following the exposure. A total of two pound of phosgene was exposed to the atmosphere and a small concentration of the dangerous gas was detected by the monitors in the plant. The investigation team concluded that the accident resulted from the usage of the braided stainless steel hose lined with Teflon instead of Monel , a strong metal alloy used in highly corrosive conditions. The lack of maintenance and inspections on the manufacturing site resulted in conditions in the plant that were necessary for the accident. Information gathered during the investigation indicated that there was no PPE(Personal Protective Equipment) been used by the workers during their supervision period.

DESCRIPTION OF ACCIDENT

The Belle plant small manufacturing unit manufactures pesticides by using phosgene in 1 tonne cylinder units, which it purchases from a chemical company. The cylinders are stored on a phosgene shed, a partially walled structure that accommodates two phosgene cylinders at one time. The cylinders are left in the atmosphere and no special chamber is allocated for its storage. Two flexible braided stainless steel hoses are used to connect each cylinders and the insides of these hoses are made of Teflon or PTFE, which is a thermoplastic polymer. One of the hoses is channeled with nitrogen gas, which is used to pressurize the phosgene in the cylinder to induce flow into the second hose. The second hose is placed on the lower part of the cylinder and transfers the liquid phosgene to other equipments. An electronic scale is used to record the weight of the cylinder and when the container is nearly empty, the alarm will ring in the control room to notify the operator in charge. The operator then closes the valves on the empty cylinder and opens the valves on the other cylinder on the shed. The remaining liquid phosgene in the empty cylinder is purged with nitrogen gas and the cylinder is then replaced on the weigh scale. Operator in charge on the day before the incident experienced flow problems with one of the hose and switched between the cylinders to prevent any problems with the plant process. During the change, the valve was closed on the cylinder filled with phosgene but purging of the liquid in the hose was not done. This caused the pressure inside the hose to build up as the temperature of phosgene increases. Between 1.45pm and 2pm on January 23rd, one of the workers was inspecting the cylinder unit as one of the daily routine. During that process, the hose exploded due to the pressure build since the day before. Liquid phosgene came directly in contact to the workers chest and face. Phosgene with a total weight of 2lbs was released during the period. The monitor at the plant detected a small concentration of the leak. The worker called for assistance and was sent to the nearest hospital. His condition worsened after four hours and he passed away a day later. Another worker was exposed to the poisonous gas and one other was potentially exposed, but none showed any of the symptoms.

CAUSE OF THE ACCIDENTS

The usage of braided stainless steel hoses lined with Teflon - It is susceptible to corrosion from phosgene. Phosgene shed open to the atmosphere -Once leakage occurred, the phosgene gas spread to the atmosphere resulting in two other staff to be infected Lack of maintenance and inspections -Hoses were not well maintained and worn out hoses were not changed resulting the leakage of phosgene. Weak emergency response and communications, and hazard recognition. -The worker were not sent immediately to the hospital after being exposed to phosgene - No usage of complete personal protective equipment (PPE) when handling phosgene. The shortage of nitrogen for purging would tend to inhibit the venting of off-gas as a method of pressure control/reduction. -The hose were not purged allowing pressure to build as the liquid phosgene warmed up.

RECOMMENDATIONS Phosgene production and storage areas to be enclosed (a chamber) and ventilated - Any other releases of phosgene will be able to be contain and control Occupational Safety and Health Administration (OSHA) update its compressed gas safety standard to include secondary enclosures for toxic gases such as phosgene. Emergency phosgene scrubbers - Destroys any toxic phosgene gas before it entered the atmosphere. Change the hose to a more suitable hose -Eg: Monel hose is susceptible to corrosion of phosgene. Strengthening the process hazards review system to expand and improve employee participation -Send employees for training and classes to provide necessary knowledge about the hazards -Ensure employees learnt the importance of PPE and ensure the PPEs provided are used. Improving maintenance and inspection system -All equipments should be inspected from time to time and ensure they are all well maintained. Phosgene cylinder is kept lower on the ground -Phosgene gas is very much denser than air, thus it stays close to the ground when liquid phosgene is released. The Compressed Gas Association (CGA) adopt more stringent guidelines of NFPA Code 55 for the safe handling of phosgene. -Heavy fines are charged to companies who tend to stray away from the guidelines.

LESSON LEARNT The phosgene hose that burst in front of a worker was supposed to be changed regularly, at least once a month. The hose type of susceptible to corrosion from phosgene should be used in the manufacturing process. Proper handling of the phosgene such as conducting the process in enclosed chamber must be practiced. A proper containment system for the phosgene gas if there is a breakout/exposure of the phosgene. A proper knowledge on the phosgene in the training would have identified the hazards and allowed them to be corrected before accident occurred. More strict safety guidelines on handling toxic gases should have followed such as wearing facial mask protection during the supervision of the manufacturing process. Improve on the maintenance and inspection system would have prevented the accident from occurred.

CONCLUSION

The accident that occurred in the Belle plant initiated in the stainless steel hose and the sudden burst occurred which results the phosgene gas to be exposed to the atmosphere. The accident occurred as a direct result of a series of unsafe operating procedures and conditions at the plant. The explosion could not have occurred without the presence of the following conditions. The conditions were a direct result of unsafe operating procedures. 1. Lack of maintenance and inspection on the cylinders and hoses. 2. The placing of the cylinders in the lower level and open to the atmosphere. 3. Lack of knowledge on the phosgene handling. 4. Management does not follow proper safety guidelines. 5. No ventilation system at the plane if emergency occurs. 6. Inappropriate chemical handling in the plant (no PPE been followed)