Investigators fault DuPont procedures in worker's 2010 death

A federal body that investigates chemical-plant accidents concluded in a report released Thursday that the January 2010 death of a DuPont Co. worker in West Virginia after exposure to phosgene had been caused by deficiencies in the Wilmington chemical giant's management systems.

The veteran worker, Carl Fish, died after a Teflon-lined, braided metal hose ruptured, causing him to be sprayed in the face and chest with the deadly chemical, which was used as a weapon during World War I and is now used to make insecticides, plastics, and other products.

The chemical release, the worst of three over two consecutive days at the site in Belle, W.Va., was a blow to DuPont's reputation as a leader in safety, which it has focused on since its origins producing explosives.

"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," said John Bresland, a member of the Chemical Safety Board, at a news conference in Charleston, W.Va. "In light of this, I would hope that DuPont officials are examining the safety culture companywide."

DuPont said Thursday that it had completed its own investigation in June 2010 and had implemented all of its own recommendations. "Safety is a core value at DuPont and is our most important priority," the company said.

The Chemical Safety Board, which makes recommendations on how to prevent accidents but does not fine or penalize companies, found a combination of human-judgment error and technical deficiencies in safety, maintenance, and investigations procedures.

A few hours before Fish's Jan. 23, 2010, accident, the discovery that Saturday of the near-failure of another quarter-inch phosgene hose failed to prompt an immediate "near-miss" investigation. Operators opted to wait until Monday, when supervisors were back at work.

Such an investigation likely would have discovered that the hoses from the phosgene tanks were not being changed every 30 days as directed by DuPont's operating procedures. A SAP plant-maintenance program had stopped generating automatic notifications to replace the hoses after data changes were made to the program in late 2006.

"DuPont could not determine who changed the SAP data, why it was changed, or when the change was executed," the safety report said.

About two pounds of phosgene was released into the atmosphere when the hose failed. The operator received a lethal dose in less than a tenth of a second, the safety board calculated.

No one was hurt in the other two releases. One continued for five days before it was discovered, because operators came to view a battery-powered alarm system as a nuisance to be ignored.

or hbrubaker@phillynews.com.