Effect Measure

Death on the job

Carl “Dan” Fish worked at Dupont’s Belle plant for 32 years until last Saturday. That’s the day he was sprayed in the face by phosgene gas. Sunday he was dead:

On Saturday, Fish was hit with a small cloud of phosgene that leaked from a line used to transfer phosgene from storage cylinders to a crop protection chemical production unit, plant officials said.

The fatal accident was the third in a series of four incidents at the Belle plant in just two days, including Friday’s discovery of a 1,900-pound leak of toxic and flammable methyl chloride that went undetected for nearly a week. (Ken Ward, Charlston [WVa] Gazaette)

Almost immediately inspectors from OHA and investigators from the Chemical Safety Board descended on the plant, which had already declared a “safety stand down.” Exactly what happened is as yet unclear. The plant manager was quoted as saying Fish was just walking by during a safety inspection when the exposure occurred. Bad luck brought on by poor safety. Phosgene (COCl2), an extremely toxic chemical feedstock used as a gas warfare agent in WWI, is considered “immediately dangerous to life or health” (idlh) at levels of only 2 parts per million. It used in the manufacture of pesticides (the correct corporate euphemism is “crop protection chemical”) and when reacted with bisphenol A (BPS) produces polycarbonate plastic. Phosgene can cause pulmonary edema (fluid fills the lungs) and cardiac failure. DuPont buys it in 2000 pound cylinders, about one pound of which is thought to have escaped in this fatal event when a hose connecting the cylinder to a machine leaked.

Freak accident? Doubtful:

William E. Wright, a member of the Chemical Safety Board, said his agency was concerned about recent events at the Belle plant “and will proceed with an investigation to understand why these unfortunate events occurred.”

The CSB does not issue citations or fines. Instead, the agency tries to find root causes for chemical accidents and recommends ways to avoid similar events.

In voting Monday to launch its own investigation, the Chemical Safety Board said it was aware of six other releases from the Belle plant since December 2006.

Dan Fish left his house for work as usual on Saturday morning. He never came home. Just another worker death.


  1. #1 Oskar
    January 27, 2010

    I am reading this while looking after 12 undergrads doing organic chemistry and a shudder went through my spine.
    I think I´ll stop browsing blogs and start to hover over them like a mother hen

  2. #2 D. C. Sessions
    January 27, 2010

    Look at the stuff we use to make semiconductors and you’ll never want to be in the same county as a fab again. Silane, arsene, phosphene — those are just a few of the essential gasses. Then there are the solvents …

  3. #3 tony
    January 27, 2010

    D.C. Sessions: you’re so right. We live near a superfund site created from careless solvent handling by IBM. Polluted nearly 500 private wells and is implicated in a number of cancer deaths in our area.

  4. #4 John
    January 27, 2010

    We live in a age that almost everything we use has a origin that involves a toxic or hazardous material in its past. These materials are handled daily by trained skilled people without indecent, but accidents happen. The plastic milk bottle has titanium tetrachloride in the process of making HDPE catalyst. Most companies push safety because in the long run it make the bottom line better. Sometime a site manager thinks he can cut a few corners and make him self look better and move on and let the next person clean up.

  5. #5 Art
    January 27, 2010

    I don’t mean to blame the victim but where was his PPE. I’ve worked around a few fairly hazardous compounds and the general rule where I was was that if there was a significant amount of hazardous chemicals being held contained by a single seal or barrier we were supposed to be wearing PPE as a rule. Only where there was a second barrier, and detectors between the first and second to show if the first leaks, were we allowed to take off the mask. We spent a lot of time in masks and suits.

    Things break. Seals fail. Hoses give up. Placing your life in danger hoping a flange or gasket won’t leak seems foolish. Failing to wear our PPE where required, pretty most of the plant, was a firing offense and people were discharged for such failures. A secretary got canned for ‘just stepping out to tell a worker he had a telephone call’. Everyone was issued PPE and even the office staff had evacuation hoods.

    If this was SOP for a small company producing specialty chemicals how could such a sad event happen at a much larger plant?

  6. #6 ginger
    January 27, 2010

    Art – that’s why it’s a system-level error, not just a worker error. If a working environment is set up right, the culture of the workplace should be that use of properly maintained PPE is universal, and failure to use it is so far outside the norm that alone is a sentinel event. But government, employers, and workers have to craft that workplace culture together, and if the sentinel event is that a worker dies of phosgene exposure, something has gone dreadfully wrong with the whole system.

  7. #7 military wife
    January 27, 2010

    including Friday’s discovery of a 1,900-pound leak of toxic and flammable methyl chloride that went undetected for nearly a week.

    holy cow

  8. #8 Fred Martin
    January 27, 2010

    The Belle plant is right down the road from my home. We’ve had other safety problems with the local plants. Shelter in place drills are common in all the schools.

  9. #9 Art
    January 28, 2010

    I hear you Ginger.

    Clearly a systems failure. It just shocked me that any reputable manufacturer could operate without an effective safety system in place. It also amazes me that anyone familiar with the chemicals wouldn’t do whatever it took to protect themselves. I guess that when the safety culture slides people start to see risk taking as normal. Perhaps even laudable. Scary. And both sad and tragic.

  10. #10 Paula
    January 28, 2010

    A workplace-culture failure with deadly results, and what sort of investigation follows? A bigger failure seems to be the embedding political culture’s focus on profits at whatever cost to the people endangered in their workplace. And this is hardly limited to chemical or nuclear facilities. I was in my office working at a small nonprofit, one day when the director was absent, and around 4:30pm one of the fellows remodeling the ground floor came to the door and asked “Can you sign for the asbestos removal? We’ve finished.” Great.

  11. #11 kim w
    January 28, 2010

    Death by phosgene in 21st century America? The Kanawha Valley, WV Dupont plant is about 25 miles east of us, and our wind usually comes out of the west, but we still don’t feel safe here. The Bayer plant is right across the Kanawha River from us. The plant had stored between 100,000 to 999,999 lbs. of methyl isocyanate at the plant as of the 2004 count, when it was not obliged to be more specific. That’s MIC, the chemical that destroyed Bhopal. They would admit to about 40,000 lbs. being stored above-ground within 80 feet of the August 2008 accident site (and also keep more above-ground in another part of the plant).

    On that August 2008 evening about ten o’clock, when I was already in bed falling asleep because I have to get up at 5:30 a.m. for work, the house shook with a huge boom. Earthquake? Not bloody likely in WV. We turned on the tv to discover what had happened. No one knew. No one knew for a very long time. People near the plant at the time of the explosion standing outside in Institute or driving down Rt 25 reported a huge fireball reaching hundreds of feet in the air. But the plant was very reticent about releasing any information, even to county emergency responders. Shelter in place, or jump into the car and probably drive due west? From which direction was the wind? Usually came out of the west.

    As various news agencies reported: “On Aug. 28, a pressurized waste tank containing Methomyl exploded, sending a fireball hundreds of feet into the air. One Bayer employee was killed instantly and another suffered third- degree burns and died more than a month later. Eight other people, including six emergency responders and two contract employees, reported symptoms of chemical exposure.

    In transcripts of radio communications among fire, police, and emergency medical personnel obtained by the committee, first responders repeatedly complained that “we can’t get through to the plant” and “we have no contact with anybody from the plant.”

    “We acknowledge fully we had a breakdown in these communications,” Bayer CropScience Chairman William Buckner told the subcommittee. “We have the process in place to make sure it doesn’t happen again.”

    Yeah, right. Now we have emergency bags packed, and the next time we think we’ve been hit by an earthquake, or even hear of Bayer plant emergency problems, we’re going to drive west by first steering uphill to Dry Ridge, as those in Bhopal learned MIC tends to stay close to the ground in gaseous form. And of course MIC is not the only toxic exposure to worry about.

    Here’s why after 08/08:

    Chemical Safety Board Chairman John Bresland said Bayer officials told emergency personnel on the day of the explosion that “no dangerous chemicals had been released.”

    “That statement is clearly incorrect, since Methomyl is toxic and its uncontrolled decomposition may release highly toxic byproducts,” Bresland said. The Chemical Safety Board is an independent federal agency.

    The explosion ruptured and threw a 2.5-ton steel tank through the plant. Had it struck the MIC container, “the subcommittee today might be examining a catastrophe rivaling the Bhopal disaster,” said Representative Bart Stupak, a Michigan Democrat and chairman of the oversight subcommittee.

    Blast Mat

    The subcommittee accused Bayer of removing and destroying a protective steel screen, or blast mat, that hung over the MIC tank, which Bayer spokesman Bryan Iams said was not true.

    The mat, Iams said in a phone interview, remains on the site and has been examined by chemical board investigators.

    “The blast mat remains on our site,” Iams said. “We did not destroy evidence.”

    Daniel Horowitz, director of the chemical board’s office of congressional and public affairs, said investigators did see the mat immediately after the explosion, but said that Bayer then moved the equipment without notifying or consulting with investigators first.

    “We examined it when it was hanging there,” Horowitz said in an interview.

    Disabling of Cameras

    The panel also found that a Bayer contractor disabled the plant’s surveillance cameras, depriving investigators of “critical video footage of the explosion.” The removal of the protective blast mat prevented “further analysis of damage caused by shrapnel and debris,” the committee report found.

    The report accused Bayer of using a media and legal strategy to limit public disclosure about the accident. In an internal Bayer “community relations strategy” memo obtained by the committee, Bayer’s public relations firm recommended undermining local community groups and news outlets, the report said.

    Buckner said “business reasons,” including “a desire to limit negative publicity,” partly motivated the company’s decision.

    He told the committee the company thought it could “refuse to provide information” to the Chemical Safety Board and began labeling documents as secret. The company used the Maritime Transportation Security Act of 2002, a homeland security law, to declare documents it turned over contained “sensitive security information” that could not be made public.

    WV is a poor state and desperate for decent-paying jobs. So we continue to allow chemical plants to operate in the midst of well-populated towns. That’s not ideal, but we’ve lived with it for many decades. However, if those who utilize toxic chemicals aren’t willing to undergo safety scrutiny, or skip on safety for profit, well, I certainly wish I could afford to move. Barring that, we’ll be bugging out at the first notice of something wrong, and hope such action is good enough. No more waiting at home for tv/radio instructions for sheltering in place.

    Yes, if everyone reacts in such a fashion, roads will be tied up. We know the back ways and hope to avoid a traffic jam. The local chemical plants do not have a good reputation for transparency, so we may very well be better off taking the twisting roads up to the ridge and then angling due west. Certainly not an ideal public health situation, but we don’t want to be a victim of waiting for official instructions that comes too late.

    Shelter in place in my house, parts of which were built in 1916, and not noted for it’s insulation and tight-fitting windows (although the window frames are wonderfully old-fashioned, made of oak)? Mellow beauty combined with low house payments, but I wouldn’t bet duct tape and towels in the cracks against what Bayer might have to offer.

  12. #12 Lisa the GP
    January 30, 2010

    Mr. Sessions, I couldn’t agree with you more.

    Let us not mention the tungsten hexaflouride, HF, hydrogen (which has a nearly invisible flame), nor the joys of high voltage…

  13. #13 kathy
    February 1, 2010

    This post picks up the honest (and hard hitting) tradition of Jordan Barab’s blog Confined Spaces — sticking up for working people and calling preventable workplace fatality what is is–a workplace crime. At least there are people now at OSHA and Chemical Safety Board who might actually investigate, prosecute and make sure it doesn’t happen again. We have a lot of work to do. Won’t read about most workplace injuries, illnesses and deaths in your local paper anytime soon.

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