CHARLESTON, W.Va. (AP) -- A federal probe blames an ineffective alarm system, maintenance deficiencies and an inadequate emergency response process for three leaks last year at a DuPont chemical plant in West Virginia, one of which resulted in the death of a worker who ingested a toxic gas that was used as a chemical weapon during WWI and today is used as a building block in synthesis of pharmaceuticals and other organic compounds.
The U.S. Chemical Safety Board issued the findings in a draft report released Thursday in Charleston.
DuPont said in a statement that it already has taken a series of corrective actions, including performing an intensive operations safety review and improving its maintenance and inspection system for hoses.
The federal board's primary jurisdiction is to investigate serious chemical accidents and make recommendations involving hazardous releases to the air by fixed industrial facilities.
The leaks occurred over a 30-hour period in January 2010. Fifty-eight-year-old Carl Fish was exposed to phosgene and died. He was taking readings when a line failed. Investigators said he was sprayed across the chest and face with a lethal dose of phosgene. They released a computer animation of how they believe it happened.
Other leaks at the Belle plant involved the release of 2,000 pounds of methyl chloride and 22 pounds of a sulfuric acid solution. Methyl chloride leaked for five days before being discovered.
Among the board's findings:
-- DuPont management approved a design for the rupture disc alarm system that lacked sufficient reliability to advise operators of a release of flammable methyl chloride.
-- Corrosion under the insulation caused a small leak in the oleum pipe.
-- DuPont relied on a maintenance software program that was subject to changes without authorization or review and did not automatically initiate a change-out of phosgene hoses at the prescribed interval, nor did they provide a backup process to ensure timely change-out of aging hoses.
-- DuPont lacked a dedicated radio/telephone system and emergency notification process to convey the nature of an emergency at the Belle plant, thereby restricting the ability of personnel to provide timely and quality information to emergency responders.
DuPont is widely considered as having a strong commitment to safety, and because of that investigators were "surprised and alarmed" at the breakdowns at the Belle plant, CSB Chairman Rafael Moure-Eraso told reporters at a news conference held to discuss the report. Board member John Bresland said he hopes DuPont re-evaluates its safety culture across its company as a result of what happened.
The board made several recommendations for the company, the government and the industry.
It said the DuPont plant should supplement the computerized system with sufficient redundancy to ensure tracking and timely scheduling of preventive maintenance for all critical equipment and revise the facility emergency response protocol to require that a responsible and accountable DuPont employee always be available to provide timely and accurate information to emergency responders.
It also said DuPont should conduct annual phosgene hazard awareness training for all employees who handle phosgene. The board recommended that federal Occupational Safety and Health Administration regulations be revised to require facilities that handle toxic materials in compressed gas cylinders to incorporate provisions that are more effective.
In its statement, DuPont said it has removed all phosgene from the plant. Phosgene is highly toxic if ingested. It was used in combat during WWI and later stockpiled by various countries. Today it is used as a building block in the manufacture of other chemicals that have various commercial uses.
"DuPont is committed to the long-term operation of the Belle plant," DuPont said. "We are hiring new employees, making capital investments in the site, and continuing to be actively involved in the local community. Safety is a core value at DuPont and is our most important priority."