(147d) Fatal Exposure: Tragedy At DuPont

This investigation by the United States Chemical Safety and Hazard Investigation Board (CSB) provides unique lessons in process safety. Three incidents occurred over a 33-hour period at the DuPont plant in Belle, WV. The most serious incident occurred on January 23, 2010, when a release of highly toxic phosgene fatally exposed a veteran operator. Emergency services transported the exposed operator to the hospital, where he died the following day. The two prior incidents were a release of chloromethane that went undetected for several days, and an oleum release from a spent sulfuric acid unit. Each incident had specific issues, but some issues were common to all three incidents. Applying the lessons from these incidents to other facilities can prevent analogous failures.