"Our Chemical Safety Board investigation shows these incidents resulted from the failure to identify potential hazards, to recognize non-routine situations and to ensure adherence to written procedures," CSB Chairman Carolyn Merritt said. "These incidents at the Honeywell Baton Rouge facility in the summer of 2003 should not have happened and would not have happened had better procedures, hazard analyses and design of critical equipment been put in place at the plant."
The three incidents one of which resulted in the death of a worker occurred during July and August of 2003.
The CSB report released at an Aug. 10 news conference in Baton Rouge asserts that there were management system deficiencies at the plant that were common to all three incidents. The company's hazard analyses did not provide an adequate review of all equipment, procedures and likely accident scenarios, according to the report, which also notes that potentially dangerous "non-routine" situations at the plant were not always recognized as such. CSB also says its investigation found that work practices at the plant did not always strictly follow written operating procedures.
"The common thread in these incidents can be found in weaknesses in some management systems at Honeywell that could have identified potential problems in each of the three seemingly different incidents," lead investigator Lisa Long said. "We believe our investigation highlights these areas and forms the basis for needed change at the plant and possibly elsewhere."
The incidents involved were:
- A July 20, 2003, chlorine gas release that injured seven Honeywell employees and required residents within a half-mile radius to shelter in their homes;
- The July 29, 2003, death of worker Delvin Henry, caused by the release of a toxic mixture containing lethal antimony pentachloride from a mislabeled cylinder; and
- The Aug. 13, 2003, release of highly toxic and corrosive hydrogen fluoride, which splashed onto a worker, causing a burn. Another worker was exposed to the toxic chemical.
As part of its report, CSB recommends that Honeywell's Baton Rouge facility revise its equipment inspection and testing procedures to prevent leaks in coolers that use chlorine. The agency also suggests that the facility establish standards and procedures for designing and maintaining critical control rooms to protect them from toxic gases, among other recommendations.
Agency: Better Chemical Identification Needed
CSB in its report also recommends that the Baton Rouge plant revise and improve its procedures to better identify chemical process hazards.
The agency says its investigation determined that the July 29, 2003, death of Delvin Henry was caused by the handling of an improperly labeled cylinder. Henry was processing what he likely believed to be an empty refrigerant cylinder when he removed a plug at one end, according to the report. CSB's investigation found that the cylinder contained 3,228 pounds of what was later determined to be a mixture containing toxic antimony pentachloride.
Henry was sprayed with the liquid and engulfed in a cloud, causing severe internal and external injuries from which he died the following day.
CSB found the cylinder had been improperly relabeled as a refrigerant at a Denver facility owned by Chemical and Metal Industries Inc. (C&MI). The agency's investigation found that Honeywell had no program to identify and address potential hazards in the ton-cylinder area, and neither the company nor C&MI had a systematic process for positively verifying the contents of cylinders.
The CSB report advises C&MI to ensure positive identification of contents of containers prior to shipping them.
The report asks the Baton Rouge Fire Department to evaluate and update its community notification procedures to include timely notification of residents in the event of a chemical release and to conduct periodic refresher training with staff on the requirements in the procedures.
The report also recommends that the East Baton Rouge Parish Office of Homeland Security and Emergency Preparedness conduct an awareness campaign to educate residents on how to respond to chemical releases.
A statement issued by Honeywell says the company "appreciates the involvement of [CSB] and we will continue to use the findings from the investigation as a learning opportunity."
"We deeply regret the incidents and any inconveniences caused to our employees, neighbors and community, and we are committed to preventing future occurrences," according to the statement. " … Honeywell's investment in people, expertise and other resources to improve company and operational procedures and employee training is part of a commitment to ensure safe operations and prevent future occurrences at Honeywell's Baton Rouge facility."
Merritt noted CSB "anticipates that Honeywell will implement the CSB's recommendations and improve its management systems to prevent incidents like this from happening here or at other sites with similar operations." "It is also our hope that Honeywell will use its standing in the industrial community to share information about this event and how it could have been prevented with chlorine producers and users," she said.