The first incident was a chlorine release that occurred on July 20, 2003. Investigator Lisa Long reported that the chlorine release, which injured eight Honeywell employees with four of them hospitalized, was caused by a failure of a chlorine cooler, which allowed liquid chlorine to enter the refrigerant system.
According to Long, chlorine gas escaped through a hole in a chlorine cooler tube. Operators first detected the release at 3:05 a.m. Local authorities activated a siren system at 4 a.m., advising residents to remain in their homes for safety.
"The company attempted to contain the release by spraying the chlorine cloud with water, but it was not until 7 a.m. that the all-clear signal was given," said Long.
Honeywell's testing of chlorine levels, beginning at 5:30 a.m., found concentrations of 1.2 parts per million parts of air (ppm). Concentrations of 1 to 3 ppm can cause mucous membrane irritation; much higher concentrations cause chest pains and death. By 7 a.m. the company reported concentrations below 0.35 ppm.
The second incident an antimony pentachloride release, occurred on July 29, 2003. Investigator Mike Morris reported that a worker, Delvin S. Henry, was fatally injured after he was sprayed with spent, or used, antimony pentachloride, a highly corrosive chemical that can cause serious chemical burns and lung damage.
Henry was engaged in an operation to prepare large, used refrigerant cylinders for off-site testing. Five years earlier, the cylinder, originally labeled as antimony pentachloride, had been relabeled as a refrigerant before shipping it to the Baton Rouge plant. A specialty company in Denver performed the re-labeling after consulting with Honeywell operators in California.
Though he had worked in the plant for about 3 years, Henry was new to this particular job, and evidently believed all of the cylinders he was working with were empty or contained only small amounts of refrigerant and were labeled as such.
Unable to properly purge the contents of one of these cylinders by hooking up hoses to the cylinder's drain valves, Henry removed a plug from the back of the cylinder. The spent antimony pentachloride sprayed out under pressure, enveloping the operator, resulting in his death the next day.
The rapid shutdown following the July 20 incident started a chain of events that would result in the Aug. 13, 2003 incident, when hydrofluoric acid (HF) spray splashed onto a worker. CSB Investigator Johnnie Banks reported the rapid shutdown after July 20 left significant amounts of the HF, a colorless chemical that can quickly destroy human tissue, in an internal piping system. A decision was made to remove it. Operators began draining it into a sewer through a 1-inch pipe where flowing water siphoned the HF into the wastewater sewer system.
On Aug. 13, the system was suspected of being clogged, and an operator opened and closed two valves in an attempt to clear the blockage. The operator then reopened the valves, resulting in a pressure surge that ran through the 1-inch pipe, called a "venturi stick."
Pressurized by nitrogen, hydrofluric acid and water escaped from the sewer, splashing onto the worker. CSB investigators found the pipe had not been properly secured, and was suspended by a single rope.
The worker was helped by a maintenance supervisor, who experienced a coughing spell from the fumes. The worker was treated and released at the local hospital; the maintenance supervisor was released from the hospital the next day.
The investigation team will continue to gather information and is taking a close look at the company's hazard evaluation process, plant safety programs and community notification issues.
"These incidents, three in a row in a period of less than four weeks, show the need for continuing safety vigilance at chemical plants and other facilities where potentially dangerous chemicals are processed," said CSB Board Member Gerald V. Poje, Ph.D. "While this investigation is not complete, I emphasize the need for chemical companies to constantly review their processes, and I would urge chemical facilities, local authorities and neighborhood groups to work together to ensure that notification and emergency response systems are in order."
