## Jan20,20U 

# CSB ISSUES REPORT ON 2008 BAYER CROPSCIENCE EXPLOSION: FINDS MULTIPLE DEFICIENCIES LED TO RUNAWAY CHEMICAL REACTION; RECOMMENDS STATE CREATE CHEMICAL PLANT OVERSIGHT REGULATION

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## praaumlld ltwaa11/1312015 CSB Issues Repa1 on 2008 Bay<r CropScience Explosion: Finds Multiple Deficiencies L.sd 

### to Runaway Chemicsl Reaction; Recommends stale Crest

... functioning and claimed noMIC was released during the incident.
CSB Chairperson Dr. Rafael Moure-Erase said, "The deaths oflhe workers as a result ofthis accident were all the more tragic because it could have been prevented had Bayer CropScience provided adequate training, and required a comprehensive pre-startup equipment checkout and strict conformance with appropriate startup procedures. This would have revealed multiple dangerous conditions and procedures that were occurring at a time when the company wanted to restart production ofa key pesticide product. Startups are always a potentially hazardous operation, butto begin with computer control systems that have not been checked, while bypassing safety interlocks, is unacceptable."
The investigation report makes recommendations to the company and its Institute plant, to the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), and several West Virginia agencies. Citing a highly successful county program to ensure refinery and chemical plant safety in Contra Costa County, California, the CSB report recommends the West Virginia Department of Health and Human Resources establish a "Hazardous Chemical Release Prevention Program" that would have the authority to inspect and regulate such plants, and make public its ongoing findings.
Dr. Moure-Erase said, "I believe a state and county-run program like this would go a long way to making chemical operations safer in places like the Kanawha Valley. OSHA and EPA, have limited resources and cannot be everywhere at once. However, local jurisdictions can puttogether highly effective and targeted inspection and enforcement programs, funded by levies on the plants themselves. The accident rate in Contra Costa County has dropped dramatically, and last year in fact they had no significant accidents, thanks, in my view, to this program."
CSB Investigations Manager John Vorderibrueggen noted that a major contributing factor to the accident was a series of equipment malfunctions that continually distracted operators. "Human factors played a big part in this**acciden~** and the absence of enforced, workable standard operating procedures and adequate safety systems meant that mistakes could prove fatal. For example, operators were troubleshooting several equipment problems and during the startup, inadvertenUy failed to prefill the residue treater vessel with solvent. A safety interlock was designed to stop workers from introducing highly-reactive methomyl, but itwas bypassed as had been done in previous operations with managers' knowledge. Once the chemical reaction ofthe highly concentrated methomyl started, it could not be stopped, and the temperature and pressure inside rose rapidly, finally causing an explosion."
Board Member John Bresland, who was CSB chairman at the time ofthe Bayer accident, noted the confusion that resulted in the community's emergency response following the explosion at 10:33 p.m. "The Bayer fire brigade was at the scene in minutes, but Bayer management withheld information from the county emergency response agencies that were desperate for information about what happened, what chemicals were possibly involved," Mr. Bresland said. "The Bayer incident commander, inside the plant, recommended a shelter in place; but this was never communicated to 911 operators. After an hour of being refused critical information, local authorities ordered a shelterin-place, as a precaution." "Proper communication between companies and emergency responders during an accident is critical," said Mr. Bresland, adding, "The community deserved beUer, especially considering the amounts of hazardous chemicals, in use and being stored at various chemical facilities in the Kanawha River valley.
The CSB report notes that two workers and four volunteer firefighters required examination for possible exposure to toxic chemicals.
The investigation examined the potential consequences ofa hypothetical trajectory ofthe careening residue treater vessel that would result in its hitting the heavy steel mesh ballistic shield surrounding the above-ground MIC tank. The analysis- using blast pressure and impact energy calculations- concluded that the shield would have protected the MIC tank from a residue treater vessel hit. However, the CSB found, had the residue treater struck the
http:llwww.csb.gov/csb-issues-repa1-an-2008-bay<r-cropsci....,...explosian-ftnds-multiple-daliciencies-led-1o-runaway-chemicsl-reection-recommends--... 2131111312015 CSB Issues Report on 2008 Bayer Crq)$cierw::e Explosion: Finds MIJtiple Deficiencies Led 

### to RI.IWMIY Chemical Reaction; Recommends Stale Creal•.• shield structure nearthe top ofthe frame, the displaced frame could have contacted an MIC pipe, which mighthave resulted in an MIC release into the atmosphere. Chairperson Moure-Eraso said, •Any significant MIC release into the atmosphere along the Kanawha valley could have proven deadly, and thatconcern has been legitimately expressed for decades in the community. This potential was reduced when Bayer announced lastyear itwould no longerstore MIC above ground; itwill be reduced 

### to zero in approximately 18 months when the company has announced itwill end MIC production and use atthe Institute facility- the only place in the country still storing large quantities ofMIC."

Dr. Moure-Erase continued, •sayer's decision 

### to end pesticide production using MIC was, I understand, done for its own business reasons. Butforwhatever reasons, the eventual elimination 

### ofthis chemical will enhance safety in the Kanawha Valley, forworkers and residents alike, and is a positive development in myview."
The CSB public meeting is scheduled for6:30 p.m. this evening atthe WestVirginia State University, Sullivan Hall, Wilson University Union, Multipurpose Room 103, in Institute. The Board will heara full reporton the investigation, and then will invite seven panelists including industry experts, community activists, and county government representatives to 

### testify. Following a public comment period, the Board will vote on the report conclusions and recommendations.
The CSB is an independentfederal agency charged with investigating indusbial chemical accidents. The agency's board members are appointed bythe presidentand confirmed bythe Senate. CSB investigations look into all aspects ofchemical accidents, including physical causes such as equipmentfailure as well as inadequacies in regulations, industry standards, and safety management systems.
The Board does not issue citations orfines but does make safely recommendations 

### to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA Visit ourwebsite, www.csb.gov

. For more information, contactActing Director ofPublic Affairs Hillary Cohan at 202.261.3601 cell 202A46.8094; or Sandy Gilmour, 202.261.7614, call202.251.5496.
The safely video animation and photos can be downloaded at flp://12.200.22.14/csbbayaiT81aasa

. Usemama: csbbayarralaase; Password: Sandus9$ Back 

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