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 

lnlllltullll, Wall VIrginia. JanuiiJY 20, 2011 -The U.S. 

ChemiCIII Sara~ Board (CS8) llldB¥ reii!Utld liB ftnlll 

report on lha Augulll28, 2008,1laprCnlp8denCII 

pallldda ITIIInuftldurlng unltuplaonlhalldlled lin 

worbrBand InJured alghtod!IHIL In 11 rapD!tiiCheduled for 

Board conlldalllllon lila public ITIIIIII!nglhla -lngln 

lnlllltullll,lha C88 found multiple daftdendM during 11 

lengthy lllartup proe~~•lhalreaullllld In arvnB.W~~¥ 

chamiCBI reacllon lnlldaa relldua n.llllr~nt 

va-l. lha va-l ultlmalllll~ -~rlmd and 

uplodad. lha va-l CBreenad lnlD lhallllllhomyl 

pallldda nwnuftldurlng unltla!Mng 11 hugallltballln 1111 

wake. 

lha report found lhalhad the lrBJIICIIIIy at the uplodlng veaa!llllcen llln 11 dlfllnntdlrwclan, plecea ofltcould 

havalmplngad upon and poalbly caullltd •1111-l'ram piping at lie IIDp of a tlnk of highly bide mall)t 1811C)'11Mm 

(MJC). 

lha accldantoccumld during lhalllartup Dl'lha rnlllhornyl unit, foUIM!ng alanglly period of~Wiance. 11111 

C88found lha lllartupwabagun pn111WIIIraly,araaultofpn188UrMioraaurMpnxluc:lan ofllef1681dd•n-.tbamyl 

and Lartlln, and took place bafont valve llnaupa, equlpmantctlltdcautl, 11 pra-dlnlp •fll\1 nwr-,end _,..amr 

callblllllon ware complabl. CS81nvelllgalDIB aim faund lla ~l' flllllld b perixm 11 IIGIOUgh Pill Hu.d 

Anary.r., or PHA, ae required by ragulallon. 

lhle raaullad In numaroue crtUcal omr..ran.,lncludlng an overly ~ax Stlndanl (l!llnlng P'Riolldura (SOP) 

lhatwaa notravlawad and approvad,ln~aiD optlfUirhlnlng an 11 naw _,..allllrcanftlllll)'Uim,llllllln.Saquatl 

conlnll Dfproca• aafaguardLA principal cau• aflha accldant, the rapartllaM, wu lie lnmnlanal Cl'alldlng of an 

lntartock .,.tamlhatwa dallgnad lD prawntaddlng!Mihornyl pn:1 I'Midue lnlo lie I'Midue taallllrveaal befonl 

fllllnglha w-1 with claan 1J111118ntand haallng ltlD lila mnlmum •• opentlng ..... .,,._ 

Fllrthamtora,lha lnwlllgaUon faund lhlllcrtUcal operallng aqulpmantand ln..,mentlwwa notlnatllad baM 

lha ralllart, and wara di1JC0118111d ID II& m..rng allarlhalllartup began.llayar'a Mellornyi-UNn unit MIC gu 

monllllrtng .,.tamwae notln eartlloa alha lllartup anaulld, yatllllyarllmllfllanqo ~nel praaumlld ltwaa 
11/1312015 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 of this 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 of a key pesticide product. Startups are always a potentially hazardous operation, but to 

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 put together 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 it was bypassed as had been done in previous operations with 

managers' knowledge. Once the chemical reaction of the 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 of the 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 of a hypothetical trajectory of the 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--... 213 
1111312015 CSB Issues Report on 2008 Bayer Crq)$cierw::e Explosion: Finds MIJtiple Deficiencies Led to RI.IWMIY Chemical Reaction; Recommends Stale Creal •.• 

shield structure near the top of the frame, the displaced frame could have contacted an MIC pipe, which might have 

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 that concern has been legitimately expressed for decades in the community. This 

potential was reduced when Bayer announced last year it would no longer store MIC above ground; it will be reduced 

to zero in approximately 18 months when the company has announced it will end MIC production and use at the 

Institute facility- the only place in the country still storing large quantities of MIC." 

Dr. Moure-Erase continued, •sayer's decision to end pesticide production using MIC was, I understand, done for 

its own business reasons. But for whatever reasons, the eventual elimination of this chemical will enhance safety in 

the Kanawha Valley, for workers and residents alike, and is a positive development in my view." 

The CSB public meeting is scheduled for 6:30 p.m. this evening at the West Virginia State University, Sullivan 

Hall, Wilson University Union, Multipurpose Room 103, in Institute. The Board will hear a full report on 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 independent federal agency charged with investigating indusbial chemical accidents. The 

agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all 

aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in 

regulations, industry standards, and safety management systems. 

The Board does not issue citations or fines but does make safely recommendations to plants, industry 

organizations, labor groups, and regulatory agencies such as OSHA and EPA Visit our website, www.csb.gov. 

For more information, contact Acting Director of Public 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$ 

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