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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Investigation Report
	Published: June 2019

	Investigation Report

	KEY ISSUES:
	• Emergency Planning and Response

	(Preparedness)

	•

	Implementation of Process Safety
	Management Systems

	• Assessment of Process Safety Culture























	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent federal
	agency whose mission is to drive chemical safety change through independent investigations to
	protect people and the environment.

	The CSB is a scientific investigative organization, not an enforcement or regulatory body.
	Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining
	accident causes, issuing safety recommendations, studying chemical safety issues, and evaluating the
	effectiveness of other government agencies involved in chemical safety. More information about the
	CSB is available at www.csb.gov.

	The CSB makes public its actions and decisions through investigative publications, all of which may
	include safety recommendations when appropriate. Types of publications include:

	Investigation Reports: Formal, detailed reports on significant chemical incidents that
	include key findings, root causes, and safety recommendations

	Investigation Digests: Plain-language summaries of Investigation Reports

	Case Studies: Reports that examine fewer issues than Investigation Reports

	Safety Bulletins: Short publications typically focused on a single safety topic

	Hazard Investigations: Broader studies of significant chemical hazards

	Safety Videos: Videos that animate aspects of an incident or amplify CSB safety messages

	CSB products can be freely accessed at www.csb.gov or obtained by contacting:

	U.S. Chemical Safety and Hazard Investigation Board
	Office of Congressional, Public, and Board Affairs
	1750 Pennsylvania Ave NW, Suite 910
	Washington, DC 20006
	(202) 261-7600

	No part of the conclusions, findings, or recommendations of the Board relating to any accidental
	release or the investigation thereof shall be admitted as evidence or used in any action or suit for
	damages arising out of any matter mentioned in such report. See 42 U.S.C. § 7412(r)(6)(G).

	Page 2







	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	U.S. Chemical Safety and
	Hazard Investigation Board

	TABLE OF CONTENTS

	EXECUTIVE SUMMARY.............................................................................................................................................. 7

	INCIDENT DESCRIPTION ......................................................................................................................................... 12

	METHYL MERCAPTAN RELEASE ............................................................................................................................... 13
	EMERGENCY RESPONSE ......................................................................................................................................... 20

	DELAYED AWARENESS OF TOXIC CHEMICAL RELEASE BY OPERATIONS .................................................................. 27

	EMERGENCY RESPONSE OPERATIONS .................................................................................................................... 30

	ERT BACKGROUND .............................................................................................................................................. 31
	PROCESS COORDINATOR WAS MISSING .................................................................................................................... 33
	DELAY IN ERT READINESS TO SEARCH FOR MISSING WORKERS ....................................................................................... 36
	4.3.1 Call for ERT Response .................................................................................................................................. 36
	ERT Mini-‐Pumper Truck Not Operational ..................................................................................................... 37
	4.3.2
	THE SEARCH FOR MISSING WORKERS WAS HIGH RISK .................................................................................................. 38
	4.4.1
	Entry into Potentially Explosive Atmosphere ................................................................................................ 38
	4.4.2 No Technology to Locate Missing Workers .................................................................................................. 40
	4.4.3 Unrecognized Manufacturing Building Collapse Hazard ............................................................................... 41
	DIFFICULTIES NAVIGATING MANUFACTURING BUILDING ................................................................................................ 42
	NO ANALYSIS OF PROCESS DATA TO IDENTIFY SOURCE OF LEAK....................................................................................... 45
	INADEQUATE CREATION AND CONTROL OF HOT ZONE .................................................................................................. 48
	DEFICIENCIES IN EVALUATING RISK TO THE PUBLIC ....................................................................................................... 50
	4.8.1 Release Modeling ....................................................................................................................................... 51
	4.8.2 Physical Properties of Methyl Mercaptan .................................................................................................... 54
	4.8.3 Chemical Sensor Data ................................................................................................................................. 56
	4.8.4 Air Monitoring ............................................................................................................................................ 57
	EMERGENCY RESPONSE CONCLUSIONS ...................................................................................................................... 58

	DUPONT’S PROCESS SAFETY MANAGEMENT SYSTEM ............................................................................................ 59

	OSHA .............................................................................................................................................................. 60
	5.1.1
	The Process Safety Management Standard ................................................................................................. 60
	5.1.2 DuPont La Porte’s Implementation of PSM .................................................................................................. 61
	5.1.3 Recent Developments Affecting the PSM Standard ...................................................................................... 63
	ENVIRONMENTAL PROTECTION AGENCY .................................................................................................................... 63
	5.2.1 Risk Management Plan Rule........................................................................................................................ 63
	5.2.2 DuPont La Porte’s Implementation of RMP .................................................................................................. 65
	5.2.3 Recent Developments Affecting the RMP Rule ............................................................................................. 65
	AMERICAN CHEMISTRY COUNCIL ............................................................................................................................. 67
	5.3.1 History of Responsible Care ......................................................................................................................... 68
	5.3.2 Responsible Care Requirements .................................................................................................................. 69
	5.3.3 Responsible Care Conformance Audits ........................................................................................................ 71

	Page 3




















	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	5.3.4 Recent Developments in Responsible Care ................................................................................................... 74
	5.3.5 Responsible Care Improvement Opportunities ............................................................................................. 75
	DUPONT’S DEVELOPMENT AND IMPLEMENTATION OF ITS PROCESS SAFETY MANAGEMENT SYSTEM ........................................ 78
	5.4.1 Building a Safety Culture ............................................................................................................................. 80
	5.4.2 Using the Process Safety Management and Risk Model ............................................................................... 90
	DUPONT’S PROCESS SAFETY MANAGEMENT SYSTEM CONCLUSIONS ................................................................................ 92

	PROCESS SAFETY MANAGEMENT DEFICIENCIES...................................................................................................... 92

	PROCESS HAZARD ANALYSIS EVALUATION .................................................................................................................. 93
	IMPLEMENTATION OF CORRECTIVE ACTIONS ............................................................................................................... 96
	PROCESS SAFETY PRACTICES DURING TROUBLESHOOTING OPERATIONS ............................................................................. 99
	MOC PRACTICES .............................................................................................................................................. 101
	6.4.1 No MOC for Heating Piping or for New Piping Alignment ........................................................................... 102
	6.4.2 No MOC for New Piping Alignment to Nitrogen Relief Valves ..................................................................... 105
	6.4.3 No MOC or Procedure for Vent Header Draining Operation ....................................................................... 106
	LINE-‐BREAKING PRACTICES .................................................................................................................................. 109
	SHIFT COMMUNICATION PRACTICES ....................................................................................................................... 113

	ADDITIONAL FACTS, CONDITIONS, AND CIRCUMSTANCES IDENTIFIED ................................................................. 114

	EMPLOYEE INCENTIVE PROGRAM ........................................................................................................................... 115

	KEY FINDINGS ....................................................................................................................................................... 120

	SAFETY GUIDANCE ................................................................................................................................................ 121

	10 RECOMMENDATIONS ........................................................................................................................................... 124

	DUPONT LA PORTE, TEXAS, CHEMICAL FACILITY ....................................................................................................... 125
	LOCAL 900C OF THE INTERNATIONAL CHEMICAL WORKERS UNION COUNCIL (ICWUC) OF THE UNITED FOOD AND COMMERCIAL

	WORKERS (UFCW) ....................................................................................................................................................... 126

	REFERENCES .................................................................................................................................................................. 128

	APPENDIX A: CAUSAL ANALYSIS.................................................................................................................................... 144

	APPENDIX B: INCIDENT TIMELINE ................................................................................................................................. 145

	APPENDIX C: ODOR COMPLAINTS FROM NOVEMBER 15, 2014 ..................................................................................... 150

	APPENDIX D: EMERGENCY RESPONSE TABLES .............................................................................................................. 151

	APPENDIX E: DUPONT SAFETY PERCEPTION SURVEYS................................................................................................... 156

	Page 4



















	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	ACRONYMS AND INITIALISMS

	AAO

	ACC

	AEGL

	API

	CCPS

	CCTV

	CSB

	DCS

	DOT

	EMT

	EPA

	EOC

	acetaldehyde oxime

	American Chemistry Council

	acute exposure guideline level

	American Petroleum Institute

	Center for Chemical Process Safety

	closed circuit television

	U.S. Chemical Safety and Hazard Investigation Board

	distributed control system

	U.S. Department of Transportation

	emergency medical technician

	U.S. Environmental Protection Agency

	Emergency Operations Center

	ERPGs

	Emergency Response Planning Guidelines

	ERT

	FBU

	emergency response team

	Fluoroproducts Business Unit

	FEMA

	U.S. Federal Emergency Management Agency

	HAZCOM

	Hazard Communication Standard

	HAZWOPER

	Hazardous Waste Operations and Emergency Response Standard

	IBU

	Insecticide Business Unit

	ICWUC

	International Chemical Workers Union Council

	IDLH

	LEL

	LFL

	LPBC

	MeSH

	MOC

	MSDS

	Immediately Dangerous to Life or Health

	lower explosive limit

	lower flammability limit

	Local Performance Based Compensation program

	methyl mercaptan

	methyl isocyanate

	management of change

	material safety data sheet

	Page 5







	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	NAICS

	North American Industrial Classification System

	mph

	NEP

	NFPA

	NIMS

	miles per hour

	National Emphasis Program

	National Fire Protection Association

	National Incident Management System

	NIOSH

	National Institute for Occupational Safety and Health

	NRS

	OSHA

	NOx (nitrogen oxides) reduced scrubbed

	U.S. Occupational Safety and Health Administration

	OSH Act

	U.S. Occupational Safety and Health Act of 1970

	PEL

	PHA

	ppb

	PPE

	ppm

	PSM

	permissible exposure limit

	process hazard analysis

	parts per billion

	personal protective equipment

	parts per million

	Process Safety Management

	RCMS

	Responsible Care Management System®

	RCS

	REL

	RMP

	Relative Culture Strength

	recommended exposure limit

	Risk Management Plan

	SCBA

	self-contained breathing apparatus

	SDS

	SHI

	TWA

	UFCW

	safety data sheet

	Substance Hazards Index

	Time-Weighted Average

	United Food and Commercial Workers

	Page 6








	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	U.S. Chemical Safety and
	Hazard Investigation Board

	1 EXECUTIVE SUMMARY

	On November 15, 2014, approximately 24,000 poundsa of highly toxic methyl mercaptan was released from an
	insecticide productionb unit (Lannate® Unit) at the E. I. du Pont de Nemours and Company (DuPont) chemical
	manufacturing facility in La Porte, Texas.c The release killed three operators and a shift supervisor inside a
	manufacturing building.d They died from a combination of asphyxia and acute exposure (by inhalation) to
	methyl mercaptan.

	The CSB determined that the cause of the highly toxic methyl mercaptan release was the flawed engineering
	design and the lack of adequate safeguards.e Contributing to the severity of the incident were numerous safety
	management system deficiencies, including deficiencies in formal process safety culture assessments, auditing
	and corrective actions, troubleshooting operations, management of change, safe work practices, shift
	communications, building ventilation design, toxic gas detection, and emergency response. Weaknesses in the
	DuPont La Porte safety management systems resulted from a culture at the facility that did not effectively
	support strong process safety performance.

	The highly toxic methyl mercaptan release resulted from a long chain of process safety management system
	implementation failures stemming from ineffective implementation of the process safety management system at
	the DuPont La Porte facility.

	The CSB investigation viewed the chain of implementation failures as starting with the flawed engineering
	design of the $20 million nitrogen oxides (NOx) reduced scrubbed (NRS) incinerator, a capital project
	implemented in 2011. DuPont La Porte had long-standing issues with vent piping to this incinerator because the
	design did not address liquid accumulation in waste gas vent header vapor piping to the NRS, and DuPont La
	Porte did not fully resolve the liquid accumulation problem through hazard analyses or management of change
	reviews. Instead, to deal with these problems, daily instructions had been provided to operations personnel to
	drain liquid from these pipes to the atmosphere inside the Lannate® manufacturing building without specifically
	addressing the potential safety hazards this action could pose to the workers. DuPont La Porte’s instructions did

	a 29 C.F.R. § 1910.119 Appendix A (2013).
	b The Insecticide Business Unit (IBU) was divided into two primary insecticide product lines: Lannate®, which is DuPont’s trade name
	for methomyl, and agricultural products intermediates, which were used to produce insecticides and nematicides known as Vydate®, the
	trade name for oxamyl [1, p. 11].
	c Multiple business units were located at the DuPont La Porte site. The Lannate® Unit was part of the IBU. In addition to the IBU, the
	facility had an Herbicides Business Unit and a Fluoroproducts Business Unit (FBU). The FBU included an anhydrous hydrogen fluoride
	(HF) manufacturing unit. FBU assets were sold to Chemours on July 1, 2015.
	d The victims included operators Robert Tisnado (39), Gilbert Tisnado (48), Crystle Wise (53), and shift supervisor Wade Baker (60).
	One victim on the third floor was located near a methyl mercaptan leak source on the wet end (east) side. The other two victims on the
	third floor were on the dry end (west) side. The IBU was further subdivided into four functional areas: the wet end, the MIC (methyl
	isocyanate) area, the damp end, and the dry end. The wet end contained liquid reaction equipment. The MIC area contained equipment
	to generate and consume the MIC intermediate. The damp end isolated and dried insecticide crystals. The dry end processed the crystals
	and packaged them into various products [1, pp. 10-11].
	e In September 2018, the CSB produced a Winterization Safety Digest that discussed DuPont La Porte’s lack of safeguards to prevent
	methyl mercaptan hydrate formation [173, p. 1].

	Page 7







	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	not specify additional breathing protection for this task (Section 6.4.3 and Interim Recommendations) [1, p. 18].
	On the night of the incident, not realizing the hydrate blockage in the methyl mercaptan feed piping was cleared,
	workers went to drain liquid from the waste gas vent piping. They did not know that high pressure in the waste
	gas vent piping was related to the fact that liquid methyl mercaptan was flowing through the methyl mercaptan
	feed piping and into the waste gas vent piping.

	The chain further developed when the ineffective building ventilation system failed to be addressed after
	DuPont auditors identified it as a safety concern about five years before the incident. DuPont La Porte’s
	management system did not resolve the process safety management recommendation (i.e., did not take
	corrective action) to address the building ventilation system (Section 6.1 and Interim Recommendations) [1, p.
	34]. The ventilation design for the manufacturing building was based on flammability characteristics and did
	not take into consideration toxic chemical exposure hazards, even though the building contained two highly
	toxic materials, chlorine and methyl mercaptan. DuPont La Porte records indicated that the manufacturing
	building’s dilution air ventilation design was based on providing sufficient ventilation to ensure that the
	concentration of flammable gases did not exceed 25 percent of the lower explosion limit (LEL).a At the time of
	the incident, neither of the manufacturing building’s two rooftop ventilation fans was working, despite an
	“urgent” work order written nearly a month earlier. Even had the fans worked, they probably would not have
	prevented a lethal atmosphere inside the building due to the large amount of toxic gas released (Section 5.4.1.2
	and Interim Recommendations) [1, pp. 3, 33-34].

	DuPont La Porte’s installation of a methyl mercaptan detection system inside the manufacturing building added
	another link to the chain. Neither the workers nor the public was protected by DuPont’s toxic gas detection
	system on the night of the incident. The building where the workers died was not equipped with an adequate
	toxic gas detection system to alert personnel to the presence of dangerous chemicals. First, DuPont La Porte set
	the detector alarms well above safe exposure limits for workers. Second, DuPont La Porte relied on verbal
	communication of alarms that automatically displayed on a continuously manned control board. Finally,
	DuPont La Porte did not provide visual lights or audible alarms for the manufacturing building to warn workers
	of highly toxic gas concentrations inside it. When a release caused a detector to register a concentration above
	the alarm limit, the toxic gas detection system did not warn workers in the field about the potential leak and the
	need to evacuate. Among other factors, this detection system contributed to workers’ growing accustomed to
	smelling the methyl mercaptan odor in the unit. Additionally, when the toxic gas detectors triggered alarms,
	DuPont La Porte personnel investigated potential methyl mercaptan leaks without using respiratory protection.
	Personnel normalized unsafe methyl mercaptan detection practices by using odor to detect the gas, further

	a DuPont records indicate that the manufacturing building ventilation system design code is NFPA 497, Recommended Practice for the
	Classification of Flammable Liquids, Gases, or Vapors and of Hazardous (Classified) Locations for Electrical Installations in Chemical
	Process Areas. NFPA 497 defines adequate ventilation as that sufficient to ensure that the concentration of flammable gases does not
	exceed 25 percent of the lower flammability limit (also referred to as lower explosion limit (LEL)) [136, p. 9]. However, there were no
	LEL detectors to monitor the atmospheric conditions inside the manufacturing building and alert workers of potential fire or explosion
	conditions. Furthermore, a methyl mercaptan concentration of 25 percent of the LEL is equivalent to 65 times greater than the 150 parts
	per million concentration that is considered immediately dangerous to life or health (IDLH).

	Page 8







	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	deteriorating the importance or effectiveness of utilizing instrumentation in response to alarms signaling
	potential toxic gas releases (Section 3 and Interim Recommendations) [1, pp. 38-39].

	In the spring of 2014, the chain propagated when DuPont La Porte’s interlock program did not require
	verification that interlocks that had been bypassed for turnaround maintenance were returned to service before
	the plant resumed operating. Because of this ineffective program, a bypassed interlock caused acetaldehyde
	oxime (AAO), a critical raw material, to become diluted, leading to a shutdown of the Lannate® Unit days
	before the November 2014 incident.a During the shutdown, water entered the methyl mercaptan feed piping
	and, due to the cold weather, formed a hydrate (an ice-like material) that plugged the piping and prevented
	workers from restarting the unit. Furthermore, DuPont La Porte did not establish adequate safeguards after a
	2011 DuPont La Porte process hazard analysis identified hydrate formation in this piping, revealing yet another
	link in the chain (Section 6.1 and Interim Recommendations) [1, p. 22].

	When the hydrate formed, lacking safeguards to control the potential safety hazards associated with dissociating
	(breaking up) the hydrate (such as using heat tracing to prevent the hydrate from forming a solid inside the
	piping or developing a procedure to dissociate the hydrate safely), DuPont workers went into troubleshooting
	mode (Section 6.3). Ineffective hazard management while troubleshooting the plugged methyl mercaptan feed
	piping formed yet another link in the chain and allowed liquid methyl mercaptan to flow into the waste gas vent
	header piping toward the NRS incinerator—a location where it was never intended to go (Section 6.4.1 and
	Interim Recommendations) [1, pp. 25-26]. As discussed earlier, DuPont La Porte did not fully resolve liquid
	accumulation in the waste gas vent header by the NRS incinerator. Consequently, DuPont La Porte workers
	dealt with the common problem of liquid accumulation in the waste gas vent header on a routine basis by
	draining the liquid (line breaking) without an engineered solution or without ensuring the use of safety
	procedures or personal protective equipment (Section 6.4.3 and Interim Recommendations) [1, pp. 18, 28].
	However, when the liquid drain valves were opened on November 15, 2014, flammable and highly toxic methyl
	mercaptan flowed onto the floor and filled the manufacturing building with toxic vapor.

	Once the methyl mercaptan release began, an ineffective emergency response program at La Porte contributed to
	the extent and duration of the chemical release, placed other workers in harm’s way, and did not effectively
	evaluate whether the chemical release posed a safety threat to the public (Section 3 and Section 4).

	a During the AAO truck unloading, a block valve downstream of what should have been an out-of-service water dilution control valve
	was inadvertently opened, allowing water to flow into the tank. The water dilution system had been installed in 2006 when container
	shipments of 100 percent AAO were judged to be more economical than diluted AAO. AAO is now typically purchased and stored as a
	50 percent solution with water. A logistical problem resulted in an unusual delivery of 50 percent AAO by tank truck instead of by
	railcar. Two factors contributed to the tank overflow incident. First, DuPont did not have a procedure for unloading a 50 percent tank
	truck of AAO. Second, the AAO water dilution control valve was supposed to interlock closed when (1) the truck-unloading pump was
	off or (2) the AAO tank had a high liquid level. However, the interlock function had been bypassed in the field so that water could be
	used to decontaminate the tank during the turnaround in spring 2014. Instrument air supply tubing was connected directly to the
	interlock valve actuator, bypassing the interlock activation solenoid, and forcing the valve to remain fully open. The interlock could not
	function because the bypass was not removed at the completion of the turnaround [1, p. 33]. DuPont defines a safety interlock as a
	system or function that detects an out-of-limits (abnormal) condition or improper sequence and brings it to a safe condition [1, p. 38].

	Page 9








	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	This chain of events illustrates DuPont La Porte’s ineffective implementation of its process safety management
	system. The individual components of this process safety management system exhibited cross-cutting
	weaknesses, resulting in the deaths of four workers and leading to the ultimate decision to close the DuPont La
	Porte facility.

	The DuPont La Porte incident is the CSB’s third investigation of a fatal DuPont incident in five years.a On
	September 30, 2015, the CSB issued a presentation, a safety video, and an Interim Recommendations report [1],
	which detailed needed safety improvements at the DuPont La Porte facility and issued recommendations for
	implementation before resuming operations of the Lannate® Unit [2].b Due to the amount of methyl mercaptan
	stored at the DuPont La Porte site, the Lannate® process was covered by the Process Safety Management (PSM)
	standard of the U.S. Occupational Safety and Health Administration (OSHA) and the Risk Management Plan
	(RMP) rule of the U.S. Environmental Protection Agency (EPA) [3]. In the Interim Recommendations, the CSB
	identified significant process safety management deficiencies at the La Porte facility, including delayed
	maintenance of safety-critical equipment, lack of written procedures, poor hazard analysis practices, lack of
	implementation of important inherently safer design concepts, and a lack of hazard recognition [1].

	In response to the CSB findings and recommendations, DuPont committed to making changes at the La Porte
	facility. DuPont La Porte, however, was not able to address all of these findings and recommendations, because
	in the spring of 2016 DuPont announced that it would not reopen the Lannate® Unit. The company had
	determined that “significant changes in market conditions during the period of the shutdown [would] persist
	over the long term” [4] and that the cost required for the restart was “not a long-term viable and cost-efficient
	option for the DuPont Crop Protection business” [5]. In 2017, DuPont dismantled and removed from the
	DuPont La Porte facility the buildings and equipment that had been associated with its insecticide and herbicide
	business units, including the Lannate® Unit.c

	Despite the closure of the insecticide and herbicide units, the CSB determined that the DuPont La Porte incident
	offers important lessons for the chemical industry relating to the following areas:

	• Emergency Response. The emergency response efforts at the DuPont La Porte facility during the
	toxic chemical release were disorganized and placed at risk operators, emergency responders, and
	potentially the public. Chemical plants need a robust emergency response program to mitigate
	emergencies and to protect the health of workers, emergency responders, and the public.d

	a The CSB also investigated an incident at a DuPont plant in Belle, West Virginia (three incidents that occurred in a 33-hour period over
	January 22–23, 2010, resulting in one fatality) [121], and another in Buffalo, New York (a single incident that occurred on November 9,
	2010, resulting in one fatality and one serious injury) [122].
	b This report incorporates by reference the DuPont La Porte Interim Recommendations [1].
	c Although DuPont dismantled the La Porte Crop Protection business, DuPont La Porte still operates as a landlord to other companies
	located at the La Porte site and provides wastewater treatment and utilities, as well as owning the emergency response program.
	d Emergency response and planning is one of five key safety topics that the CSB found needed improvement across industry nationwide;
	as a result, the CSB included that topic in its Drivers of Critical Chemical Safety Change program. Inadequate or poor emergency
	planning or response is a recurring finding in CSB investigations. At least 17 CSB incident investigations, including this one, identified
	emergency response deficiencies, resulting in 46 emergency response recommendations [33].

	Page 10







	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	• DuPont’s Process Safety Management System. DuPont created its own corporate process safety
	management system that integrated its internal safety requirements with those of the American
	Chemistry Council’s Responsible Care® programa and those required by regulations under the EPA
	RMP rule and the OSHA PSM standard. Over the course of five years, despite implementing its
	corporate process safety management system, DuPont experienced three major process safety
	incidents.

	In addition to developing an integrated process safety management system, DuPont established a
	program to implement it. According to DuPont, the implementation of the process safety
	management system can be broken down into two parts: (1) Building a Safety Culture and (2) Using
	the Process Safety Management and Risk Model. Although DuPont’s corporate standard
	recommended that its sites assess their process safety culture, DuPont La Porte had not formally
	evaluated process safety culture at its facility before the November 2014 incident. DuPont La Porte
	used a proprietary Safety Perception Survey that focused on personal or occupational safety but did
	not evaluate or assess the process safety culture. Because the Safety Perception Survey did not
	reasonably evaluate all safety aspects of culture, it could not help identify the significant process
	safety weaknesses at the DuPont La Porte facility, leaving the site vulnerable to potential process
	safety incidents. While measuring worker perceptions of personal safety is important, a safety
	culture assessment program should also provide an effective gauge of process safety. The second
	tool that DuPont used to implement its process safety management system was the Process Safety
	Management and Risk Model, the company’s visual representation of an effective process safety
	management system, showing the implementation and interaction of Management Leadership and
	Commitment, Comprehensive Process Safety Management Program, and Operational Discipline.

	• DuPont La Porte’s Process Safety Management Deficiencies. The CSB identified significant

	process safety deficiencies at the DuPont La Porte site that contributed to the incident. DuPont’s
	corporate process safety management system did not identify, prevent, or mitigate these
	deficiencies. A company must effectively implement a process safety management system and its
	corresponding programs to reap the accompanying process safety benefits.

	• DuPont La Porte’s Employee Incentive Program. The DuPont La Porte bonus structure may have

	disincentivized workers from reporting injuries, incidents, and “near misses.” Ensuring that
	employees can report injuries or incidents in accordance with the Occupational Safety and Health
	(OSH)Act and OSHA regulations, without fear of discrimination, retaliation, or other adverse
	consequence is central to protecting worker safety and health, and aiding accident prevention.

	a The American Chemistry Council (ACC) is a trade group that represents chemical companies. ACC’s Responsible Care Program is a
	voluntary industry program.

	Page 11








	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	This report encourages legacy DuPonta sites to strengthen employee incentive programs. It additionally presents
	a set of recommendations to the DuPont La Porte facility and Local 900C of the International Chemical Workers
	Union Council (ICWUC) of the United Food and Commercial Workers (UFCW) to improve emergency
	preparedness and response at the La Porte facility. Based on the CSB’s investigative findings related to
	emergency response, process safety management systems, and incentive programs (see Appendix A: Causal
	Analysis), this report presents lessons for the chemical industry in Guidance to Industry sections and
	summarizes them at the end of the report in Section 9: Safety Guidance.

	2 INCIDENT DESCRIPTION

	The November 15, 2014 incident occurred in DuPont
	La Porte’s Lannate®b Unit, which produced
	insecticides. Part of the Lannate® process occurred
	inside a closed building (the manufacturing building)

	Figure 1. The Lannate® Manufacturing Building. The methyl
	mercaptan release occurred in the manufacturing building. Source:
	CSB.

	a DuPont and Dow completed a merger of equals on August 31, 2017. The combined entity operated as a holding company called
	DowDuPont [105]. On April 1, 2019, DowDuPont successfully completed the spin-off of its Material Science division, Dow.
	DowDuPont intends to separate its Agriculture and Specialty Products divisions into independent, publicly traded companies by June
	2019, subject to board approval [134].
	b Lannate® is the DuPont trade name for methomyl, an insecticide [94, p. 1]. For more detail on the incident, see public meeting
	presentation, DuPont La Porte animation, public meeting transcript, and Interim Recommendations report [2].

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	(Figure 1),a where most of the methyl mercaptan release occurred.b The Lannate® process used methyl
	mercaptan, a toxic and flammable chemical.c,d

	The sections below discuss the eventse leading to the methyl mercaptan release and the subsequent emergency
	response.

	METHYL MERCAPTAN RELEASE

	On Monday, November 10, 2014, an inadvertent chemical dilution caused operating difficulties that forced a
	shutdown of DuPont’s Lannate® Unit.f In response, DuPont La Porte personnel adjusted the unit’s control
	system to resume operations. On Wednesday, November 12, 2014, operators tried to restart the Lannate®
	process. During the shutdown, the methyl mercaptan piping to the reaction section of the process had become
	plugged due to the formation of a clathrate hydrate (hydrate),g halting restart. At that time, operators did not

	a Chlorine and methyl isocyanate (MIC) were also used in the manufacturing building.
	b Although the bulk of the release occurred inside the manufacturing building, methyl mercaptan was also released from the nitrogen
	relief valves located at the methyl mercaptan railcar spots.
	c Symptoms of methyl mercaptan toxicity include narcosis (a state of stupor, drowsiness, or unconsciousness) and cyanosis (blue or
	purple coloration of the skin or mucous membranes caused by inadequate oxygenation of the blood) [50]. Methyl mercaptan is also a
	chemical asphyxiant [95]. Chemical asphyxiants are toxic agents that prevent red blood cells from carrying oxygen [90, p. 58]. The
	OSHA ceiling exposure limit is 10 parts per million (ppm). OSHA recommends that employers consider using the alternative
	occupational exposure limits because the agency believes that exposures above some of these alternative occupational exposure limits
	may be hazardous to workers, even when the exposure level complies with the relevant permissible exposure limit (PEL) [162]. The
	Division of Occupational Safety and Health of California (Cal-OSHA) PEL is an 8-hour time-weighted average (TWA) of 0.5 ppm, and
	the National Institute of Occupational Safety and Health (NIOSH) recommends a recommended exposure limit (REL) of a 15-minute
	ceiling limit of 0.5 ppm [163]. Methyl mercaptan is immediately dangerous to life and health at 150 ppm [50]. For methyl mercaptan, the
	10-minute acute exposure guideline level (AEGL)-2 (disabling) is 40 ppm and the 10-minute AEGL-3 (lethal) is 120 ppm. According to
	the National Center for Biotechnology Information, “AEGL-2 is the airborne concentration (expressed as ppm or mg/m3) of a substance
	above which it is predicted that the general population, including susceptible individuals, could experience irreversible or other serious,
	long-lasting adverse health effects or an impaired ability to escape. AEGL-3 is the airborne concentration (expressed as ppm or mg/m3)
	of a substance above which it is predicted that the general population, including susceptible individuals, could experience life-threatening
	health effects or death” [130].
	d Methyl mercaptan is flammable at concentrations between 3.9 percent and 21.8 percent in air [50].
	e The sequence of events is also presented in

	Appendix B: Incident Timeline.
	f The chemical involved in this dilution was acetaldehyde oxime (AAO). Additional information about the AAO dilution portion of the
	incident is in the CSB DuPont La Porte Interim Recommendations [1, pp. 20-21].
	g At low temperatures (≤ 52 degrees Fahrenheit (°F)), water and methyl mercaptan form a solid, ice-like material called methyl
	mercaptan clathrate hydrate [72]. Temperatures in the Houston area for the 24 hours preceding the incident averaged approximately
	40°F and had been consistently below 55°F since Tuesday, November 11, 2014. Although the potential for methyl mercaptan hydrate
	formation had been identified in DuPont’s methyl mercaptan technical standard and in process hazard analyses years earlier, DuPont
	never implemented safeguards, such as heat tracing, or developed a procedure to dissociate the hydrate safely [1, p. 22].

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	know the source of the plugging and began troubleshooting the process to try to clear the piping, unaware that
	the solid hydrate had formed.

	Two days later, on Friday, November 14, 2014, the troubleshooting efforts to clear the plugging were still
	ongoing. That morning, the Lannate® Unit Technical Team (Technical Team), composed of engineers and other
	employees experienced in the process, met with operations personnel to discuss troubleshooting options to clear
	the plugging. This meeting identified the likely scenario that water had entered the methyl mercaptan system,
	forming a solid hydrate.

	DuPont’s methyl mercaptan technical standard identifies the potential to form a hydrate at low temperatures.
	The technical standard states that methyl mercaptan “will form a hydrate with water, which is a solid below 40
	deg F [degrees Fahrenheit] per information provided by a [methyl mercaptan] supplier.” Based on this
	understanding, the Technical Team asked that operators put hot water on the outside of the methyl mercaptan
	piping, under the insulation, to warm the piping and its contents to break up (dissociatea) the plugging. The
	Technical Team also realized that when heated, methyl mercaptan would expand, requiring a safe place to vent
	to avoid over-pressuring the piping. To address this concern, operations personnel opened valves between the
	methyl mercaptan piping and a waste gas vent header (vent header), not recognizing that this alignment created
	a pathway for liquid methyl mercaptan to eventually release from the piping inside the manufacturing building
	when drain valves were opened.

	In addition, when operations personnel opened other valves while troubleshooting, such as drain valves, methyl
	mercaptan was released to the atmosphere, causing a strong methyl mercaptan odorb that could be smelled by
	site personnel. During troubleshooting, methyl mercaptan was released both outside and inside the
	manufacturing building, triggering 32 methyl mercaptan gas alarmsc on the control panel throughout the 17
	hours preceding the incident. Although methyl mercaptan is a toxic and flammable chemical, and at high
	enough concentrations lethal, some operations personnel did not respond in accordance with the nature of the
	emergency circumstances because they associated the alarms with the ongoing troubleshooting efforts. They
	did not perceive the methyl mercaptan alarms as signifying a serious hazard because they had normalizedd the
	methyl mercaptan odor within the Lannate® Unit, as well as the detector alarms.

	Early in the morning on Saturday, November 15, 2014, the hot water from the hoses warmed the hydrate
	plugging, causing it to dissociate, clearing the plugging. Due to the valve alignment, liquid methyl mercaptan

	a Methyl mercaptan clathrate hydrate dissociates back to the liquid phases of methyl mercaptan and water at approximately 52°F [72].
	b Methyl mercaptan has a low odor threshold. It gives off a smell like rotten cabbage. It can be smelled at only two parts per billion
	(ppb) [80, p. 1]. OSHA’s permissible exposure limit (PEL), however, is 10 parts per million (ppm), which is 5,000 times the minimum
	concentration that can be smelled. The low odor threshold of mercaptans makes them useful as fuel gas odorants [80, p. 2].
	c DuPont used hydrogen sulfide (H2S) detectors to identify methyl mercaptan. The alarms activated when the detectors sensed the
	hydrogen sulfide equivalent of 25 ppm methyl mercaptan. Twenty-five ppm is the ERPG-2 level for methyl mercaptan (see Section 4.8)
	[82, p. 27]. This level “is the maximum airborne concentration below which nearly all individuals could be exposed for up to 1 hour
	without experiencing or developing irreversible or other serious health effects or symptoms which could impair an individual’s ability to
	take protective action.” Emergency responders use ERPG-1, -2, and -3 concentration data to determine how to protect the public [167].
	DuPont records indicate that the device manufacturer stated the detector should be capable of detecting methyl mercaptan within 1 ppm
	[1, p. 37].
	d Normalization of deviance is a phenomenon in which individuals or work teams gradually accept a lower standard of performance until
	the lower standard becomes the norm. It is typically the result of slowly changing and eroding conditions over time [79, p. 4].

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	flowed into the waste gas vent header, located inside the manufacturing building [1, pp. 25-26]. The vent
	header, however, was not intended nor designed for liquid methyl mercaptan. At 2:51 am, alarms began to
	sound on the control system indicating high pressure in equipment inside the manufacturing building.

	Operations personnel did not realize that liquid methyl mercaptan was causing the high pressure. Instead, they
	attributed the high pressure to a common, long-standing problem with process condensate, which DuPont La
	Porte personnel believed to be mostly water, accumulating in the vent header piping [1, p. 28]. The Lannate®
	control room board operator (Board Operator) contacted the night shift supervisor (Shift Supervisor) and another
	operator (Operator 1) separately, asking them to help troubleshoot the high-pressure situation. Manually
	draining the vent header inside the manufacturing building, a long-standing practice, was the typical approach
	used to remove process condensate from the vent header, as it successfully reduced system pressure many times
	in the past.a The Shift Supervisor and Operator 1 each went separately to the manufacturing building, likely in
	order to drain liquid from the vent header piping manually.

	Sometime between 3:01 am and 3:13 am, a worker (likely the Shift Supervisor)b manually opened two sets of
	drain valves on the vent header piping, located on the third floor of the manufacturing building (Figure 2). But
	instead of the expected condensate composed mostly of water, the liquid methyl mercaptan that had filled the
	piping escaped out of the valves, vaporized, and killed the Shift Supervisor. Between 3:24 am and 3:26 am,
	three methyl mercaptan detectors inside the manufacturing building sensed at least 25 parts per million (ppm)c
	of methyl mercaptand and triggered alarms at the control panel (Figure 3). The Board Operator—still focused
	on reducing the high pressure—did not realize a major chemical release was occurring inside the manufacturing
	building (Section 3).

	a In 2011, DuPont installed a NOx (nitrogen oxides) reduced scrubbed (NRS) incinerator system. The waste gas vent header piping to the
	NRS incinerator was designed without sufficient consideration of liquid accumulation. It contained low points where liquid could
	accumulate, and there was no engineered equipment provided, such as a knock-out drum, to remove liquid safely from the waste gas vent
	header piping system. The liquid accumulation in the piping would create pressure in process equipment. Pressure buildup within the
	equipment was resolved by manually draining liquid from the waste gas vent header. See Section 6, Process Safety Management
	Deficiencies, and DuPont La Porte, Texas Chemical Facility Toxic Chemical Release: Interim Recommendations [1, p. 18].
	b The Shift Supervisor was most likely the worker who opened the valves, based on both the location in the manufacturing building
	where he was recovered and information learned in interviews that suggested he was the worker most likely to have opened those specific
	valves to drain the vent header piping.
	c The methyl mercaptan detectors were evaluated post-incident. Although the detectors inside the building have the ability to span 0–50
	ppm, these detectors were set to span 0–25 ppm. Post-incident, the span was increased to 50 ppm. Additionally, information from the
	methyl mercaptan detectors inside the manufacturing building displayed only on the distributed control system (DCS) monitor and was
	not recorded by the site’s DCS and data historian [1, p. 37]. CSB investigators, however, were able to obtain information about the
	alarms associated with the detectors from alarm logs.
	d The methyl mercaptan detectors alarm at 25 ppm—well above the NIOSH recommended exposure limit (REL) of 0.5 ppm and the
	OSHA enforceable PEL ceiling limit of 10 ppm. OSHA recommends that employers consider using the lower alternative occupational
	exposure limits because the agency believes that exposures above some of these alternative occupational exposure limits may be
	hazardous to workers, even when the exposure levels comply with the relevant PELs [149]. The Cal-OSHA permissible exposure limit
	(PEL) is an 8-hour time-weighted average (TWA) of 0.5 ppm, and the NIOSH REL is a 15-minute ceiling limit of 0.5 ppm [159], [50].

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	Figure 2. Waste Gas Vent Header Piping on the Third Floor of the Manufacturing Building. This portion, where several waste gas
	sources come together, is referred to as the waste gas vent header. Waste gas from this portion of the vent header traveled up to
	reach the NRS incinerator, a piping configuration that created a low spot where liquid accumulated. To remove the liquid during waste
	gas vent header piping high-‐pressure events, operators were instructed to open valves (yellow circle) and drain the system through a
	hose routed to a floor drain located near a safety shower. The floor drain is connected an open trench-‐type sump on the first floor. At
	the time of the incident, a second set of drain valves (red circle) were also opened directly to the floor inside the manufacturing
	building. Source: CSB.

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	Figure 3. Depiction Showing Where Drain Valves Were Opened. These drain valves released toxic methyl mercaptan into the
	manufacturing building. Methyl mercaptan detectors on the first and fourth floors detected high concentrations of methyl
	mercaptan shortly after the release began. This depiction is a simplified graphic of the manufacturing building (see Section 4.5) and
	does not show the location of Operator 1. Source: CSB.

	At about 3:30 am, Operator 1 made an urgent call for help over the radio. Various personnel interpreted her
	communication in different ways, generally as either “We need help!” or “I need help on the fourth floor!” The
	Board Operator tried to get more information through radio communication, but neither the Shift Supervisor nor
	Operator 1 ever responded [1, p. 29].

	Two operators (Operator 2 and Operator 3) who were in the control room and heard the distress call ran to the
	manufacturing building to help. Another operator (Operator 4) saw Operator 2 and Operator 3 running to the
	manufacturing building, and he followed them. None of these operators knew of the major release of toxic
	methyl mercaptan inside of the manufacturing building; therefore, they did not wear any respiratory protection
	when they ran into the manufacturing building. The manufacturing building lacked automatic visual or audible

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	alarms to alert fieldworkers or prevent them from entering a potentially toxic atmosphere (Section 3). In
	addition, the building’s ventilation fans were not working, a situation that, in DuPont’s operating procedures,
	required “restricted access” to the building. But DuPont La Porte’s procedures did not define “restricted access”
	or require that operators wear respiratory protection in the building when access was restricted, even though a
	toxic chemical release could accumulate in the unventilated building [1, p. 29].

	Operator 2, Operator 3, and Operator 4 each entered the south stairway and took different a route inside the
	manufacturing building to try to find Operator 1 (Figure 4). Operator 2 went to the third floor, where he was
	fatally overcome by methyl mercaptan [1, p. 29]. Operator 4 went to the second floor. He walked about 10 feet
	and hit what he later described as a “wall” of methyl mercaptan, but he managed to retreat to the stairwell [1, p.
	29]. Operator 3 went to the fourth floor but did not find anyone. He then announced on the Lannate® Unit’s
	public-address system that he did not see anyone on the fourth floor. The Board Operator responded that the
	Shift Supervisor and Operator 1 may be on the third floor [1, p. 29]. Operator 3 then began to feel light-headed.
	He made his way to the stairwell and lost consciousness while descending from the fourth floor [1, p. 29].

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	Figure 4. Depiction of Paths Taken by Operator 2, Operator 3, and Operator 4 When Whey Responded to Operator 1’s Distress Call.
	Locations of the deceased Shift Supervisor and Operator 1 are also shown. Operator 2 was killed by methyl mercaptan exposure,
	and Operator 3 and Operator 4 were exposed to high concentrations of methyl mercaptan. This figure shows the opposite side of
	the manufacturing building from the view in Figure 3. Source: CSB.

	The Board Operator then tried to reach the Shift Supervisor, Operator 1, and Operator 2 over the radio, but they
	did not respond. An operator in the control room, Operator 6a (the brother of Operator 2), then grabbed three 5-
	minute escape respirators. Other operators in the control room warned him not to enter the manufacturing
	building because they did not know what was going on or where the nonresponsive operators were. Operator 6,
	however, took the escape respirators and rushed to the manufacturing building [1, p. 29].

	At about 3:40 am, Operator 6 encountered Operator 4 in the south stairway of the manufacturing building and
	put an escape respirator on him (Figure 5). The breathing air helped Operator 4 recover, and he exited the
	manufacturing building safely. A worker—likely Operator 6—then manually activated the manufacturing
	building fume release alarm, an alarm intended to alert area workers of a toxic chemical release in the building.
	Operator 6 then went to the third floor of the manufacturing building. At some point after helping Operator 4,

	a Operator 6 was a board operator for another process in the Lannate® Unit.

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	Operator 6 retrieved a self-contained breathing apparatus (SCBA) from inside the manufacturing building. He
	tried to rescue his brother (Operator 2) by putting one of the escape respirators on his face. Operator 6 was then
	fatally overcome by methyl mercaptan before he could connect his own respirator mask to his SCBA tank.

	Figure 5. Depiction of the Path Taken by Operator 6 Inside the Manufacturing Building. Operator 6 helped Operator 4 escape by
	providing him with a respirator. Operator 6 was fatally overcome by methyl mercaptan when trying to rescue his brother,
	Operator 2, on the third floor. Source: CSB.

	EMERGENCY RESPONSE

	At about 3:50 am, the Board Operator called for the plant emergency response team (ERT)a to respond to the
	manufacturing building, stating over the intercom system, “We need rescue people, and there’s people missing.”
	This announcement started a chain of miscommunication. To the ERT, a request for “rescue” meant specifically

	a At the time of the incident, three companies (DuPont, Kuraray, and Invista) operated at the La Porte site and shared one ERT for the
	site, which had members from each company and was managed by DuPont. The ERT members worked other, primary jobs for one of
	the three companies (such as unit operators), and they responded as ERT members during emergencies. The site’s ERT staffing included
	about 60 employees. Section 4.1 discusses the composition of the ERT in more detail.

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	high-anglea or confined-space rescue. Therefore, the ERT responded to the request for help by gathering only
	technical rescue gear (e.g., harnesses and ropes), not knowing that there was a major toxic chemical release
	(Section 4.3.1) [1, p. 30].

	At 3:57 am, the Board Operator called the security guard at the main entrance to ask the guard to call 9-1-1. The
	Board Operator communicated only that workers were missing and requested rescue. The guard, in turn, gave
	limited information to the 9-1-1 operator:

	9-1-1 Operator: Harris County 911. What is the location of your emergency?

	Caller: This is DuPont on Strang Road…. They had an emergency out here. They got four people
	missing.… I was just called by the Lannate® supervisor [Board Operator] that he has four people
	missing.

	9-1-1 Operator: So, are they somewhere there, or you don’t know where they’re at?

	Caller: I don’t know, ma’am. I am up in the front. I just got the phone call.

	9-1-1 Operator: Okay, you don’t know their names or anything?

	Caller: No ma’am, just they needed rescue.

	9-1-1 Operator: They need rescue?

	Caller: Yes ma’am.

	9-1-1 Operator: And you don’t know their names, no descriptions, nothing?

	Caller: No ma’am. I just know that they’re workers.

	At 3:58 am, site emergency responders from the ERT arrived at the scene with only their technical rescue gear.
	They quickly realized that there was an ongoing chemical release and that they needed additional personal
	protective equipment (PPE). At 4:05 am, the Incident Commander, who had responded to the initial rescue
	request, called for the ERT to come to the scene with bunker gearb and SCBAs—the PPE necessary to enter an
	area with a toxic and flammable chemical release. When ERT members attempted to start the mini-pumper
	truck that contained SCBAs and radios, however, it would not start and could not make it to the incident scene
	(Section 4.3.2).c

	a A high-angle rescue uses a variety of technical rope rescue techniques to retrieve injured or otherwise incapacitated persons on terrain at
	slopes of 60º or greater. Victims are hoisted from one level to another using ropes, pulleys, harnesses, belay devices, and various hauling
	implements [120].
	b “Bunker gear” is a common term for firefighting protective clothing [96].
	c The mini-pumper truck was located more than 2,000 feet from the control room.

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	The Incident Commander also requested safety data sheets for chemicals processed inside the manufacturing
	building, including methyl mercaptan. The ERT, however, did not initially use air monitoring equipment to
	determine what chemical was leaking. According to DuPont La Porte’s Lannate® emergency response plan,a
	area personnel control air monitoring equipment for their unit. Because the Shift Supervisor (Process
	Coordinator) who oversaw process operations was a victim of the incident and was not available to fulfill the
	assigned role of providing chemical hazard and unit-specific information about each of the processes to the ERT
	during an emergency, air monitoring was delayed during the early hours of the incident. Meanwhile, site
	personnel recognized the release by odor and believed that methyl mercaptan was the chemical leaking inside
	the building.b

	At around 4:10 am, the Incident Commander established a hot zone around the manufacturing building. The hot
	zone’s boundaries, however, were not clearly communicated or marked by the ERT (Section 4.7).

	At 4:12 am, an emergency operations center coordinator made a second 9-1-1 call, but he had not yet been
	informed by ERT personnel what chemical was leaking, or whether the leak posed a public threat, and was
	therefore unable to relay this critical information to the 9-1-1 operator:

	9-1-1 Operator: Harris County 911. What is the location of your emergency?

	Caller: This is in La Porte, Texas.… We have an emergency at the DuPont Plant in La Porte.…
	We have a possible casualty five, is what my medics are telling me. We have some injuries. We
	need La Porte EMS for transportation.…

	9-1-1 Operator: Okay, sir. How did this happen? Is it chemical-related?

	Caller: I am not certain. I just know … they’re doing a rescue—they’re doing a rescue right now.
	We have some injured people. I’m not sure if there’s any chemicals involved or not. I am just
	relaying the message.

	…

	Caller: I have just got some more information. We have five people unaccounted for. We have
	had a chemical release … I am not sure what chemical, in one of our buildings. Five people are
	unaccounted for. Rescue team is trying to reach them at this point. That’s all the information I
	can give you right now.

	…

	a The Lannate® Unit emergency planning and response manual was developed to comply with the OSHA Process Safety Management of
	Highly Hazardous Chemicals standard, 29 C.F.R. § 1910.119(n) (2013). Under this standard, facilities are required to develop an
	emergency action plan and potentially an emergency response plan (29 C.F.R. § 1910.38 (2002); 29 C.F.R. §§ 1910.120 (a), (p), and (q)
	(2013)). An emergency response plan under the Hazardous Waste Operations and Emergency Response (HAZWOPER) standard is
	required if an internal emergency response team is responding to or has substantial threat of responding to releases of hazardous
	substances (29 C.F.R. §§ 1910.120 (a)(2)(iv) and (q)(1) (2013)). Because the La Porte site had an internal emergency response team that
	responded to releases of hazardous substances, HAZWOPER required that the site have an emergency response plan.
	b Using smell to locate or characterize sources of a release is a poor practice. Chemicals have different physical properties, including
	olfactory fatigue, no odor, and toxicity if inhaled.

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	9-1-1 Operator: Okay sir. And can you tell me, is this any risk to the public? Is it going to be a
	possible escaping from your premises?

	Caller: No ma’am, it is not.

	9-1-1 Operator: No threat?

	Caller: No ma’am.

	…

	9-1-1 Operator: And we don’t know what kind of chemical it is?

	Caller: No ma’am. As soon as I find out, I will let you know. I’ve got my team trying to
	determine that right now.

	At about 4:15 am, ERT members assigned an operator
	(Operator 7) to bring them SCBAs because the ERT
	mini-pumper truck holding SCBAs could not respond
	to the scene. DuPont stored additional SCBAs outside
	a building closer to the manufacturing building.
	Assisting the ERT as requested, Operator 7 went alone
	to retrieve these SCBAs and unknowingly walked into
	the path of the methyl mercaptan being released from
	the manufacturing building (Figure 6).a The hot zone
	was not clearly identified or communicated to plant
	personnel. As a result, when Operator 7 went to
	retrieve the SCBAs, she was unaware that she was
	entering a potentially hazardous area. When Operator
	7 went outside, though unable to smell methyl
	mercaptan, she felt ill.b Realizing that she might be in
	a dangerous position, she retreated to the control roomc
	(Section 4.7).

	At about 4:20 am, Operator 3 regained consciousness and
	managed to exit the manufacturing building [1, p. 29].

	Figure 6. Depiction of Path Taken by Operator 7 to Retrieve
	SCBAs for ERT When the Mini Pumper Truck Would Not Start.
	The hot zone was not controlled adequately to ensure that
	personnel did not enter a hazardous area. Source: Google
	Earth, with annotations by CSB.

	a At 3:50 am, at Ellington Field, Texas (about 10.5 miles southwest of the DuPont La Porte facility), the wind was blowing from the
	northeast at 8.1 miles per hour (mph) [100].
	b These symptoms are consistent with methyl mercaptan exposure. Olfactory fatigue is known to occur with exposure to methyl
	mercaptan, resulting in the exposed person not being able to detect the chemical by smell. Inhaling methyl mercaptan can also induce
	headaches, dizziness, nausea, vomiting, coma, and death [80].
	c Operator 7 believes she was exposed to a high concentration of methyl mercaptan, but she was able to return to safety.

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	ERT members saw him near the manufacturing building and escorted him to safety.

	Beginning at about 4:25 am, the first ERT entry team entered the manufacturing building. Although the ERT
	used breathing air (SCBAs) to protect themselves from toxic exposure, they did not monitor the atmosphere
	during this building entry to assess explosive hazards. Portions of the building likely had an explosive
	atmosphere during the incident (Section 4.4.1), and air monitoring could have alerted personnel to this potential
	hazard during this entry. The ERT’s post-incident critique stated “metering and [air] monitoring equipment
	were maintained by the unit. Since the technical knowledge basea was incapacitated, there was a delay in
	establishing [air] monitoring.”

	During the building entry, an ERT member found drain valvesb from the waste gas vent header on the third floor
	open, with a gas (later identified as methyl mercaptan) flowing from them. The ERT members also found the
	Shift Supervisor on the floor of the third story, about 30 feet north of the drain valves. They also found
	Operator 6 next to his brother (Operator 2), and both men were unresponsive. Operator 2 had a 5-minute escape
	respirator bag over his head. This respirator was one of the three escape packs brought into the building by
	Operator 6. Operator 6 had a 30-minute SCBA air bottle in front of him and the mask on his face, but he had
	not connected the mask to the air bottle. Methyl mercaptan likely incapacitated Operator 6 while he was trying
	to don his SCBA [1, p. 31]. A postmortem examination determined that the Shift Supervisor, Operator 2, and
	Operator 6 were killed by asphyxia through exposure to methyl mercaptan.

	During the release, the ERT used a plume dispersion model to predict the methyl mercaptan plume (cloud) size
	and concentration profile releasing from the manufacturing building. To predict the methyl mercaptan plume
	effectively, the modeling software required an estimate of the methyl mercaptan release rate. The emergency
	response personnel, however, did not have an available method to estimate the methyl mercaptan release rate.
	Lacking other data sources and based on the perceived low odor of methyl mercaptan outside the manufacturing
	building, they estimated a release rate of 10 pounds per hour. With this input, the model predicted that methyl
	mercaptan would not leave DuPont property at concentrations harmful to the public. The CSB determined,
	however, that the emergency response personnel greatly underestimated the release rate. It was not possible for
	the CSB to determine the exact off-site methyl mercaptan concentration immediately after the release; however,
	the CSB concluded that the total release of about 24,000 pounds of methyl mercaptan created the potential for a
	dangerous concentration of methyl mercaptan to have been released off-site (Section 4.8.1).

	Beginning at 5:08 am, three external firefighter groups arrived on-site, and at 5:15 am the ERT conducted its
	second entry into the manufacturing building. On the third floor, an ERT responder closed the open drain valves
	from which he had observed vapor (methyl mercaptan) escaping.

	a The Shift Supervisor who served as the Process Coordinator—that is, the technical liaison—was killed by the release.
	b These drain valves were not closed at this time.

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	At about 5:40 am, emergency responders established and barricaded the hot zone. Until this point, the hot zone
	had not been marked clearly. At 5:57 am, the Incident Commander requested Harris County personnel to
	perform air monitoring off-site.

	At 6:02 am, approximately three hours after the release started, DuPont La Porte personnel turned off the methyl
	mercaptan storage tank pump, which had been operating since the last startup attempt, before the release began
	(Figure 7). Shutting off this pump significantly slowed the methyl mercaptan release rate (Section 4.6).a

	Figure 7. Location of Methyl Mercaptan Pump. The pump was turned off nearly three hours after the release began. Source:
	Google Earth, with annotations by CSB.

	From 6:10 am to 9:30 am, the ERT conducted the third, fourth, and fifth ERT building entries to search for
	Operator 1, who was still missing. Due to the complex layout and emergency responders’ lack of knowledge of
	the manufacturing building, the emergency responders had difficulty finding Operator 1. They had no maps to
	reference during their search, and DuPont La Porte did not have cameras in the manufacturing building to

	a The design of the nitrogen relief valves at the railcar loading and unloading stations did not consider a scenario in which the relief
	valves could be lined up with the discharge of the methyl mercaptan pumps, as they were at the time of the incident. The methyl
	mercaptan pump discharge pressure (90 pounds per square inch gauge (psig)) was higher than the set pressure (80 psig) of these nitrogen
	relief valves. Therefore, the methyl mercaptan pump would cause the relief valve to open and release the highly toxic and highly
	flammable chemical to the atmosphere. When tested post-incident, three of the four nitrogen rupture discs burst, and all four of the
	nitrogen relief valves leaked. Because the rupture discs and relief valves would not hold pressure when tested, an atmospheric release of
	highly toxic and highly flammable liquid methyl mercaptan likely occurred during the incident through this relief system that was
	intended to release and disburse nitrogen vapor [1, p. 46]. A rupture disc is a non-reclosing pressure relief device, a type of emergency
	relief device. According to the Center for Chemical Process Safety (CCPS), an emergency relief device is designed to open during an
	emergency or during abnormal conditions to prevent rise of internal fluid pressure in excess of a specified value. The device also may be
	designed to prevent excessive internal vacuum [110]. For more information on pressure relief devices, see “An Overview of Pressure
	Relief Devices” [111, pp. 20-27].

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	provide a view of the different floors of the building (Section 4.5). To facilitate the search efforts, the ERT
	assigned area operators—including the Board Operator—to draw building maps to help emergency responders
	navigate the manufacturing building. During this time, ERT responders continued closing valves throughout the
	Lannate® Unit to stop the release of methyl mercaptan.

	At 6:14 am, a Harris County Sheriff’s sergeant noticed an “intense smell” in Deer Park (west of La Porte), and
	at 6:30 am, he communicated, “the odor on [Highway] 225 [is] strong” (Figure 8).

	At 8:07 am, Harris County’s Hazardous Materials Team performed off-site air monitoring to measure the
	concentration of toxic methyl mercaptan outside of the DuPont fence line. Harris County’s instrumentation did
	not detect methyl mercaptan in the air (Section 4.8.4).

	At 10:07 am—seven hours after the release began—DuPont activated the methyl mercaptan tank emergency
	isolation valve to isolate the methyl mercaptan storage tank completely from the leaking process piping (Section
	4.6).

	Between 11:15 am and 11:55 am, during the sixth ERT entry into the manufacturing building, Operator 1 was
	found unresponsive in the north stairwell of the manufacturing building. The coroner later determined that
	Operator 1 had died from asphyxia and acute exposure to methyl mercaptan.

	Figure 8. Locations Where a Sheriff’s Sergeant Reported Strong Methyl Mercaptan Odor During the Incident. Source: Google Earth, with
	annotations by CSB.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	3 DELAYED AWARENESS OF TOXIC CHEMICAL RELEASE BY OPERATIONS

	Highly toxic methyl mercaptan was released into the manufacturing building for about 40 minutes before
	operations personnel in the control room realized the extent of the emergency in the building, and for more than
	six additional hours before the release was fully controlled. The CSB identified factors that led to this delay in
	recognizing a major chemical release, including:

	1. The Board Operator was focused on process equipment high-pressure events that he believed
	were critical. Operations personnel became aware of the high-pressure events when insecticide
	manufacturing equipment venting into the waste gas vent header began to exhibit high-pressure
	alarms. At this point, operations personnel shifted their attention from the problem of plugging in
	the methyl mercaptan feed system to the current problem of high pressure in the waste gas vent
	header piping to the NRS incinerator. DuPont La Porte operations staff did not correlate the high-
	pressure problem with the troubleshooting efforts to unplug the methyl mercaptan feed piping
	through hydrate dissociation. Rather, they attributed the high-pressure events to the routine problem
	of liquid accumulation in the waste gas vent header piping. The Board Operator directed personnel
	to help troubleshoot the high-pressure problem [1, p. 28]. The operating pressure of various pieces
	of process equipment inside the manufacturing building, however, continued to increase, in some
	equipment exceeding the high-scale detection limits of process instrumentation. The Board
	Operator was concerned about the potential for equipment overpressure and the release of toxic
	chemicals to the atmosphere outside the manufacturing building. Even though methyl mercaptan
	detectors were beginning to alarm, the Board Operator either was unaware of them or had
	normalized them, not realizing the alarms were alerting him that a significant release had started to
	occur inside the building. Unaware that a significant methyl mercaptan release had begun, the
	Board Operator remained focused on controlling the high pressure he was observing inside the
	equipment.a

	2. Lannate® Unit personnel accepted methyl mercaptan releases and the associated alarms as

	normal because of methyl mercaptan’s low odor threshold,b a history of frequent alarms, and
	a lack of hazard recognition that methyl mercaptan could be lethal. Methyl mercaptan is a
	highly toxic chemical, but its odor can be detected at very low concentrations that are not

	a Although the Board Operator acknowledged the methyl mercaptan alarms on the control system during the incident, afterwards he did
	not recall that any methyl mercaptan detectors inside the manufacturing build had alarmed.
	b Odor threshold, in general, is the lowest concentration of a gas or other material’s vapor that can be detected by odor. Odor threshold
	values are not fixed physiological parameters or physical constants but instead statistical points representing the best estimated value
	from a group of individual responses [112, p. 2]. The odor threshold for methyl mercaptan is approximately two parts per billion (2 ppb).
	However, olfactory fatigue is known to occur with methyl mercaptan, causing the exposed person no longer to be able to detect the
	chemical by smell. As a result, odor may not provide adequate warning of hazardous concentrations [80, p. 1].

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	considered a health risk to people.a Additionally, the Lannate® Unit used methyl isocyanate (MIC)b
	and chlorine,c which are generally accepted as being more hazardous (toxic) than methyl
	mercaptan.d As a result, even though Lannate® Unit personnel were trained on methyl mercaptan
	toxicity hazards,e personnel at the site became accustomed to smelling methyl mercaptan daily
	without experiencing negative health effects, leading workers to become less wary of methyl
	mercaptan leaks and the risks associated with them. According to one DuPont worker, there was a
	perception that methyl mercaptan (which workers called “MeSH”) was not dangerous:

	And I smell MeSH all the time … but it never … I smelled MeSH, but I
	never felt I couldn’t breathe. Like whether it’s, there’s—whether it’s a
	small leak or anything, it just never—I didn’t think MeSH was that
	dangerous. I thought it, you know, but it is.

	During the troubleshooting efforts before the major release began, smaller releases of methyl
	mercaptan had caused the site to have a strong odor of methyl mercaptan. Therefore, when the
	major release began, site personnel did not realize there was a major release, in part because they
	were accustomed to smelling the chemical.

	3. Personnel were not wearing personal methyl mercaptan detectors. DuPont La Porte had some

	personal methyl mercaptan detectors available, but they were never issued to operators to wear in
	the field. Such detectors could have warned Operator 2, Operator 3, and Operator 4 (personnel who
	initially responded to Operator 1’s distress call) of the high methyl mercaptan concentration inside
	the manufacturing building.

	a Methyl mercaptan gives off a smell like rotten cabbage. It can be smelled at only 2 parts per billion [80, p. 1]. OSHA’s permissible
	exposure limit, however, is 10 parts per million, which is 5,000 times the minimum concentration that can be smelled. The low odor
	threshold of mercaptans makes them useful as fuel gas odorants [80, p. 2].
	b MIC is a raw material used in the production of insecticides at La Porte, including the Lannate® process. The 1984 MIC release at the
	Union Carbide insecticide plant in Bhopal, India, that killed thousands of people is an example of the extremely toxic properties of MIC
	[148]. For more information, see Reflections on Bhopal after Thirty Years [148].
	c DuPont’s corporate standard for the management of highly toxic materials identifies both methyl mercaptan and chlorine as highly
	toxic. DuPont considers a material to be highly toxic if it is handled, stored, or shipped in a sufficient quantity that a credible event could
	result in a concentration of Emergency Response Planning Guidelines (ERPG)–3, and if it has a Substance Hazards Index (SHI) greater
	than or equal to 4,000. This level “is the maximum airborne concentration below which nearly all individuals could be exposed for up to
	1 hour without experiencing or developing life-threatening health effects.” Emergency responders use ERPG-1, -2, and -3 concentration
	data to determine how to protect the public [167]. DuPont determines the SHI using vapor pressure and ERPG-3 data for each chemical.
	Using this approach, DuPont derived an SHI of 19,855 for methyl mercaptan and 385,197 for chlorine.
	d Methyl mercaptan’s threshold quantity (5,000 pounds) that presents the potential for a catastrophic event, under PSM, is larger than that
	of chlorine (1,500 pounds) or MIC (250 pounds), making it less hazardous than either of the other two chemicals (29 C.F.R. § 1910.119,
	Appendix A).
	e DuPont La Porte used computer-based training to communicate hazards about methyl mercaptan (i.e., to perform hazard
	communication, or HAZCOM), consisting of methyl mercaptan hazard information and a quiz. The information gives some of the toxic
	exposure limits for methyl mercaptan. Additionally, the training details that gross exposure can result in death, but it does not specify the
	value at which the chemical is immediately dangerous to life and health. The training advises workers to use at a minimum an SCBA
	when responding to a methyl mercaptan alarm, and not to use smell to detect leaks because methyl mercaptan can cause olfactory fatigue,
	causing anyone exposed to it to stop perceiving an odor within minutes. If there is a leak, personal protective equipment (PPE) is
	supposed to be upgraded. Upgraded PPE also applies to line breaking, and it includes a chemical suit with taped sleeves and cuffs,
	chemical hood, chemical boots, chemical gloves, and an SCBA.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	4. DuPont La Porte did not have audible or visual alarms on or in the manufacturing building to
	alert field personnel of a methyl mercaptan release automatically. DuPont La Porte relied on
	verbal communication of alarms, which automatically displayed on a continuously manned control
	board.

	The delay in recognizing this event as a major toxic chemical release that was becoming a deadly concentration
	of methyl mercaptan inside the building contributed to the response of Operator 2, Operator 3, and Operator 4 to
	Operator 1’s distress call without respiratory protection. According to DuPont La Porte’s Lannate® emergency
	planning and response manual, if a sensor detected a methyl mercaptan leak and initiated an alarm, personnel
	were required to notify a shift supervisor, sound a plantwide fume release alarm, and wear appropriate PPE
	(including SCBA) during any attempts to stop the leak. The manufacturing building, however, including the
	building’s overall construction, detectors, and alarms, was not designed such that personnel could be readily
	notified of a major chemical release in the manufacturing building. Without being made aware of the major
	chemical release inside the building, Operator 2, Operator 3, and Operator 4 entered without respiratory
	protection. As a result, Operator 2 was killed by methyl mercaptan exposure, and Operator 3 and Operator 4
	were exposed to dangerous concentrations of methyl mercaptan.

	GUIDANCE TO INDUSTRY
	It is crucial that workers understand when an emergency is occurring. OSHA’s Hazardous Waste Operations
	and Emergency Response (HAZWOPER) standard requires that an emergency response plan address emergency
	recognition and prevention.a For this standard to be effective, companies should ensure that their systems
	associated with emergency recognition and prevention, such as alarms and training, can inform workers of
	hazards and emergencies.

	For example, audible or visual alarms can automatically relay to personnel in the field information about a
	hazardous condition—such as a release of a toxic chemical. Systems like those implemented at DuPont, on the
	other hand, where alarms displayed only on an operator’s control board and still needed an operator to verbally
	communicate alarms, have inherent potential delays. The Center for Chemical Process Safety’s book
	Continuous Monitoring for Hazardous Material Releases provides guidance on the use of such alarms:

	There are occasions when process equipment must be located indoors due to weather-related or
	quality control issues. Combustible [and toxic] gas detection should be provided in these
	buildings…. This detection should be configured to:

	• Send an alarm signal to a continuously manned location;

	• Activate visible and audible alarm devices on the exterior of the building at each
	entranceway and within the structure. The devices within the structure should be

	a 29 C.F.R. § 1910.120 (q)(2)(iii) (Feb. 8, 2013).

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	configured using the guidance for fire alarm devices, as provided in NFPA 72, National
	Fire Alarm and Signaling Code®; and

	•

	Include a local means of silencing the alarms [6, pp. 63-64].

	Training is another important way to address emergency recognition and prevention. Under OSHA’s Hazard
	Communication (HAZCOM) standard, companies are required to provide information to employees about the
	hazardous chemicals that they may be exposed to at work, including through training.a Companies should
	ensure that, in addition to having access to chemical information, employees understand the hazards of all
	chemicals they are working with and may be potentially exposed to if there is a release. In cases of multiple
	hazardous chemicals, such as MIC, chlorine, and methyl mercaptan, it is important that companies effectively
	train workers on the hazards of each chemical. This training is important for workers to help ensure they have a
	working knowledge of chemical hazards.

	Working knowledge of the hazards of all chemicals they are working with and may be potentially exposed to if
	a release occurs can improve employees’ recognition of emergency conditions and help them prevent major
	accidents in the manner that an emergency response plan intends.

	4 EMERGENCY RESPONSE OPERATIONS

	On the night of the incident, the Board Operator’s request for the emergency response team (ERT) to come to
	the scene triggered the start of emergency response operations. From this initial request for ERT aid to the final
	response activities, the La Porte site’s emergency response efforts were characterized by miscommunication,
	disorganization, and a lack of situational awareness. The following key emergency response weaknesses are
	discussed in this section:

	• Based on DuPont La Porte’s emergency response plan, emergency response personnel relied on the
	expertise of the shift supervisor, who was the designated process coordinator. The Shift Supervisor,
	however, was a victim of the incident, and no one else on the shiftb was designated to backfill the role of
	process coordinator. This gap led to weaknesses in several aspects of the emergency response
	operations (Section 4.2), including the initial assessment of the problem and of the resources needed for
	an effective response.

	• There was a delay in ERT deployment and readiness to respond to the release, due to both a

	misunderstanding of the type of emergency and the failure of an ERT mini-pumper truck that stored
	SCBAs to start (Section 4.3).

	• Searching for the missing workers put the ERT responders at high risk. ERT responders entered a

	hazardous and potentially explosive atmosphere without performing air monitoring. Additionally—

	a 29 C.F.R. § 1910.1200 (b)(1) (Feb. 8, 2013).
	b The Lannate® Unit’s emergency planning and response manual designated a primary and secondary backup for the process coordinator.
	These backups, however, were not on-site during the evenings and weekends, including when the incident occurred on November 15,
	2014.

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	unbeknownst to them—they entered an area of the manufacturing building that DuPont La Porte had
	previously identified as a collapse risk in the event of an explosion (Section 4.4).

	• DuPont La Porte’s emergency planning and response manual lacked a building map or floor plans to aid
	emergency responders in navigating the manufacturing building. As a result, the ERT experienced
	difficulties navigating the manufacturing building while searching for a missing operator; they resorted
	to assigning unit operators, including the Board Operator, to draw maps of the building to help guide
	them. This assignment diverted the Board Operator’s attention from other critical tasks, such as
	viewing process data on the control room computer screen to try to identify the source of the release
	(Section 4.5).

	• The methyl mercaptan release was not controlled until three hours after it began. Personnel did not
	evaluate process data to determine the cause of the release until hours into the response efforts.
	Analysis of process data from the methyl mercaptan storage tank earlier during the release may have
	revealed that the methyl mercaptan storage tank level was continually dropping and that isolating the
	tank could stop the release (Section 4.6).

	• Emergency responders established a hot zone that was not clearly marked or communicated, thereby

	allowing an operator to be potentially exposed to a dangerous concentration of methyl mercaptan when
	tasked to assist the ERT (Section 4.7).

	• The ERT underestimated the quantity of toxic methyl mercaptan released. Because DuPont La Porte
	lacked fence-line monitors and the ERT did not conduct air monitoring to determine the concentration
	of methyl mercaptan leaving the site, the ERT did not have accurate values to use in its dispersion
	model. Instead, ERT members estimated a small quantity of methyl mercaptan based on verbal
	descriptions of the release’s downwind odor. As a result, the incident command did not issue warnings
	to the community surrounding the La Porte facility to take protective actions from the possibility of
	toxic concentration of methyl mercaptan exiting the site during the release. Furthermore, because air
	monitoring had not occurred during the release, neither DuPont La Porte nor the CSB can pinpoint the
	exact methyl mercaptan concentration that left the site, or what the potential health risk was to the
	public, if any (Section 4.8).

	ERT BACKGROUND

	DuPont was originally the sole operator of the La Porte site. In recent years, however, DuPont had sold portions
	of the operations and leased its facilities to other companies, including Kuraraya and Invista.b Kuraray, Invista,
	and DuPont formed a consolidated ERT at the site, managed by DuPont but jointly staffed by members of the

	a Kuraray is a chemical company that specializes in functional materials [169].
	b Invista is a subsidiary of Koch Industries, Inc., that manufactures nylon, spandex, polyester, and specialty materials.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	three companies.a All of the ERT members had other primary jobs for one of the three tenant companies (such
	as unit operators), and they responded as ERT members when alerted during emergencies. In its 2012 Risk
	Management Plan, DuPont La Porte stated that it used the National Incident Management System (NIMS) to
	systematically manage safety, tactics, strategy, personnel, equipment, and logistics, and to work seamlessly with
	any responding departments and agencies [7].b The site’s ERT was staffed by about 60 employees and had the
	following structure:

	•

	Incident Command Organization: 2–4 trained incident commanders on each shift

	o Training: National Pro Board Certifiedc as Fire Service Instructors (based on National Fire

	Protection Association, or NFPA, 1041 competencies), and Advanced Exterior Fire Fighters,
	Interior Structural Fire Fighters, and Industrial Fire Brigade Leaders (based on NFPA 1081
	competencies)

	• Fire Brigade Members: 12 members on each shift

	o Training: National Pro Board Certified as Advanced Exterior Fire Fighters and Interior

	Structural Fire Fighters (based on NFPA 1081 competencies)

	• Emergency Medical Services: 2–3 members on each shift

	o Training: Texas Department of State Health Services–Certified Emergency Medical

	Technicians (EMTs), Basic and Intermediate Training

	• Rescue Technicians: 3–5 members on each shift

	o National Pro Board Certified in Rope, Confined Space, and High Line Rescue (based on

	NFPA 1006 competencies)

	• HAZMAT Technicians: most ERT members

	o Training: National Pro Board Certified (based on NFPA 472 competencies)

	Although ERT members were trained to perform emergency response functions, they were not trained on the
	specific hazards of each unit because there were many units within the three companies that processed various
	chemicals with different hazards. The La Porte site attempted to bridge this gap by designating a technical
	liaison position called the “process coordinator” to provide chemical hazard and unit-specific information about
	each of the processes to the ERT during an emergency. This position, along with the emergency operations

	a Post-incident, on July 1, 2015, DuPont La Porte’s performance chemicals business unit was spun off to Chemours [107], [108, p. 35].
	Chemours also provides ERT members to the La Porte site.
	b According to the U.S. Federal Emergency Management Agency (FEMA), “NIMS provides a common, nationwide approach to enable
	the whole community to work together to manage all threats and hazards. NIMS applies to all incidents, regardless of cause, size,
	location, or complexity” [132].
	c The National Board on Fire Service Professional Qualifications (aka the Pro Board) is an accreditation body in the fire service training
	community. It accredits fire service training organizations, which in turn certify emergency responders to specific levels of training and
	competency in accordance with professional qualification consensus standards developed by the National Fire Protection Association
	[97].

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	center coordinators, was intended to play a critical role in interfacing with and helping to develop and execute
	emergency response actions with the ERT incident commander.

	PROCESS COORDINATOR WAS MISSING

	The DuPont La Porte’s emergency response plan required the appointment of a shift “process coordinator” from
	each unit to assist the incident commander in providing technical knowledge specific about their unit. The
	emergency response plan defined the process coordinator as “the area emergency response director of the shop,
	warehouse, office building, or process unit involved in the incident who is responsible for developing an action
	plan with the Incident Commander and directing area resources.” The process coordinator was responsible for
	assisting the incident commander in several tasks during emergencies (see Figure 10), including the following:

	1. Communicating (by radio) with the ERT’s incident commander and the site’s emergency operations

	center, as the operations technical liaison

	2. Determining the source and size of chemical leaks (see Figure 9)

	Figure 9. Responsibilities of the Process Coordinator (Production Shift Supervisor). In the Lannate® Unit’s emergency
	planning and response manual, DuPont La Porte provided this checklist for a process coordinator to use to gather
	information. Source: DuPont.

	3. Deciding whether the site needs to perform off-site air monitoring

	4. Deciding whether to evacuate the unit

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	Toxic Chemical Release at the
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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 10. A Section from the Lannate® Unit’s Emergency Planning and Response Manual. It details the process
	coordinator’s role during an emergency. Source: DuPont.

	As with most shifts, the Lannate® area process coordinator on the night of the incident was the Shift Supervisor.
	The Shift Supervisor in this case, however, was a victim of the toxic chemical release, and DuPont La Porte had
	not designated an on-site backup process coordinator for this shift.a As a result, these important functions were
	either performed in a disorganized manner by other operations personnel or never performed at all.

	In DuPont’s emergency response critiques conducted after the incident, emergency response personnel
	communicated the following:
	- “Weakness: Loss of area technical expertise led to confusion and lack of communication about the
	process. Personnel that would have staffed the technical specialists’ positions … were victims.”
	- “What are contingency plans? If team leader or subject expert are not available, how is that handled?”

	a The primary and secondary backup coordinator noted in Figure 10 were day shift employees and were not on-site at the time of the
	incident.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	GUIDANCE TO INDUSTRY
	Specific technical knowledge from process unit experts—including technical and operations personnel—can be
	invaluable to the incident commander in an emergency at a chemical processing facility. The Hazardous Waste
	Operations and Emergency Response (HAZWOPER) standard identifies persons who can provide this
	information as specialist employees.a Companies need to ensure that these individuals are preidentified as
	technical support personnel and to provide backup capability for all situations in the event the primary technical
	support personnel are unavailable.

	The emergency response plan can address how technical and operations personnel are integrated into emergency
	response roles—the HAZWOPER standard requires that the emergency response plan address “personnel roles,
	lines of authority, training, and communication.”b When developing an emergency response plan, companies
	should also consider the nature and extent of duties designated to particular people to ensure they can reasonably
	carry out those duties during an emergency.

	One way companies can ensure that a backup is available during a shift is to have a recall list that identifies
	alternates who can provide technical support. The Center for Chemical Process Safety (CCPS) gives the
	following guidance in its book Guidelines for Technical Planning for On-Site Emergencies:

	Technical support consists of personnel within the organization and outside emergency response
	groups. Technical support personnel within the organization include engineers, chemists,
	operators, maintenance personnel, and managers having special knowledge of process operations,
	emergency systems, building plans and equipment layout, and hazardous materials present. A
	technical support team consisting of these experts or others with similar qualifications will
	provide the incident commander with a pool of knowledge to draw on during emergencies.
	Technical support team members should be placed on the recall list with designated alternates
	in the event team members are directly involved with the emergency or are not available [8, pp.
	283-284] (emphasis added).

	Another valuable tool that an emergency response team can use is a checklist. As suggested by CCPS,

	Planners should develop emergency action checklists to augment the emergency plan by
	providing memory joggers for actions. Action checklists are concise reminders to personnel of
	key actions that need to be undertaken [8, pp. 158-159].

	a The HAZWOPER standard defines specialist employees as “employees who, in the course of their regular job duties, work with and are
	trained in the hazards of specific hazardous substances, and who will be called upon to provide technical advice or assistance at a
	hazardous substance release incident to the individual in charge”; it further specifies that they “shall receive training or demonstrate
	competency in the area of their specialization annually” (29 C.F.R. § 1910.120 (q)(5)).
	b 29 C.F.R. § 1910.120 (q)(2)(ii).

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	A company can develop these checklists in the incident response planning stage and use them during
	emergencies to ensure proper performance of important emergency response tasks like those DuPont assigned to
	the process coordinator, even in scenarios in which the primary assignee is unavailable.

	DELAY IN ERT READINESS TO SEARCH FOR MISSING WORKERS

	It took 35 minutes from the request for ERT assistance for the La Porte ERT to initiate the first entry into the
	manufacturing building to search for the missing workers. Discussed below, miscommunication, the lack of a
	process coordinator, and inadequate emergency preparation by DuPont all contributed to the ERT’s delayed
	response.

	4.3.1 CALL FOR ERT RESPONSE

	When the Board Operator made his call for ERT assistance over the intercom system, he stated, “We need
	rescue people, and there’s people missing.” To the ERT, rescue specifically meant retrieval of a person from an
	area, so the team brought to the scene only technical rescue gear (e.g., ropes and harnesses). As discussed in
	Section 2.2, ERT members realized upon arrival that contrary to their presumption, there was a chemical release
	and they needed additional PPE.

	DuPont provided the CSB with a May 2014 slide presentation for new employees showing the structure of the
	ERT and how to request assistance from the ERT. The presentation detailed the differences in response groups
	(fire brigade, EMT, rescue, and fume release). While some operations personnel may have understood the
	organization of the ERT, a key problem at the time of the request for the ERT during the incident under study
	was that the incident was not yet fully understood. As a result, important details could not be communicated in
	the initial ERT call. In addition, DuPont lacked an on-site backup process coordinator to communicate and
	coordinate response operations with the ERT.

	In one of DuPont’s emergency response critiques conducted after the incident, emergency response
	personnel communicated the following:
	- “There was confusion on who was to respond.… For [a request for] EMT, only EMT responds.
	For [a request for] rescue, only rescue responds, and for [a request for] ERT (fume/fire) then
	everyone responds.”
	- “There was a communication problem initially. [We attempted] radio communication, not
	realizing that [the] leader had been lost. Operators were lost. No one [in the unit] knew how ERT
	worked.”

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	GUIDANCE TO INDUSTRY
	Plant emergency procedures should clearly define the alerting and notification process for different types of
	plant emergencies. These procedures should also include guidance for situations in which initial information to
	effectively assess the nature of the problem and the amount and type of ERT resources required is incomplete.

	4.3.2 ERT MINI-‐PUMPER TRUCK NOT OPERATIONAL

	When the ERT learned that the incident involved a chemical release, the Incident Commander asked ERT
	members to come to the scene with bunker gear and SCBAs. ERT members stored their SCBAs on a mini-
	pumper truck. When an ERT member tried to start this mini-pumper truck to bring the gear to the site where it
	was needed,a the vehicle did not start because of multiple mechanical malfunctions. An October 2, 2014, work
	order states, “Check[ed] batteries and they were not good, remove[d] and replace[d] with new ones.” Replacing
	the batteries, however, did not fully repair the truck, which failed to start at the time of the incident, impairing
	the effectiveness of the ERT response. After the incident, DuPont La Porte personnel replaced the truck’s
	alternator, battery cable, and belts to make it operable. Although the pumper truck was a critical piece of
	emergency response equipment, DuPont La Porte did not adequately maintain it before the incident to ensure its
	availability during an emergency.

	In DuPont’s emergency response critiques conducted after the incident, emergency response
	personnel communicated:
	- “Opportunity: Exercise and inspect the emergency services apparatus on a more frequent basis.
	Perform maintenance in a timely fashion to ensure the functionality and reliability.”
	- “Weakness: I had gear and equipment that didn’t make it to the scene. We get in a comfort zone
	and [think] it won’t happen to us, and it did.”

	Since the mini-pumper truck holding SCBAs could not come to the scene, the ERT assigned an operator to
	retrieve additional SCBAs in the Lannate® Unit for the ERT to use.b Retrieving the SCBAs may have exposed
	the operator to a high methyl mercaptan concentration because these SCBAs were downwind of the methyl
	mercaptan release point (Section 4.7).

	a The pumper truck was a Ford F-450 Mini Pumper.
	b The SCBAs on the truck were rated for 60 minutes. Initially, the ERT had to use SCBAs from the area that were rated for 30 minutes.
	Later on, 60-minute SCBAs were transported to the scene.

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	GUIDANCE TO INDUSTRY
	Under the HAZWOPER standard, an emergency response plan must address PPE and emergency equipment,a
	such as the SCBAs and mini-pumper truck. It should also contain information on how to ensure that PPE and
	emergency equipment are always functional.

	Even though industrial facilities may call upon emergency response vehicles infrequently, it is essential that
	these vehicles operate as intended when needed. To ensure emergency vehicle reliability, companies need to
	develop and apply regular maintenance schedules. The National Fire Protection Association’s Standard for the
	Inspection, Maintenance, Testing, and Retirement of In-Service Emergency Vehicles (NFPA 1911) requires
	weekly visual and operational checks for emergency vehicles.b Annex C of NFPA 1911, titled Developing a
	Preventive Maintenance Program, also provides guidance and example checklists to use when performing
	preventive maintenance on emergency vehicles [9, pp. 79-99].

	THE SEARCH FOR MISSING WORKERS WAS HIGH RISK

	When the HAZMAT-trained ERT members and the necessary PPE arrived at the scene of the release, the
	emergency response still faced three major issues:

	1. The ERT initially did not use air monitoring equipment to identify whether the building had an

	explosive atmosphere.

	2. Emergency responders did not know the locations of the missing workers.

	3. Emergency responders were not familiar with the layout of the building and processes.

	While no emergency responders were injured, operations under these conditions exposed responders to
	increased risk.

	4.4.1 ENTRY INTO POTENTIALLY EXPLOSIVE ATMOSPHERE

	During the incident, Harris County emergency responders used a QRAE monitorc and a MultiRAE monitord
	during their building entries. These monitors can inform personnel whether the environment is explosive or

	a 29 C.F.R. § 1910.120 (q)(2)(xi).
	b The 2017 version of NFPA 1911 states, “A visual and operational check of the apparatus shall be performed within 24 hours of a run or
	at least weekly” [9, p. 17]. The 2012 version of NFPA 1911, which was the applicable standard at the time of the incident, states, “An
	operational check and visual check of the fire apparatus shall be performed on a daily/weekly basis to ensure the operational readiness of
	the unit” [98, p. 13].
	c The QRAE monitor is a four-sensor monitor specifically manufactured by RAE to continuously monitor, for example, oxygen,
	percentage of lower explosive limit, and toxic gases [124].
	d The MultiRAE monitor, specifically manufactured by RAE, has up to six gas sensors to continuously monitor, for example, percentage
	of lower explosive limit (LEL), oxygen, and toxic gases [123]. To obtain percentage LEL, this type of detector is typically calibrated
	using methane, and the user multiplies the percentage LEL reading by a given correction factor to obtain the percentage LEL of the
	chemical of interest [84].

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	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	immediately dangerous to life or health (IDLH). Colorimetric gas detection tubes (e.g., Dräger-Tubes) can also
	measure gas concentrations during emergencies.a Air monitoring by ERT personnel is a critical element in
	employing a risk-based emergency response operation.b Failure to conduct air monitoring increases the
	potential for significant risks to emergency responders, employees, and the public, and it can lower the
	probability of a safe and effective emergency response. Emergency responders typically use portable air
	monitors to measure gas concentrations during entries into hazardous areas.

	During the ERT’s initial entry into the manufacturing building to search for the missing workers, ERT members
	did not use air monitoring equipment to characterize the building atmosphere. DuPont La Porte had assigned
	operations personnel to maintain and control air monitoring equipment within each of their business units to be
	made available to the incident commander or the process coordinator during emergencies. The DuPont La Porte
	emergency response plan identifies the incident commander as being responsible for directing personnelc to
	conduct air monitoring downwind of the release.

	There was a delay in air monitoring inside the building, and the ERT could not determine if there was an
	explosive atmosphere (methyl mercaptan is a flammable gas)d during the initial entry into the manufacturing
	building.e Without this monitoring, the ERT may have unknowingly entered an explosive atmosphere. Later,
	the ERT entered the building with other external emergency response groups that had air monitoring equipment.
	The potential for a methyl mercaptan explosion in the building posed a serious hazard to emergency responders,
	due to both the inherent explosion effects (e.g., overpressure, shrapnel) and the structural collapse risk (Section
	4.4.3).

	GUIDANCE TO INDUSTRY
	Entering a structure with an unknown environment may pose additional risks to emergency responders. For
	example, it may have the potential to be explosive, as in the situation at DuPont La Porte. Recognizing the
	issues associated with uncharacterized environments, the HAZWOPER standard requires the individual in
	charge (here, the incident commander) to identify to the extent possible “all hazardous substances or conditions
	present and shall address as appropriate site analysis, use of engineering controls, maximum exposure limits,
	hazardous substance handling procedures, and use of any new technologies.”f Additionally, the HAZWOPER

	a “Dräger-Tubes are glass vials filled with a chemical reagent that reacts to a specific chemical or family of chemicals. A calibrated 100
	ml sample of air is drawn through the tube. If the targeted chemical(s) is present, the reagent in the tube changes color and the length of
	the color change typically indicates the measured concentration” [125].
	b A risk-based emergency response operation is an approach that sets policy and programmatic priorities based upon measured levels of
	risk to lives, property, and the environment [165, p. 6].
	c Personnel can be either mechanics, operators, or emergency response personnel who are trained on air monitoring equipment and
	familiar with the area.
	d Methyl mercaptan is flammable at concentrations between 3.9 percent and 21.8 percent by volume [50].
	e At approximately 7:30 am, the ERT was pulled out of the building to resolve issues with PPE because it was determined that methyl
	mercaptan posed a flammability risk.
	f 29 C.F.R. § 1910.120 (q)(3)(ii).

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	standard also identifies a safety officer as an individual who assists the incident commander in identifying these
	hazardsa and makes safety decisions surrounding them.b This standard gives the incident commander the
	responsibility of determining the risks associated with the emergency response using available personnel and
	tools (emergency equipment and PPE). Before directing emergency response activities, the nature of the
	hazards needs to be identified and characterized to determine the appropriate actions to be taken.

	Incident commanders, safety officers, and other emergency response personnel can look to industry guidance to
	help them determine the safest course of action in a given situation. For example, NFPA 472, Standard for
	Competence of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents, gives illustrative
	example conditions—including those conditions present during the DuPont La Porte incident—in which NFPA
	recommends prohibiting emergency response personnel from entering the hot zone. They include, among other
	conditions:

	•

	•

	flammable or explosive atmosphere present and

	insufficient personnel to perform tasks [10, p. 100].

	One method emergency responders can use to characterize unknown environments is air monitoring. To ensure
	that emergency responders can perform air monitoring of hazardous atmospheres, industrial facilities should
	provide ERT members with their own air monitoring equipment and train them in how to operate it (e.g., NFPA
	472 requires that hazardous materials technicians be able “through detection, monitoring, and sampling,… [to]
	verify the presence of hazardous materials… [and] determine the concentration of hazardous materials in the
	atmosphere” [10, pp. 42-43]).

	If facilities choose to assign maintenance and storage of portable air monitoring equipment to non-ERT
	members, the company should also ensure that the ERT can readily locate and access the stored equipment.

	4.4.2 NO TECHNOLOGY TO LOCATE MISSING WORKERS

	DuPont La Porte did not equip the manufacturing building with technology either to account for the entry of
	personnel into the building or to track their location once inside. The manufacturing building processed highly
	hazardous chemicals—including methyl mercaptan and chlorine—in an enclosed environment. Companies can
	use technology (such as cameras, badges, or chip readers) to track the locations of personnel upon entry into
	high-hazard areas or in the event of an incident. Knowing the location of personnel could help emergency
	responders conduct targeted rescues by allowing them to reach affected personnel quickly and minimize ERT
	member exposure to hazardous environments.

	a “The individual in charge of the [incident command system] shall designate a safety officer, who is knowledgeable in the operations
	being implemented at the emergency response site, with specific responsibility to identify and evaluate hazards and to provide direction
	with respect to the safety of operations for the emergency at hand” (29 C.F.R. § 1910.120 (q)(3)(vii)).
	b “When activities are judged by the safety officer to be an IDLH and/or to involve an imminent danger condition, the safety officer shall
	have the authority to alter, suspend, or terminate those activities. The safety official shall immediately inform the individual in charge of
	the [incident command system] of any actions needed to be taken to correct these hazards at the emergency scene” (29 C.F.R. § 1910.120
	(q)(3)(viii)).

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	GUIDANCE TO INDUSTRY
	Facilities that handle large quantities of flammable or toxic chemicals have a responsibility to monitor high-
	hazard areas, such as DuPont’s Lannate® manufacturing building, for releases and personnel injuries. That
	monitoring capability must be available to emergency response personnel to assess the scope and nature of any
	incident, including possible locations of employees within the area. High-hazard areas should be equipped with
	sufficient monitoring devices, such as detectors, alarms, and surveillance technology, to identify whether there is
	a chemical release (or other type of emergency) and whether personnel are affected.a When surveillance
	cameras are used, companies should consider having the camera feeds go to multiple plant locations, including
	control rooms, plant security stations, and the plant emergency operations center (EOC).

	4.4.3 UNRECOGNIZED MANUFACTURING BUILDING COLLAPSE HAZARD

	A 2002 DuPont La Porte facility siting study predicted potential damage to the manufacturing building based
	upon various explosion scenarios. In the analysis of a hypothetical methyl mercaptan explosion on the first floor
	of the manufacturing building, the study listed the “Predicted Building Damage Level” as “Collapse []-Building
	fails completely. Repair is not feasible.”

	Neither DuPont La Porte’s emergency response plan nor the Lannate® Unit’s emergency planning and response
	manual included information from the 2002 study on the potential risk of structural collapse in the event of an
	explosion. DuPont La Porte did not have a system in place to ensure that emergency planning documents were
	updated when site studies, such as a process hazard analysis (PHA), identified relevant information.
	Consequently, the emergency planning documents did not prepare ERT members for the risk that the
	manufacturing building could collapse.

	Although an explosion did not occur and the manufacturing building did not collapse, entry into the
	manufacturing building posed a serious safety risk to members of the ERT during emergency response activities
	following a significant methyl mercaptan release.

	GUIDANCE TO INDUSTRY
	NFPA 1620, Standard for Pre-incident Planning, states, “The pre-incident plan shall address the structural
	integrity of walls, roofs, and floors” [11, p. 9]. This standard is intended to provide information to the incident
	commander. To help emergency responders become knowledgeable of known unit hazards, companies should
	develop a system to update emergency planning documents when other studies identify pertinent hazards and
	risks.

	a According to Sutton, author of Plant Design and Operations, closed circuit television (CCTV) “can help with fire response—not so
	much with the initial detection but in providing information that can help with control of the facility and direction of the emergency
	response team. Cameras can be installed in a fixed position focused on high-risk areas or may permanently scan large areas.… Typical
	locations for CCTV cameras are pump floors in process and oil movement areas, road/railcar loading areas, jetties, and buildings that
	contain process equipment” [85, p. 203].

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	DIFFICULTIES NAVIGATING MANUFACTURING BUILDING

	Many of the emergency responders searching the manufacturing building worked at the La Porte site as
	operators in other units or for other companies located there. Some of these responders, therefore, were
	unfamiliar with the manufacturing building—a four-story building containing a large amount of piping and
	process equipment, dividing walls, multiple stairwells, and an elevator. Figure 11 shows photos taken inside the
	manufacturing building, illustrating the complexity of the layout inside the building.

	Figure 11. Photos of the Interior of the Lannate® Manufacturing Building. Source: CSB.

	The CSB found that the Lannate® Unit’s emergency planning and response manual did not have a building map
	or floor plan to aid emergency responders in understanding and navigating the manufacturing building during
	the incident. Emergency responders assigned Lannate® Unit operators—including the Board Operator—to draw
	maps of the manufacturing building to assist in the search. The Board Operator informed the CSB as follows:

	They got the big pad … and had me sit down and start drawing pictures. And [the emergency
	responder] said, “We want it as detailed as you can get.” So, I drew the building, I drew the
	stairwells, I drew the reactors, what reactors were where, you know, and coolers, you know, on
	each floor. That’s what they wanted me to do, draw a description of each floor as well as I could
	… so when they go in, they know where they’re going. They can look, and of course three of
	[the missing operators were] found already, but they never did—at that time, they didn’t know
	where [the fourth missing operator] was.… It took me about an hour and a half to draw stuff, you
	know.

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Seven months before the incident, DuPont La Porte performed a response drill for operators in the Lannate® Unit
	and developed a follow-up action item that “plot plans should be readily available for responder reference”
	(Figure 12). The CSB found that the drill leader, however, did not assign this action item to specific personnel
	or input the item into the site’s action item tracking system. Consequently, no one took responsibility for the
	action items, and the recommended plot plans were never created.

	Figure 12. Excerpt from an April 2014 Drill Follow-‐Up. It recommended that plot plans be readily available
	for responder reference. A plot plan was never made for the manufacturing building. Source: DuPont.

	GUIDANCE TO INDUSTRY
	Although the HAZWOPER standard requires that emergency response plans detail evacuation routes,
	evacuation procedures, safe distances, and places of refuge, it does not specifically require development of plot
	plans.a NFPA 1620, Standard for Pre-incident Planning, on the other hand, supports the development of plot
	plans in complex hazardous environments. The standard establishes criteria for developing “pre-incident plans
	to assist personnel in effectively managing incidents and events for the protection of occupants, responding
	personnel, property, and the environment” [11, p. 5]. It also defines different complexity levels of pre-incident
	plans: (1) Level 1, Basic, (2) Level 2, Intermediate, and (3) Level 3, Comprehensive. NFPA 1620 states,

	Level 3 information is the most detailed level of pre-incident planning and is intended to include
	process hazards and protection schemes, detailed occupancy considerations, room or area layouts,
	and operational features (e.g. ventilation, power) [11, p. 17]. (emphasis added)

	In addition, it is a good practice for site-level emergency responders—and external emergency response
	groups—to be familiar with the layout of enclosed buildings within chemical facilities in the event of an
	emergency. Familiarity with buildings and process areas can reduce recovery time and aid in life-saving rescue

	a 29 C.F.R. § 1910.120 (q) (February 8, 2013).

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	operations. Periodic drills inside process structures can help familiarize responders with the buildings and
	improve responder navigation during emergencies.a

	To help prepare for emergencies, chemical facilities should do the following:

	1. Develop site maps and plot plans of the facility, including the layout of process buildings. Ensure these

	maps are up-to-date and readily available to emergency responders.

	2. Coordinate regularly scheduled site tours for both plant and external emergency responders to establish
	strong working relationships and help ensure emergency responders are familiar with facility access
	points, hazards, emergency response issues, and site or facility layout.b

	3. Familiarize responders with process structures or buildings to improve responder navigation during
	emergencies by having periodic drills inside them at established, recurring intervals. To enhance
	responder performance, members of an emergency response team should train together, especially in
	situations in which multiple companies are staffing a single team.

	a NFPA 1, Fire Code, Annex D, “Hazardous Materials Management Plans and Hazardous Materials Inventory Statements,” requires
	detailed site, building, and structure drawings. Additionally, facilities are required to have inventory assessments that include chemical
	names and their common names. Annex D is not a requirement of NFPA 1 unless it is specifically adopted [106, pp. 731-740].
	b NFPA 600, Standard on Industrial Fire Brigades, states, “Facility fire brigade management should maintain a close working relationship
	with all emergency response organizations that could reasonably be expected to respond to the facility during an incident. This
	relationship should include … an invitation to the emergency response organizations to participate in a pre-fire planning walk-through or
	tour of the facility” [103, p. 19].

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	NO ANALYSIS OF PROCESS DATA TO IDENTIFY SOURCE OF LEAK

	Figure 13. Location of Methyl Mercaptan Emergency Isolation Valve Relative to Manufacturing Building
	Where Leak Occurred. The emergency isolation valve was not activated until seven hours after the
	release began. Source: Google Earth, with annotations by CSB.

	DuPont La Porte had installed an emergency isolation valve for the methyl mercaptan storage tank. Companies
	often install emergency isolation valves to avoid the need to isolate chemical release points manually during
	large releases of a flammable or toxic chemical; locations for such valves include, for example, points near
	property lines, at the boundaries of process units, or at liquid outlets of vessels containing flammable or toxic
	chemicals.a The installation and use of these valves can help prevent someone from having to enter a flammable
	or toxic atmosphere to stop a chemical release. Even though the methyl mercaptan storage tank had an
	emergency isolation valve, its closure was significantly delayed.

	The release began just after 3:00 am, but

	1.

	2.

	the methyl mercaptan storage tank pump was not turned off until 6:02 am—three hours after the release
	began—significantly reducing the rate of the methyl mercaptan release, and

	the methyl mercaptan storage tank emergency isolation valve was not closed until 10:07 am—seven
	hours after the release began—finally isolating the methyl mercaptan storage tank from the process
	(Figure 13).

	a Emergency isolation valves could be designed to (1) close automatically, for example, during an emergency shutdown of a unit; (2)
	close remotely, by manual activation; or (3) be manually closed [81, pp. 123-124].

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Earlier performance of these two critical equipment manipulations could have controlled the release much
	sooner.

	The CSB determined that the delay in isolating the methyl mercaptan storage tank from the process occurred for
	two reasons:

	1. Personnel did not recognize the need to close the methyl mercaptan storage tank isolation valve when
	they determined that methyl mercaptan was the chemical being released inside the manufacturing
	building.

	2.

	No one evaluated process data to determine what was causing the release until hours into the response
	efforts. Had personnel looked at the process data earlier during the release, it should have been clear
	that methyl mercaptan was flowing from the methyl mercaptan storage tank, requiring closure of the
	emergency isolation valve (Figure 14).

	Figure 14. Process Data from November 15, 2014. Data shows that methyl mercaptan was
	abnormally flowing from the methyl mercaptan storage tank. No one analyzed these data during
	the first hours of the incident. Source: CSB graph based on DuPont data.

	The CSB identified three causes for not analyzing process data earlier during the release:

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	1. The Lannate® Unit’s Shift Supervisor (Process Coordinator), who was responsible for determining the

	source of any chemical release and identifying the valves to close to stop the release, had been
	overcome by methyl mercaptan exposure, and there was no designated backup on shift (Section 4.2).

	2. During the chemical release, the Board Operator, who could have analyzed the process data, was

	repeatedly pulled away from monitoring the process to communicate with emergency responders and
	perform tasks such as drawing maps of the building (Section 4.5).

	3. Even though there was a troubleshooting operation going on in the Lannate® Unit before the release,
	there was no technical or engineering support on-site to help the operators if the Lannate® process
	responded abnormally. Site personnel did not contact the on-call DuPont La Porte technical employeesa
	during the early stages of the incident for assistance in identifying the source of the methyl mercaptan
	release (Section 4.6).

	GUIDANCE TO INDUSTRY
	When a process safety incident such as a chemical release occurs, it can be beneficial for technical personnel
	who are not immediately involved in emergency response functions to analyze process data and quickly identify
	the cause, scope, and magnitude of the incident. This analysis will help the company (or incident commander)
	identify needed equipment manipulations to stop or control the incident, such as shutting down equipment or
	closing isolation valves, to mitigate the effects of a release and the threat to responders and the public. In
	Guidelines for Technical Planning for On-Site Emergencies, CCPS provides guidance on the possible
	emergency roles of various plant personnel during an incident [8, p. 161] (Figure 15).

	a The DuPont La Porte technical employees were contacted individually throughout the morning by a variety of persons.

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 15. Example Roles for Various Plant Personnel During and after an Emergency.
	Source: CCPS.

	INADEQUATE CREATION AND CONTROL OF HOT ZONE

	The ERT did not adequately establish, physically mark, or communicate the boundary of the hot zone during the
	early stages of the emergency response efforts. The zone was physically marked only after external emergency
	services groups arrived at the scene. The absence of a clear hot zone boundary as part of the early emergency
	response led to poor incident scene control, including trouble determining who had entered and exited the hot
	zone and whether they were wearing proper PPE.

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	During the incident, the ERT asked an operator who was not an ERT member (Operator 7) to assist the team by
	retrieving SCBAs from the Lannate® Unit. Because the hot zone was not physically defined, and entry/exit
	control points were not staffed and controlled, the operator did not realize the SCBAs were in a potentially
	hazardous location. She entered the hot zone without respiratory protection and, based on the symptoms she
	exhibited, believes she was exposed to a high concentration of methyl mercaptan (Figure 6).

	In one of DuPont’s emergency response critiques conducted after the incident, emergency response
	personnel communicated:
	“Weakness: Visual markers and communication of the control zone boundaries.”

	GUIDANCE TO INDUSTRY
	The establishment, communication, and control of a hot zone is necessary to help protect plant personnel and
	emergency responders. Under the HAZWOPER standard, an emergency response plan must address “safe
	distances and places of refuge.”a An emergency response plan can provide guidance in determining safe
	distances and places of refuge for different types of emergencies and in effectively communicating these zones.

	Companies can look to voluntary consensus standards for guidance on how to establish hot zones. For example,
	NFPA 472, Standard for Competence of Responders to Hazardous Materials/Weapons of Mass Destruction
	Incidents, requires that the hazardous materials safety officerb “identify whether the boundaries of the
	established control zones are clearly marked … and are being maintained” and “verify that each team is
	protected and prepared to perform its assigned tasks by … verify[ing] whether the selection of PPE and
	equipment is consistent with the site safety and control plan” [10, p. 61].

	Once personnel establish and communicate a hot zone, they must control entry and exit. HAZWOPER states
	that the incident commander “shall limit the number of emergency response personnel at the emergency site, in
	those areas of potential or actual exposure to incident or site hazards, to those who are actively performing
	emergency operations. However, operations in hazardous areas shall be performed using the buddy system in
	groups of two or more.”c These requirements help ensure that emergency response personnel minimize their
	potential exposure to hazards.

	a 29 C.F.R. § 1910.120 (q)(2)(iv).
	b The hazardous materials safety officer is part of the incident command system and ensures that safe practices are followed during
	hazardous materials incidents [10, p. 58].
	c 29 C.F.R. § 1910.120 (q)(3)(v).

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	ERPG Levels

	Emergency Response Planning Guidelines
	(ERPGs) are chemical concentration levels used
	when preparing for and responding to
	emergencies. They are designed to anticipate
	public health effects, not occupational health
	effects, from exposure to airborne chemicals.
	The three ERPG levels are as follows:

	ERPG-3: The maximum airborne concentration
	below which nearly all individuals could be
	exposed for up to one hour without experiencing
	or developing life-threatening health effects.

	ERPG-3 is a worst-case planning level.
	Exposure to concentrations above the ERPG-3
	level will be lethal to some members of the
	community.

	ERPG-2: The maximum airborne concentration
	below which nearly all individuals could be
	exposed for up to one hour without experiencing
	or developing irreversible or other serious health
	effects, or symptoms that could impair an
	individual’s ability to take protective action.

	At concentrations above ERPG-2, some members
	of the community may experience significant
	health effects, which could impair them from
	taking protective action. Emergency responders
	often alert the community to take protective
	action in areas susceptible to the ERPG-2
	concentration and above.

	ERPG-1: The maximum airborne concentration
	below which nearly all individuals could be
	exposed for up to one hour without experiencing
	more than mild, transient adverse health effects
	or without perceiving a clearly defined
	objectionable odor [86].

	To prevent a similar hazardous situation to personnel assisting
	industrial emergency response teams, companies should ensure
	that emergency response team members are trained (1) to
	physically designate the hot zone, and (2) to communicate the
	location of the hot zone and its entry control points to all
	personnel assisting with the emergency response, including
	operations personnel.

	DEFICIENCIES IN EVALUATING RISK TO THE

	PUBLIC

	DuPont La Porte did not effectively evaluate the impact of a
	potential major methyl mercaptan release on members of the
	public. Site personnel had several available methods (discussed
	below) to help identify whether a hazardous concentration of
	toxic methyl mercaptan was traveling off-site. As discussed in
	this section, the emergency responders

	•

	•

	•

	•

	•

	used a model of the chemical release that had
	inaccurate model inputs,

	did not use available on-site methyl mercaptan
	concentration data to evaluate the potential for an off-
	site release,

	misinterpreted methyl mercaptan physical property
	data by mistakenly believing methyl mercaptan was
	lighter than air and would not expose people off-site to
	hazardous concentrations,

	did not adequately communicate to external emergency
	response parties the name of the chemical being
	released, and

	did not perform air monitoring during the release to
	predict possible off-site consequences.

	Although there was a potential that methyl mercaptan may have
	exceeded ERPG-3a concentrations outside the fence line (see
	ERPG Levels box), the CSB is not aware of the actual

	a The ERPG values for methyl mercaptan in parts per million are ERPG-1, 0.005; ERPG-2, 25; ERPG-3, 100 [82]. People can typically
	detect methyl mercaptan odor at about 2 parts per billion (ppb) [80, p. 1].

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	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	concentrations because timely air monitoring was not performed. Additionally, the CSB is unaware of any
	reported off-site injuries.

	4.8.1 RELEASE MODELING

	The ERT used software called SAFERa to model chemical releases in real time to help identify areas susceptible
	to hazardous concentrations of the chemical being released. Chemical release modeling is commonly used for
	assessing response scenarios during the emergency planning process and can also be used as part of incident
	management activities during a response. Its use is dependent upon having accurate source data, such as the
	chemical release rate. To create an effective model of a chemical release, SAFER needs an estimated chemical
	release rate based on accurate data.

	The Lannate® Unit’s emergency planning and response manual called for the SAFER operator to create a model
	of the release. Because there was no air monitoring information available, the SAFER operator estimated a
	release rate based upon an ERT member’s observations regarding the relative strength of the chemical odor
	outside of the manufacturing building. The SAFER operator informed the CSB as follows:

	Once I found out what the chemical was—methyl mercaptan—I plugged it in [to SAFER] and
	we still didn’t know what kind of release rate we had. So, I went ahead and plugged in 10 pounds
	[per hour] because based on what [they’re] telling me [they] could barely smell anything. I didn’t
	realize it was a significant release. … So, I just had to plug something in, so I plugged in 10
	pounds an hour release rate. … We were just guessing at the release rate.

	Using the estimated release rate of 10 pounds per hour, the SAFER software predicted that a hazardous
	concentration of methyl mercaptan would not leave the company property. In part because the software model
	showed the chemical was not hazardous off-site, DuPont La Porte did not notify the authorities to alert the
	community to shelter-in-place or to divert traffic from the nearby Highway 225 (Figure 16).

	a At the time of the incident, DuPont La Porte was using SAFER Real-Time to do its emergency response dispersion modeling. This
	program is no longer supported, and SAFER has transitioned this program to SAFER TRACE [99].

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 16. Overhead Image of DuPont La Porte Facility. A plume of methyl mercaptan left the DuPont property in a
	southeasterly direction toward a major highway and residential area. Source: Google Earth, with annotations by CSB.

	Companies should not rely on unsupported data when making critical emergency response decisions, such as
	those affecting workers or the surrounding public and community. Companies are best positioned to determine
	the types of hazards that their processes and chemicals pose. Moreover, in developing emergency response
	plans, companies can develop scenarios for potential releases, which can be an important resource during an
	emergency. The U.S. Department of Transportation’s (DOT) 2016 Emergency Response Guidebooka provides a
	format that can be used by companies to guide initial emergency response.b Table 1 in the guidebook provides

	a The 2016 Emergency Response Guidebook is a joint publication of Transport Canada, the U.S. Department of Transportation (DOT),
	and the Secretariat of Communications and Transport of Mexico, with collaboration from Centro de Información Química para
	Emergencias of Argentina. The guidebook “is primarily a guide to aid first responders in quickly identifying the specific or generic
	hazards of the material(s) involved in the incident, and protecting themselves and the general public during the initial response phase of
	the incident.” It is primarily intended for use in transportation incidents involving dangerous goods [12, p. 358].
	b The CSB has found in several of its investigations that application of the Emergency Response Guidebook may not be appropriate at all
	fixed industrial facilities due to larger quantities of chemicals at fixed facilities, hazardous process conditions, or possible proximity to
	other hazardous chemicals [142, p. 1]. Fixed facilities may find guidance in the Emergency Response Guidebook beneficial in some
	scenarios, but such facilities should also consider other information when conducting emergency response operations, such as equipment
	inventory, site-specific emergency response plans, and company-specific safety data sheets. If a site does use the Emergency Response
	Guidebook as an initial reference early in the release, process data, equipment inventory, and specific site hazards should always be
	evaluated to help determine effective emergency response operations.

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	standardized instructions for determining the isolation and protective action distances for small and large spills
	by predicting the size of downwind areas that could be affected by a cloud of toxic gas [12, p. 292]. This
	information is used as initial guidance to determine the size of the public area that should be alerted to take
	protective measures, including evacuation.

	The 2016 Emergency Response Guidebook is intended to be a reference for emergency responders during
	transportation emergency events that could affect the public. It has limitations when it comes to fixed chemical
	facilities. For example, in the guidebook, a large spill is anything greater than 55 gallons, yielding a very wide
	range in spill amounts. On the night of the incident, approximately 2,530 gallons of methyl mercaptan was
	released inside the Lannate® Unit,a which is about 46 times larger than 55 gallons. Even at 55 gallons, the
	guidebook recommends that in the event of large outdoor methyl mercaptan spills at night, emergency
	responders alert people to take protective action within 1.9 miles (3.1 kilometers) downwind of the release [12,
	p. 297]. Figure 17 shows the area to be protected if this guidance had been followed, which includes Highway
	225 and a residential area. If DuPont La Porte had created its own version of a guidebook for release scenarios
	(including release of methyl mercaptan), actions may have been taken to protect the public.

	Following the incident, based on the methyl mercaptan storage tank level decrease, the CSB calculated that the
	methyl mercaptan release rate was closer to 9,000 pounds per hour, much of which was inside the
	manufacturing building—a rate 900 times greater than the dispersion model input. In an earlier study, DuPont
	determined that a leak greater than 4,500 pounds per hour (from an outdoor, elevated source) could result in
	hazardous off-site concentrations (ERPG-3 level) of methyl mercaptan.b According to DuPont’s guide for
	consequence analysis, concentrations above ERPG-2 require evacuation of the affected area. No evacuation
	occurred, because DuPont lacked adequate release information to provide to authorities.

	a The amount of methyl mercaptan released is based on DuPont’s calculations of how much was released during the incident.
	b Previously, DuPont had found in a study on a methyl mercaptan storage tank that in the event of a fire, the tank’s relief valves could
	release about 10,000 pounds per hour of methyl mercaptan to the atmosphere, causing off-site concentrations exceeding the ERPG-3
	value. To reduce this release rate, DuPont insulated the methyl mercaptan storage tank to decrease the amount of methyl mercaptan that
	would exit the relief valves during a fire. DuPont aimed to prevent any methyl mercaptan release rate of greater than 4,500 pounds per
	hour “to avoid ERPG-3 concentrations.” During the incident, methyl mercaptan released at a rate of 9,000 pounds per hour—double the
	threshold release rate DuPont specified to avoid ERPG-3 (100 ppm) concentrations.

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 17. Overhead Image of DuPont La Porte Facility with Recommended Downwind Protection Zone (Shown in Yellow) Based
	on the 2016 Emergency Response Guidebook [12, p. 297]. Downwind sections of Highway 225 and residential areas were within
	the area recommended for public protection from a methyl mercaptan chemical leak. Source: Google Earth, with annotations by
	CSB.

	GUIDANCE TO INDUSTRY
	Chemical dispersion modeling can be an effective risk-based emergency response tool, but its results are highly
	dependent on accurate input data. During an emergency, it can be difficult to obtain an accurate release rate,
	limiting the validity of resulting models [8, p. 239].

	Companies can better protect the public from hazardous chemical exposures by identifying a conservative area
	where people should take protective action (e.g., sheltering-in-place) in the event of a chemical release, and then
	scaling back that area only when reliable information becomes available to justify reducing the protection zone.
	In addition, the data available to emergency responders can be enhanced by fence-line monitoring using fixed or
	portable monitors (Section 4.8.4). Such monitors can provide real-time data on whether the hazardous chemical
	is migrating off-site at dangerous concentrations.

	4.8.2 PHYSICAL PROPERTIES OF METHYL MERCAPTAN

	The ERT did not alert the local authorities to notify the public of the chemical release because some emergency
	response personnel believed methyl mercaptan was lighter than air and would not affect the local community. A
	La Porte facility employee informed the CSB as follows:

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	The [sheriff’s deputy] asked me, how did I know that [methyl mercaptan] was not affecting
	anybody in the La Porte area. I said, “I’ll ask that question while I’ve got [an emergency response
	representative] on the phone.” So, I asked, and that’s when I was told that methyl mercaptan is
	lighter than air and it dilutes out, and that it would have dissipated, pretty much, by the fence
	line.

	Methyl mercaptan, however, is heavier than aira and will tend to stay near ground level. DuPont’s technical
	standard for methyl mercaptan states that methyl mercaptan “gas is colorless and heavier than air, so that it can
	spread at ground level.” Also, DuPont’s safety data sheet (SDS)b for methyl mercaptan specifies its vapor
	density, showing that methyl mercaptan is heavier than air (Figure 18). The CSB could not determine why the
	emergency response representative communicating this information believed that methyl mercaptan was lighter
	than air.

	Figure 18. DuPont’s Safety Data Sheet for Methyl Mercaptan. It indicates that methyl mercaptan is heavier
	than air. Source: DuPont.

	County emergency responders also had difficulty understanding the chemical properties of methyl mercaptan
	during the release. A post-incident narrative written by a member of the Harris County Hazardous Materials
	Response Team states:

	a The relative gas density or vapor density of methyl mercaptan is 1.66, meaning it is heavier than air, whose density is 1 [50].
	b Beginning in 2012, OSHA’s Hazard Communication Standard (HAZCOM) renamed material safety data sheet (MSDS) to safety data
	sheet (SDS) [156, pp. 5, 7]. Although referred to in this report as an SDS, the document shown in Figure 16 uses the older MSDS
	language.

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Copies of the Safety Data Sheets were retrieved from the [Channel Industries Mutual Aid]
	Command Van. The terms “methyl mesh and methyl mash” were used in multiple conversations
	but there was no data in the SDSs concerning either term.

	“MeSH” is an industry initialism for methyl mercaptan, which DuPont personnel also use,a but personnel did not
	adequately communicate the formal chemical name to external emergency response agencies.b

	GUIDANCE TO INDUSTRY
	Companies should ensure that all personnel who may assist with technical emergency response functions are
	trained on and understand the information contained in SDSs. Companies should also consider how to
	communicate formal chemical names to outside parties, such as emergency responders, by either ensuring that
	all staff are trained on and familiar with formal chemical names (e.g., methyl mercaptan, rather than MeSH) or
	by ensuring that SDSs include all alternative substance names, such as shorthand names, initialisms, or
	abbreviations [13].

	4.8.3 CHEMICAL SENSOR DATA

	During the release, methyl mercaptan detectors inside and outside of the manufacturing building alarmed on the
	control panel. DuPont La Porte had designed the outside detectors to alarm on the control panel when they
	sensed a methyl mercaptan concentration of 25 parts per million (ppm) or greater,c specifically to “provide an
	early warning for a significant release of [methyl mercaptan] that could have impact off-site.” The three

	a “MeSH” is shorthand based upon methyl mercaptan’s chemical formula: CH3SH. “Me” represents the methyl group (CH3) and “SH”
	represents the mercaptan group (SH)—these initialisms combine to form “MeSH.”
	b The material safety data sheet in Figure 16 does include the term “MeSH” as a synonym for methyl mercaptan. Emergency responders
	had access to this sheet; however, they may have been specifically looking for the term “methyl mesh” as a synonym and may not have
	realized that the listed synonym “MeSH” referred to the same chemical.
	c The ERPG-2 level for methyl mercaptan is 25 ppm. This level “is the maximum airborne concentration below which nearly all
	individuals could be exposed for up to one hour without experiencing or developing irreversible or other serious health effects or
	symptoms which could impair an individual’s ability to take protective action.” Emergency responders use ERPG-1, -2, and -3
	concentration data to determine how to protect the public [167].

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	detectors inside the manufacturing buildinga (Figure 3) were also set to alarm on the control panel when they
	detected 25 ppm methyl mercaptan and were intended to protect workers from exposure to methyl mercaptan.b

	From DuPont’s management of change documentation for installation of methyl mercaptan detectors
	inside the manufacturing building:
	“Present Conditions and Description of Proposed Change: Personnel can enter a potentially
	hazardous location without knowing MeSH [methyl mercaptan] has been released to the environment.”

	The ERT, however, did not use the data from these detectors to identify whether there was a potential for an off-
	site release.c The CSB found that during the incident, the Board Operator communicated information about the
	process to emergency response personnel, possibly including readings from these detectors, but these
	concentration data do not appear to have been considered when determining the potential for dangerous methyl
	mercaptan concentrations off-site. The loss of the Shift Supervisor (Process Coordinator) appears to have
	contributed to DuPont La Porte’s not considering these data when assessing the magnitude of the release during
	the incident.

	4.8.4 AIR MONITORING

	DuPont La Porte personnel did not monitor (test) the air for methyl mercaptan along the site’s property line
	(fence line) during the release. DuPont did not have fixed fence-line detectors, necessitating the assignment of
	individuals to perform air monitoring manually. The company never performed this critical monitoring along
	the fence line during the initial release.

	Harris County personnel performed air monitoring near Texas Highway 225 (Figure 16) at approximately 8:07
	am and did not detect methyl mercaptan in the air.d This air monitoring, however, was performed five hours
	after the release began and two hours after the methyl mercaptan pump was turned off (which significantly
	slowed the release). This value, therefore, did not accurately represent the off-site methyl mercaptan

	a There were three methyl mercaptan detectors located inside the manufacturing building, on the first and fourth floors. The third floor,
	where the release occurred, did not have any methyl mercaptan detectors.
	b The 25 ppm alarm set point is 50 times NIOSH’s REL of 0.5 ppm, and more than double OSHA’s ceiling limit of 10 ppm [50].
	Therefore, alarming at this detection level could not protect workers from exposure to methyl mercaptan.
	c Post-incident, the methyl mercaptan detectors were tested and evaluated to determine whether they worked. Not all of the detectors had
	the correct span of 0 to 50 ppm, and so some of them would not have been able to read up to 50 ppm. Additionally, these detectors are
	limited to detecting a maximum concentration of 50 ppm.
	d During the morning of November 15, 2014, the Harris County Pollution Control Services Department and the Houston Bureau of
	Pollution Control and Prevention investigated odor complaints. There were 10 confirmed odor complaints downwind from the DuPont
	La Porte facility (see Appendix C: Odor Complaints).

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	concentrations during the release. A measurable concentration of methyl mercaptan would have been more
	likely to be detected when the methyl mercaptan pump was operating.

	GUIDANCE TO INDUSTRY
	Monitoring for hazardous gases along the fence line at chemical facilities can help the company, emergency
	responders, and the public understand the nature and extent of a chemical release. Monitoring for hazardous
	gases at fence lines can be performed by fixed detectors, which can continually collect and record data,
	providing early notification of releases outside the property.a When fixed detectors are not available, a person
	using a portable gas detector may also perform air monitoring. This strategy, however, introduces additional
	risk because that individual may enter a hazardous or toxic environment. Proper PPE, including respiratory
	protection, must be worn during manual air monitoring operations. In conditions with an unknown
	concentration and a potential inhalation hazard, the proper respiratory PPE for personnel, under HAZWOPER,
	would be positive pressure air-supplying respirators (i.e., SCBAs) until it is determined to be otherwise.b

	Including air monitoring requirements in company emergency response plans and action checklists can help
	ensure that fence-line air monitoring is performed during emergencies. Personnel responsible for performing air
	monitoring should also be preassigned and quickly able to access air monitoring equipment.

	EMERGENCY RESPONSE CONCLUSIONS

	As discussed in this section, there were significant deficiencies in DuPont La Porte’s emergency response to the
	toxic and flammable methyl mercaptan release. Many of the deficiencies stemmed from a flawed emergency
	response system, including flawed implementation of the emergency response plan. Solutions to most of these
	deficiencies are covered in Appendix D: Emergency Response Tables. The CSB encourages companies to
	review their emergency response systems and related plans to ensure they incorporate the lessons learned from
	this investigation.

	a In 2015, the EPA finalized a rule for refineries to monitor benzene at their fence lines [153, p. 3], [154], 40 C.F.R §§ 60, 63 (2015). In
	promulgating this rule, the EPA acknowledges the importance of monitoring potential sources of hazardous materials and their impact on
	the surrounding community [153, pp. 6, 9]. The CSB supported the EPA’s proposal for fence-line monitoring and advocated for an
	automatic, continuous system providing real-time data for several reasons, including strengthening community planning and
	preparedness [141, pp. 1-3].
	b “Employees engaged in emergency response and exposed to hazardous substances presenting an inhalation hazard or potential
	inhalation hazard shall wear positive pressure self-contained breathing apparatus while engaged in emergency response, until such time
	that the individual in charge of the [incident command system] determines through the use of air monitoring that a decreased level of
	respiratory protection will not result in hazardous exposures to employees” (29 C.F.R. § 1910.120 (q)(3)(iv).

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	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	5 DUPONT’S PROCESS SAFETY MANAGEMENT SYSTEM

	DuPont, an American Chemistry Council (ACC) member company and Responsible Care practitioner,
	experienced three major process safety incidents that the CSB investigated over the course of five years, despite
	implementing its own corporate process safety management system. These incidents were the 2014 La Porte,
	Texas, methyl mercaptan release; the 2010 Belle, West Virginia, phosgene release [14];a and the 2010 Buffalo,
	New York, hot work incident [15].b During the present investigation, the CSB found a large number of
	significant process safety deficiencies at DuPont La Porte that contributed to the incident (see Interim
	Recommendations and Section 6) [1].

	According to CCPS, process safety management systemsc are “comprehensive sets of policies, procedures, and
	practices designed to ensure that barriers to episodic incidents are in place, in use, and effective” [16]. A
	process safety management system will have a variety of programs to address process safety. In addition to
	process safety, chemical manufacturing facilities typically also have programs to address personal safety.
	Personal safetyd programs and process safetye programs are distinct, and both are important.

	DuPont developed its own corporate process safety management system that integrated regulatory requirements
	and voluntaryf elements. Companies create their own process safety management systems to address regulatory
	requirements, including those under OSHA’s Process Safety Management (PSM) standard and the EPA’s Risk
	Management Plan (RMP) rule. Based on the chemicals stored on-site, including methyl mercaptan, DuPont La
	Porte determined that PSM and RMP applied to the Lannate® process (Sections 5.1.1 and 5.2.1). These federal
	safety regulations provide a process safety management system framework for companies to use in developing
	their own programs. In addition to meeting these regulatory requirements, DuPont also voluntarily sought to
	integrate the Responsible Careg Management System (RCMS) framework into the company’s own management
	system.

	a The CSB investigated three separate incidents that occurred in a 33-hour period at a DuPont facility in Belle, West Virginia. One
	worker was killed by the release of the highly toxic chemical phosgene [14].
	b The CSB investigated a hot work incident in Buffalo, New York, that killed one contractor and seriously injured another [15].
	c In general, the term process safety management system is interchangeable with process safety management program.
	d “Personal safety” incidents affect individual workers, resulting in first aid cases, recordable injuries, lost-time injuries, or fatalities.
	Typical causes of personal safety incidents include slips, trips, falls, lacerations, and dropped objects. Personal safety programs try to
	reduce the number of worker injuries from these types of hazards by managing individual behaviors. Common areas that personal safety
	programs address include personal protective equipment, stop work authority programs, working at heights, hazardous material
	communications, confined space permitting, lockout/tagout, cranes and heavy lifts, area access controls, and vehicle operation.
	e “Process safety” incidents, on the other hand, include chemical releases, fires, and explosions. Process safety incidents can result in
	large-scale destruction to site and community infrastructure and can lead to multiple injuries and fatalities. Process safety programs try to
	prevent these incidents by identifying and controlling the process hazards. Examples of process safety programs include process hazard
	analysis, inherently safer design, pressure relief systems, automated safety controls, operating procedures, management of change, audits,
	emergency response systems, and community involvement programs.
	f ACC’s Responsible Care Management System is one example of a voluntary process safety management system. Another is CCPS’s
	Risk Based Process Safety Management System, whose 20 process safety elements are detailed in Guidelines for Risk Based Process
	Safety [52].
	g The chemical industry developed Responsible Care to help guide companies toward safe and responsible operation.

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	U.S. Chemical Safety and
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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	This section addresses DuPont’s requirements under OSHA, the EPA, and ACC that the DuPont La Porte site
	integrated into its site process safety management system used at the time of the November 15, 2014 incident:

	• OSHA’s Process Safety Management Standard (Section 5.1)

	• EPA’s Risk Management Plan Rule (Section 5.2)

	• ACC’s Responsible Care (Section 5.3)

	Additionally, this section discusses how DuPont integrated and implemented the frameworks provided by PSM,
	RMP, and Responsible Care into its own corporate safety management system. Ultimately, this PSM system
	governed operations at the DuPont La Porte facility at the time of the November 2014 incident (Section 5.4).
	DuPont La Porte’s ineffective implementation of the PSM standard, the RMP rule, Responsible Care, and
	DuPont’s corporate process safety management system resulted in numerous process safety deficiencies that led
	to the incident (Section 6). The incident prompted OSHA and the EPA to investigate the DuPont La Porte site
	and resulted in each of these agencies’ initiating enforcement actions for alleged violations of federal process
	safety regulations (Section 5.1.2 and Section 5.2.2). The November 2014 incident also caused both ACC and
	DuPont to evaluate and make changes to their process safety management systems (Section 5.3.4, Section
	5.4.1.3, and Section 6.1).

	OSHA

	The Occupational Safety and Health Act of 1970 (OSH Act) was
	enacted “to assure safe and healthful working conditions for working
	men and women; by authorizing enforcement of the standards
	developed under the Act; by assisting and encouraging the States in
	their efforts to assure safe and healthful working conditions; by
	providing for research, information, education, and training in the field of occupational safety and health; and
	for other purposes.”a The Act led to the establishment of OSHA on April 28, 1971 [17, p. 16].

	OSHA developed the Process Safety Management standard in response to the 1990 Clean Air Act Amendments
	and multiple safety incidents, such as the 1984 Union Carbide toxic release in Bhopal, India, and the 1989
	Phillips Petroleum Company explosions and fires in Pasadena, Texas [18].

	5.1.1 THE PROCESS SAFETY MANAGEMENT STANDARD

	The stated purpose of the PSM standard is to prevent or minimize the consequences of catastrophic releases of
	toxic, reactive, flammable, or explosive chemicals that may result in toxicity, fire, or explosion hazards.b The
	standard aims to prevent these releases in locations where employees and others could be exposed to serious

	a President Richard M. Nixon signed the Willams-Steiger Occupational Safety and Health Act of 1970 on December 29, 1970 [17, p. 17].
	The OSH Act of 1970 (Jan. 1, 2004).
	b 29 C.F.R. § 1910.119.

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	hazards resulting from chemicals that pose catastrophic risk when stored in quantities greater than stated
	thresholds [19].

	Through this standard, OSHA strives to bring a systematic approach to addressing the hazards associated with
	these chemicals by establishing a framework for a process safety management system that integrates
	technologies, procedures, and management practices [18]. It does so through the PSM standard’s 14 elements,a
	which formalize bedrock safety principles in the form of regulatory requirements. Some of the requirements
	include performing a process hazard analysis (PHA), managing changes to a process or equipment, establishing
	sound operating procedures, ensuring adequate employee training and involvement, maintaining the mechanical
	integrity of all process equipment, and ensuring a satisfactory level of emergency preparedness in the event of a
	hazardous chemical release.b

	5.1.2 DUPONT LA PORTE’S IMPLEMENTATION OF PSM

	One of the avenues for the PSM standard to apply to a process is that a facility must store at least the established
	threshold quantity of what OSHA considers to be a highly hazardous chemical.c Based on the amount of methyl
	mercaptan stored at the DuPont La Porte facility, DuPont La Porte determined that PSM regulations applied.d
	Additionally, DuPont La Porte personnel integrated PSM requirements into the site’s process safety
	management system, including performing periodic PSM compliance audits. DuPont La Porte’s first-party PSM
	compliance audits,e which were divided over a three-year cycle, took 68 auditor-days to complete between 2012
	and 2014.f These audits, however, did not identify or effectively correct long-standing PSM deficiencies in
	DuPont La Porte’s process safety management system (e.g., deficiencies in performing process hazard analysis
	and management of change) (for more detail, see Section 6: Process Safety Management Deficiencies). In the 10
	years before the November 2014 incident, OSHA conducted one inspection at the DuPont La Porte facility
	following an oleumg release from the fluoroproducts section of the plant [20] [21]. After the November 2014

	a The 14 PSM elements are the following: employee participation, process safety information, process hazard analysis, operating
	procedures, training, contractor management, pre-startup safety review, mechanical integrity, hot work permits, management of change,
	incident investigation, emergency planning and response, compliance, and trade secrets. See 29 C.F.R. § 1910.119.
	b 29 C.F.R. § 1910.119.
	c The PSM standard applies to “(i) A process which involves a chemical at or above the specified threshold quantities listed in appendix
	A to this section; (ii) A process which involves a Category 1 flammable gas (as defined in 1910.1200(c)) or a flammable liquid with a
	flashpoint below 100°F (37.8°C) on-site in one location, in a quantity of 10,000 pounds (4,535.9 kg) or more except for: (A)
	Hydrocarbon fuels used solely for workplace consumption as a fuel (e.g., propane used for comfort heating, gasoline for vehicle
	refueling), if such fuels are not a part of a process containing another highly hazardous chemical covered by this standard; (B) Flammable
	liquids with a flashpoint below 100°F (37.8°C) stored in atmospheric tanks or transferred which are kept below their normal boiling point
	without benefit of chilling or refrigeration.” The PSM standard does not apply to “(i) Retail facilities; (ii) Oil or gas well drilling or
	servicing operations; or (iii) Normally unoccupied remote facilities” (29 C.F.R. § 1910.119(a)).
	d Under the PSM standard, the threshold quantity of methyl mercaptan is 5,000 pounds. 29 C.F.R. § 1910.119 (App. A).
	e 29 C.F.R. § 1910.119(o).
	f By dividing the PSM audits into a three-year cycle, the DuPont La Porte site was continually evaluated to see if it met PSM
	requirements.
	g Oleum is a dense, corrosive liquid consisting of concentrated sulfuric acid containing excess sulfur trioxide in solution [133].

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	incident, OSHA investigated DuPont La Porte’s Lannate® facility for potential violations,a including identified
	PSM deficiencies that contributed to the methyl mercaptan release [22].b OSHA also performed an expanded
	inspection of the DuPont La Porte site (i.e., evaluated other business units’ compliance) under its National
	Emphasis Program (NEP) for chemical facilities [22].c

	Although the PSM standard was intended to be performance-based [23],d, e in some respects it functions
	primarily as a reactive and activity-basedf regulatory scheme. While OSHA intends for PSM program elements
	to reduce risk, no explicit requirement appears under the PSM standard to reduce risks or prevent catastrophic
	accidents. Moreover, OSHA is not responsible for proactively evaluating the effectiveness of controls or
	safeguards [24, pp. 31-32]. As discussed in the CSB’s investigation report Drilling Rig Explosion and Fire at
	the Macondo Well, Volume 4, the United States relies on a regulatory framework that can be satisfied by
	“checking the box” when completing a variety of required safety-related activities, such as a PHA or MOC. Yet
	mere compliance with those requirements can still fail to improve safety. The safety-related activity may not
	adequately identify major hazards or control major accident events, in part because the regulatory regime lacks
	targeted risk-reduction, goal-setting requirements [25, p. 26].g For example, a properly completed MOC can
	effectively reduce the potential for an accident; however, an ineffective one can satisfy regulatory requirements
	and still leave a facility with substantial unmitigated risk.

	Under the OSH Act, it is the employer’s responsibility to “furnish to each of his employees employment and a
	place of employment which are free from recognized hazards that are causing or are likely to cause death or
	serious physical harm to his employees” and to “comply with occupational safety and health standards.”h
	Consequently, it is a company’s responsibility to ensure that its implementation of the PSM standard protects

	a Under Section 9 of the OSH Act, OSHA has six months to issue citations after a violation has occurred.
	b In May 2015, OSHA cited DuPont for 11 alleged safety violations stemming from the incident, including deficiencies in PHAs,
	operating procedures, equipment, MOCs, process safety information, training, alarm system, preventing toxic exposure, and contractor
	injury logs [164]. DuPont entered into a formal settlement with OSHA on July 17, 2017 [161].
	c On July 9, 2015, OSHA cited DuPont for 8 alleged safety violations from an NEP inspection of the adjacent herbicide and
	fluoroproducts (hydrofluoric acid) business units at the DuPont La Porte site, including deficiencies in process safety information,
	process hazard analysis, operating procedures, inspections, and documenting and using recognized and generally accepted good
	engineering practices [155]. After issuing these citations, OSHA placed DuPont in its Severe Violator Enforcement Program [22]. On
	July 17, 2017, DuPont entered into a formal settlement agreement with OSHA [157].
	d Also referred to as performance-based regulations, such goal-setting regulatory requirements and acceptance criteria are specified, and
	industry must document that its specific solutions meet the requirements, for example in terms of achieving acceptable risk levels.
	e Preamble to Process Safety Management of Highly Hazardous Chemicals; Explosives and Blasting Agents. Section III. Summary and
	Explanation of the Final Rule (February 24, 1992).
	f Activity-based standards and regulations require the mere completion of an activity and do not focus on the effectiveness of major
	accident prevention or risk reduction efforts.
	g The only two PSM elements that include goal-setting attributes are process hazard analysis and mechanical integrity. The PSM
	standard requires a PHA to “be appropriate to the complexity of the process and [to] identify, evaluate, and control the hazards involved
	in the process” (29 C.F.R. §1910.119(e)(1)). Additionally, under the heading “Mechanical Integrity,” the PSM standard requires that
	“the employer shall correct deficiencies in equipment that are outside acceptable limits (defined by the process safety information in
	paragraph (d) of this section) before further use or in a safe and timely manner when necessary means are taken to assure safe operation”
	(29 C.F.R. §1910.119(j)(5)). None of the other 12 elements include goal-setting requirements. Another example of a goal-setting system
	is ALARP (“As Low as Reasonably Practicable”).
	h 29 U.S.C. § 654 (a) (2010).

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	workers. OSHA typically investigates whether a company is effectively complying with PSM requirements,
	such as management of change, after an incident occurs. Some companies may be complying with PSM
	elements without actually reducing risks to employees, and that situation may not be recognized until after an
	incident occurs. For PSM elements to be effective in accident prevention, a facility’s implementation must be
	aimed at risk reduction, and company audits must be substantive, helping companies ensure that their PSM
	programs are working.

	5.1.3 RECENT DEVELOPMENTS AFFECTING THE PSM STANDARD

	The PSM standard has undergone little reform since its inception in the 1990s. Following the April 2013
	explosion and fire at a fertilizer storage and distribution facility in West, Texas, President Obama issued
	Executive Order 13650, “Improving Chemical Facility Safety and Security.”a The executive order tasked a
	working group of federal agencies, including OSHA and the EPA, with modernizing policies, regulations, and
	standards to improve the safety and security of chemical facilities. In addition, the CSB placed “process safety
	management for the 21st century” on its Drivers of Critical Chemical Safety Change list because additional
	work is necessary to modernize federal process safety regulations [26].

	ENVIRONMENTAL PROTECTION AGENCY

	In early 1970, the United States began to experience a new and
	elevated sense of public concern about the environment, including
	air, land, and water pollution and protection. President Nixon sent
	to Congress a plan to consolidate many of the federal government’s
	environmental responsibilities under one new agency, the Environmental Protection Agency. Reorganizing
	would permit response to environmental problems in a manner that would exceed the previous capability of
	government pollution control programs. The EPA was established on December 2, 1970 [27].

	5.2.1 RISK MANAGEMENT PLAN RULE

	The EPA’s Risk Management Plan rule constitutes that agency’s efforts aimed at chemical accident prevention
	through the creation of a process safety management system framework, paralleling OSHA’s PSM standard,
	discussed in the previous section.b Similar to OSHA’s PSM standard, the RMP rule applies to facilities that the
	Clean Air Act defines as stationary sources of air pollution, and that use or store specific regulated substances
	that the EPA has determined to be extremely hazardous in nature. If any of the specified toxic chemicals or
	flammable substances are present at a facility at or above established threshold quantities listed by the EPA in its
	regulation, then the RMP rule applies to the chemical process using that substance at that facility.

	a Exec. Order No. 13,650, 80 Fed. Reg. 34936 (Aug. 1, 2013).
	b 40 C.F.R. § 68.

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	After determining that the RMP rule covers a process, a facility must determine which “prevention program”
	level (Program 1, 2, or 3) applies to the process, based on the process’s potential impact on the public, by using
	off-site consequence analyses, accident history, North American Industrial Classification System (NAICS) code
	classification, and PSM program applicability. Program 3a processes are subject to additional, more stringent
	requirements than Program 1b and Program 2c processes and must implement elementsd of a prevention program
	that are based primarily on OSHA’s PSM standard. In addition, the RMP rule requires all facilities to complete
	a hazard assessment based on analysis of worst-case and alternative (more likely) accident scenarios, and
	identify off-site consequences, compile a 5-year accident history, and coordinate with local emergency
	responders. Program 2 and 3 facilities must develop a management system to implement the RMP elements and
	address emergency response requirements of a responding or nonresponding facility to accidental releases of
	RMP substances. All of these facilities must submit to the EPA a risk management plan, which is a high-level
	summary of a facility’s implementation of and conformance with the RMP rule for all covered processes.

	A facility’s EPA risk management plan summary must include

	•

	•

	•

	•

	•

	•

	an executive summary;

	the registration information of the facility;

	at least one worst-case scenario for regulated toxics and at least one worst-case scenario for flammables;

	the five-year accident history of covered processes;

	information concerning emergency response at the facility;

	at least one alternative release scenario analysis for each regulated toxic substance and at least one
	alternative release scenario to represent all flammable substances;

	•

	a summary of the prevention program for each Program 2 process; and

	a Program 3 is the highest-level management program. Most PSM-covered processes are in Program 3, which requires a rigorous
	management program with detailed record retention criteria and all PSM program elements. Program 3 processes are either subject to
	OSHA’s PSM standard under federal or state OSHA programs or classified in one of 10 specified NAICS codes that require placement in
	Program 3. This designation imposes OSHA’s PSM standard as the prevention program as well as additional hazard assessment,
	management, and emergency response requirements [152], (40 C.F.R. § 68.12).
	b Program 1 is the lowest, simplest management program, covering processes that would not affect the public in a worst-case scenario
	and facilities that have recorded no accidents with specific off-site consequences within the past five years. This designation imposes
	limited hazard assessment requirements and minimal prevention and emergency response requirements [152], (40 C.F.R. § 68.12).
	c Program 2 is an intermediate management-level program and covers processes that cannot be designated as Program 1 but are not
	hazardous enough to be in Program 3. Program 2 imposes streamlined prevention program requirements, as well as additional hazard
	assessment, management, and emergency response requirements [152], (40 C.F.R. § 68.12).
	d Elements of RMP, similar to PSM requirements, include the following: process safety information, process hazard analyses, standard
	operating procedures, training, mechanical integrity, compliance audits, incident investigations, management of change, pre-startup
	reviews, employee participation, hot work permits, and contractors (40 C.F.R. §§ 68.65–68.87, Program 3 Prevention Program).

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	•

	a summary of the prevention program for each Program 3 process [28, pp. 1-2].

	According to the EPA, the risk management plan can provide valuable information by identifying potential
	impacts of a chemical release, steps taken to prevent that release, and emergency procedures should the release
	occur, enhancing local first responders’ ability to prepare for and respond to an accident on a covered RMP
	process by fostering communications about and understanding of the hazards in the event of an emergency
	situation [29].

	5.2.2 DUPONT LA PORTE’S IMPLEMENTATION OF RMP

	Based on the amount of methyl mercaptan stored at the DuPont La Porte facility, DuPont La Porte personnel
	determined that the RMP rule applied to the Lannate® process.a Additionally, DuPont La Porte personnel
	decided that Program 3 requirements applied to the Lannate® process and integrated Program 3 requirements
	into its process safety management system. For example, DuPont La Porte personnel conducted first-party
	compliance audits on its RMP program. These audits, however, were superficial, focusing on information
	presented in the submitted EPA risk management plan summary and not the substance of the RMP rule
	requirements. Although completing and submitting the risk management plan summary satisfies a part of the
	EPA’s regulatory requirement, the EPA typically does not assess the risk management plan’s effectiveness in
	reducing risk until after an incident. Similar to PSM, a company and its site managers are responsible for
	making their risk management plan effective.b

	After the incident, the EPA conducted an inspection of the DuPont La Porte facility and alleged 22 separate
	violations of the RMP, including failure to develop and implement written operating procedures, failure to
	adequately implement MOC procedures, failure to implement safe work practices, and mechanical integrity
	violations. This RMP inspection was the first one conducted at the DuPont La Porte facility. Based on these
	allegations, on behalf of the EPA, the U.S. Department of Justice filed a complaint on Monday, July 23, 2018,
	along with a stipulation of settlement with DuPont, in the U.S. District Court for the Southern District of Texas.
	According to the settlement, DuPont was required to pay $3.1 million in civil penalties without admitting
	liability. The EPA did not seek corrective actions because the DuPont La Porte facility is no longer
	manufacturing chemicals [30].

	5.2.3 RECENT DEVELOPMENTS AFFECTING THE RMP RULE

	As noted above, President Obama’s Executive Order 13650, “Improving Chemical Facility Safety and
	Security,” created what the order referred to as the Chemical Facility Safety and Security Working Group. The

	a Under RMP, the threshold quantity for methyl mercaptan is 10,000 pounds (40 C.F.R. § 68.130, Table 1). DuPont La Porte identified in
	its RMP a methyl mercaptan scenario that could lead to an off-site impact.
	b Under the General Duty Clause of the Clean Air Act Amendments of 1990, the owners and operators of facilities that have regulated
	and other extremely hazardous substances are responsible for ensuring that their chemicals are managed safely (42 U.S.C. § 7412(r)(1)).

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	working group took on many tasksa required by the executive order, including reviewing chemical hazards
	covered by RMP and PSM to determine if the RMP or PSM regulatory structures could and should be expanded
	to address additional regulated substances and types of hazards. In addition, the EPA and the Department of
	Labor were thereafter required to develop a plan, including a timeline and resource requirements, to implement
	and enforce any expansion of RMP and PSM in a manner that would address those additional regulated
	substances and types of hazards.b

	In response to the executive order, on July 31, 2014, the EPA published a request for information concerning its
	proposed supplementation of its RMP rule [31]. On March 14, 2016, the EPA published its proposed rule, titled
	Accidental Release Prevention Requirements: Risk Management Programs Under the Clean Air Act, Section
	112(r)(7), for notice and comment [32]. On January 13, 2017, the EPA published a final RMP rule amending 40
	C.F.R. § 68 requirements (82 Fed. Reg. 4594). Before the rule took effect, the EPA delayed the implementation
	of the January 13, 2017 amendments until February 19, 2019, to review three petitions it had received requesting
	reconsideration of the final rule.c Because PSM and RMP modernization is a priority goal of the CSB (see
	“Drivers of Critical Chemical Safety Change” [33]), the CSB provided written comments to the EPA on these
	occasions.d On September 21, 2018, the U.S. Court of Appeals for the D.C. Circuit issued its mandate, making
	the 2017 RMP Amendments Rule effective [34]. On December 3, 2018, the EPA published a final rule that will
	incorporate the RMP amendments into the Code of Federal Regulations (40 C.F.R. § 68) [34]. The EPA is also
	working on an RMP Reconsideration Rule, which proposes rescinding certain amendments, including those
	related to safer technology and alternative analyses, third-party audits, incident investigations, and information
	availability [35]. This proposed rule would also modify amendments relating to local emergency coordination,
	emergency exercises, public meetings, and compliance dates [35].

	a For more information, see the Department of Homeland Security’s “Actions to Improve Chemical Facility Safety and Security—A
	Shared Commitment.”
	b Exec. Order No. 13,650, 80 Fed. Reg. 34936 (Aug. 1, 2013).
	c On June 14, 2017, the EPA published a final rule to delay the effective date of the RMP rule amendments until February 19, 2019 (82
	Fed. Reg. 27133 (June 14, 2017)). In July 2017, various plaintiffs filed a petition for judicial review of the June 14, 2017 delay rule. On
	August 17, 2018, the U.S. Court of Appeals for the D.C. Circuit vacated the June 14, 2017 EPA regulation that delayed the effective date
	of the final RMP Amendments Rule (Air Alliance Houston et al. v. EPA et al., No. 17-1155 (DC Cir. 2018)).
	d Before the EPA issued its final RMP Amendments Rule on January 13, 2017, the CSB also expressed encouragement to the EPA over
	the needed improvements contained in its new regulations intended to prevent chemical incidents. The CSB viewed this activity to be a
	good initial step, since the rule adopted several new requirements to help advance chemical safety and the prevention of accidental
	releases, including improving communication between facilities and emergency responders, requiring root cause analyses of incidents
	and near misses, and requiring chemical facilities to consider “inherently safer” chemicals and production processes [143]. That is why,
	in July 2018, the CSB wrote with great concern to the EPA in response to that agency’s May 30, 2018, proposed rule, which proposed
	scaling back what had been previously proposed on January 13, 2017 [137]. For more information on the current RMP rule requirements,
	see “RMP Amendments Compliance Information” from the EPA.

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	AMERICAN CHEMISTRY COUNCIL

	The roots of the American Chemistry Council
	(ACC) go back to the late 1800s and the formation
	of the Manufacturing Chemists’ Association. In
	1978, the association changed its name to
	Chemical Manufacturers’ Association. Finally, in
	2000, the association became the ACC [36].

	The ACC’s mission is “to deliver value to our members through advocacy, using best-in-class member
	engagement, political advocacy, communications, and scientific research” [37]. The ACC is a trade
	organization in the United States that represents chemical companies [37] and requires its member companies to
	adhere to its Responsible Care program, a voluntary program developed by the chemical industry to help guide
	companies toward safe and responsible operation [38]. The design and implementation of this program are
	independent of government involvement and legislative or regulatory requirements.a According to the ACC,
	industry-based trade associations and process safety management systems, however, can only supplement
	government process safety regulations.b

	Even though DuPont experienced major chemical safety incidents and process safety management deficiencies,
	it still met its Responsible Care requirements. At the time of the November 15, 2014 incident, DuPont’s process
	safety management system conformed to the requirements of the Responsible Care Management System
	(RCMS), a key part of Responsible Care. As part of RCMS, DuPont La Porte’s process safety management
	system was audited for conformance. Neither first-party nor third-party Responsible Care conformance audits
	identified, prevented, or mitigated deficiencies in DuPont La Porte’s implementation of its management system
	(see Section 6). The November 15, 2014 incident at DuPont La Porte played a role in the ACC’s launch of a
	Process Safety Performance Improvement Task Force, discussed later in this section, endorsed to drive
	continuous improvement in process safety and occupational safety.

	This section discusses the history of Responsible Care (Section 5.3.1), the current requirements for Responsible
	Care (Section 5.3.2), the Responsible Care conformance audits at DuPont La Porte (Section 5.3.3), recent

	a Responsible Care is practiced in 65 economies around the world [89]. In some instances, Responsible Care is a requirement of a local
	trade association, allowing the associations to implement it according to their needs [88, p. 2].
	b In the ACC’s public comment to the EPA’s RMP revisions (see Section 5.2.1), it suggested that instead of having new requirements for
	Safer Technology and Alternatives Analysis, there should be a working group to evaluate leveraging the use of voluntary programs such
	as Responsible Care to achieve these goals [126, p. 43]. Additionally, the ACC’s Process Safety Code states that the code “is also
	intended to complement regulatory requirements (e.g., OSHA’s PSM standard and EPA’s RMP standard). Regulatory standards, by
	necessity, focus on process safety at an individual facility. In contrast, the Process Safety Code addresses issues at a more universal
	level, such as across a division or corporation, and includes a company commitment to set expectations regarding process safety, define
	accountability for process safety performance, and allocate adequate resources to achieve performance expectations” [44, p. 1].

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	developments in Responsible Care (Section 5.3.4), and improvement opportunities for Responsible Care
	(Section 5.3.5).

	5.3.1 HISTORY OF RESPONSIBLE CARE

	Prompted by several serious process safety incidents in the 1980s (notably the 1984 Bhopal disaster),a the
	Canadian Chemical Producers’ Association drafted the original Responsible Care Codes. Member companies
	were required to adhere to these codes to build public trust by showing that they were committed to “doing the
	right thing” by operating safely and responsibly [39]. In 1988, the ACCb—a U.S. trade association that
	currently represents 187 companiesc—adopted Responsible Care and made it a condition of membership [40].d

	Since its adoption, ACC’s Responsible Care program has evolved through efforts to meet the needs of industry
	and its members.e For example, in 2003, ACC reshaped its Responsible Care obligations from a series of codes
	into a management system called RCMS,f which is intended to provide a framework for integrating Responsible
	Care within a company’s management system. In 2003, ACC also added a third-party audit verification
	requirement to determine whether member companies are meeting their Responsible Care obligations. ACC
	made additional changes to the Responsible Care requirements in 2004, 2005, 2008, 2012, 2013, and 2017.g
	Furthermore, according to the ACC, “the development of the Process Safety Code demonstrates how
	Responsible Care evolves to maintain and improve effectiveness, as well as responds to industry trends and field
	learnings.” The ability to make such changes to the Responsible Care program quickly gives the ACC the
	flexibility to adapt the program as needed areas of improvement are identified from industry trends and field
	learnings. Regulatory changes, on the other hand, are historically more difficult and time-intensive to
	implement (see Sections 5.1.1 and 5.2.1).

	a On December 3, 1984, a methyl isocyanate release at the Union Carbide insecticide plant in Bhopal, India, resulted in an estimated
	3,800 deaths within days, and tens of thousands of injuries. Over a period of years, the release killed tens of thousands of people [148].
	b At the time of adoption of Responsible Care, the ACC was known as the Chemical Manufacturers Association. It changed its name to
	American Chemistry Council in June 2000 [119].
	c The ACC represents 140 members, 17 affiliates, and 17 associate companies [170].
	d An international trade association, the International Council of Chemical Associations, manages Responsible Care. The requirements,
	however, vary between member countries [89]. In this section, unless otherwise stated, Responsible Care requisites refer to the ACC’s
	obligations in the United States.
	e For example, an explosion occurred at the First Chemical plant in Pascagoula, Mississippi, in 2002. The CSB investigated the incident
	and found significant differences between what the company asserted in its Responsible Care self-audit report and the actual facility
	status before the explosion. After the accident, the ACC changed its audit methodology from sole reliance on first-party audits to the use
	of independent third-party audits [146, p. 59], [87, p. 20].
	f The ACC defines a management system as a set of organized policies, procedures, and practices that express a set of commitments
	around a set of core objectives and values.
	g The ACC changed the Technical Specification in 2004, 2005, 2008, and 2013 [41, p. 18]. The Guiding Principles were revised in 2008
	[40]. The third-party audit requirements were changed in 2017 [92]. The Product Safety Code and Process Safety Code were approved
	in 2012 and required beginning in 2013 [40], [41, p. 16].

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	5.3.2 RESPONSIBLE CARE REQUIREMENTS

	Today’s Responsible Care program has four main program elements:

	1. Adhering to the Responsible Care Guiding Principles

	2. Implementing the Responsible Care Product Safety Code, Process Safety Code, and Security Code

	3. Measuring and publicly reporting performancea

	4. Applying the Responsible Care Management System to achieve and verify results [38]

	According to the ACC, the Guiding Principles serve as the ethical foundation of the Responsible Care program
	[41, p. 1]; the Technical Specification of the RCMS and the supplemental codes are the portions of the system
	that have to be audited [42]. DuPont—as a member of the ACC—agreed to implement the latest versions of the
	Guiding Principles, Technical Specification, Security Code,b Product Safety Code,c and Process Safety Code.

	Per the ACC, Responsible Care’s 12 Guiding Principles are its foundation [41, p. 1]. ACC member companies
	endorse and commit to these aspirational objectives, which include the following:

	• To design and operate facilities in a safe, secure, and environmentally sound manner

	• To instill a culture throughout all levels of the organizations to continually identify, reduce, and manage

	process safety risks

	• To make continual progress toward a goal of no accidents, injuries, or harm to human health and the
	environment from products and operations, and openly report health, safety, environmental, and
	security performance [43]

	The ACC built the RCMS from its Responsible Care principles. The ACC asserts that the RCMS “is an
	integrated health, safety, security and environmental management system based on the principles of Responsible
	Care and the Policy-Plan-Do-Check-Act continual improvement cycle” [41, p. 1]. The Responsible Care
	Technical Specification divides the requirements of the RCMS into five categories: policy and leadership;
	planning; implementation, operation, and accountability; performance measurement and corrective and
	preventive action; and management review [41, p. 5]. The requirements stated in the Technical Specification
	overlap with both PSM and RMP. These requirements incorporate developing a management system that

	a The ACC publicly reports specific personal and process safety metrics by company and personal and process safety metrics in
	aggregate [127].
	b According to the ACC, it adopted the Responsible Care Security Code “to further enhance the security of our facilities, our
	communities, and the essential products we produce” [128].
	c According to the ACC, it adopted the Responsible Care Product Safety Code “to drive continuous improvement in chemical product
	safety as part of the industry’s signature environmental, health, safety, and security management system” [129].

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	includes employee participation, process safety information, compliance (conformance audits), incident
	investigation, training, emergency planning and response, MOC, PHA, and contractor management.

	The ACC expanded its third-party audit requirements by adding codes. The organization states that these codes
	aim to supplement the Technical Specification of the RCMS [44, p. 1]. In 2012, the ACC published its
	Responsible Care Process Safety Code of Management Practices [44], requiring member companies to
	implement it by January 1, 2013 [41, p. 16]. The ACC states that the code sets forth its “collective commitment
	to a culture of process safety throughout our chemical processing operations, management systems and
	leadership organizations” [44, p. 1]. Additionally, the code “aims to supplement existing process safety
	requirements contained within the Responsible Care Management System® … technical specifications, by
	specifically addressing process safety concepts such as leadership, accountability, and culture in order to drive
	overall process safety performance improvement” [44, p. 1]. The Process Safety Code breaks down its
	management practices into seven categories: leadership and culture; accountability; knowledge, expertise, and
	training; understanding and prioritization of process safety risk; comprehensive process safety management
	system; information sharing; and monitoring and improving performance [44, pp. 1-3]. This code strengthens
	and expands obligations stated in the Responsible Care Technical Specification for practitioners to establish a
	comprehensive process safety management system [44, p. 2].

	From Responsible Care’s Process Safety Code of Management Practices:

	“Companies will design systems to manage and mitigate identified risks with adequate safeguards.
	Management of process safety will take into account passive controls; engineering controls; operational
	controls; inherently safer approaches; inspection, maintenance and mechanical integrity programs;
	management of change procedures; and scenario planning” [44, p. 2].

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	5.3.3 RESPONSIBLE CARE CONFORMANCE AUDITS

	To verify conformance with the RCMSa and Responsible Care Codes,b ACC member companies must undergo
	an independent third-party auditc performed by a qualified auditord every three years [41, pp. 4, 16]. This audit
	evaluates the practicese of the corporation’s headquarters and a sampling of the company’s facilities,f depending
	on the number of facilities a company has [42, pp. 6-8]. For example, large companies, such as DuPont, which
	had more than 40 facilities at the time of the 2014 incident, can retain their certification by auditing only eight of
	their facilities and their headquarters every three years.g The ACC designed the auditing system to allow
	companies to manage their auditing process, including multiple location visits over their audit cycles.
	According to the ACC, companies can consider risk and other factors to determine which facilities to submit for
	third-party audits [42, pp. 7-8]. For example, DuPont’s Responsible Care auditing process began in 2005 and
	the company planned on completing all of its facility audits by 2019. As seen in DuPont’s plan, it could take
	more than 14 years before a facility is audited again under Responsible Care, potentially allowing facilities to
	fall out of certification or to be inconsistent with other company facilities for many years while the company
	remains certified under Responsible Care. Additionally, Responsible Care’s third-party audit requirements are
	divided into three groups, depending on the number of facilities a company has. As shown in Figure 19, the
	more facilities a company has, the smaller the percentage of its facilities that have to be audited during an audit
	cycle to obtain Responsible Care certification [42, p. 7].

	a RCMS is contained in the Technical Specification of the code. This specification is the only portion of RCMS that is required to be
	audited. Responsible Care has undergone multiple changes including a shift to third-party audits and the addition of a Process Safety
	Code. The CSB recommended to the ACC in its investigation into an explosion at First Chemical that the ACC “ensure that ACC
	members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety
	programs” [146, p. 67]. Beginning in 2004, the ACC shifted from first-party to independent third-party audits for certification of a
	company’s RCMS program. It also required companies to report their statistics on the Responsible Care website. In 2012, Responsible
	Care added the Process Safety Code to supplement the Technical Specification, making it auditable as well [40].
	b In November 2017, the ACC changed its third-party audit requirements [92, pp. 3-4].
	c DuPont used both third-party audits and self-audits (first-party) to demonstrate conformance with Responsible Care. Self-audits are
	conducted by auditors from the facility being audited, and third-party audits are conducted by auditors from an independent organization
	[66, pp. 27-28].
	d Third-party audits are not done by ACC; they are performed by independent auditing firms accredited by the ANSI-ASQ National
	Accreditation Board (ANAB).
	e The portions of Responsible Care that are audited are the Technical Specification and supplemental codes (Process Safety, Security, and
	Product) [45, p. 10].
	f According to the ACC, for purposes of auditing, a facility is defined as a “location falling under an ACC member’s/Responsible Care
	Partner’s dues calculations at which commercial chemicals are manufactured, handled, transported, [and] stored and where employees or
	others working on behalf of the ACC member/Responsible Care Partner are present” [42, p. 2].
	g The ACC requires that two-thirds of the facilities currently being audited be among those not audited in the previous audit cycle [42, p.
	7].

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	Figure 19. Excerpt from Responsible Care’s Third-‐party Audit Requirements. It shows the more facilities a
	company has, the lesser are the audit requirements [42, p. 7]. Source: ACC.

	The ACC acknowledged that the DuPont La Porte site met its Responsible Care requirementsa in 2007,
	following a third-party audit conducted at the DuPont La Porte facility that certified the facility to be in
	conformance with the RCMS Technical Specification requirements.b This was the only third-party Responsible
	Care evaluation ever performed at the DuPont La Porte facility. A third-party evaluator determines only if a
	facility is meeting the Responsible Care requirements that exist at the time of the third-party audit. Furthermore,
	a third-party certification does not imply that a facility is meeting its RCMS requirements years later without an
	additional evaluation of the facility. Additionally, DuPont La Porte personnel performed six self-audits between
	2007 and the date of the incident.c None of these audits, however, identified or effectively corrected the many
	serious and long-standing process safety deficiencies at the site. These process safety deficiencies were
	discussed in the CSB Interim Recommendations for this incident and are also described in this report in Section
	6 [1].

	a At the time of the 2007 audit, the Product Safety and Process Safety codes were not in place and the Guiding Principles were located in
	the Technical Specification.
	b According to the ACC, conformance means meeting code implementation and reporting deadlines; completion of required RCMS third-
	party certification in three-year cycles; and annual reporting of performance results, including process safety incident data.
	c The DuPont La Porte facility did include in its first-party audit the new requirements for Responsible Care.

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	Although Responsible Care requires robust process safety programs at its member facilities, the CSB found that
	the RCMS on its own is not sufficient to ensure that a particular facility’s safety programs are effective.a For
	example, the quality of an audit or assessment can be affected by the amount of information it evaluates. An
	average Responsible Care third-party audit that evaluates a facility’s management system lasts three to five days
	[45, p. 6],b a relatively short amount of time to analyze significant and complex matters, which could potentially
	limit the scope and depth of any audit.

	The ACC’s expectation is that a company’s internal audit process be more detailed than the Responsible Care
	external audit. For example, a DuPont La Porte environmental, health, and safety manager stated that the
	facility’s Responsible Care audits were not as detailed as the audits the company performed to verify
	compliance under OSHA’s PSM standard.c DuPont La Porte’s 2007 third-party audit, which covered about 800
	employees and contractors and three business units, took 12 auditor-days.d On the other hand, DuPont La
	Porte’s first-party PSM compliance audits,e which were divided over a three-year cycle, took 68 auditor-days to
	complete between 2012 and 2014.f Despite taking more than five times the auditor-days of the Responsible
	Care audit, the PSM compliance audit requirements were not sufficientg to identify and resolve process safety
	management deficiencies that contributed to the November 2014 incident (see Section 6). The ACC believes
	that Responsible Care audits verify that a robust, effective management system is in place [46]. The ACC
	further believes its auditable Process Safety Code “differs from regulatory standards that, by necessity, focus on
	process safety at an individual facility. The Process Safety Code is more universal—it addresses issues across a
	division or corporation, and includes a company commitment to set process safety expectations, define
	accountability for process safety performance and allocate adequate resources to achieve performance
	expectations” [47]. Understanding the health of an organization’s process safety management system, however,
	requires a comprehensive assessment of the content and implementation of its programs.

	a The ACC has stated to the CSB, “RCMS is not intended to be a company’s sole safety program. RCMS is one component of the
	Responsible Care program.… Responsible Care is intended to complement regulatory requirements, a company’s safety processes, and
	other initiatives—not replace them.” Moreover, the 2004 RCMS Technical Specification states, “the RCMS is also designed to
	incorporate individual company processes for maintaining regulatory compliance and implementing other company programs and
	commitments such as sustainable development initiatives.”
	b According to a 2015 ACC document, the usual cost for a third-party conformance audit ranges from $6,000 to $10,000. The audit
	typically costs $2,000 per audit day (travel plus auditor time). The CSB calculated the three to five days for audits based on these
	numbers [45, p. 6]. See American Chemistry Council and National Association of Chemical Distributors, A Comparison of ACC
	Responsible Care® and NACD Responsible Distribution® Initiatives.
	c OSHA requires PSM audits to be performed at least every three years at all facilities covered by the standard (29 C.F.R. § 1910.119(o)).
	d Two auditors worked six days to complete the audit.
	e 29 C.F.R. § 1910.119(o).
	f Through the division of the PSM audits into a three-year cycle, the DuPont La Porte site was continually evaluated to see if it met PSM
	requirements.
	g In past investigations, the CSB has identified areas of PSM that could be improved upon. “Modernization of U.S. Process Safety
	Management Systems,” previously on the CSB’s Drivers of Critical Chemical Safety Change List, was renamed in 2018 to “Process
	Safety Management for the 21st century” and remains on the list [26].

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	Although the ACC can remove membership from companies not satisfactorily conforming to the Responsible
	Care program,a one of the program’s objectives “is to keep as many companies actively implementing the
	program and striving to continuously improve their performance as possible” [48, p. 1]. This objective is
	contained in its Guiding Principles:

	To make continual progress toward a goal of no accidents, injuries or harm to human health and
	the environment from products and operations and openly report health, safety, environmental
	and security performance [43].

	DuPont was meeting its Responsible Care requirements, as demonstrated by its audits, even though it
	continued to have major process safety incidents across the company.b The ACC informed the CSB that
	the November 2014 incident at the DuPont La Porte facility, however, “played a role in the launch of an
	ACC Process Safety Performance Improvement Task Force.”

	5.3.4 RECENT DEVELOPMENTS IN RESPONSIBLE CARE

	As noted in the previous section, the November 15, 2014 incident played a role in launching the ACC Process
	Safety Performance Improvement Task Force. The ACC Board’s Responsible Care Committeec proposed the
	task force, and it was endorsed by the ACC in November 2015 to drive continuous improvement by industry in
	process safety and occupational safety. In June 2016, the ACC Board approved the task force’s
	recommendations, including the following:

	• Establishment of new incident information and practice sharing forums

	• Formation of regional support networks

	• Enhanced collaboration with professional societies

	• Enriched data analytics and modified responsible metrics reporting

	• Continuous improvement

	Since the adoption of these recommendations, the ACC has begun implementing several of them. According to
	the ACC, starting in 2016, its Process Safety Committee has held annual process safety forums for ACC
	members to “share process safety information, lessons learned, and exemplary practices.” Additionally, the
	ACC developed a regional network model for sharing noncompetitive process safety knowledge and solutions
	between site process safety practitioners. Specifically, the ACC established regional networks in Houston and

	a In the last 10 years, the ACC has removed six companies from its membership due to their failure to meet their Responsible Care
	requirements, and in other instances, companies opted to resign voluntarily from Responsible Care prior to potential removal.
	b The three major investigations were CSB DuPont La Porte Interim Recommendations [1]; E.I. DuPont de Nemours & Co., Inc., Belle,
	West Virginia: Methyl Chloride Release, Oleum Release, Phosgene Release [121]; E.I. DuPont de Nemours & Co Inc. Buffalo, New York
	Flammable Vapor Explosion [122].
	c The Board Responsible Care Committee is composed of ACC member CEOs or presidents [45, p. 22].

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	Philadelphia and is developing three additional networks. Another development within the Responsible Care
	program is the ACC’s adoption of American Petroleum Institute (API) Recommended Practice 754—Process
	Safety Indicators for the Refining and Petrochemical Industries [49].a The ACC assessed some of its 2017 data
	and publicly reported its high-level findings in 2018.b

	5.3.5 RESPONSIBLE CARE IMPROVEMENT OPPORTUNITIES

	In light of the multiple DuPont incidents, the CSB encourages the ACC to evaluate Responsible Care and the
	RCMS for additional improvement opportunities, with the goals of helping member companies identify and
	correct process safety deficiencies, and preventing major chemical incidents at member company facilities.c

	An example of an opportunity for Responsible Care to strengthen its verification systems is including the
	aspirational Guiding Principles in its third-party verification audits. For example, a Responsible Care auditor
	could delve deeper than the management system and evaluate buildings that contain process equipment, given
	that one of the Responsible Care Guiding Principles is “to design and operate facilities in a safe, secure, and
	environmentally sound manner” [43].d As demonstrated by the facts of this incident, the Lannate®
	manufacturing building had design deficiencies. The portion of the manufacturing building where the incident
	took place did not have a stated design purpose—the building was not designed for the process, and the process

	a API 754 covers leading and lagging process safety indicators. According to API 754, “The purpose of process safety indicators is to
	identify events or conditions that could ultimately lead to higher-level consequences. Indicators provide a means to measure activity,
	status, or performance against requirements and goals. Monitoring and analyzing performance enables Companies to take corrective
	action as needed. Properly defined and understood indicators can give Companies confidence that the right things are being managed and
	tracked” [49, p. 23]. API further explains, “Leading indicators tend to be forward-looking and indicate the performance of the key work
	processes, operating discipline, or protective barriers that prevent incidents. They are designed to give an indication of potential
	problems or deterioration in key safety systems early enough that corrective actions may be taken” [49, p. 24]. Conversely, API 754
	elaborates, “Lagging indicators tend to be outcome-oriented and retrospective; they describe events that have already occurred and may
	indicate potential recurring problems [that] may include fires, releases, and explosions” [49, p. 23]. In reliance on the now-familiar four-
	tier pyramid diagram first introduced by H. W. Heinrich in 1931 as a representation of his study of accident data gleaned from the
	insurance industry, API 754 breaks down indicators across four tiers. From top to bottom, indicators progress from lagging (Tier 1) to
	leading (Tier 4) [49, pp. 11-12]. The ACC has adopted API 754 to the Tier 2 level—a loss of primary containment but of lesser
	consequence than a Tier 1 incident (e.g., no casualties, property damage less than $2,000, on a release of less than a predefined reportable
	quantity of a process chemical) [145, p. 153]. The ACC has required mandatory reporting under API 754 beginning in calendar year 2018
	for 2017.
	The CSB has discussed API 754 in its Macondo (Volume 3) and Williams investigations. Additionally, as part of the Macondo
	investigation, the CSB held a public hearing on process safety indicators. The CSB has also looked toward CCPS on approaches to
	leading and lagging indicators in its Guidelines for Process Safety Metrics.
	b The ACC reported Tier 1 findings and is still in the process of reviewing Tier 2 events [104]. For more information, see Responsible
	Care Process Safety.
	c As a result of its First Chemical investigation, the CSB previously made a recommendation to the ACC to evaluate its audit program:
	“Ensure that ACC members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility
	process safety programs” (2003-01-I-MS-R11), [146, p. 67].
	d At the time of the 2007 third-party RCMS conformance audit, the Responsible Care Guiding Principles were different and were
	included in the RCMS Technical Specification. The principle at the time of the audit that most closely relates is “To operate our facilities
	in a manner that protects the environment and the health and safety of our employees and the public.”

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	equipment did not need to be inside a fully enclosed manufacturing building.a Yet even without a process
	requirement to do so, DuPont accepted significant process risk by housing process equipment inside the
	enclosed building, making personnel vulnerable to highly toxic chemical exposure and asphyxiation hazards that
	DuPont had not effectively identified or controlled.

	The manufacturing building was not designed to limit the impact of a toxic chemical leak by containing the leak
	and routing it to a destruction device, such as an incinerator or scrubber. The manufacturing building trapped
	vapors from highly toxic chemical leaks and concentrated them inside the building, increasing risk to workers
	[1, p. 3]. Furthermore, this design did not eliminate the hazards associated with a release to the community or
	environment, which an effectively designed containment buildingb could have done. Since the manufacturing
	building’s ventilation fans (if functional) routed any toxic chemicals within the manufacturing building to the
	roof, discharging them directly to the atmosphere without an additional destruction device, they did not decrease
	the potential for a hazardous off-site release [1, p. 33]. In this case, a robust assessment of the process’s location
	inside the manufacturing building could have identified the hazards presented. To achieve the ACC’s
	aspirational objectives, such as “design[ing] and operat[ing] facilities in a safe, secure and environmentally
	sound manner” [43], Responsible Care auditors should look for deficiencies inconsistent with Responsible
	Care’s Guiding Principles.

	When the ACC developed the original RCMS Technical Specification in 2003, it fully incorporated the entire
	aspirational Guiding Principles into the specification. The ACC informed the CSB that adding the Guiding
	Principles as an element into its RCMS Technical Specification proved challenging for auditors and those
	audited, since the Guiding Principles overlapped with requirements found in other sections of the Technical
	Specification or within a company’s existing procedures, creating confusion as to whether separate, additional
	actions were necessary to show conformance with this element. In 2008, the ACC replaced the listing of the
	Guiding Principles within the RCMS Technical Specification with what it believed was a streamlined set of
	auditable requirements intended to reflect the key objectives of the Guiding Principles. The ACC stated that
	based on its experience, it believes the change it adopted in 2008 is the most effective way to address the key
	objectives of the Responsible Care Guiding Principles.

	Another opportunity for Responsible Care to improve its verification program is to evaluate whether the
	company’s process safety management system is functioning as the company intends. For example,
	Responsible Care requires companies to establish and maintain systems to “protect the environment, conserve
	resources, protect worker health and create a safe and secure work environment” and to “establish and maintain
	procedures to respond to accidents and emergency situations, and for preventing and/or mitigating the impacts
	that may be associated with them” [41, pp. 8-9]. The CSB identified that the DuPont La Porte Responsible Care

	a The packaging area of the building on the ground floor (west side) may have had a legitimate need to be inside a building. Dust control
	and keeping the packaging equipment and methomyl product dry appeared to be important considerations that may have justified keeping
	packaging area equipment housed inside a building [1, p. 32].
	b A containment building is an enclosure around process equipment to contain potential releases to the environment. Companies
	typically use containment buildings to reduce off-site risk. DuPont La Porte has stated that the manufacturing building was not a
	containment building [1, p. 3]. According to CCPS, “a containment building provides protection outside the building, but can also trap
	and concentrate material from small leaks inside the building, increasing the risk to personnel. Provisions must be made to ensure worker
	protection for a process located in a containment building, such as monitoring the atmosphere in the containment structures, restricting
	access, and requiring proper personal protective equipment when entry into the containment structure becomes necessary” [109, p. 59].

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	audits, however, did not evaluate whether the safety programs implemented to protect employees from
	potentially hazardous environments, such as the toxic methyl mercaptan detectors inside the manufacturing
	building, met the facility’s stated design purpose.

	For example, the 2007 La Porte Responsible Care third-party audit identified the existence of the methyl
	mercaptan detection system but did not evaluate whether this system could effectively protect workers by
	warning them of potentially toxic environments. It found the detection system to be in conformance simply
	because it existed. The CSB, on the other hand, found by evaluating DuPont La Porte’s MOC documentation
	and relevant chemical safety information that the alarm limits did not meet the intent of protecting personnel.
	Specifically, the methyl mercaptan detectors inside the manufacturing building were set to alarm at 25 parts per
	million—a value 50 times greater than the NIOSH recommended exposure ceiling limit and more than double
	OSHA’s ceiling limit [50], [51]. During the November 2014 incident, these methyl mercaptan detectors were
	alarming; however, the system did not signify an early release of methyl mercaptan (see Section 4.8.3), and the
	detectors did not warn workers that they were potentially in a life-threatening toxic environment, because the
	alarms were set above OSHA’s ceiling limit and they were not communicated to personnel. Additionally,
	Responsible Care audits did not identify the gaps in DuPont’s corporate standard for the Management of Highly
	Toxic Materials that allowed toxic gas detection systems to be set above OSHA exposure limits.

	Although the ACC does not make prescriptive requirements for its member companies, it should ensure that
	safety systems, such as toxic gas detection systems, will protect workers from unsafe conditions by functioning
	as the company intended. An effective Responsible Care audit can identify these discrepancies and an auditor
	can issue nonconformances or recommendations (opportunities for improvement) at the end of the audit.

	The ACC has multiple opportunities to improve Responsible Care, including assessing Responsible Care’s
	Guiding Principles in conformance audits, ensuring that safety systems effectively control hazards presented,
	and seeking to add value to the safe operation of member companies where possibilities present themselves.
	Because Responsible Care is a voluntary program applied by 187 companies in the United States and can readily
	adapt to change, it has the potential to be a powerful process safety program.a To fulfill Responsible Care’s
	original mission to build public trust by showing that chemical companies are committed to “doing the right
	thing” by operating safely and responsibly, and its Guiding Principles “to seek continual improvement in the
	integrated Responsible Care Management System to address environmental, health, safety and security
	performance,” the ACC should continue to seek opportunities to strengthen its Responsible Care program [15],
	[43].

	GUIDANCE TO INDUSTRY
	Although this section focused on Responsible Care, these learnings can apply to any safety management system.
	Companies can use a variety of programs to manage and evaluate their process safety management systems.
	Without an adequate focus on the effectiveness of a process safety management system and its corresponding

	a The ACC’s Responsible Care program covers multiple aspects of safety, including process safety, security, product safety,
	environmental protection, and occupational safety.

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	safety program elements, such as the 20 elements of Risk Based Process Safety [52], implementing the system
	will likely not be sufficient to prevent major chemical incidents. Chemical companies should conduct
	comprehensive assessments of their process safety management systems and the accompanying implementation
	of those systems and safety program elements to understand the overall health of their organizations, including
	the effectiveness of accident prevention efforts and the resiliency of operations.

	Companies should assess the implementation of these systems and their associated safety program elements
	associated with them. Some ways in which a company can ensure effectiveness include these:

	1. Ensuring that all company sites adhere to core process safety management system elements and stay
	current with all updates and changes to that system. Because companies can adapt to process safety
	learnings quickly, their process safety management systems should ensure that sites are evaluated to
	ensure consistency with evolving practices to maximize the effectiveness of these safety improvements.

	2. Investing sufficient time and resources to conduct robust audits. This investment should help ensure
	that audits are not rushed and help companies meet the goal of preventing major chemical accidents.

	DUPONT’S DEVELOPMENT AND IMPLEMENTATION
	OF ITS PROCESS SAFETY MANAGEMENT SYSTEM

	DuPont has long been perceived as a safety leadera and has asserted
	that its history of process safety extends over two centuries, from its
	gunpowder manufacturing through its present-day production of
	chemicals [53, p. 114]. Over the course of this time, DuPont’s process safety management system evolved with
	the emergence of federal regulations, such as the PSM standard and the RMP rule, as well as the decision to
	engage in Responsible Care.

	DuPont developed several methods that it uses to manage and integrate its process safety systems, including its
	proprietary Safety Perception Surveys and Process Safety Management and Risk Model.b Its corporate process
	safety management system and implementation process involves four steps: (1) building a safety culture, (2)
	management leadership and commitment, (3) implementing a comprehensive process safety management
	program, and (4) operational discipline [54, p. 2]. According to DuPont, the effective implementation of these
	steps will result in a robust process safety management system [55, p. 10]. Consequently, DuPont La Porte used

	a As recently as 2013, the DuPont Corporation received the Robert W. Campbell Award from the National Safety Council. According to
	the National Safety Council, “winners represent organizations that have taken great strides in [environmental health and safety]
	excellence. Award winners are acknowledged not only as leaders in the business realm, but also as those that recognize the value of
	protecting employees and their environment” [115].
	b According to DuPont, there was a demand from other companies for DuPont to share its learnings and safety practices. In 1968, it
	established DuPont Sustainable Solutions, the branch of DuPont (now DowDuPont) that sells the company’s safety systems [113], [114].
	DowDuPont’s Specialty Products division announced it will divest its DuPont Sustainable Solutions to create a new, independent global
	operations management consulting firm. The transaction is expected to close in July 2019 pending the completion of all closing
	conditions [135].

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	both the Safety Perception Surveys and the Process Safety Management and Risk Model in implementing its
	process safety management system.

	Despite having robust written process safety management programs (i.e., MOC and PHA), over the course of
	five years, DuPont had major process safety incidents—including those at its Belle, West Virginia; Buffalo,
	New York; and La Porte, Texas sites, each of which resulted in fatalities. The CSB found that DuPont La
	Porte’s ineffective implementation of its integrated process safety management system contributed to the
	severity of the highly toxic material release in the manufacturing building at La Porte.

	According to DuPont Sustainable Solutions’ “Quick 4-Step Review of Process Safety Management,”

	“A strong safety culture, based on a commitment to core values on safety, health, and environmental
	issues, and as evidenced by organizational policies, goals, metrics, and day-to-day decision-making,
	supports establishing safety systems where safety priorities are recognized, not as conflicting with
	other priorities, but rather as inherently necessary for completing any task the right way” [54].

	DuPont’s corporate process safety management standard lists four key steps for the implementation and
	sustainability of an effective process safety management program:

	1. Establishing an effective and sustainable unified safety culture (addressed in Section 5.4.1 below)

	2. Providing management leadership and commitment (Section 5.4.2)

	3. Implementing a comprehensive process safety management program, including organizational learning

	and continuous improvement to integrate new risk management knowledge, learnings, and practices into
	existing site and corporate systems (Section 5.4.2)

	4. Achieving operational excellence through operational discipline (Section 5.4.2)

	This section breaks down these steps into two parts: (1) Building a Safety Culture (step one); and (2) Using the
	Process Safety Management and Risk Model (steps two through four).

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	5.4.1 BUILDING A SAFETY CULTURE

	DuPont’s corporate process safety management standard states that process safety culturea “determines the
	manner by which PSM is implemented and managed at each site as part of both individual and group values and
	behaviors to enable sound decision making and continuous improvement.” Therefore, DuPont links the
	effectiveness of process safety management implementation to the process safety culture of a facility.
	Moreover, previous CSB investigations also support DuPont’s corporate standard that links effective process
	safety management systems with a strong process safety culture.b

	According to DuPont, establishing a safety culture is the first step in developing a process safety management
	system because a system will be only as effective as its safety culture permits. Additionally, DuPont’s corporate
	process safety management standard recommends periodic site evaluations of process safety culture.c DuPont’s
	standard further recommends that sites use the results of process safety culture assessments to highlight
	strengths and develop potential improvement strategies.

	In Essential Practices for Creating, Strengthening, and Sustaining Process Safety Culture, CCPS
	states,

	“A strong, positive process safety culture enables the facility’s [process safety management system] to
	perform at its best. This gives the facility its best chance to prevent catastrophic fires, explosions, toxic
	releases, and major environmental damage” [56, p. 2].

	For more than a decade, DuPont developed and honed a safety culture program to reduce its OSHA total
	recordable injury rate by assessing and improving occupational (personal) safety, using its Bradley Curve and
	Safety Perception Survey tools (Appendix E). These tools, however, focus on only one aspect of safety
	culture—personal safety.

	DuPont La Porte used the Safety Perception Survey without doing a process safety culture assessment as
	recommended in the corporate process safety management standard. Because this survey did not formally
	assess process safety culture perceptions, DuPont La Porte never evaluated its process safety culture. Had its
	efforts included a focus on perceptions of process safety as well as personal safety in its Safety Perception

	a Examples of a process safety culture from DuPont’s corporate standard include maintaining a sense of vulnerability in terms of process
	safety management risks to prevent complacency or overconfidence, and transparent, timely, and thorough responses to PSM concerns,
	action items, and issues, including leadership measures to prevent a “check-the-box” mentality (i.e., simply accomplishing a task as the
	objective rather than ensuring a high degree of focus on risk management and prevention).
	b Among other investigations, the CSB investigation of the Williams Geismar Olefins Plant Reboiler Rupture and Fire demonstrates the
	CSB’s position that to prevent process incidents, organizations must develop a culture that promotes effective process safety management
	systems [71, p. 52].
	c DuPont’s corporate process safety management standard does not specifically address how its sites should perform process safety
	culture assessments. DuPont’s standard directs sites to include interactions and discussions with employees, review results of audits, and
	observe physical conditions of the site in performing process safety culture assessments.

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	Survey, or had it performed a separate process safety culture assessment with the intent of improving process
	safety culture as recognized in DuPont’s corporate process safety management standard, DuPont La Porte likely
	would have been more aware of potential process safety issues and better positioned to prevent or mitigate
	future process safety incidents. CCPS recognizes the importance of a strong process safety culture in preventing
	major accidents [56, p. 2].

	This section discusses the following:

	• The investigations into the catastrophic 2005 BP Texas City explosion that emphasized the way in

	which culture is shaped by the level of focus an organization places on process safety (Section 5.4.1.1)

	• The lack of formal process safety culture assessments at DuPont La Porte (Section 5.4.1.2)

	• Post-incident initiation of formal process safety culture assessments at DuPont legacy sites to address

	gaps in process safety culture perceptions in 2017 (Section 5.4.1.3)

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	U.S. Chemical Safety and
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	5.4.1.1 BP TEXAS CITY INCIDENT

	The CSB investigated a 2005
	incident at a BP refinery in Texas
	City, Texas,a and due to concerns
	about the effectiveness of the safety
	management systems at this refinery
	and BP’s other North American
	refineries, as well as concerns about
	BP’s corporate safety culture, the
	CSB issued an urgent safety
	recommendation to the BP Global
	Executive Board of Directors to
	commission an independent panel to
	conduct a thorough review of BP’s
	corporate organizational culture,
	safety management systems, and
	corporate safety oversight at its U.S.
	refineries [57, pp. 3-4]. As a result,
	BP formed the BP U.S. Refineries
	Independent Safety Review Panel,
	commonly referred to as the Baker
	Panel,b which conducted an independent organizational assessment of BP’s culture and its corporate-level
	oversight of safety management systems at its U.S. refineries [58, pp. viii-ix]. The Baker Panel developed a
	process safety culture survey and supervised its administration among BP’s U.S. refinery workforce, including
	employees and contractors [58, p. 7]. The survey contained 65 items related to the process safety culture at
	participants’ workplaces.

	Figure 20. Excerpt from the Baker Panel Report. The Baker Panel found that BP
	emphasized personal (worker) safety performance and did not adequately focus on
	process safety. Similarly, 12 years after this accident, DuPont La Porte’s safety culture
	assessments at its site focused solely on personal safety performance. Source: Baker
	Panel Report [58].

	The Baker Panel concluded that BP “mistakenly interpreted improving personal [worker] injury rates as an
	indication of acceptable process safety performance” (Figure 20) [58, p. xii]. The panel also noted, “the
	presence of an effective personal safety management system does not ensure the presence of an effective process
	safety management system … [and] BP’s [worker] injury rates were not predictive of process safety
	performance at BP’s five U.S. refineries” [58, p. 21].

	a On March 23, 2005, a series of explosions occurred at the BP Texas City, Texas, refinery during the restarting of a hydrocarbon
	isomerization unit—killing 15 workers and injuring 180 others. The explosions occurred when a distillation tower flooded with
	hydrocarbons and was overpressurized, causing a geyser-like release from the vent stack [140]. For more information, see the CSB’s BP
	America Refinery Explosion investigation.
	b Former Secretary of State James Baker III chaired the BP U.S. Refineries Independent Safety Review Panel (the Baker Panel) [58, p.
	viii].

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	After the 2005 BP accident and the published findings of both the Baker Panel and the CSB, much of the
	chemical process industry began to emphasize the importance of understanding and assessing process safety
	culture.a A major process safety incident, such as the one at DuPont La Porte, can reveal weaknesses in the
	management of process safety.b

	5.4.1.2 DUPONT LA PORTE DID NOT FORMALLY ASSESS PROCESS SAFETY CULTURE

	DuPont La Porte did not use any type of robust, formal process safety culture assessment. Process safety culture
	can affect whether a site has a sense of vulnerability in terms of process safety management risks; complacency
	or overconfidence; and transparent, timely, and thorough responses to PSM concerns, action items, and issues,
	including leadership measures to prevent a “check-the-box” mentality (i.e., simply accomplishing a task as the
	objective rather than ensuring a high degree of focus on risk management and prevention). The Safety
	Perception Surveys conducted at the DuPont La Porte facility before the November 2014 incident were designed
	to lower OSHA total recordable injury rates [59, p. 8]. DuPont did not intend for these surveys to measure or
	address the perception of process safety performance.

	As part of DuPont La Porte’s 2012 Safety Perception Survey, comments were collected and organized by job
	position. Some of these comments, from different levels of the organization, raised safety culture concerns. For
	example, one hourly worker (operator) stated,

	Some fi[rs]t line [supervisors]c turn the other way if a worker put[s] production over safety.d

	A professional employee expressed concerns about PSM initiatives at the site:

	Some days it seems like the focus is more about creating documentation and reviewing that
	documentation than on targeting those areas that will have the biggest impact on improved PSM
	performance. From my perspective, I feel like “real” process safety management has suffered in
	some respects and that our processes may actually be less safe than they were before the
	initiatives.

	Safety concerns were expressed by multiple supervisors in the survey comments:

	I hate to say it but not all employees put the same value on safety. That includes [wage roll]
	employees and first line supervisors. DuPont employee actions demonstrate to me that safety
	rules are suggestions and do not have to be followed.

	a In March 2007—two years after the BP Texas City explosion—CCPS published its book Guidelines for Risk Based Process Safety,
	which featured “process safety culture” as an element in its new Risk Based Process Safety model [91].
	b Other CSB investigations that found a weak process safety culture contributing to an incident include Williams Geismar Olefins Plant
	Reboiler Rupture and Fire [71, p. 52], CSB Macondo Investigation Report, Volume 3 [61, pp. 233-241], and CSB BP Texas City
	Investigation Report [60, pp. 142-195].
	c At DuPont La Porte, first-line supervisors include shift supervisors.
	d Original comment was written using all capital letters.

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	DuPont has always been a strong leader in safety principles for the industry that we work in. The
	[La Porte] plant has a strong leadership for safety yet sometimes the message does not always
	get across to the employe[es]. Some still feel that production is above safety yet all managers
	have stated and demonstrated that production is far down the list when it comes to safety.

	I believe our “passion” for safety has slipped over the past 10 years. I believe this has impacted
	[our] ability to consistently achieve safety excellence. I interact with safety professionals from
	many companies in our area and my opinion is that, as a company, we are no longer the safety
	leader we were once thought of as.

	Despite concerns about its safety culture expressed by multiple levels of personnel within the organization,
	DuPont La Porte did not use these comments to take corrective actions that would institute process safety
	culture change at the DuPont La Porte facility.

	In 2014, DuPont La Porte hired an organizational consultant to increase production in the Lannate® Unit. Safety
	concerns resembling the ones from the 2012 Safety Perception Survey were raised again. According to an
	interview of a front-line supervisor in July 2014, four months before the incident,

	“…we just are not as good as we think we are.… not in pay, benefits, safety, etc.… We used to
	sell the safety program. We spend more time on driving incidents down, to keep the number
	down. We just have to make it look good. Don’t need to report every detail. Long slow slide—
	may not even notice how far we have fallen.

	This supervisor also noted in that interview that DuPont La Porte was at its most vulnerable point because
	younger engineers were most impressed by improved production, and “safety first” was not always the practice.

	Had DuPont La Porte formally assessed its process safety culture and taken effective corrective actions, cultural
	weakness that contributed to significant and long-standing process safety program deficiencies, which the CSB
	determined were causal to the November 15, 2014 incident (listed below), may have been identified,
	communicated, and addressed. These deficiencies are discussed in further detail in the CSB Interim
	Recommendations report on the incident [1] and Section 6:

	• Poor hazard analysis practices. Site personnel did not perform a hazard analysis on the

	troubleshooting techniques that they used leading up to the incident. Additionally, the DuPont La Porte
	site did not adequately analyze hazards associated with the manufacturing building’s ventilation system
	in PHAs. A PHA on the ventilation system could have evaluated the ability of the fans to handle toxic
	releases and established more robust management systems to protect workers when a fan was broken [1,
	pp. 47; 25-26].

	• Poor design of the manufacturing building. DuPont housed the Lannate® process inside a

	manufacturing building. The building design increased hazards for the workforce by confining toxic
	chemicals indoors. The building’s ventilation design also did not consider chemical toxicity hazards
	inside the building [1, p. 33].

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	• Failure to maintain safety-critical equipment. Two “PSM critical”a ventilation fans were not
	operational at the time of the incident [1, pp. 33-35]. DuPont recognized that a ventilation fan
	breakdown could result in a high-consequence event. Both fans, however, exhibited poor reliability.
	One fan had been down since June 2014, five months prior to the incident, due to an electrical problem.
	On October 20, 2014, the other fan was making a noise significant enough that DuPont operators turned
	it off and wrote an “urgent”b work order to have it repaired [1, p. 20]. Even had the fans worked, they
	probably would not have prevented a lethal atmosphere inside the building due to the large amount of
	toxic gas released [1, p. 3].

	• Failure to develop written procedures for operator actions. DuPont La Porte did not establish a

	formal procedure for draining liquid from the waste gas vent header piping, aside from its line-breaking
	policy (Section 6.5). In addition, when the DuPont Technical Team met to discuss how to clear the
	plugging in the piping system, they did not develop a written procedure for the techniques used to clear
	plugging in equipment, even though the plugging formed where it had never been before [1, p. 25].

	• Lack of hazard recognition. The methyl mercaptan detectors installed in the manufacturing building
	were not intended for worker safety—the alarms were set to alarm at 25 parts per million (ppm), which
	was above OSHA’s ceiling limitc of 10 ppm. Operators also normalized smelling methyl mercaptan
	because of its low odor threshold and perceived lack of negative health impacts at those low
	concentrations, even though it is a toxic chemical. Although formally trained,d numerous employees
	lacked a working knowledge of methyl mercaptan’s hazards and did not recognize that the chemical
	could be both lethal and explosive. As a result, operators often confirmed methyl mercaptan leaks by
	purposely smelling for the chemical’s odore without understanding the dangers of this practice.
	Furthermore, this method of leak confirmation is a poor, unsafe, and unreliable practice that could have
	been replaced by using portable monitors set at appropriate levels [1, pp. 37-39].

	Further, as the CSB concluded in its 2005 BP Texas City investigation, personal safety performance is not an
	effective gauge of process safety performance [60]. Similar to its investigation findings from BP Texas City,
	the CSB found that DuPont La Porte also focused on personal safety and did not place enough emphasis on its
	process safety programs. For example, the Safety Perception Surveys used at the DuPont La Porte facility
	evaluated only the perception of personal safety performance and did not identify process safety weaknesses at
	the facility. Even though DuPont La Porte was aware of the importance of BP Texas City’s findings, before the

	a DuPont assigns the designation of “PSM Critical” to equipment whose failure could result in a high-consequence event [1, p. 34].
	b While the timing required to complete an “urgent” work order is not specifically defined, based on CSB’s review of DuPont records and
	interviews conducted with DuPont employees, it has a practical meaning of two to three days.
	c The ceiling limit for a substance is the concentration that must never be exceeded under OSHA (29 C.F.R. § 1910.1000(a)(1) (2016)).
	d DuPont La Porte included a toxic fume release and methyl mercaptan procedures in its emergency response plan.
	e The DuPont La Porte facility had an emergency response procedure for a methyl mercaptan leak. If a leak was detected, personnel were
	required to put on an air demand mask and contact a supervisor or the control room to sound a plantwide fume alarm.

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	incident it continued to use the Safety Perception Survey without conducting additional formal process safety
	culture assessments that could identify process safety weaknesses.

	5.4.1.3 DUPONT’S INITIATION OF PROCESS SAFETY CULTURE ASSESSMENTS

	DuPont La Porte’s safety culture assessment program (the Safety Perception Survey) before the November 2014
	incident focused on lowering its OSHA total recordable injury rate. Even as the industry concentrated on
	improving process safety following the 2005 BP Texas City incident, and DuPont’s consultant arm developed
	process safety questions for the survey, DuPont La Porte lagged and did not incorporate DuPont’s process safety
	questions into its Safety Perception Survey.a Furthermore, DuPont La Porte did not formally assess aspects of
	its culture beyond the Safety Perception Survey.

	In 2017, however, DuPont required each site to assess its process safety culture periodically and added process
	safety questions to the Safety Perception Surveys.b This shift in incorporating process safety culture questions
	in its Safety Perception Surveys is important because, as explained in Chapter 6.2 of Volume 3 of the CSB’s
	Macondo report, the accuracy of a site’s culture assessment may be called into question if all aspects of culture
	are not considered as part of the assessment [61, pp. 236-238]. Furthermore, DuPont practice has become more
	aligned with its corporate philosophy that a process safety management program is only as effective as its safety
	culture. The CSB views the adoption of process safety culture questions in DuPont’s Safety Perception Survey
	as a positive development.

	GUIDANCE TO INDUSTRY
	The CSB has investigated several major incidents caused by weaknesses in process safety culture.c In recent
	years, process safety culture has been studied as a component of the broader topic of organizational culture, an
	analytical approach that the CSB first articulated in Volume 3 of its Macondo report [61, pp. 233-41].
	Referencing the work of Sonja Haber and Edgar Schein, the CSB explained that organizational culture refers to
	characteristics of the overall environment, values, and rules that shape employees’ perceptions and attitudes [61,
	pp. 234-36]. This analytical framework extends to a culture for process safety, as these same varied components
	work together to determine the importance that an organization places on process safety. A “safety culture” is
	thus often accurately described as “the way we do things around here,” or “how the organization behaves when
	no one is watching” [62, pp. 9-10]. The chemical process industry then further defined process safety culture as

	a DuPont corporate conducted Safety Perception Surveys at all of its manufacturing sites. It chose not to include process safety
	perception questions in these surveys.
	b DuPont changed some of its process safety culture questions and increased the number of questions from 13 to 14. In 2017, DuPont
	updated its corporate process safety management standard to require each site to evaluate the process safety culture survey results and
	identify opportunities for improvement.
	c Other CSB investigations in which a weak process safety culture was found to contribute to the incident include Williams Geismar
	Olefins Plant Reboiler Rupture and Fire [71, p. 52], CSB Macondo Investigation Report, Volume 3 [61, pp. 233-241], and CSB BP Texas
	City Investigation Report [60, pp. 142-195].

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	“the common set of values, behaviors, and norms at all levels in a facility or in the wider organization that affect
	process safety” [63].

	According to CCPS, a sound or positive safety culture is “the pattern of shared written and unwritten attitudes
	and behavioral norms that positively influence how a facility or company collectively supports the successful
	execution and improvement of its Process Safety Management System (PSMS) resulting in preventing process
	safety incidents” [56, p. 6]. Additionally, a company’s espoused commitments and values, its messages from
	management to its workforce and the public, the quality of its written safety management programs, and the
	effectiveness of the implementation of those programs in sound operations are all paramount.a

	In its book Guidelines for Risk Based Process Safety, CCPS identified six themes of process safety culture:

	• Maintain a sense of vulnerability

	• Combat normalization of deviance

	• Establish an imperative for safety

	• Perform valid/timely hazard/risk assessments

	• Ensure open and frank communications

	• Learn and advance the culture [56, p. 23], [52, pp. 39-66]

	CCPS expanded on these process safety culture themes in Guidelines for Risk Based Process Safety and
	developed 10 core principles of process safety culture in Essential Practices for Creating, Strengthening, and
	Sustaining Process Safety Culture [56, p. 23]. To successfully implement the process safety culture principles
	in Figure 21, the later principles should build upon the earlier principles because each principle depends on the
	others [56, pp. 24-25].

	a CCPS focuses on the quality of programs and the fidelity to those programs as “Conduct of Operations” and “Operational Discipline,”
	respectively [63].

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	Figure 21. Excerpt from “Overview of Core Principles of Process Safety Culture,” in CCPS, Essential
	Practices for Creating, Strengthening, and Sustaining Process Safety Culture [56, p. 24]. Source:
	CCPS.

	One tool to evaluate a facility’s process safety culture is the use of anonymous process safety culture
	assessments of staff. These assessments have historically been conducted by surveying a site’s employees
	through multiple-choice questionnaires. Facilities may also use qualitative assessment practices that go beyond
	simple employee questionnaire surveys. Such process safety culture assessments include personnel interviews,
	focus group discussions, and detailed document analyses. In qualitative assessments, workers interact with

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	auditors, “using their own terms and concepts to express their point of view…. Intensive and in-depth
	information can be obtained using the [workers’] own language” [64].

	Guidance published in recent years describes how to conduct process safety culture assessments of chemical
	process facilities. In 2011, Contra Costa County in California published a guidance document on conducting
	process safety culture assessments, and CCPS released the second edition of its book Guidelines for Auditing
	Process Safety Management Systems [65], [66]. Chapter 4 of the CCPS book provides detailed guidance for
	auditors evaluating an organization’s process safety culture [66]. Additionally, in 2018, CCPS published
	Essential Practices for Creating, Strengthening, and Sustaining Process Safety Culture, which details how to
	assess, develop, and sustain a process safety culture in relation to a company’s process safety management
	system [56].a In developing a process safety culture assessment, companies should follow the findings of the
	Baker Panel and ensure that improved injury rates are not perceived as an indication of acceptable process safety
	performance.b

	Process safety culture assessments are a tool for understanding a company’s overall commitment to process
	safety. Furthermore, companies can use the assessments’ findings to develop action items for continual
	improvement efforts. To ensure a strong culture of process safety, companies must address any process safety
	culture assessment findings not consistent with the core principles of their process safety culture. Leadership plays an
	important role in ensuring that deficiencies in the process safety culture are addressed. As Andrew Hopkins noted in
	his article “Why Safety Cultures Don’t Work,” improving an organization’s process safety culture flows from top
	management commitment and cascades down to managers and employees [67, pp. 1, 3-4]. Hopkins argued that
	companies with strong leadership will best achieve process safety excellence by establishing systems (including the
	use of leading indicators) that drive catastrophic accident prevention [48, pp. 1-3]. Such companies are better
	equipped to avoid or prevent major process safety incidents because, as Hopkins observed, such companies can better
	“identify the obvious precursors to catastrophe and get serious about eliminating them” [67, pp. 1, 3-4].

	a Essential Practices for Creating, Strengthening, and Sustaining Process Safety Culture includes in an appendix that contains a sample
	process safety culture assessment protocol [56, pp. 343-380].
	b The Baker Panel found that BP “mistakenly interpreted improving personal injury rates as an indication of acceptable process safety
	performance” (see Figure 20).

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	5.4.2 USING THE PROCESS SAFETY MANAGEMENT AND RISK MODEL

	Figure 22. DuPont’s Process Safety Management and Risk Model [54, p. 2]. Source: DuPont
	Sustainable Solutions.

	DuPont created the Process Safety Management and Risk Model (also called the PSM Wheel) to represent
	visually how the last three steps (management leadership and commitment, implementing a comprehensive
	process safety management program, and operational discipline) should interact with each other, using a wheel
	to show that DuPont’s process safety management system integrates management leadership and commitment
	with operational discipline (Figure 22) [54, p. 2].

	The second step in implementing DuPont’s process safety management system, management leadership and
	commitment, is at the center of the PSM Wheel. According to DuPont, it placed this core value at the center
	because it affects all aspects of a process safety management system, from forming and fostering a safety culture
	to implementing policies and providing resources for safety-related activities [54, p. 2]. Additionally, “the
	actions of all levels of management must support and reinforce strong PSM programs and accountability” [54, p.

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	2]. DuPont believes that visible top management involvement (i.e., “felt leadership”a) in safety systems,
	processes, and programs is necessary for their sustainability. In addition, it notes that felt leadership,
	commitment, and role modeling greatly influence employees’ interest in, understanding of, and value for safety.

	The third step in establishing DuPont’s process safety management system, Implementing a Comprehensive
	PSM Program, is in the spokes of the wheel. Each spoke represents one of 14 aspects of DuPont’s corporate
	process safety management program.b These spokes are divided into three groups:

	a. Facilities to handle and manufacture hazardous materials:

	1. Management of “subtle changes”
	2. Mechanical integrity
	3.
	4. Quality assurance

	Pre-startup safety reviews

	b. Technology of the process:

	1. Management of technology change
	2. Operating procedures and safe practices
	3.
	4.

	Process hazards analysis
	Process safety information

	c. Personnel who operate, maintain, and support the process:

	1. Auditing
	2.
	Emergency planning and response
	3. Management of personnel change
	4.
	5.
	6.

	Incident investigation
	Contractors
	Training and performance [68, p. 2]

	a DuPont defines “felt leadership” as a respect through action for the well-being of people. It is a building block in constructing trust and
	real-world relationships among employees, customers, shareholders, and communities [116]. CCPS also defined felt leadership in its
	CCPS Vision 20/20: “Felt leadership means that the executives and other leaders personally involve themselves in process safety
	activities. Employees know the executives care about process safety because of what they see and feel executives doing, not just by
	[what] they hear them saying. Felt leadership is leading by passionate example” [56, p. 31].
	b Note that DuPont’s PSM Wheel does not include trade secrets and employee participation, which are elements of OSHA’s PSM
	standard.

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	The final step, Operational
	Discipline, is the rim of the
	PSM Wheel. DuPont defines
	operational discipline as “the
	deeply rooted dedication and
	commitment by every member
	of an organization to carry out
	each task, the right way, each
	time” [54, p. 2]. According to
	DuPont, operational discipline
	translates a documented
	process safety management
	system into tangible results
	(see Figure 23). Additionally,
	DuPont believes that it reflects
	the strength of an
	organization’s safety culture in
	making safety, health, and
	environmental (also known as
	SHE) systems effective and in
	providing observable results for preventing injuries and incidents [69, p. 58].

	Figure 23. Excerpt from DuPont Presentation Titled “Developing a Robust PSM Framework
	at DuPont.” This slide illustrates DuPont’s perception of the characteristics of an effective
	operational discipline program that translates to operational excellence [118, p. 11].
	Source: DuPont Sustainable Solutions.

	DuPont management uses the Process Safety Management and Risk Model at its sites, including DuPont La
	Porte, and sells its process safety management system to other companies.

	DUPONT’S PROCESS SAFETY MANAGEMENT SYSTEM CONCLUSIONS

	DuPont integrated the PSM standard, RMP rule, and Responsible Care into its corporate process safety
	management system. In addition to other requirements, these frameworks obligate companies to establish a
	comprehensive corporate process safety management system. As shown in this section, companies need to
	ensure that there is an adequate focus on the effectiveness of a corporate process safety management system and
	its corresponding safety program elements. Without sufficient focus, implementing a corporate process safety
	management system will likely not be enough to prevent major chemical incidents. At the DuPont La Porte
	facility, an inadequate focus on the effective implementation of the corporate process safety management system
	resulted in process safety management deficiencies that led to the November 2014 incident. The following
	section discusses some of the deficiencies in DuPont La Porte’s process safety management system.

	6 PROCESS SAFETY MANAGEMENT DEFICIENCIES

	As part of its investigation, the CSB evaluated DuPont La Porte’s implementation of its process safety
	management system at the site (see Appendix A: Causal Analysis). The CSB found that DuPont La Porte had
	multiple deficiencies in its process safety management program elements that contributed to the incident,

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	including process hazard analysis (PHA), auditing, management of change (MOC), operating procedures, and
	safe work practices.a This section details some of these process safety management system deficiencies at the
	DuPont La Porte facility. Section 4 discusses the deficiencies in DuPont La Porte’s emergency response
	program.b Additionally, the CSB found that DuPont La Porte’s incentive compensation program did not
	conform to the OSHA guidance that existed at the time of the incident.

	Even though DuPont and DuPont La Porte had extensive written policies, these policies did not translate into
	effective implementation of or adequate focus on the effectiveness of its process safety management system at
	the DuPont La Porte site. The CSB determined that a company’s development of its own process safety
	management system is critical to prevent major accidents. Companies should ensure that the safety program
	elements within their process safety management system are effective, fully implemented, and functioning as
	intended.

	PROCESS HAZARD ANALYSIS EVALUATION

	DuPont’s internal PHA training
	documents state, “historically, the
	most significant failure in PHAs,
	identified through the investigation
	of incidents in which a breakdown
	of the PHA element was found to be
	a key factor, is the failure to identify
	the specific sequence of events that
	led to the accident (e.g., either failed
	to ask the right What If question or
	failed to completely develop the
	hazardous event scenario).”
	Without identifying the full extent of
	a potential hazardous event scenario,
	PHA teams are not likely to develop
	adequate safeguards to mitigate a
	hazard.

	Figure 24. Where PHA is Located on DuPont’s Process Safety Management and Risk
	Model (PSM Wheel) [54, p. 2]. Source: DuPont, with annotations by CSB.

	One of the causes of the highly toxic
	methyl mercaptan release was a lack
	of safeguards to prevent the methyl
	mercaptan hydrate from solidifying in the feed piping. In one of the hundred-plus what-if scenarios considered

	a Section 4 covers process safety management deficiencies related to emergency response.
	b The PSM standard requires companies to have either an emergency action plan or an emergency response plan. Although the standard
	does not detail requirements for an emergency response program, it incorporates by reference regulations that dictate requirements for
	emergency action plans and emergency response plans (29 C.F.R. § 1910.119(n)).

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	in the 2011 PHA, the DuPont La Porte PHA team acknowledged the potential for methyl mercaptan hydrate to
	solidify in the feed piping. The PHA team identified a scenario in which water back-flowing into the methyl
	mercaptan feed system could cause the formation of methyl mercaptan hydrate (Figure 25). The consequence of
	this scenario was the hydrate plugging the methyl mercaptan feed piping. The team identified that heating
	would dissociate the hydrate and unplug the system, but it did not fully develop (evaluate) the potential hazards
	resulting from the plugging, including hazards caused by dissociating the methyl mercaptan hydrate. The PHA
	team assessed the plugging as presenting an unlikely, low-severity hazard, assigning it the lowest possible risk
	ranking.a As a result of this risk ranking, no additional safeguards or further protective actions were required to
	address this scenario.

	Figure 25. CSB’s Reproduction of the Hazard Evaluation Worksheet from the 2011 PHA. It that identified the methyl mercaptan
	hydrate formation as a hazard. Source: DuPont, with modifications by CSB for readability.

	As discussed earlier, the PHA team did not comprehensively evaluate this scenario. For example, it did not
	ensure that a procedure or safeguard existed to heat the piping safely. Figure 25 shows that the PHA team
	identified one existing safeguard for the hydrate plugging scenario—the company’s standard for backflow
	prevention. This safeguard, however, was inadequate because this standard addresses backflow from a process
	(MeSNa cooler) to a service or a utility (water supply). Therefore, applying this standard would not have
	prevented or offered protection from water flowing into the methyl mercaptan feed piping.

	Hence, the PHA team underestimated the risk, noting, “Ultimately by heating the line externally it will vaporize
	and return to [methyl mercaptan] and water vapor.” Even though the PHA team identified heating as a means to
	dissociate the methyl mercaptan hydrate, DuPont La Porte did not identify the need to develop a formal
	procedure or engineered system to safely heat the line and address the hazard the team had identified. As a
	result, on November 14, 2014, the DuPont Technical Team had to develop a troubleshooting plan to address the

	a DuPont La Porte used a risk matrix that evaluated risk by assessing consequence and frequency. The DuPont La Porte PHA team
	assigned the lowest-level possible consequence (C-1) and frequency (F-1) to the methyl mercaptan hydrate. This assignation resulted in
	the methyl mercaptan hydrate having the lowest possible risk (IV), which meant the PHA team did not have to mitigate the hazard. A C-
	1 consequence equates to no significant injury or health impact on-site or off-site and no significant environmental impact. As long as
	the consequence was classified as C-1, the frequency of the event would not have mattered; the PHA still would not have had to mitigate
	the risk.

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	hydrate plugging (Section 6.3). This plan was developed without performing any hazard analysis, developing a
	written procedure, training personnel, or providing sufficient technical resources for the night shift.

	Although DuPont La Porte’s 2011 PHA of the process identified methyl mercaptan hydrate formation,a the PHA
	team did not recognize the need to address the potential methyl mercaptan hydrate formation risk by providing
	additional safeguards, such as heat tracing,b or to develop a written procedure to safely dissociate the hydrate
	(see Section 6.3). When critically evaluating any PHA scenario following a major accident, it is not uncommon
	to identify how a PHA team could have recommended additional or more effective safeguards. The difficulty
	PHA teams face is how to ensure that what is perceived as “good enough” when evaluating a potential hazard
	scenario will ultimately provide sufficient protection (effective risk mitigation). Had DuPont La Porte installed
	effective safeguards, such as heat tracing, to maintain the piping contents above 52°F, the facility could have
	avoided the abnormal situation that led to the deaths of four workers. Following the November 15, 2014
	incident, DuPont completed two new baseline PHAs using a more robust PHA methodology for the Insecticide
	Business Unit. Despite performing PHAs for more than 30 years, DuPont La Porte employees told CSB
	investigators that the improved approach for conducting PHAs was resulting in hundreds of action items, never
	previously identified, to control hazards. Difficulties in performing PHAs highlight the importance of having a
	strong process safety culture foundation to drive site personnel to effectively respond to real-time events with
	robust process safety management system programs, including MOCs or safe work practices.

	GUIDANCE TO INDUSTRY
	PHAs can be subjective and can result in underestimating the risk of potential hazardous event scenarios.
	Because in PHAs the assignment of event frequencies and consequence severities can make a significant
	difference in safeguard requirements, companies need to ensure that PHA teams have a robust process and
	adequate resources in place to fully develop hazard scenarios and assign appropriate initiating event frequencies
	and consequence severities to them. Additionally, PHA teams need to ensure that the safeguards applied to the
	hazard scenarios are relevant and effective in controlling the hazards.

	a The methyl mercaptan hydrate hazard was also identified in DuPont La Porte’s technical standard (see Section 6.3).
	b “Heat tracing is used to prevent heat loss from liquids inside process piping in situations where low fluid temperatures could lead to
	problems such as an unacceptable increase in viscosity, hydrate formation, congealing or solidification, the separation of components, or
	when water in the line could form corrosive materials” [131, p. 157]. Heat tracing can be either steam or electrical heat applied to the
	surface of a pipe and covered by insulation [131, p. 158].

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	IMPLEMENTATION OF CORRECTIVE ACTIONS

	According to OSHA’s Process
	Safety Management Guidelines for
	Compliance, taking corrective
	actions is one of the most
	important parts of an audit and
	includes identifying deficiencies,
	planning, following up, and
	documenting needed corrections
	[19]. Audits, PHAs, incident
	investigations, and emergency
	response drills are among the
	various PSM program elements
	that can generate corrective action
	items. At times, the corrective
	action program at DuPont La Porte
	did not appropriately correct gaps
	identified by site PSM audits
	(Figure 26).

	Figure 26. Where Auditing is Located on DuPont’s PSM Wheel [54, p. 2]. Source:
	DuPont, with annotations by CSB.

	One of DuPont’s process safety metrics was tracking the completion of corrective action items. However, this
	metric addressed only one aspect of the site’s corrective action program—time needed to close the corrective
	action. Time to close corrective actions can indicate the priority management gives to completion of corrective
	action items. DuPont La Porte’s focus on time to complete, however, sometimes resulted in closing action items
	after developing a plan to correct a deficiency rather than actually correcting it. In Guidelines for Risk Based
	Process Safety CCPS states,

	A safety management system can be seriously deficient, yet appear satisfactory by superficial
	measures—the paperwork appears to be in place and no serious incidents have been recorded.
	Complacency replaces a sense of vulnerability, and the execution of program tasks becomes
	perfunctory [52, p. 639].

	Similarly, based on its corrective actions metric, the DuPont La Porte facility did not appear to have a large
	number of process safety management deficiencies—while the CSB’s review of corrective actions at La Porte

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	revealed that some corrective actions were closed without addressing the issue identified by the underlying
	recommendation.a As such, closing out some corrective actions became perfunctory paperwork closures.

	For example, in 2009, a second-party PSM audit found that the DuPont La Porte site lacked documentation
	showing the manufacturing building’s ventilation systemb was ever tested to ensure it could effectively
	distribute fresh air within the building. Based on this finding, the audit recommended that the site set up a
	program to test the manufacturing building’s ventilation system periodically.

	The two sides of the manufacturing building were separately ventilated by dilution air exhaust fans located on
	the roof of the building. The dilution air ventilation system design used roof-mounted fans to pull fresh dilution
	air into the manufacturing building. Fans drew fresh air into each floor on each side of the building, at floor
	level, through a mechanical louver system.c When the system operated properly, air would flow from the fresh
	air louvers, across the process equipment, and up into return ducts on the ceiling along the internal wall to sweep
	away any flammable or toxic gases.d Exhaust air from each side of each floor moved inside the ceiling-mounted
	duct toward the north end of the building (Figure 27), where it was collected in a vertical duct header that
	directed the exhaust air from all of the floors on each side up to the respective (wet or dry end) dilution air
	exhaust fan on the roof. Exhaust air from the fans discharged directly to atmosphere. The ventilation system
	was not equipped with any kind of environmental destruction system, such as a scrubber or incinerator, to
	remove contaminants.

	a The CSB found multiple incidents at the DuPont La Porte facility in which corrective actions were closed by sending emails to relevant
	parties without following up to ensure effective implementation (e.g., coordination with other companies located on-site, deviation from a
	highly toxic material requirement, etc.).
	b The stated design objective for the ventilation system is as follows: “The main objectives of industrial ventilation for the LANNATE®/
	[agricultural products intermediates] manufacturing building are to: a. control contaminants to acceptable work place exposure levels,
	e.g., comply with OSHA regulation or Corporate AELs (acceptable exposure limits), and b. prevent fires and explosions.” The actual
	design calculations, however, do not take toxicity into consideration. In addition, DuPont has not established an AEL for methyl
	mercaptan [1, p. 33].
	c The louver is a set of angled slats or flat strips fixed or hung at regular intervals in a shutter to allow air to pass through [1, p. 13].
	d DuPont La Porte records indicate that the manufacturing building ventilation system design code is National Fire Protection
	Association (NFPA) 497, Recommended Practice for the Classification of Flammable Liquids, Gases, or Vapors and of Hazardous
	(Classified) Locations for Electrical Installations in Chemical Process Areas. NFPA 497 defines adequate ventilation as that sufficient
	to ensure that the concentration of flammable gases does not exceed 25 percent of the lower flammability limit (also called the lower
	explosive limit (LEL)). DuPont’s methyl mercaptan safety data sheet indicates that the LEL for methyl mercaptan is 3.9 percent [1, p.
	13].

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	Figure 27. Simplified Graphical Representation of a Typical Floor of the Manufacturing Building. It shows how fresh
	air was pulled in from the outside walls, swept across the floor, and entered the exhaust return air ducts on each
	side. Source: CSB.

	To close the action item generated—to ensure the ventilation system was routinely tested—DuPont La Porte
	personnel created a program within their computerized maintenance system that periodically generated a work
	order to conduct dilution air flow testing [1, p. 34]. DuPont La Porte closed the corrective action in March 2010
	after creating this program. But the CSB found serious deficiencies in the implementation of this program:

	• DuPont La Porte personnel were supposed to schedule the first ventilation system test in November
	2010. This test was delayed and did not occur until two years later, in 2012 [1, p. 34]. This delay
	occurred in part because personnel closed the corrective action without assigning a specific individual
	to ensure completion of the ventilation testing.

	• On the dry end side of the building, DuPont La Porte personnel measured dilution air flow without

	analyzing the data or establishing acceptable air flow criteria. Additionally, they never measured the
	air flow on the wet end side where the November 15, 2014 release occurred. Therefore, DuPont La
	Porte never verified whether the manufacturing building’s ventilation system could effectively remove
	flammable or toxic chemical leaks.

	Had the corrective action met the intent of the PSM audit recommendation, the need for additional safeguards in
	the manufacturing building (e.g., a better ventilation system, increased chemical detectors, respiratory
	protection) should have been evaluated. Effective ventilation system testing and analysis should have identified
	and corrected poorly ventilated areas to reduce worker hazards posed by potential flammable or toxic gas leaks
	in the manufacturing building.a

	a For more information on the ventilation systems, see the Interim Recommendations report (CSB DuPont La Porte Interim
	Recommendations [1, pp. 12-16]).

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	At the time of the November 2014 incident, neither the wet end nor the dry end fans were functioning. Had the
	deficiencies in the DuPont La Porte ventilation system been recognized, access to the manufacturing building
	should have been restricteda and personnel could have been required to wear SCBAs inside it. Adequate
	safeguards could have protected workers when the fatal toxic release occurred.

	Closing corrective action items with only a limited plan to address an audit finding is a poor practice—it can
	result in the action item’s being implemented ineffectively or not at all. At DuPont La Porte, even though
	personnel closed as complete the ventilation system testing action item, they never completed the testing to
	ensure the effectiveness of the ventilation system.

	GUIDANCE TO INDUSTRY
	Companies should ensure that their corrective actions meet the intent of their recommendations. One way to
	make the intention of the recommendation the focus of any follow-up activity is to evaluate the substance of the
	corrective action in addition to the time it takes to complete the action.

	PROCESS SAFETY PRACTICES DURING TROUBLESHOOTING OPERATIONS

	A robust strategy for troubleshooting
	is important because if hazards are not
	identified before starting an activity,
	workers could be unprepared for
	dealing with them, like what happened
	during the November 2014 incident.
	Troubleshooting implicates multiple
	PSM elements, including management
	of change, operating procedures, and
	safe work practices (Figure 28).
	Although DuPont La Porte had written
	policies and procedures for MOCs,
	operating procedures, and safe work
	practices, it did not have a strong
	process safety approach for dealing
	with troubleshooting operations.

	Figure 28. Where troubleshooting Could Fall on DuPont’s PSM Wheel [54, p.
	2]. Source: DuPont, with annotations by CSB.

	During the morning of November 14, 2014, Lannate® Unit engineers and managers (Technical Team) met as a
	group with the day shift supervisor to discuss the plugging problem in the methyl mercaptan piping and to
	develop a troubleshooting plan for clearing the piping and restarting both the Lannate® and agricultural products

	a The CSB Interim Recommendations report discusses how DuPont La Porte’s emergency procedures called for restricting access to the
	manufacturing building if a ventilation fan, such as the wet end or dry end fans, is out of service. However, the actual practice for
	manufacturing building access was no different with a fan out of service than if all the fans were operating [1, p. 35].

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	intermediates processes [1, p. 23]. In this meeting, the Technical Team identified the likely scenario that water
	had entered the methyl mercaptan system, developing a solid hydrate. DuPont’s methyl mercaptan technical
	standard shows the potential formation of a hydrate at low temperatures. The technical standard states that
	methyl mercaptan “will form a hydrate with water, which is a solid below [40°F [degrees Fahrenheit]] per
	information provided by a [methyl mercaptan] supplier” [1, p. 23].

	Prior to implementing the troubleshooting plan developed by the Technical Team, however, site personnel did
	not develop written procedures, conduct any type of hazard analysis for abnormal conditions, conduct a job
	safety analysis, perform an MOC process, or conduct any other type of hazard analysis [1, p. 25]. Several
	methods can identify potential hazards and prevent or mitigate potential incidents caused by troubleshooting,
	including development and use of MOC processes, operating procedures, or safe work practices. A robust
	troubleshooting approach can include the following methods:

	• An MOC approach, which should identify and address possible hazards [52, pp. 423-426, 255-256]

	• An operating procedure approach, which should incorporate safeguards while methodically working

	through troubleshooting steps [52, pp. 255-256]

	• A safe work practices approach, which should address unexpected process upsets by using work permits

	(i.e., line-breaking permits) that can address specific troubleshooting hazards [70, p. 393], [52, pp. 285-
	298]

	A combination of these PSM approaches may be prudent depending on the complexity and urgency of the
	problem. One or more of the noted PSM approaches could have identified the pathway the liquid methyl
	mercaptan took into the manufacturing building before personnel put hot water on the insulated piping, leading
	to the November 2014 incident.

	GUIDANCE TO INDUSTRY
	Companies should develop an action plan to manage troubleshooting operations. There are multiple approaches
	a company can take, including addressing troubleshooting hazards in PHAs, operating procedures, MOCs, or
	work permits.

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	U.S. Chemical Safety and
	Hazard Investigation Board

	MOC PRACTICES

	According to OSHA, “contemplated
	changes to a process must be
	thoroughly evaluated to fully assess
	their impact on employee safety and
	health and to determine needed
	changes to operating procedures”
	[18]. Therefore, to prevent safety
	incidents and ensure worker safety,
	companies must ensure that the
	following considerations are
	addressed in their MOC process
	prior to the implementation of any
	change:

	• The technical basis for the

	proposed change

	Figure 29. Where MOC is Located on DuPont’s PSM Wheel [54, p. 2]. Source:
	DuPont, with annotations by CSB.

	•

	Impact of the change on employee safety and health

	• Modifications to operating procedures

	• Necessary time period for the change

	• Authorization requirements for the proposed change [18]a

	As explained in the CSB’s Williams Geismar Olefin Plant Case Study, robust management of change practices
	are needed to ensure that personnel review hazards for the entire process affected by the change [71, p. 23].
	Within DuPont, MOC policies are defined in standards at the corporate level and adopted according to each
	site’s procedures. The DuPont corporate standard defines three types of MOCs: technology, subtle changes, and
	personnel (Figure 29). An MOC for technology is defined as “any change in the technology of the process.”b A
	“subtle change” is defined as “any change within the documented technology that is not a replacement in kind.”c,
	d MOCs are intended to be completed prior to any implementation of these types of change. DuPont La Porte
	adopted DuPont’s corporate MOC policies into its own site policies and procedures. The CSB found, however,

	a 29 C.F.R. § 1910.119 (l)(2).
	b According to DuPont, management of change of “subtle changes” includes rerouting a piping system during field modifications or
	replacement and installation of an automatic valve to replace a manual valve with the same function.
	c According to DuPont, management of change technology includes managing changes in the design basis for existing equipment,
	changes in process materials or operating parameters, and process control changes.
	d In its Belle investigation, the CSB recommended that DuPont “[r]eevaluate and clarify the DuPont corporate MOC policies to ensure
	that staff can properly identify and use the distinctions between subtle and full changes and train appropriate personnel how to properly
	apply the distinctions on any changes in the policy.” [144, p. 110]. The CSB closed the recommendation in April 2013 [147].

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	that DuPont La Porte personnel did not use MOCs for changes to equipment or procedures that contributed to
	the incident.

	6.4.1 NO MOC FOR HEATING PIPING OR FOR NEW PIPING ALIGNMENT

	To clear the plugging, the Technical Team asked operators to put hot water on the outside of the methyl
	mercaptan feed piping, under the insulation, to warm the piping and its contents to dissociate the hydrate back to
	liquid methyl mercaptan and water (Figure 30) [1, p. 23].

	Figure 30. Hot Water Hose Positioned on the Liquid Methyl Mercaptan Feed Piping. Hot water flowed
	between the piping and the insulation to heat the piping and dissociate the solid hydrate that had formed
	after water inadvertently entered the methyl mercaptan storage tank. Source: CSB.

	At low temperatures (≤ 52°F), water and methyl mercaptan form a solid, ice-like material called methyl
	mercaptan clathrate hydrate [72]. Temperatures in the Houston area for the 24 hours preceding the incident
	averaged approximately 40°F and had been consistently below 55°F since Tuesday, November 11, 2014.
	Although years earlier, DuPont’s methyl mercaptan technical standard and a PHA identified the potential for
	methyl mercaptan hydrate formation, DuPont did not have safeguards, such as heat tracing, or develop a
	procedure to dissociate the hydrate safely [1, p. 22].

	The Technical Team realized that when methyl mercaptan was heated it would expand and need a safe place to
	vent to avoid overpressure in the feed piping. To address this concern, DuPont operations personnel opened
	three valves between the methyl mercaptan feed line and the waste gas vent header—piping intended to remove
	excess or unwanted vapor from the process and route it to the NRS incinerator for thermal destruction. DuPont
	La Porte personnel used pressure gauges at those three valves (Figure 31) to determine the location of the

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	blockage and their progress in clearing it. At the time of the incident, one of these three valves between the
	methyl mercaptan feed system and the waste gas vent header was fully open, and a second valve was slightly
	open [1, p. 25].

	Figure 31. Excerpt from CSB Animation. It depicts the three locations where valves connected the methyl mercaptan feed piping
	(blue) to the waste gas vent header piping (orange). Workers used the pressure gauges shown at these locations to monitor the
	progress of clearing the hydrate blockage inside the methyl mercaptan feed piping. Source: CSB.

	Operations personnel began implementing the plan that the Technical Team had developed by applying hot
	water under the insulation, on the outside of the liquid methyl mercaptan piping. DuPont La Porte operators
	started this process at the methyl mercaptan storage tank and the associated methyl mercaptan feed pump piping
	segments, and then worked their way down the methyl mercaptan feed piping toward the reaction system.
	Workers used pressure gauges at each of the three block valves between the liquid methyl mercaptan feed piping
	and the vapor waste gas vent header piping system to determine the success and progress of the work [1, p. 26].

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	Figure 32. Excerpt from CSB Animation. It depicts the piping arrangement that allowed liquid methyl mercaptan from the
	feed line (blue) to flow into the waste gas vent header piping (orange). Source: CSB.

	Using these valves in this way followed the plan developed by the Technical Team. This alignment, however,
	created a direct path between the liquid methyl mercaptan system and the waste gas vent header (vapor system),
	as shown in Figure 32, which was not DuPont’s design intent [1, p. 26]. Additionally, applying hot water to the
	outside of the methyl mercaptan liquid piping system exceeded the heat input design for the thermal expansion
	relief valve on this system [1, p. 26]. But DuPont La Porte personnel did not perform an MOC before
	instructing operations personnel to use the hot water to heat the piping, or before creating the piping alignment.
	DuPont corporate standards, as well as the EPA’s Risk Management Plan (RMP) rule and OSHA’s PSM
	regulations, require an MOC for these types of process changes [1, p. 25]. Performing an effective MOC before
	heating the piping with the hot water hose, and before creating the unusual piping alignment, could have
	identified and controlled the hazards that led to the incident.

	An MOC should have also triggered the creation of a written troubleshooting procedure. On the day of the
	incident, the Technical Team did not provide a written procedure to guide operations or to track the progress
	toward clearing the plugged methyl mercaptan feed piping. A written procedure should communicate the
	planned approach to multiple shifts and help avoid confusion. Additionally, it should alert personnel to potential
	hazards, such as the valve alignment that created the pathway for liquid methyl mercaptan to flow into the
	manufacturing building.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	6.4.2 NO MOC FOR NEW PIPING ALIGNMENT TO NITROGEN RELIEF VALVES

	During the troubleshooting operations, the nearly identical nitrogen relief systems located at two railcar loading
	and unloading stations were lined up to the discharge of the methyl mercaptan pumps (Figure 33). The nitrogen
	relief valves, however, were not designed for this new piping alignment. DuPont La Porte PHAs and relief
	valve design documents did not consider the possibility of lining up the methyl mercaptan storage tank pumps to
	these relief valves—as they were at the time of the incident. As a result, liquid methyl mercaptan discharged
	from a system designed for nitrogen vapor because the methyl mercaptan pump discharge pressure (90 psig)a
	was higher than the set pressure (80 psig) of these nitrogen relief valves. Pressurized methyl mercaptan from
	the pump caused the relief valves to open and release the highly toxic and highly flammable methyl mercaptan
	to the atmosphere [1, p. 46]. No one recognized this serious hazard because DuPont La Porte personnel did not
	perform an MOC when it changed the piping alignment during troubleshooting operations. An effective MOC
	should look at the design basis for equipment to determine whether the proposed use is compatible with its
	design.

	a The abbreviation psig stands for pounds per square inch gauge (pressure).

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 33. Nitrogen Relief Valves at One of the Two Methyl Mercaptan Railcar Unloading Stations. DuPont PHAs and
	relief valve design documents never considered the possibility of lining up the methyl mercaptan storage tank pumps
	to these relief valves—as they were at the time of the incident. As a result, liquid methyl mercaptan was discharged
	from a system designed for nitrogen vapor. Source: CSB.

	6.4.3 NO MOC OR PROCEDURE FOR VENT HEADER DRAINING OPERATION

	In 2011, DuPont La Porte invested about $20 million in a project to increase production rates and reduce
	environmental emissions for the Insecticide Business Unit.a The key piece of equipment installed for this
	project was the nitrogen oxides (NOx) reduced scrubbed incinerator (NRS) shown in Figure 34.b

	a Lannate® was a sold-out product, and DuPont routinely looked for opportunities to increase capacity [1, p. 17].
	b The NOx (nitrogen oxides) reduced scrubbed (NRS) incinerator system was a vertical thermal oxidizer system for the destruction of
	organics, halogenated organics, and nitrogen-containing wastes with removal of acid gas from discharge [1, p. 18].

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 34. NRS Incinerator. NRS was installed in 2011 to reduce emissions and allow
	increased production at the DuPont La Porte facility. Source: CSB.

	The NRS incinerator destroyed process waste gas streams that vented from equipment throughout the process.
	One of these waste gas streams contained methyl mercaptan vapor collected in a process vent system, referred to
	as the waste gas vent header piping. This header originated from various Lannate® and agricultural products
	intermediates process vessels, from methyl mercaptan railcar unloading facilities, and from the methyl
	mercaptan storage tank. The waste gas vent header piping provided the path for these waste gas streams to be
	directed to the NRS incinerator for thermal destruction (combustion) [1, p. 18].

	Following the 2011 installation of the NRS incinerator, DuPont experienced frequent high-pressure events in
	equipment connected to the waste gas vent header piping.a DuPont decided one significant cause of these high-

	a The high pressure in the waste gas vent header piping restricted vent sources flowing into the header, causing high-pressure events in
	process equipment. If left unaddressed, these high-pressure events could result in relief valves’ opening and discharging hazardous
	chemicals to the atmosphere [1, p. 18].

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	pressure events was liquid accumulation in the vapor waste gas vent header piping.a DuPont La Porte personnel
	had designed and installed the waste gas vent header piping to the NRS incinerator in 2011 without sufficient
	consideration of liquid accumulation. For example, the piping had low points where liquid could accumulate,
	and with no engineered equipment provided, such as a knock-out drum,b liquids could not be safely removed
	from the waste gas vent header piping system.c Because some of the process vents contained water vapor, the
	common belief was that the accumulated liquid consisted primarily of condensed water with small amounts of
	other process chemicals, including methyl mercaptan. As a result, area management instructed operations
	personnel to address high-pressure events in the waste gas vent header piping by opening manual drain valves
	from the waste gas vent header piping to the atmosphere, directing the liquid toward floor drains located within
	the manufacturing building [1, p. 18].

	DuPont La Porte personnel never completed an MOC or established a specific procedure or used safe work
	practices, such as line-breaking permits, for draining this liquid from the waste gas vent header piping. Rather,
	area management directed operators to drain the system through written instructions to operations staff in a daily
	instruction log book [1, p. 18]. Beginning January 14, 2014, and continuing until the incident, the daily
	instructions directed operators to drain the methyl mercaptan waste gas vent header’s “low point” on the third
	floor once per shift. After installation of a flexible hose from the waste gas vent header drain valve to the floor,
	the instructions changed to include directing the liquid through the hose under a running safety shower until the
	liquid stopped flowing from the hose [1, p. 18].

	DuPont La Porte personnel never sampled or analyzed the liquid workers routinely drained from this system [1,
	p. 18]. Daily instructions before the incident asked the operators to sample the unknown liquid. DuPont La
	Porte wanted samples of the liquid for a subsequent laboratory analysis to identify its chemical composition
	because workers reported that the liquid had a strong, noxious odor of sulfur compounds [1, p. 18]. Even
	though DuPont La Porte was aware that the liquid likely contained more than just water and was unaware of the
	actual chemical composition [1, p. 18], instructions to workers did not specify that additional precautions—such
	as wearing additional personal protective equipment (PPE)—were needed when draining the waste gas vent
	header.

	Weeks before the November 2014 incident, DuPont La Porte employees started an MOC to reduce liquid
	buildup by connecting a hose from the waste gas vent header piping to a process vessel, thus eliminating the
	need to drain the header liquid onto the floor. This MOC recognized that draining the waste gas vent header on
	the third floor was “not a good practice, since sometimes nitrogen is used to purge the line, which can lead to a

	a DuPont personnel believed the likely source of liquid accumulation was condensation from saturated vapor streams that originated in
	equipment operating above ambient temperatures. As these vapor streams entered the cooler waste gas vent header, liquid could
	condense and accumulate over time [1, p. 18].
	b Knock-out drum is an industry term for a process vessel that provides for separation of vapor and liquid.
	c The CSB identified three locations in the waste gas vent header piping to the NRS incinerator where liquid could accumulate: (1) inside
	the manufacturing building, (2) the piping outside the manufacturing building as it passed through the MIC unit, and (3) at detonation
	arresters just prior to where the waste gas from the waste gas vent header entered the NRS incinerator. Each location was equipped with
	a drain valve—two locations had atmospheric drains and only one location’s drain was routed to a caustic scrubber [1, p. 18].

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	nitrogen release inside the building.” Although area management recognized that this draining “was not a good
	practice” and could lead to a release of nitrogen,a the practice continued. Once personnel recognized the
	hazardous nature of this practice, the draining should have at least required additional safeguards, such as
	restricted access and respiratory protection.

	GUIDANCE TO INDUSTRY
	Companies should always use MOCs where required by corporate policy or federal process safety regulations.
	Special attention should be paid to nonroutine or abnormal operations because these may involve issues with
	safety systems, equipment, procedures, or personnel practices that can create additional hazards, potentially
	leading to serious safety incidents if there are poor MOC practices. Company MOC reviewers should be
	thoughtful and comprehensive so that potential dangers can be avoided or mitigated.

	LINE-‐BREAKING PRACTICES

	Companies should ensure the use of
	safe work practices,b such as line-
	breaking permits, to manage
	nonroutinec processes, such as
	draining the waste gas vent header
	piping. Under the PSM standard, a
	company must develop and
	implement safe work practices to
	provide for the control of hazards
	during work activities, such as
	lockout/tagout, confined space entry,
	or opening process equipment or

	Figure 35. Where Safe Work Practices Are Located on DuPont’s PSM Wheel [54, p.
	2]. Source: DuPont, with annotations by CSB.

	a As an asphyxiant, nitrogen can displace oxygen, creating a potentially hazardous environment [168, p. 2].
	b CCPS defines safe work practices as “an integrated set of policies, procedures, permits, and other systems that are designed to manage
	risks associated with non-routine activities such as performing hot work, opening process vessels or lines, or entering a confined space”
	[150].
	c CCPS defines a nonroutine activity as any activity that is not fully described in an operating procedure. Additionally, nonroutine does
	not refer to the frequency of an activity; rather, it refers to whether the activity is part of the normal sequence of converting raw materials
	to finished materials [52, p. 288].

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	piping (i.e., line breaking).a According to Guidelines for Risk Based Process Safety, from CCPS, safe work
	practices help control hazards and manage risks involved with nonroutine activities [52, p. 286]. Managing
	risks associated with nonroutine processes requires robust systems, thorough training and awareness, sound
	culture, and diligence [52, p. 293]. CCPS further suggests developing an integrated system for safe work
	practices, including safe work procedures, permits, checklists, and other written standards [52, pp. 291-92]
	(Figure 35).

	Any time a valve is opened to the atmosphere, the mechanical integrity of the system is compromised. Under
	PSM, employers must develop and implement safe work practices to control hazards during line breaking [18].b
	Figure 36 shows an approach to line and equipment opening (breaking) from a document that was produced
	under OSHA’s grant program.

	Figure 36. Triangle Approach to Line and Equipment Opening Permits. This slide is from a training
	document about OSHA operating procedures, safe work practices, and training [73, p. 27].
	Source: OSHA website.

	Employees at the DuPont La Porte facility understood that there were hazards associated with nonroutine
	procedures, such as line breaking. DuPont’s corporate standard, which was also DuPont La Porte’s line-
	breaking procedure, specifically includes opening a valve to the atmosphere in its definition of line breaking,

	a 29 C.F.R. § 1910.119 (f)(4).
	b According to OSHA, line breaking “means the intentional opening of a pipe, line, or duct that is or has been carrying flammable,
	corrosive, or toxic material, an inert gas, or any fluid at a volume, pressure, or temperature capable of causing injury” 29 C.F.R. §
	1926.1202.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	which requires a written job plan if it involves a hazardousa process or system.b Personnel at the DuPont La
	Porte facility, however, did not understand that draining the waste gas vent header through the flexible hose
	constituted a line break and required a permit. To drain the header using the existing equipment and work
	instructions, operations personnel had no choice but to open a valve to let the liquid flow toward the floor drain
	(and thus to the atmosphere), breaking the mechanical integrity of the line.

	Although area management left written instructions, there was no written job plan and no specific requirement
	to obtain a line-breaking permit before draining the header. Had the instructions specified the requirement, the
	personnel could have recognized the need.c

	Figure 37. Photo Showing Another Line Break. Operators drained liquid accumulation in another vent header
	without using line-‐breaking procedures. Source: CSB.

	In addition to the periodic draining of the waste gas vent header, the CSB found that DuPont La Porte operators
	routinely drained other hazardous process equipment (see Figure 37 and Figure 38) without using line-breaking
	procedures.

	a DuPont line-breaking training defines a hazardous process or system as a “process or system that contains any material at any pressure
	that could cause a risk of injury to an individual(s), a risk of fire or explosion, an environmental risk, or an off-site risk. Examples of
	hazardous processes or systems include, but are not limited to, compressed fluids, especially gases in pipes and vessels; corrosive and/or
	flammable substances and toxic process lines; and any other lines that could contain material that is hazardous on contact or inhalation,
	including fluid whose temperature is higher than 140°F (60°C) or lower than 14°F (-10°C).”
	b DuPont’s corporate line-breaking standard and DuPont La Porte’s site line-breaking procedure states, “A written job plan that
	specifically addresses safety, health, and environment (SHE) issues shall be prepared and implemented for all line breaks on hazardous
	processes and systems until all hazards have been learned or controlled. The job plan shall be prepared by qualified personnel and
	reviewed by everyone involved in the work prior to the start of the line break.”
	c At the DuPont La Porte site, if a procedure described how to do a line break and the appropriate precautions to take, personnel were not
	required to obtain a permit.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 38. Methylene Chloridea Compressor. Photo shows where operators routinely drained liquid accumulation
	from a methylene chloride compressor without using line-‐breaking procedures. Source: CSB.

	In both February and October 2014, DuPont La Porte personnel held problem-solving meetings with two
	different shifts of operations personnel to discuss high-pressure events in the waste gas vent header, and both
	times personnel identified liquid accumulation in piping low points as well as draining liquid from the vent
	header. Additionally, both shifts proposed modifying piping to eliminate low points where liquid accumulated
	as a potential solution. These meetings, however, did not ensure that personnel were safely troubleshooting the
	high-pressure events. It is important for companies to recognize that problem-solving sessions are opportunities
	to evaluate hazards and ensure that MOCs, operating procedures, and safe work practices are being used.

	In situations with unknown conditions, safe work practices required by PSM provide an organized approach to
	proceed safely. Consistently using safe work practices, such as line-breaking permits, ensures that each time a
	piece of process equipment is put into a nonroutine situation, personnel use effective safeguards. Furthermore, a
	permit process can address procedures, hazard analysis, PPE, and safeguards. Additionally, if hazards are
	identified, corrective actions should be developed, and effective safeguards should be implemented.

	GUIDANCE TO INDUSTRY
	Companies should recognize that nonroutine operations such as line breaking—even with established permit
	processes—can represent significant potential dangers. One way to help ensure that personnel understand the
	permit process is to train them on the different scenarios that would trigger a permit. Companies should analyze

	a Methylene chloride is a toxic chemical that can cause death at certain concentrations [93].

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	recurring operational or safety issues that trigger permits and eliminate the underlying causes of those issues. In
	instances requiring repeated line breaking, a hazard analysis should be performed, and an engineering solution
	should be applied (following an effective MOC) to avoid recurrence of the hazard.

	SHIFT COMMUNICATION PRACTICES

	Companies should develop procedures
	and practices for effective
	communication among their personnel
	(Figure 39). Effective communication
	depends on reliable and complete
	information that is transmitted and
	received in a timely manner.
	Understanding the information is
	imperative for safe operations.

	In its Guidelines for Risk Based
	Process Safety, CCPS outlines several
	approaches for communications
	including formalizing
	communications between workers,
	formalizing communications between
	shifts, and formalizing communications
	between work groups. Depending on the type of communication and group involved, verbal or written
	communication may be appropriate. When verbal communication is used, there should be a sufficient dialogue
	to verify that the person receiving information understands it. Additionally, personnel can use log books and
	written communications to transmit particularly important information. Using a combination of these two
	methods can benefit operations, as the CCPS book notes in the section on how formalize shift communications
	[52, pp. 475-76].

	Figure 39. Where Shift Communication Falls on DuPont’s PSM Wheel [54, p. 2].
	Source: DuPont, with annotations by CSB.

	During the troubleshooting operations, DuPont personnel relied upon verbal communications to convey the
	Technical Team’s plan to the incoming shift (the shift working at the time of the incident) [1, pp. 25-26]. Post-
	incident, it remains unclear what the prior shift communicated to the incoming shift about the Technical Team’s
	plan and the status of the troubleshooting, because this information was communicated only verbally.a

	According to a DuPont training, “An effective shift turnover is important for chemical operations to ensure
	continuity across operating shifts and ensure all operating personnel fully understand both normal and abnormal
	or unusual conditions within the operating area in order to avoid misunderstandings or lack of information.”

	a The only written communication to the night shift supervisor was a note in the shift log that stated: “Unplugging M[e]SH Header.”
	MeSH is DuPont’s abbreviation for methyl mercaptan [1, p. 26].

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	Having continuity in operations from shift to shift ensures that processes run smoothly and equips workers
	coming on shift with information that helps strengthen process safety performance.

	During the troubleshooting operations, DuPont relied upon verbal communications at several key times:

	• The Technical Team’s verbal communication of the plan to the day shift supervisor [1, p. 25].

	• The face-to-face verbal communication between shift supervisors to transition the efforts from the day

	shift to the night shift [1, pp. 25-26].

	Reliance on verbal communication during this troubleshooting operation proved detrimental because this
	problem was novel, and the night shift supervisor (referred to in this report as the “Shift Supervisor”) was
	learning of the shutdown and subsequent startup difficulties for the first time when he came on shift. Although
	the Technical Team verbally communicated with the day shift supervisor, the Technical Team did not meet with
	the newly involved night shift supervisor, nor did it communicate verbally or in writing with the night shift
	operations personnel. Improved communication could have helped ensure continuity of the troubleshooting
	operation by better informing the night shift of all the relevant activities that had occurred during the week and
	the steps needed to continue with the troubleshooting process.

	It is important for a company to assess the type of communication necessary for effective information sharing
	between shifts and between departments or divisions of a company. The more complicated the process and the
	more novel the problem, the more imperative it is to have effective communication. Consideration should be
	given to using multiple modes of communication (including written communication) to ensure that all affected
	employees get the information they need to perform their jobs safely, within the broader context of other
	ongoing operational and process safety issues, to maximize the chance for continuity and safety in operations.

	GUIDANCE TO INDUSTRY
	Effective communication between different operational units at a facility, and between supervisors and workers
	on changing shifts, is critical to safety. Communication is necessary to convey the status of operations, ongoing
	changes, abnormalities, unusual operating conditions, or other relevant issues associated with chemical process
	equipment. The more complex the process involved, the greater the imperative to ensure that communication is
	effective. Reliance solely upon one form of communication, especially verbal communication, can leave the
	workforce vulnerable to potential gaps in information communicated, misunderstandings, or absence of critical
	information in what oftentimes can be an evolving situation.

	7 ADDITIONAL FACTS, CONDITIONS, AND CIRCUMSTANCES IDENTIFIED

	The CSB is tasked with investigating and reporting “to the public in writing the facts, conditions, and
	circumstances and the cause or probable cause of any accidental release resulting in a fatality, serious injury, or

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	substantial property damages.”a This information is beneficial in promoting safe workplaces and helping to
	protect workers, the public, and the environment.

	The CSB identified numerous conditions and circumstances that existed at the time of the November 15, 2014
	DuPont La Porte incident. In September 2015, the CSB issued an Interim Recommendations report to address
	conditions and circumstances, some of which were causal to the incident, before the DuPont La Porte Lannate®
	facility restarted [1]. Similar to its Interim Recommendations, the CSB identified a condition and circumstance,
	DuPont La Porte’s employee incentive program, that could be strengthened to further promote safe workplaces
	at DuPont legacy sites. Section 7.1 addresses the guidance for incentive compensation programs that existed at
	the time, and the corresponding Guidance to Industry section covers newly published OSHA guidance and
	industry guidance.

	EMPLOYEE INCENTIVE PROGRAM

	Companies should ensure that safety incentive programs do not disincentivize personnel from reporting injuries
	or other deficiencies in process safety management systems.b The DuPont La Porte facility implemented a
	variable compensation (bonus) system called the La Porte Local Performance Based Compensation (LPBC)
	program. The LPBC, however, did not use process safety management performance metrics. Instead, it used a
	safety modifier based solely on OSHA total recordable injuries, and it was constructed in a way that could have
	potentially disincentivized reporting injuries.

	The stated purpose of the LPBC, which was in effect at the time of the November 2014 incident, was “to
	provide the opportunity for eligible employees to share in business results that exceed expectations.” This
	program created incentive compensation opportunities for DuPont La Porte employees in various categories,
	including operators, mechanics, and general helpers, who were represented by the International Chemical
	Workers Union Council of the United Food and Commercial Workers (ICWUC/UFCW) Local 900C labor
	union.

	The structure of the LPBC program for this group of employees evolved over the established range of
	performance years but involved two primary components. The first part, referred to as the Business Metric,

	a 42 U.S.C. § 7412(6)(C)(i).
	b Under OSHA’s Recording and Reporting Occupational Injuries and Illnesses regulations, an employer “must establish a reasonable
	procedure for employees to report work-related injuries and illnesses promptly and accurately. A procedure is not reasonable if it would
	deter or discourage a reasonable employee from accurately reporting a workplace injury or illness” (29 C.F.R. § 1904.35(b)(1)(i)). The
	OSH Act and OSHA regulations, including its Recording and Reporting Occupational Injuries and Illnesses regulations, prohibit
	employers from discriminating, retaliating, or instituting other adverse consequences on employees who report injuries or other safety
	concerns. According to OSHA, “OSHA’s Whistleblower Protection Program enforces the whistleblower provisions of more than twenty
	whistleblower statutes protecting employees who report violations of various workplace safety and health, airline, commercial motor
	carrier, consumer product, environmental, financial reform, food safety, health insurance reform, motor vehicle safety, nuclear, pipeline,
	public transportation agency, railroad, maritime, and securities laws. Rights afforded by these whistleblower protection laws include, but
	are not limited to, worker participation in safety and health activities, reporting a work-related injury, illness or fatality, or reporting a
	violation of the statutes herein” [166] (29 C.F.R. § 1904.35(b)(1)(iv)).

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	rewarded success with respect to site financial goals, such as increases in after-tax operating income and
	improvement in cash flow from operations. The second part, referred to as Line of Sight, represented a
	weighted average of operational performance metrics among the different units at the DuPont La Porte site, and
	consisted of things like reducing costs and exceeding production targets.

	Any incentive eligible to be paid for exceeding business performance goals, however, would then potentially be
	reduced by what the LPBC termed a “safety modifier.” For example, in performance year 2011, the DuPont La
	Porte site established the safety modifier based on the number of OSHA total recordable injuries, with the
	number of recordable injuries causing a reduction in available incentive award payments that were otherwise
	due to be paid to members of that portion of the workforce. Specifically, at the program’s start in 2011, if there
	were three or fewer recordable injuries, the LPBC set the safety modifier value at 1, which did not reduce the
	incentive payable for business performance; however, as more recordable injuries occurred, the safety modifier
	incrementally reduced the total incentive paid to employees.a

	Over the years, the LPBC evolved in terms of how the safety modifier worked. In 2014, the year of this
	incident, the LPBC adjusted the safety modifier so that every reported worker injury would decrease the group’s
	bonus payout by 5 percent, with a maximum 50 percent reduction of any available bonus paid to employees.

	By using a safety modifier that considered only worker injuries, DuPont La Porte equated safety performance
	with occupational safety metrics, similar to DuPont’s Safety Perception Surveys. Thus, DuPont La Porte did not
	include a process safety performance metric in its incentive. A disproportionate emphasis on occupational
	safety metrics as the measurement for safety performance could confuse personnel into viewing occupational
	safety and process safety as the same or perceiving that occupational safety is more important than process
	safety. Furthermore, emphasizing a low number of total recordable injuries could give personnel false
	confidence about process safety performance.

	As stated recently by CCPS in its publication on process safety culture, Essential Practices for
	Creating, Strengthening, and Sustaining Process Safety Culture,

	“Money is one of the strongest influences on human behavior, for better or worse. When developing
	compensation and incentive schemes based on process safety performance, it is critical to design them
	carefully to reinforce the desired cultural attributes and behaviors. It is equally critical to be aware of
	the many pitfalls that lead a well-intentioned compensation scheme to unwittingly support negative
	behaviors [56, p. 109].”

	a In 2011, if there were four recordable injuries, then the modifier reset to 0.9, if there were five recordable injuries it reset to 0.8, and for
	six or more recordable injuries it reset to 0.75. Over subsequent years, the safety modifier became more impactful in a negative way if the
	site had not improved its total recordable injury rate from the previous year.

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	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	If a company decides to use an incentive to focus on safety performance, it should consider having a process
	safety component that uses leading indicators over multiple years. Because process safety incidents are
	typically infrequent, personnel can perform poorly in process safety for a long time without experiencing a
	major accident [56, p. 110]. Therefore, using lagging indicators, such as the number of process safety incidents,
	could hide poor process safety performance [56, p. 110]. On the other hand, using leading indicators related to
	correct behaviors, such as percentage of inspection completion, is better because the events on which such
	indicators are based happen more frequently [56, p. 110]. Additionally, companies can drive long-term process
	safety performance by using multiyear incentives because process safety needs to be performed consistently
	well over time [56, p. 110]. If companies employ yearly schemes, management should ensure that rewards are
	provided in recognition of steady process safety performance over the course of a year [56, pp. 110-111]. If a
	process safety incentive is used, companies should ensure that process safety incentives are measuring key
	aspects of process safety management systems or process safety culture, and not personal or occupational safety
	metrics [56, p. 112]. Furthermore, to prevent confusion between process safety and occupational safety,
	management should not combine process safety indicators and occupational safety indicators into a single safety
	incentive [56, p. 112].

	Regardless of its precise formulation and despite small changes made to the safety modifier throughout the
	range of years represented in this program, DuPont La Porte’s LPBC potentially created a disincentive for
	workers to report injuries. Employees working under these types of programs would report injuries at financial
	risk to themselves and their co-workers. In addition, safety incentive programs like this one may not be
	effective in driving safety improvement [74]. Furthermore, when constructed in this manner, a safety incentive
	program can be susceptible to “gaming,” with workers refraining from reporting workplace injuries to earn the
	otherwise available incentive due to be paid [74].a This phenomenon can make it difficult to spot trends in
	worker safety issues, leaving other workers vulnerable to the same injury as potentially dangerous conditions go
	uncorrected, among other practical concerns. As OSHA Deputy Assistant Secretary Fairfax explained in a
	March 12, 2012, memorandum to agency regional administrators and whistleblower program managers,

	If employees do not feel free to report injuries or illnesses, the employer’s entire workforce is
	put at risk. Employers do not learn of and correct dangerous conditions that have resulted in
	injuries, and injured employees may not receive the proper medical attention, or the workers’
	compensation benefits to which they are entitled. Ensuring that employees can report injuries
	or illnesses without fear of retaliation is therefore crucial to protecting worker safety and health
	[75].

	The memorandum further expressed concern that these types of safety incentive bonus programs may place
	implicit pressure on employees not to report workplace injuries or illnesses:

	a In a recent National Safety Council article, one corporate safety manager noted that these types of incentive programs have surface
	allure but do not usually drive actual safety improvement, and suggested that some incentive programs may instead actually promote
	“covering up” and “cooking the books” through underreporting or nonreporting of workplace illnesses or injuries so employees can
	remain eligible for rewards [74].

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	Some employers establish programs that unintentionally or intentionally provide employees an
	incentive to not report injuries. For example, an employer might enter all employees who have
	not been injured in the previous year in a drawing to win a prize, or a team of employees might
	be awarded a bonus if no one from the team is injured over some period of time. Such
	programs might be well-intentioned efforts by employers to encourage their workers to use safe
	practices. However, there are better ways to encourage safe work practices, such as incentives
	that promote worker participation in safety-related activities, such as identifying hazards or
	participating in investigations of injuries, incidents or “near misses.” OSHA’s [Voluntary
	Protection Programs] Guidance materials refer to a number of positive incentives, including
	providing tee shirts to workers serving on safety and health committees; offering modest
	rewards for suggesting ways to strengthen safety and health; or throwing a recognition party at
	the successful completion of company-wide safety and health training [75].

	After the November 2014 incident, the DuPont La Porte site changed its LPBC bonus system to align it with
	OSHA guidance that existed at the time, such that the safety modifier would not discourage workers from
	reporting injuries. The new 2015 La Porte safety modifier was based on employees’ completing computer-
	based training courses and annual medical examinations. The CSB viewed DuPont La Porte’s correction of the
	potential disincentive in the LPBC as a positive development.

	The CSB lacks documentation showing that workers on DuPont La Porte’s Safety Committee or those covered
	by the LPBC objected to this safety modifier prior to the incident. None of the workers on the Safety
	Committee participated in the capacity of official union representative of ICWUC/UFCW Local 900C.
	However, when workers have concerns about an incentive program that can impact the reporting of incidents,
	they should report these concerns to their union, if they are represented, or to a health and safety committee or a
	manager. It is imperative, regardless of having a particular incentive program, that workers report unsafe
	conditions and safety (personal or process) incidents to help prevent future incidents.

	Consistent with OSHA regulations and guidance, all legacy DuPont sites should evaluate any safety incentive
	programs or variable pay initiatives that reduce employee bonus awards based solely upon injury rates, or that
	otherwise potentially impair OSHA record-keeping requirements, and change the payout structure to incentivize
	improved safety performance. OSHA itself does not consider “conditioning a benefit on compliance with
	legitimate safety rules or participation in safety-related activities” to violate section 1904.35(b)(1)(iv), so long as
	programs that do so are instituted appropriately.a As DuPont reviews incentive programs at its legacy sites, the
	CSB similarly encourages DuPont to continue to explore ways to encourage positive safety performance, with
	respect to both personal and process safety. Specifically, the CSB encourages DuPont to consider expanding
	consideration of safety incentive programs by broadening the company’s focus beyond personal safety

	a “For example, raffling off a $500 gift card each month in which employees universally complied with legitimate workplace safety
	rules—such as using required hard hats and fall protection and following lockout-tagout procedures—would not violate the rule.
	Likewise, rewarding employees for participating in safety training or identifying unsafe working conditions would not violate the rule.
	On the contrary, OSHA encourages employers to find creative ways to incentivize safe work practices and accident-prevention measures
	that do not disproportionately penalize workers who report work-related injuries or illnesses” [158].

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	programs. If DuPont desires to retain safety incentive programs, the company should also consider how it can
	incentivize safety more holistically, ensuring that process safety and major accident prevention efforts are
	bolstereda along with more traditional efforts aimed at reducing workplace illnesses and injuries. In no case,
	however, should any incentive program act in any way to discourage the required reporting of safety issues such
	as injuries, illnesses, incidents, hazards, or near-miss incidents.

	GUIDANCE TO INDUSTRY
	Understanding how incidents occur can be beneficial in preventing future worker injuries and strengthening
	process safety management systems. Some safety incentive programs, however, may create a culture of
	nonreporting of safety incidents, potentially hampering learning from the underlying events, possibly resulting
	in a failure to address the causes of the incident. In response to these types of concerns, OSHA created record-
	keeping requirements and issued regulations to prevent whistleblower retaliation for reporting injuries.b, c
	Additionally, OSHA recently published guidance on how to formulate an incentive without disincentivizing
	workers from reporting injuries.

	On October 11, 2018, Kim Stille, Acting Director of Enforcement Programs at OSHA, issued a memorandum to
	Regional Administrators titled “Clarification of OSHA’s Position on Workplace Safety Incentive Programs and
	Post-Incident Drug Testing Under 29 C.F.R. § 1904.35(b)(1)(iv)” [76]. In that memorandum, Acting Director
	Stille sought to clarify OSHA enforcement around workplace safety incentives paid by employers. She stated
	that “29 C.F.R. § 1904.35(b)(1)(iv) does not prohibit workplace safety incentive programs” as long as such
	programs “are not implemented in a manner that discourages reporting” of workplace injuries [76]. The
	memorandum then elaborated on how an employer could avoid even “inadvertent deterrent effects of a rate-
	based incentive program by taking positive steps to create a workplace culture that emphasizes safety, and not

	a According Andrew Hopkins, “Other things like incentives need to be rethought. Performance agreements and bonuses now reinforce
	the priorities of speed and production. They’ve been made to reinforce personal safety in recent years. They need now to be rethought
	again to incentivize the avoidance of catastrophe” [67, p. 3].
	b According to the 2012 Fairfax memorandum, “Incentive programs that discourage employees from reporting their injuries are
	problematic because, under section 11(c), an employer may not ‘in any manner discriminate’ against an employee because the employee
	exercises a protected right, such as the right to report an injury.… If an employee of a firm with a safety incentive program reports an
	injury, the employee, or the employee’s entire work group, will be disqualified from receiving the incentive, which could be considered
	unlawful discrimination. One important factor to consider is whether the incentive involved is of sufficient magnitude that failure to
	receive it ‘might have dissuaded reasonable workers from’ reporting injuries. Burlington Northern & Santa Fe Railway Co. v. White,
	548 U.S. 53, 68 (2006).” The memorandum continues, “In addition, if the incentive is great enough that its loss dissuades reasonable
	workers from reporting injuries, the program would result in the employer’s failure to record injuries that it is required to record under
	Part 1904. In this case, the employer is violating that rule, and a referral for a recordkeeping investigation should be made.… This may
	be more likely in cases where an entire workgroup is disqualified because of a reported injury to one member, because the injured worker
	in such a case may feel reluctant to disadvantage the other workgroup members” [75].
	c In explaining OSHA’s amended regulation found at 29 C.F.R. § 1904.35(b)(1)(i), OSHA Deputy Assistant Secretary Dorothy
	Dougherty made explicit the longstanding requirement for employers to have a reasonable procedure for employees to report work-
	related injuries and illnesses, and (b)(1)(iv) incorporated the existing prohibition on retaliating against employees for reporting work-
	related injuries or illnesses under section 11(c) of the OSH Act, 29 U.S.C. § 660(c). She also made clear, however, that “Section
	1904.35(b)(1)(iv) does not prohibit safety incentive programs. Rather, it prohibits taking adverse action against employees simply
	because they report work-related injuries or illness. Withholding a benefit—such as a cash prize drawing or other substantial award—
	simply because of a reported injury or illness would likely violate section 1904.35(b)(1)(iv) regardless of whether such an adverse action
	is taken pursuant to an incentive program [158].”

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	just rates” [76]. For example, Acting Director Stille noted that any inadvertent deterrent effect caused by a rate-
	based incentive program could be “counterbalanced” by affirmative steps such as

	•

	•

	•

	creating an incentive program that rewards employees for identifying unsafe conditions in the
	workplace;

	implementing a training program for all employees to reinforce reporting rights and responsibilities,
	emphasizing the employer’s nonretaliation policy; or

	instituting a mechanism for accurately evaluating employees’ willingness to report injuries and illnesses
	[76].

	In Essential Practices for Creating, Strengthening, and Sustaining Process Safety Culture, CCPS posed the
	question of whether a company should forgo all process safety–related incentives. CCPS stated that an
	argument can be made to that effect, with working injury-free serving as a long-term benefit for any worker.
	Nevertheless, money is a strong human motivator, and if used with care, it can influence behavior for the better
	[56, p. 109]. As with occupational safety–based incentives, management should consider whether the use of a
	process safety incentive creates a potential for inverse effects. An incentive could lead to the opposite of the
	desired behavior (e.g., using incident numbers or incident reduction for the basis of an incentive “may drive
	personnel to hide or under-report incidents”) [56, p. 110].

	Companies should assess safety incentive programs currently in place to ensure they are effective in driving
	positive safety change and do not serve as a disincentive for reporting workplace safety issues.

	8 KEY FINDINGS

	In its investigation of the November 15, 2014, DuPont La Porte incident, the CSB found that

	1. DuPont did not effectively respond to a toxic chemical release;

	2. DuPont’s corporate process safety management system did not ensure that DuPont La Porte

	implemented and maintained an effective process safety management system; and

	3. DuPont La Porte did not assess its culture for process safety in the site’s Safety Perception Surveys or
	any other formal assessment program, allowing serious process safety deficiencies to exist at the site.

	The CSB issues recommendations to the DuPont La Porte facility, DuPont, and the Local 900C of the
	International Chemical Workers Union Council of the United Food and Commercial Workers, as well as
	guidance and key lessons for the chemical industry, to address these key findings and to help prevent future
	incidents.

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	U.S. Chemical Safety and
	Hazard Investigation Board

	9 SAFETY GUIDANCE

	The CSB, through the course of its investigation, identified key lessons from the November 15, 2014 incident
	that companies can use at their facilities (for more information, see Guidance to Industry from referenced
	sections).

	1. Companies should ensure that employees understand the hazards of chemicals that they are working
	with and may be potentially exposed to if there is a release. Where there are multiple hazardous
	chemicals, such as methyl isocyanate (MIC) and methyl mercaptan, it is important that companies
	effectively train workers on the hazards of each chemical at their facility. Furthermore, companies
	should train workers who handle multiple highly toxic chemicals, such as methyl mercaptan and MIC,
	to treat these chemicals with equal importance. This training is important for workers to help ensure
	they have a working knowledge of the relevant chemical hazards. (Section 3: Delayed Awareness of
	Toxic Chemical Release)

	2. Automatic alarms designed to alert personnel of hazardous conditions—such as a release of a toxic

	chemical or the existence of an explosive atmosphere—can relay critical safety information immediately
	to personnel, without the potential delays inherent in a system that relies solely on a control room
	operator to communicate safety alarms verbally to operators in the field. (Section 3: Delayed
	Awareness of Toxic Chemical Release)

	3. Specific technical knowledge from unit experts—including technical and operations personnel—can be
	invaluable to the incident commander in an emergency at a chemical processing facility. Companies
	need to ensure that these individuals are preidentified as technical support personnel and that backup
	capability is available in the event the primary technical support personnel become unavailable.
	(Section 4.2: Process Coordinator Was Missing)

	4. Plant emergency procedures should clearly outline the alerting and notification protocols for different

	types of plant emergencies. These procedures should also include guidance for situations in which there
	is insufficient initial information to effectively assess the nature of the problem and the level of
	emergency response team resources required. (Section 4.3.1: Call for ERT Response)

	5. Even though industrial facilities may infrequently call upon emergency response vehicles, it is essential

	that those vehicles function as intended when needed. To ensure emergency vehicle reliability,
	companies must develop and apply regular maintenance and testing schedules for their emergency
	response vehicles. (Section 4.3.2: ERT Mini-Pumper Truck Not Operational)

	6. Companies need a reliable means for emergency response teams to characterize hazardous atmospheres.
	Companies should provide air monitoring equipment to emergency response teams and train those
	teams on how to operate the equipment and interpret monitoring results. At facilities that assign the
	inspection, maintenance, and storage of portable air monitoring equipment to personnel who are not
	members of the emergency response team, the company should ensure that team members know where

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	the equipment is stored and can access it. (Section 4.4.1: Entry into Potentially Explosive
	Atmosphere)

	7. High-hazard areas should be equipped with adequate detectors, alarms, and surveillance technology to
	identify whether there is a chemical release (or other type of emergency) and if personnel are affected.
	(Section 4.4.2: No Technology to Locate Missing Workers)

	8. Companies need to develop a system to update emergency planning documents when pertinent hazards
	are identified. Changes to emergency planning documents should be effectively communicated to the
	site emergency response team. (Section 4.4.3: Unrecognized Manufacturing Building Collapse
	Hazard)

	9. Chemical facilities should ensure that their emergency response plans include maps showing the layout
	of buildings containing hazardous chemicals, for use by emergency responders and to aid evacuation
	and rescue efforts. Facilities should also coordinate regularly scheduled site tours for both plant and
	external emergency responders to develop strong working relationships and help ensure responders are
	familiar with facility access points, hazards, emergency response issues, and site or facility layout.
	Additionally, facilities should familiarize responders with process structures or buildings by having
	periodic drills inside them, to improve responder navigation during emergencies. To enhance responder
	performance, members of an emergency response team should train together, especially when multiple
	companies are staffing a single, integrated team. (Section 4.5: Difficulties Navigating Manufacturing
	Building)

	10. When a process safety incident occurs, such as a chemical release, it can be beneficial for technical

	personnel who are not immediately involved in emergency response functions to analyze process data to
	assess the source, scope, and magnitude of the incident. This analysis can help the company (and the
	incident commander) identify needed equipment manipulations to stop or control the incident, such as
	shutting down pumps or closing isolation valves. (Section 4.6: No Analysis of Process Data to
	Identify Source of Leak)

	11. Companies should ensure emergency response team members are trained to (1) physically designate the
	hot zone; (2) communicate the location of the hot zone and entry control points to all personnel assisting
	with the emergency response, including operations personnel; and (3) control entry and exit points of
	the hot zone. (Section 4.7: Inadequate Creation and Control of Hot Zone)

	12. Dispersion modeling of chemical releases can be an effective risk-based emergency response tool, but
	its results are highly dependent on accurate input data. During an emergency, it can sometimes be
	difficult to obtain an accurate release rate, limiting the accuracy of resulting models. Companies should
	not rely on unsupported data when making critical emergency response decisions, such as those
	affecting workers, members of the public, or people or property in the surrounding area. In emergencies
	that could affect the public and in which chemical release rates cannot be accurately estimated (for
	model input), written guidelines for how and when to alert the public should be available to emergency
	responders. As better information about the release becomes available, the public protection zone can
	be adjusted accordingly. (Section 4.8.1: Release Modeling)

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	13. Monitoring for hazardous gases along the fence line at chemical facilities can help companies

	understand the extent of a release. This monitoring can be performed by fixed detectors, which can
	continually collect and record data, providing early notification of releases outside the property. When
	fixed detectors are not available, a person using a portable gas detector may also perform air monitoring.
	This strategy, however, introduces additional risk because that individual may enter a hazardous
	environment unknowingly. Proper personal protective equipment, including respiratory protection, is
	needed during manual air monitoring operations. (Section 4.8.4: Air Monitoring)

	14. Employing any particular management system on its own, without additional work aimed at successful
	implementation, may not be sufficient to prevent major chemical incidents. Companies should conduct
	periodic comprehensive assessments of their process safety management systems and their
	implementation of these systems at established intervals to evaluate and identify opportunities to
	strengthen their systems’ effectiveness. (Section 5.3: American Chemistry Council)

	15. Companies should ensure that when a process safety management system changes, their sites update
	their programs simultaneously and adhere to those changes. The ability to adapt quickly to industry
	trends and field learnings can be beneficial. To maximize the value of improvements, companies should
	consider reevaluating sites to ensure consistency with evolving practices. (Section 5.3.3: Responsible
	Care Conformance Audits)

	16. Companies should invest time and resources to conduct audits. These resources should be used to

	ensure that audits are robust and comprehensive. (Section 5.3.3: Responsible Care Conformance
	Audits)

	17. Personal safety performance and process safety performance are two different safety measures that all
	chemical process facilities should evaluate. Personal injury statistics are not an effective gauge of the
	quality of process safety management systems or process safety culture. (Section 5.4.1: Building a
	Safety Culture)

	18. Companies should have a process in place to ensure that hazard scenarios are fully developed and that
	process hazard analysis (PHA) teams assign appropriate initiating event frequencies and consequence
	severities to the scenario because it can make a significant difference in safeguard requirements.
	Additionally, PHA teams need to ensure that the safeguards applied to the hazard scenario are relevant
	and effective in controlling the hazard. (Section 6.1:Process Hazard Analysis Evaluation)

	19. Companies should ensure before corrective actions are closed that the intent of a recommendation is

	met. One way to make the intention of the recommendation the focus of a corporate or site action is to
	evaluate the substance of the corrective action in addition to the time it takes to complete the action.
	(Section 6.2: Implementation of Corrective Actions)

	20. Companies should develop an action plan to identify and control hazards during troubleshooting

	operations. There are multiple approaches a company can take to address troubleshooting, including
	PHAs, operating procedures, management of change (MOC) procedures, and safe work practices.
	(Section 6.3: Process Safety Practices during Troubleshooting Operations)

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	21. Companies should always use MOCs where required by corporate policy or federal safety regulations
	(OSHA’s Process Safety Management standard or the EPA’s Risk Management Plan rule). Special
	attention should be paid to nonroutine or abnormal operations because there may be issues with safety
	systems, equipment, procedures, or personnel practices that can create additional hazards, potentially
	leading to serious safety incidents if there are poor management of change practices. MOC reviewers
	should be thoughtful and comprehensive, so potential dangers can be avoided or mitigated. (Section
	6.4: MOC Practices)

	22. Companies should recognize that nonroutine operations such as line breaking—even with established
	permit processes—can represent significant potential dangers. One way to help ensure that personnel
	understand the permit process is to train them on the different scenarios that would trigger a line-
	breaking permit. Companies should analyze recurring operational or safety issues that trigger permits
	and eliminate their underlying causes. In instances requiring repeated line breaking, for example, a
	hazard analysis should be performed, and an engineering solution should be applied (following an
	effective MOC) to avoid recurrence of the hazard. (Section 6.5: Line-Breaking Practices)

	23. Effective communication between different operational units at a facility, and between supervisors and
	workers on changing shifts, is critical to safety. Communications are essential to convey the status of
	operations, any ongoing changes, abnormalities, unusual operating conditions, or other relevant issues
	associated with chemical process equipment. The more complex the process involved, the more of an
	imperative exists to ensure that communication is effective. Reliance solely upon one form of
	communication, especially verbal communication, can leave the workforce vulnerable to potential gaps
	in information communicated, misunderstandings, or the absence of critical information in what
	oftentimes can be an evolving situation. (Section 6.6: Shift Communication Practices)

	24. Employee incentive programs that reduce bonuses to employees based upon the number of recordable
	injuries—or other similar metric—can create a disincentive for workers to report injuries or incidents.
	Understanding how incidents occur can be beneficial in preventing future worker injuries and
	strengthening process safety management systems. Some safety incentive programs, however, may
	create a culture of nonreporting of safety incidents, potentially hampering learning from the underlying
	events, possibly resulting in a failure to address the causes of the incident. If employees do not feel free
	to report workplace injuries, incidents, or near misses, the employer’s entire workforce is put at risk.
	Ensuring that employees can report injuries or other process safety management system deficiencies is
	therefore central to protecting worker safety and health and aiding accident prevention. (Section 7.1:
	Employee Incentive Program)

	10 RECOMMENDATIONS

	The CSB makes the following safety recommendations:

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	DUPONT LA PORTE, TEXAS, CHEMICAL FACILITY

	2015-01-I-TX-R8

	Work together with emergency response team (ERT) member companies (DuPont, Chemours, Kuraray, and
	Invista), the International Chemical Workers Union Council of the United Food and Commercial Workers
	(ICWUC/UFCW) Local 900C, and the ICWUC/UFCW staff (if requested by the Local 900C) to update the
	DuPont La Porte emergency response plan. The emergency response program should ensure that periodic
	exercises or drills are performed on new procedures developed to address key lessons to strengthen ERT
	capabilities. The emergency response program should address the following:

	• Preidentifying unit experts as technical support personnel and ensuring that backup capability is
	available in the event the primary technical support personnel become unavailable. (Section 4.2:
	Process Coordinator Was Missing)

	• Clearly detailing in plant emergency procedures the alerting and notification protocols for different

	types of plant emergencies. Provide initial training to new plant personnel and periodic training to all
	plant personnel on these emergency communication procedures. These procedures should also include
	guidance for emergency responders when there is insufficient initial information to effectively assess
	the nature of the problem and the level of ERT resources required. (Section 4.3.1: Call for ERT
	Response)

	• Developing and applying regular maintenance schedules for emergency response vehicles consistent

	with the National Fire Protection Association’s Standard for the Inspection, Maintenance, Testing, and
	Retirement of In-Service Emergency Vehicles (NFPA 1911), which requires weekly visual and
	operational checks of emergency vehicles and has example checklists to use when performing
	preventive maintenance on emergency vehicles. (Section 4.3.2: ERT Mini-Pumper Truck Not
	Operational)

	• Ensuring that ERTs have reliable means to characterize hazardous atmospheres, for example equipment
	that monitors toxicity, explosivity, and oxygen levels. Additionally, ensure that ERT members know
	where the equipment is stored, can access it, and are trained on its proper use. (Section 4.4.1: Entry
	into Potentially Explosive Atmosphere)

	• Evaluating high-hazard areas, including PSM covered processes, to determine whether detectors and
	alarms are necessary to identify chemical releases (or other types of emergencies). Additionally,
	consider equipping high-hazard areas with surveillance technology to identify personnel in the field.
	(Section 4.4.2: No Technology to Locate Missing Workers)

	• Developing and implementing written policy and procedures to update emergency response plan

	documents when hazards are identified. For example, personnel can identify these types of hazards in
	process hazard analyses, facility siting studies, management of change reviews, and incident
	investigations. Changes to emergency planning documents should be effectively communicated to the

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	site ERT as soon as possible after identifying the hazard. (Section 4.4.3: Unrecognized
	Manufacturing Building Collapse Hazard)

	• Ensuring that emergency response planning accounts for difficulties in conducting response efforts,
	including (1) maps included in emergency response plans to show the layout of buildings containing
	hazardous chemicals, for use by emergency responders and to aid evacuation and rescue efforts; (2)
	coordination of periodic (at least annual) site tours for plant and external emergency responders; (3)
	training emergency responders to help ensure familiarity with facility access points, hazards, emergency
	response issues, and site or facility layout; and (4) building teamwork by having members (from the
	different companies) of the ERT field train (by conducting drills) together when practicable. (Section
	4.5: Difficulties Navigating Manufacturing Building)

	• Assigning knowledgeable personnel the responsibility to analyze process data to assess the source,

	scope, and magnitude of any incident. (Section 4.6: No Analysis of Process Data to Identify Source
	of Leak)

	• Training emergency response team members to (1) physically designate the hot zone; (2) communicate
	the location of the hot zone and entry control points to all personnel assisting with the emergency
	response, including operations personnel; and (3) control entry and exit points of the hot zone. (Section
	4.7: Inadequate Control of Hot Zone)

	• Addressing in the emergency response plan how to characterize (including size, concentration, location,
	and direction of release) hazardous chemical releases and providing guidance on how and where people
	should take protective action (e.g., sheltering-in-place) in the event of a chemical release. (Section
	4.8.1: Release Modeling)

	• Developing a procedure in the emergency response plan to effectively monitor for hazardous gases
	along the fence line at chemical facilities during the release to help workers understand and clearly
	communicate the extent of a release. (Section 4.8.4: Air Monitoring)

	In addition, provide a copy of the emergency response plan to the Emergency Response Team and their local
	union representatives.

	LOCAL 900C OF THE INTERNATIONAL CHEMICAL WORKERS UNION COUNCIL
	(ICWUC) OF THE UNITED FOOD AND COMMERCIAL WORKERS (UFCW) a

	2015-01-I-TX-R9

	a The union members at the DuPont La Porte facility were represented by the (ICWUC) of the (UFCW) and Local 900C.

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Work together with DuPont to develop and implement the emergency response plan described in
	Recommendation R8 (2015-01-I-TX-R8).

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	U.S. Chemical Safety and
	Hazard Investigation Board

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	U.S. Chemical Safety and
	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

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	Hazard Investigation Board

	Toxic Chemical Release at the
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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

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	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

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	Hazard Investigation Board

	Toxic Chemical Release at the
	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	https://training.fema.gov/hiedu/docs/principlesofem/principles%20of%20em%20-%20session%205%20-
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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	APPENDIX A: CAUSAL ANALYSIS

	The AcciMapa (size 11" x 17") can be found at www.csb.gov on the DuPont La Porte investigation page.

	a An AcciMap is a multilayered causal diagram that arranges the various causes of an accident in terms of their remoteness from the
	initiating events. This approach differs from other analysis techniques in that it identifies causes in all parts of the system, ranging from
	the physical sequence of events right up to causes at the governmental, regulatory, and societal levels. It is a CSB internal investigation
	procedure that is especially useful for developing broadly applicable recommendations for prevention.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	APPENDIX B: INCIDENT TIMELINE

	Approximate Time Activity
	Wednesday,
	November 12, 2014

	2:00–3:00 pm

	3:00 pm
	Friday, November
	14, 2014

	10:00 am–3:02 am

	Investigation Note

	Saturday, November
	15, 2014 (Day of
	Incident)

	2:51 am–2:54 am

	2:58 am–3:03 am

	3:01 am–3:13 am

	Operators attempt to restart the Lannate® process after a unit shutdown, but flow is
	not established because equipment is plugged.
	Operators begin troubleshooting the Lannate® process to try to clear the plugging.

	Methyl mercaptan is released outside and inside the manufacturing building while
	troubleshooting to clear the plugging continues. Detectors inside and outside the
	manufacturing building identify high levels of methyl mercaptan and trigger alarms
	32 separate times. These alarms display only on the control panel (there are no
	building or exterior alarms). Operations personnel who are aware of the alarms and
	the troubleshooting do not perceive the leaks as posing a serious hazard (see
	Investigation Note below).
	Operations personnel likely normalized both the methyl mercaptan odor and the
	detector alarms. Personnel associated these methyl mercaptan leaks with the ongoing
	troubleshooting activities.

	High pressure in equipment inside the manufacturing building triggers control system
	alarms. Operations personnel attribute the high pressure to a common long-standing
	problem with process condensate accumulating in the waste gas vent header piping.
	Unknown to the operations personnel, in this instance the high pressure is not caused
	by the typical process condensate accumulation. The high pressure is a symptom of a
	different problem: liquid methyl mercaptan flowing into the waste gas vent header
	piping, due to the piping alignment being used to clear the plugging during the
	troubleshooting efforts.
	Shift Supervisor and Operator 1 separately go to the third floor of the manufacturing
	building to try to reduce the equipment pressure. They plan to drain the equipment of
	what they believe is normal process condensate to reduce the high pressure—a long-
	standing practice used to reduce pressure in this equipment.
	Two drain valves on the waste gas vent header are manually opened on the third floor
	of the manufacturing building. Highly toxic and highly flammable liquid methyl
	mercaptan flows out of the valves, overcoming the Shift Supervisor.

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	3:13 am

	3:24 am–3:26 am

	3:30 am

	3:30 am

	3:30 am – 3:40 am

	3:30 am

	3:30 am

	Investigation Note

	3:30–3:35 am

	3:30–3:35 am

	3:30–3:35 am

	3:35 am

	The second-floor chlorine detector records a value of -1. This type of detector is
	known to go negative when sensing methyl mercaptan (-1 parts per million chlorine
	indication ≈ 33 parts per million methyl mercaptan).
	Three methyl mercaptan detectors inside the manufacturing building (two on the first
	floor and one on the fourth floor) sense at least 25 parts per million methyl mercaptan,
	triggering alarms at the control panel. The Board Operator may see these alarms but
	does not realize a chemical release has begun, likely associating the alarms with
	process troubleshooting. His focus is on mitigating the equipment high-pressure
	event.
	Operator 1, who is likely on third floor of manufacturing building, makes an urgent
	distress call over the radio for help. Personnel do not know where Operator 1 is
	located or the type of emergency she is experiencing. Some DuPont La Porte
	personnel who hear her distress call interpret the communication to mean that
	Operator 1 has a personal injury—such as a broken leg. Personnel in the control room
	do not yet realize there is a toxic chemical release.
	Control room operator tries to get more information through radio communication,
	but neither the Shift Supervisor nor Operator 1 responds.
	An operator (Operator 5) on the first floor of the manufacturing building is exposed to
	methyl mercaptan and experiences dizziness and blurry vision. He escapes from the
	manufacturing building, runs across the street, and lies down in the grass, where he
	starts to recover.
	Two operators (Operator 2 and Operator 3) in the control room run into the
	manufacturing building to respond to the distress call made by Operator 1. They do
	not realize they are responding to a serious toxic methyl mercaptan leak. They do not
	wear or take with them any respiratory protection.
	Operator 4, who is outside, sees Operator 2 and Operator 3 running into the
	manufacturing building and follows them. He also does not realize they are
	responding to a serious toxic methyl mercaptan leak. He does not wear or take with
	him any respiratory protection.
	No visual or audible alarms are installed inside the manufacturing building to warn
	operators in the field of the hazardous concentration of methyl mercaptan inside the
	manufacturing building. Operations personnel entering the manufacturing building
	responding to Operator 1’s distress call have no indication of a lethal methyl
	mercaptan concentration in the manufacturing building.
	Operator 2 enters the south stairway and likely goes directly to the third floor, where
	he is incapacitated by methyl mercaptan.
	Operator 3 goes up the stairs to the fourth floor but does not find anyone.
	Operator 4 goes up the stairs to the second floor. He walks about 10 feet and hits a
	“wall” of methyl mercaptan. He manages to retreat to the stairwell.
	Operator 3 announces on the unit’s public-address system that he does not see anyone
	on the fourth floor. The control operator responds that the Shift Supervisor and

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Operator 1 may be on the third floor. Operator 3 begins to feel light-headed. He
	makes his way to the staircase and loses consciousness while descending the stairs
	from the fourth floor.
	The Board Operator attempts to reach the Shift Supervisor, Operator 1, and Operator
	2 over the radio, but they do not respond. Personnel in the control room begin to
	realize something is wrong. Operator 6—the brother of Operator 2—grabs three 5-
	minute escape respirators. Other operators in the control room tell him not to enter
	the manufacturing building because they do not yet know what is going on or where
	the nonresponsive operators are. Operator 6, however, takes the escape respirators
	and heads into the manufacturing building.
	Operator 6 encounters Operator 4 in the stairway and puts an escape respirator on
	him. The breathing air helps Operator 4 recover, and he exits the manufacturing
	building safely.
	Operator 5 attempts to communicate by radio to inform co-workers of his exposure to
	a chemical release in the manufacturing building. (It is unclear if others hear him.)
	The manufacturing building fume release alarm sounds. It is a manually activated
	alarm intended to alert area workers of a toxic chemical release in the building.
	Operator 6 likely activated it.
	The Board Operator calls for the plant emergency response team (ERT) to respond,
	communicating that workers are missing. ERT members believe they are called to
	perform a rescue (e.g., broken bone) and do not know there is a toxic chemical
	release.
	The Board Operator calls the security guard at the main entrance and asks the guard to
	call 9-1-1. There is still confusion about what is going on, and the Board Operator
	communicates that workers are missing and requests rescue. The guard gives limited
	information to the 9-1-1 operator.
	Site emergency responders from the ERT arrive at the scene, but they do not have
	proper personal protective equipment (PPE) to enter a building with an active
	hazardous chemical release (methyl mercaptan is both highly toxic and highly
	flammable). They have prepared and responded to perform a technical rescue and
	brought gear only for that operation (harnesses, ropes, and haul systems). When they
	arrive at the manufacturing building, they realize it is a chemical release and they
	need additional PPE.
	The site Incident Commander who responded to the initial rescue request calls for the
	ERT to come to the scene with bunker gear and self-contained breathing apparatus
	(SCBA)—necessary PPE to enter an area with a toxic chemical release.

	3:35 am

	3:40 am

	3:40 am

	3:40 am

	3:50 am

	3:57 am

	3:58 am

	4:05 am

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	4:10 am

	4:12 am
	4:18 am

	4:20 am

	4:25–4:45 am

	5:08 am
	5:09 am
	5:10 am

	5:15 am

	6:02 am

	6:10 am–9:30 am

	The truck containing the ERT’s SCBAs and radios does not start and cannot come to
	the scene. An October 2, 2014 work order stated, “Check batteries and they were not
	good, remove and replace with new ones.” Replacing the battery did not fully repair
	the truck, and it still could not start at the time of the incident. After the incident,
	DuPont replaced the truck’s alternator, battery cable, and belts. DuPont did not
	adequately maintain the SCBA truck before the incident to ensure it could operate
	during an emergency.
	A second 9-1-1 call is made by one of the area supervisors.
	Harris County Sherriff’s deputies arrive at control room.
	Operator 3 regains consciousness and manages to exit the manufacturing building of
	his own volition. Fire brigade members escort him to safety.
	First ERT team enters manufacturing building. While they are in the manufacturing
	building they do not monitor the concentration of methyl mercaptan, which in
	addition to being toxic, is a highly flammable chemical. CSB calculations indicate
	that at times a portion of the building had an explosive atmosphere from the release.
	A 2002 DuPont study found that a methyl mercaptan vapor cloud explosion could
	cause the manufacturing building to collapse, but the ERT did not know that.
	An ERT member finds drain valves from the waste gas vent header on the third floor
	open with a gas (later determined to be methyl mercaptan) flowing from them. The
	Shift Supervisor is found unconscious on the third floor approximately 30 feet north
	of the drain valves. Operator 6 is found next to his brother (Operator 2), both
	unconscious. Operator 2 has a 5-minute escape respirator on his head. The respirator
	is one of the three escape packs brought into the building by his brother (Operator 6).
	Operator 6 has a 30-minute SCBA air bottle in front of him and the mask on his face,
	but he has not connected the mask to the air bottle. (Operator 6 was likely
	incapacitated by methyl mercaptan while trying to don the SCBA, before he
	connected his mask to the SCBA air bottle.) It is later determined that the Shift
	Supervisor, Operator 2, and Operator 6 died from toxic exposure / asphyxiation.
	First group of external fire fighters arrive on-site.
	Second group of external fire fighters arrive on-site.
	Third group of external fire fighters arrive on-site.
	Second ERT entry conducted. DuPont and other plant ERT emergency responders do
	not monitor the methyl mercaptan concentration inside of the manufacturing building.
	On the third floor, an ERT responder closes an open drain valve from which a gas
	(methyl mercaptan) is escaping.
	Methyl mercaptan storage tank pump is turned off, significantly slowing the methyl
	mercaptan release to the atmosphere.
	Third, fourth, and fifth ERT entries are conducted to look for missing Operator 1.
	DuPont and other plant ERT emergency responders do not monitor the methyl
	mercaptan concentration inside of the manufacturing building. (When Harris County
	emergency responders conduct building entries, beginning after about 6:40 am, they

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	monitor the air inside the manufacturing building using a QRAE monitor and a
	MultiRAE monitor.)
	Emergency responders cannot find Operator 1, possibly because there could be areas
	inside the manufacturing building that they are not aware they have not searched.
	They have no maps to reference during their search, and the manufacturing building is
	not equipped with cameras to view the different floors of the building. Area
	operators—including the Board Operator—draw building maps to assist emergency
	responders in navigating the manufacturing building.
	ERT responders continue closing valves to stop the release of methyl mercaptan.
	Sheriff’s sergeant notices an “intense smell” in Deer Park (west of La Porte).
	A sheriff’s sergeant driving on Texas Highway 225 communicates that “the odor on
	225 is strong.”
	Harris County performs first off-site air monitoring (near Highway 225) and does not
	detect methyl mercaptan in the air.
	DuPont activates the methyl mercaptan tank emergency isolation valve to stop methyl
	mercaptan from flowing to the process.
	Sixth ERT entry is conducted. Operator 1 is recovered in the north stairwell of the
	manufacturing building. She is later determined to be deceased, having died from
	toxic exposure / asphyxiation.
	Final waste gas vent header drain valve is closed to fully stop methyl mercaptan
	release.

	6:14 am

	6:38 am

	8:07 am

	10:07 am

	11:15 am–11:55 am

	11:40 am

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	APPENDIX C: ODOR COMPLAINTS FROM NOVEMBER 15, 2014

	Figure 40. Map of the Odor Complaints (Yellow Pins) from the November 15, 2014 Incident. Source: Harris County, Texas.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	APPENDIX D: EMERGENCY RESPONSE TABLES

	The regulatory tables in this appendix focus on the most significant OSHA and EPA requirements regarding
	Emergency Response and Preparedness. Companies should first determine what regulations apply to their
	process or facility and whether they are statutorily required to conduct or will voluntarily conduct an emergency
	response.a Based on this information, companies should develop an integrated approach to their requirements.

	Table 1. OSHA and EPA Regulations That Apply to Emergency Response Preparedness.

	Regulation

	Name

	Requirement

	29 C.F.R. § 1910.119

	Process Safety Management of
	Highly Hazardous Chemicals (PSM)

	29 C.F.R. § 1910.38

	Emergency Action Plans

	29 C.F.R. § 1910.120

	Hazardous Waste Operations and
	Emergency Response (HAZWOPER)

	42 U.S.C. § 116

	Emergency Planning and Community
	Right-to-Know Act (EPCRA)

	40 C.F.R. § 68(G)

	Risk Management Plan (RMP)b

	Requires an emergency action plan or an
	emergency response plan (if there is an
	internal emergency response team).
	Dictates the minimum procedures necessary
	to alert emergency personnel of an
	emergency.
	Requires an emergency response plan if there
	are hazardous materials and there is an
	internal emergency response.
	Requires states to develop a state emergency
	planning commission and local emergency
	planning committees (LEPC). Requires an
	emergency response plan and emergency
	notifications.
	Requires an emergency response program.
	Requirements may potentially be fulfilled by
	developing emergency response plans
	required by other agencies.

	a The term response has the same meaning under OSHA’s Hazardous Waste Operations and Emergency Response (HAZWOPER)
	standard and EPA’s Risk Management Plan rule [151, p. 2]. OSHA defines emergency response under the HAZWOPER standard as “a
	response effort by employees from outside the immediate release area or by other designated responders (i.e., mutual aid groups, local
	fire departments, etc.) to an occurrence which results, or is likely to result, in an uncontrolled release of a hazardous substance.
	Responses to incidental releases of hazardous substances where the substance can be absorbed, neutralized, or otherwise controlled at the
	time of release by employees in the immediate release area, or by maintenance personnel are not considered to be emergency responses
	within the scope of this standard. Responses to releases of hazardous substances where there is no potential safety or health hazard (i.e.,
	fire, explosion, or chemical exposure) are not considered to be emergency responses” (29 C.F.R. § 1910.120(a)(3)).
	b The EPA has published general guidance on Emergency Response Programs and other aspects of RMP.

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Table 2. Requirements for an Emergency Action Plan (29 C.F.R. § 1910.38) and Emergency Response Plan (29 C.F.R. § 1910.120) under
	OSHA.

	Requirement

	Procedures for reporting a fire or other emergency

	Procedures for emergency evacuation, including type of evacuation
	and exit route assignments
	Procedures for employees who remain to operate critical plant
	operations before they evacuate
	Procedures to account for all employees after evacuation

	Procedures for employees performing rescue or medical duties

	The name or job title of every employee who may be contacted by
	employees who need more information about the plan or an
	explanation of their duties under the plan
	Pre-emergency planning and coordination with outside parties

	Personnel roles, lines of authority, training, and communication

	Emergency recognition and prevention

	Safe distances and places of refuge

	Site security and control

	Evacuation routes and procedures

	Decontamination

	Emergency medical treatment and first aid

	Emergency alerting and response procedures

	Critique of response and follow-up

	Personal protective equipment and emergency equipment

	Emergency
	Action Plan
	✓

	Emergency
	Response Plan

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

	✓

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Table 3. Emergency Response Program requirements under RMP for Responding Facilities.

	Elements
	Emergency response plan

	Planning coordination

	Emergency equipment

	Employee training
	Response plan evaluation

	Requirement

	An emergency response plan maintained at the facility that includes (1)
	procedures for informing the public and emergency response agencies about
	releases, (2) documentation of proper first aid and emergency medical treatment
	necessary to treat human exposures, and (3) procedures and measures for
	emergency response
	Coordination with local response agencies on responses to potential release of
	regulated substances
	Procedures for using, inspecting, testing, and maintaining emergency response
	equipment
	Training for all employees in relevant procedures
	Procedures for reviewing and updating the response plan to reflect changes at the
	facility and for ensuring that employees are informed of the changes

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Table 4. Industry and Government Guidance Related to Emergency Response.

	Organization
	Federal Emergency
	Management
	Agency (FEMA)

	American Petroleum
	Institute (API)

	National Fire
	Protection
	Association (NFPA)

	National Fire
	Protection
	Association (NFPA)

	National Fire
	Protection
	Association (NFPA)
	National Fire
	Protection
	Association (NFPA)

	National Fire
	Protection
	Association (NFPA)

	Name

	Description

	National Incident Management
	System (NIMS)

	RP API 1174, API Recommended
	Practice for Pipeline Emergency
	Preparedness and Response
	NFPA 472, Standard for
	Competence of Responders to
	Hazardous Materials/Weapons of
	Mass Destruction Incidents
	NFPA 475, Recommended Practice
	for Organizing, Managing, and
	Sustaining a Hazardous
	Materials/Weapons of Mass
	Destruction Response Program

	A common framework for overall incident
	management. A comprehensive approach that is
	applicable at all jurisdictional levels
	Enhanced framework for an emergency
	management system for onshore hazardous liquid
	pipeline operators

	Minimum levels of competence required by
	responders to emergencies involving hazardous
	materials or weapons of mass destruction

	Criteria for the organization, management, and
	deployment of personnel, resources, and
	programs for entities responsible for the
	hazardous materials/weapons of mass destruction
	emergency preparedness function

	NFPA 600, Standard on Facility Fire
	Brigades

	Requirements for organizing, operating, training,
	and equipping industrial fire brigades

	NFPA 704, Standard System for the
	Identification of the Hazards of
	Materials for Emergency Response
	NFPA 1221, Standard for the
	Installation, Maintenance, and Use
	of Emergency Services
	Communications Systems

	National Fire
	Protection
	Association (NFPA)

	NFPA 1250, Recommended Practice
	in Fire and Emergency Service
	Organization Risk Management

	National Fire
	Protection
	Association (NFPA)

	NFPA 1561, Standard on Emergency
	Services Incident Management
	System and Command Safety

	National Fire
	Protection
	Association (NFPA)

	NFPA 1600, Standard on Continuity,
	Emergency, and Crisis Management

	The NFPA’s Hazard Diamond, a labeling system
	that identifies the hazards of materials

	The installation, performance, operation, and
	maintenance of communications systems and
	facilities used by public emergency services

	Criteria to develop, implement, or evaluate a fire
	and emergency service organization risk
	management program for effective risk
	identification, control, and financing
	Requirements for the structure and operation of
	an incident management system for emergency
	services, including principles of command safety
	to be incorporated into all incidents, training, or
	emergencies, to ensure the safety of emergency
	responders and others on the scene of an incident
	Common set of criteria for all hazards, disaster,
	emergency management, and business continuity
	or continuity-of-operations programs

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Organization

	National Fire
	Protection
	Association (NFPA)

	Name

	Description

	NFPA 1620, Standard for Pre-
	Incident Planning

	Criteria for developing pre-incident plans to help
	responders effectively manage emergencies

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	APPENDIX E: DUPONT SAFETY PERCEPTION SURVEYS

	For more than a decade, DuPont developed and honed a safety culture program to reduce its OSHA total
	recordable injury rate by assessing and improving occupational (personal) safety, using its Bradley Curve and
	Safety Perception Survey tools.

	In the 1990s, DuPont identified a significant discrepancy in safety performance at different DuPont sites around
	the world. Some of the company’s sites had few recordable injuries, and other sites had many. To improve
	safety performance at DuPont sites, a former DuPont Chairman and CEO created a team dubbed the Discovery
	Team to find a sustainable way to strengthen safety performance at all DuPont facilities, with the ultimate goal
	of having zero incidents throughout the entire organization [77].

	The Discovery Team found that the sites with the best worker safety records more prevalently practiced DuPont
	safety principles. The Discovery Team also asserted that sites with the most worker injuries had a lack of
	management commitment to safety, more communication breakdowns, and inconsistent safety leadership.
	Overall, the Discovery Team claimed that DuPont sites with fewer worker injuries had a distinctive safety
	culture that permeated the entire facility [77].

	Verlon Bradley, then manager of the DuPont plant in Beaumont, Texas, along with the Discovery Team, created
	a model named the Bradley Curve (Figure 41). The Bradley Curve aimed to illustrate the strength of an
	organization’s safety culture and its relationship to the number of worker (OSHA recordable) injuries [77].
	DuPont began using the Bradley Curve model internally, and in 1995, DuPont’s consulting service, DuPont
	Sustainable Solutions, began applying the Bradley Curve model to improve safety performance at other
	companies in various industries [78].

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 41. The DuPont Bradley Curve. The Bradley Curve correlates improved safety culture with reduced OSHA
	recordable injury rates. For more information, see Bradley Curve. Source: DuPont.

	In 1999, DuPont formalized a method to assess an organization’s safety culture with its Safety Perception
	Surveya to measure the strength of the safety culture at each site. The Safety Perception Survey consists of 24
	multiple-choice questions to measure safety culture across three categories of safety management: (1)
	leadership, (2) processes and actions, and (3) structure [59, p. 2]. The survey addresses only 12 of DuPont’s 22
	essential elements of an integrated safety management system (Figure 42). It focuses on elements it labels
	“cultural” and places under “Management Commitment” and does not address components related to what it
	calls “risk-based” process safety, such as management of change. According to DuPont Sustainable Solutions,
	the Bradley Curve benchmarking system, combined with DuPont’s Safety Perception Surveys, has helped
	DuPont and its clients improve their safety culture performance [78].

	a A safety management consultant and former DuPont executive developed the Safety Perception Survey, which was first published in
	1999. DuPont acquired the survey in 2000. DuPont modified it and incorporated it into its consulting methodology for benchmarking
	and action planning [59, p. 2].

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Figure 42. To DuPont, Each Wheel Represents Different Aspects of Safety. The wheel on the left
	(Cultural) represents the only aspects of safety that DuPont’s Safety Perception Surveys cover.
	The wheel on the right (Risk-‐Based) represents aspects of safety typically associated with process
	safety. Source: DuPont.

	Beginning in 2007, DuPont began calculating a “Relative Culture Strength” (RCS) score based on responses to
	the Safety Perception Surveys.a DuPont found that higher RCS correlated with a lower OSHA total recordable
	injury rate.b The correlation also fit the Bradley Curve (Figure 43) [59, p. 7]. Because of this correlation,
	DuPont often uses the OSHA total recordable injury rate “as [its] measure of safety performance” [59, p. 2].
	Additionally, DuPont uses the RCS in combination with the Bradley Curve (Figure 43) to determine what stage
	of safety culture a facility has achieved. The curve represents the progress of a facility’s culture strength. The

	a RCS is a proprietary number calculated by comparing a company’s responses to survey questions against a benchmark established by
	DuPont in 2008 based on the best and worst sites that had taken the Safety Perception Survey [59, p. 3].
	b The OSHA recordable injury rate is the annual number of injuries and illnesses per 100 full-time workers. The
	OSHA injury rate, which excludes fatalities, is a normalized rate that is used for comparison across industries [171, p. 75].

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	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	higher the score, the further along the facility is on the curve, with the highest level designated “World Class.”a
	DuPont classified facilities with a calculated RCS value of 80 or greater as having a “World Class” safety
	culture. Results from a 2012 Safety Perception Survey conducted at the La Porte site, the last safety culture
	survey conducted at the site before the incident, classified its perception of safety performance as “World
	Class.” This safety classification, however, relied on the DuPont La Porte site’s employees’ perception of
	personal (worker) safety performance only, because the Safety Perception Survey used at DuPont La Porte did
	not include process safety considerations.

	Figure 43. DuPont Bradley Curve with Plotted RCS results from 169,000 Safety Perception Surveys. The yellow bars show the range
	of the middle 50 percent of the data in each category, and the horizontal blue line in each box indicates the median. DuPont found
	that a higher RCS correlated with a lower worker injury rate (OSHA total recordable injury rate). Source: DuPont.

	a The Safety Perception Survey ranks performance by five categories (from best to worst): World Class, Excellence, Skill, Awareness,
	and Fundamentals. World Class is defined as “the organization leads its industry in safety performance as a direct result of its safety
	focus, leadership, deliberate organizational design, and the portfolio of activities it carries out to maintain a safe workplace.” Excellence
	is defined as “the organization has strong capabilities to identify, learn from, and correct at-risk behaviors and workplace hazards. Safety
	is a top priority. There is a free flow and exchange of information without the fear of retribution, and the organization is focused on
	learning and improving. Hazard reporting, auditing, and corrective implementation are well designed and executed on a regular basis.”
	The Skill level is defined as “the organization shows numerous signs of continuous improvement and has a track record of modest and
	consistent improvement in safety performance. Personnel are skilled in the application of basic safety management tools and
	techniques.” The Awareness level is defined as “the organization is aware of its performance and has established basic policies and
	processes to measure and improve safety performance. There is relatively high value for safety efforts, and an auditing system is in place
	to eliminate workplace hazards.” The Fundamentals level is defined as “the organization has processes in place to avoid known
	workplace hazards and uses trailing injury statistics for performance measurement. Injuries and incidents are the main driving force
	behind discussion of safety management practices. There is a written safety policy that may not be familiar to employees or be perceived
	as of high value. Safety performance is known to some in the organization but is not widely known or thought out.”

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	DuPont Sustainable Solutions responded to the new learnings about process safety culture after BP Texas City
	by developing 13 new process safety questions for its Safety Perception Surveys. These questions are
	considered optional and may be included in the survey at clients’ request.

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	DuPont La Porte Chemical Facility
	La Porte, Texas \| Incident Date: November 15, 2014 \| No. 2015-01-I-TX

	Members of the U.S. Chemical Safety and Hazard Investigation Board:

	Kristen Kulinowski, PhD
	Interim Executive

	Manuel Ehrlich
	Member

	Richard Engler
	Member

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