Chemical maker DuPont failed to promptly inform emergency crews about a phosgene leak that killed a worker last year, according to a U.S. government report released on Thursday.

The report by the Chemical Safety Board (CSB), a federal agency that investigates industrial accidents, found that a host of small oversights by DuPont over several days led to the death of 58-year-old Carl Fish.

DuPont said it completed an internal investigation and is cooperating with the CSB.

On January 23, 2010, a tube connected to a phosgene tank at DuPont's Belle, West Virginia, plant frayed, spraying the chemical on Fish's chest.
Fish, a 32-year DuPont veteran, was taken to the hospital where he died a few hours later.

For a CSB video animation on the incident, click here. 

"The CSB determined there were safer ways DuPont could have run its phosgene operation," John Bresland, a CSB board member, said during a Thursday conference call on the report.

Phosgene has a green hue and smells like freshly cut grass. It is currently used to make herbicide and was also used in chemical warfare during World War One.

In its 173-page report, the CSB found that DuPont did not give "timely and detailed" information to emergency crews about the phosgene leak.

The company relied on a security guard to call 911 and did not tell crew members a phosgene leak had occurred until they arrived at the plant, the CSB said.
When 911 officials tried to call DuPont en route for more information, they found the line busy, the report said.

While waiting for crews to arrive, Fish washed his face and hands, but was not put into a safety shower, which was required as part of the company's emergency procedures, the report said.

The report also criticized DuPont's use of Teflon in the phosgene tube that frayed. Teflon is one of DuPont's signature products; it is most commonly used to make nonstick cookware.

Teflon was paired to make the tube with stainless steel, which corrodes in the presence of chlorides found in phosgene. And Teflon itself can be permeated by phosgene.

The report faulted DuPont for relying solely on SAP automated software to remind workers to change tubes and not having some type of redundant backup.

The tubes are supposed to be replaced once a month, but the tube that eventually ruptured had not been changed in seven months, the CSB said.

"We found the phosgene transfer hose was susceptible to failure," Bresland said. "We learned another phosgene hose had failed in a similar manner, but that failure was not investigated by DuPont."

This incident received so much attention from the CSB because two other leaks occurred at the same West Virginia DuPont plant just prior to the phosgene-related death.

Methyl chloride, which can be used to make rubber, was released on Jan. 22, and oleum, a type of sulfuric acid, was released on Jan. 23. No injuries were reported in those two cases.

"We at the Chemical Safety Board were quite surprised and alarmed to learn that DuPont had not one, but three preventable accidents that occurred over a 33-hour period," CSB Chairperson Rafael Moure-Eraso said during the conference call.

DuPont no longer uses or stores phosgene at the Belle plant, a spokesman said.

"We will continue to cooperate with the CSB, including reviewing the draft report and providing input to the CSB," DuPont said in a statement to Reuters.

A contract worker at a DuPont plant in Tonawanda, New York, was killed last fall after a chemical storage tank exploded during a welding operation.
The CSB is currently investigating that incident.