More information, the report and a CSB video here.
Board investigators blamed the explosion and fire in the plant's methomyl-Larvin pesticide unit on a long string of equipment failures, management lapses, unsafe procedures and poor planning.
"This accident should never have happened," said board member John Bresland, a longtime chemical plant manager who was chairman of the CSB when the Bayer incident occurred.
In a more than two-year probe, CSB officials found that many of the accident's causes were longstanding issues that have previously been identified by the company or by federal regulators -- but still had not been corrected.
The board's 169-page report recommends the state and Kanawha County begin new chemical plant safety programs that would include regular government safety audits and requirements for new accident prevention programs by companies.
John Vorderbrueggen, the board's investigations manager, said such programs would force companies to allow government reviews before they make major changes to complex chemical-making units, a mandate that "keeps the pencil very sharp" for company and government safety planners.
"With the extra set of eyes and the extra-sharp pencil, all of the things that were overlooked would not have occurred," Vorderbrueggen said during a morning press conference at West Virginia State University's campus adjacent to the plant.
The board urged the state Department of Health and Human Resources to work with the Kanawha-Charleston Health Department to start a statewide program, citing existing legal authority for DHHR to "make inspections" and "conduct hearings" concerning "occupational and industrial health hazards."
"I believe a state and county-run program like this would go a long way to making chemical operations safer in places like the Kanawha Valley," said board Chairman Rafael Moure-Eraso. "Local jurisdictions can put together highly effective and targeted inspection and enforcement programs, funded by levies on the plants themselves."
Many of the board's findings were previously released at an April 2009 congressional hearing and in a preliminary report, both of which warned that the methomyl-Larvin explosion came dangerously close to damaging a tank of methyl isocyanate. Also known as MIC, the chemical killed thousands of people in a 1984 leak at a Union Carbide plant in Bhopal, India. Board officials and congressional investigators also previously reported that Bayer had tried to use an anti-terrorism law to keep confidential many details of the incident to avoid negative publicity and public pressure about its huge MIC stockpile.