Plant operators began "switching between" the hillside cylinder and a second tank known as the "riverside cylinder," the DuPont report said. "Sufficient flow was obtained from the riverside cylinder, but switching the cylinders did not resolve the low flow issue on the hillside cylinder," the report said.
According to the report, plant operators thought, "the flow issue was due to a problem with the valve on the hillside phosgene hose assembly" because the valve would not open as much as it usually did.
"The operators left the manual valves from the riverside cylinder to the process open after the batch was complete," the report said. "The liquid phosgene was not evacuated from the hose and valve assembly."
That evening, DuPont decided to replace the hillside cylinder's hose assembly the next morning before starting another batch of chemicals.
Workers cleared phosgene from the hillside cylinder's hose assembly, and at the same time closed the valves between the riverside cylinder and the pesticide unit, the report said.
At about 9:15 a.m. on Jan. 23, a mechanic replaced the hillside cylinder hose and valve assembly. The next batch of chemicals was started at about 9:55 a.m. using the hillside cylinder.
Workers put the hillside cylinder's old hose into a bucket of water to decontaminate it, the report said. Later, they noticed "there was a section of the wire over-braid approximately one-half inch long that was missing around the full circumference of the hose.
"The missing over-braid on the hillside hose had not been apparent to the operators or mechanics when they removed it from service because it is believed that a manufacturer's tag was tightly wrapped around the hose and covered the area of missing over-braid," the DuPont report said. "The manufacturer's tag was no longer present when the hillside hose was removed from the bucket of water.
"After the missing over-braid was observed on the hillside hose, the operators visually checked the riverside hose for similar damage while it was in service," the report said. "A manufacturer's tag was wrapped around the riverside hose, and no deterioration of the wire over-braid was apparent on the riverside hose."
At about 2 p.m. that afternoon, Fish went into the phosgene shed to check the hillside phosgene cylinder weight on a scale.
"While the operator was checking the hillside phosgene cylinder weight on the scale, he heard a 'pop' and was sprayed with phosgene from the riverside hose, believed to be in the form of a fine mist/vapor," the DuPont report said. "The operator passed away the following day."
Reach Ken Ward Jr. at kw...@wvgazette.com or 304-348-1702.