Read the reportCHARLESTON, W.Va. -- It was May 1988, and DuPont Co. engineers and managers were debating how to best build a facility where their company's Belle plant could turn the poison gas phosgene into valuable chemicals for products to protect crops.One option was to buy phosgene in one-ton cylinders from an outside vendor. Cylinders would be hauled to Belle, and phosgene transferred by hose to the plant's reactor.Another possibility was building a unit to make phosgene at Belle. That proposal called for totally enclosing areas where phosgene was made and used, so workers and plant neighbors wouldn't be exposed to potential leaks.DuPont experts estimated the enclosed plant would cost an additional $2 million. But it would also be safer, saving an estimated 14 lives over 10,000 years, according to a theoretical project put together by DuPont.DuPont -- a company that prides itself on its much-touted commitment to protecting the safety of workers, the environment and the communities where it operates -- rejected the safer option, citing concerns that it would set an unwanted standard for other decisions about handling dangerous chemicals."It may be that in the present circumstances, the business can afford $2 million for an enclosure," an unnamed DuPont official said in a May 19, 1988, internal memo. "However, in the long run, can we afford to take such action which has such a small impact on safety and yet sets a precedent for all highly toxic material activities."Twenty-two years later, in January 2010, longtime Belle plant employee Danny Fish died after he was sprayed in the face by phosgene gas that leaked from a hose at the facility's phosgene unit.U.S. Chemical Safety Board investigators last week cited DuPont's decision to reject the phosgene enclosure as one factor among a long list of corporate lapses that led to Fish's death."They basically decided to take the risk of not building it, and hope for the best," said CSB chairman Rafael Moure-Eraso.DuPont hasn't used phosgene at the Belle plant since Fish died, citing business instead of safety reasons for the decision. At a press conference in Charleston, Moure-Eraso urged the chemical giant not to resume using phosgene unless it builds a new enclosed facility. DuPont officials said they have no plans to start using phosgene again.But in its 172-page report, the CSB details -- through previously confidential DuPont records and other evidence -- a long history of decisions in which DuPont ignored its own respected safety guidelines and delayed any action on internal recommendations for better handling of phosgene.In one memo, dated April 29, 1988, a DuPont official criticized General Electric for spending $40 million on an enclosed phosgene facility for a plant near Mount Vernon, Ind.DuPont believed the safety improvement from the enclosed facility at GE was so marginal that its costs, averaged out per life saved, were actually far more than the real cost of the project."If we accept the premise that we spend money on process hazards to save lives, prevent damage and avoid public outrage, and if we use the number of lives saved as a measure of these three contributions, then the $40 million GE spent to enclose their plant ... represents a spending rate of about $4 billion per life saved," the DuPont memo said. "Such a precedent is neither in the interests of GE, DuPont, the chemical industry, nor the public as a whole."After its 1988 phosgene plant study, DuPont did begin construction of an on-site -- but open air, rather than enclosed -- phosgene generation facility at Belle. That project was abandoned for reasons that the CSB could not confirm, and the company instead bought phosgene from outside vendors, and processed it in a partially enclosed shed.Nearly 20 years later, in 2004, an internal DuPont safety study recommended adding an enclosure for the phosgene operation at Belle. The study said such an enclosure would help prevent "multiple fatalities" from the release of phosgene from the 2,000-pound cylinders being used in the shed.Initially, the due date for construction of the enclosure was December 2005. That was extended until December 2006."Work to define the scope of this item is progressing, but not yet complete," a DuPont memo written in 2006 said. "We are evaluating potential lower cost alternatives to total shed enclosure."The due date was extended three more times, and the enclosure wasn't completed at the time of the January 2010 leak, the CSB reported.CSB investigators said a completely enclosed phosgene unit would not only protect nearby communities from a toxic leak, but also make things safer for workers inside the plant. An enclosed facility could have allowed workers to change phosgene tanks without entering the area, by using protective gloves built into the unit. Also, the enclosure would have been equipped with a scrubber to contain any leaks that did occur, the CSB investigators said."The right way to do it would be to have the phosgene completely enclosed," said CSB member John Bresland, a longtime chemical plant manager and former DuPont lab technician.In addition, CSB investigators criticized DuPont's policy of not requiring complete "personal protective equipment," or PPE -- such as protective suits or breathing devices -- for all work around the phosgene cylinders.Johnnie Banks, the CSB's team leader for the Belle investigation, said DuPont actually had been storing protective suits inside the phosgene shed, so that workers would have to enter that area before they could don the suits.CSB officials noted that a DuPont plant in Mobile, Ala., uses the same one-ton phosgene cylinders as had been used at Belle."The phosgene cylinders and weigh scales at the Mobile plant are housed in an enclosed room," the CSB report said. "The cylinder room vents to an emergency scrubber that pulls a slight negative pressure on the room and scrubs air before venting to the atmosphere."The scrubber is designed to capture vapors from a release of an entire cylinder," the CSB reported. "Operators at the Mobile plant enter the phosgene cylinder area under the same PPE requirements as Belle for isolating and changing cylinders (hard hat, steel-toed shoes, safety glasses, and phosgene dosimeters). However, at Mobile, to capture and scrub phosgene vapors in the event of a release, the operator turns on the emergency scrubber and pump before entering the enclosure."CSB investigators explained, "Like Belle, Mobile has phosgene analyzers located in and around the unit to continuously monitor concentrations. At Mobile, alarms in the cylinder enclosure activate local audible alarms inside the enclosure and a flashing light outside to alert employees. If no operators are present in the enclosure when the alarm activates, the emergency vent scrubber automatically starts."The Belle plant analyzer in the phosgene shed had no audible alarm to alert personnel in the area; instead, Belle plant procedures require the board operator to notify personnel of the release and only operators at the phosgene shed can activate the switch for the warning light," the CSB report said."The emergency scrub system and automated alarms at Mobile are examples of higher level controls that protect workers from hazards," the report said. "Mobile has automated alarms where Belle relies on operator action to initiate alarms to warn personnel of a suspected or actual release."Mobile implemented the scrubber system, an example of an engineering control, to manage the concentrations of phosgene in the cylinder enclosure in the event of a release," the report said. "The Belle plant phosgene shed design allows only for natural ventilation to carry unwashed phosgene gases that can potentially harm personnel in or around the shed and possibly enter the community."Reach Ken Ward Jr. at firstname.lastname@example.org or 304-348-1702.