Brazilian Worker Killed
in Industrial Explosion

DuPont Faulted for Not Installing Control Devices

Investigation into the accident at the company resulting in a fatality (excerpts)
GRIFFIN BRASIL LTDA (DUPONT), Camaçari, BA, Brazil

Occupational Health Research Center (CESAT)
Government of the State of Bahia
December 28, 2005

"The occupational accident that resulted in the fatality of the worker Leandro Vieira Mira (L.V.M.) occurred at around 10:50 PM on September 22, 2005 as a result of an explosion followed by a fire in the filtration vessel (F-1366) when L.V.M. was alone carrying out work activities at the Nitration Unit (13/14). The explosion provoked the rupture of the structure of the filtration vessel, projecting fragments within a radius of approximately 30 meters from the location of the accident.

According to the information obtained, minutes before the occurrence of the incident, L.V.M. had gone to this unit to carry out the action of closing the dichloronitrobenzene (DCNB) transport valve of the D-1430B tank for Unit 15, given that the transfer had been completed.

The body of L.V.M. was found close to the damaged area, with practically his entire skin surface burned by the flames....

The circumstances that contributed to the accident are numerous, but they clearly constituted a network of causality that was foreseeable and preventable given the knowledge and technology available.

A factor deemed relevant in the explanation of this accident was the lack of greater attention by the Company paid to the conditions prior to the event that indicated the existence of the lack of operational control, in particular the increase in pressure in the filter and the difficulties in transferring the product. It was known beforehand that hydrazine is incompatible with various materials, potentially provoking dangerous and explosive reactions, and possibly creating dangerous products in some phases of the production process. Despite this fact, the Company felt safe in maintaining the plant operation without effecting the improvements initially established.

Given this situation, the conclusion reached is that there were problems in the Company’s planning in terms of the safety issues related to the industrial process. First, by introducing the use of a highly reductive and explosive substance in its production process without having adequate technology for determining by means of a test-analysis method the heavy and/or dangerous compounds likely present in the residues formed. These compounds resulting from the reactions with hydrazine and/or intermediate compounds formed were (and are) capable of provoking explosions. Second, by continuing the DCNB pre-hydrogenation process immediately after conducting the test of the addition of hydrazine, in breach of the prior recommendation of constant control by the Preliminary Risk Analysis. No automatic control devices were installed in the panel (DCS) capable of monitoring the progressive increase in pressure in the system and executing the blocking of its functioning (the DCNB transfer process) before this variable reached an uncontrollable value.

Crucially, the only test conducted by the Company during the DCNB hydrogenation and transfer process was to determine the pH. This analysis was insufficient for monitoring the presence of the probable heavy and unwanted compounds resulting from the processes of reaction with hydrazine.

During the inspection, the Company requested that CESAT not make any photographic record, given that this was Company policy. This was accepted after agreeing that CESAT technicians would accompany the photographic record made by a Company Safety Technician and that the record would be delivered to CESAT. However, the Company did not fulfill this agreement, without providing any justification. This fact, however, did not impair the understanding of the occurrences in the event or the preparation of the technical document by CESAT."

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Major problems in Dupont Camaçari

The Brazillian union, Union of Chemistries and Petroleiros (BA), has previously called attention for the necessity of a bigger investment in health and safety for employees at this facility. Before the explosion, two accidents already had occured in Camaçari, on July 5th and August 25th. In July, an increase of pressure in a column of the aniline unit resulted in an improper reaction, causing the release of formed polymer, CO 2 , water and a trace of hydrochloric acid. The August accident involved an operator who discovered a potential phosgene release. The worker attempted to close the valve to prevent a bigger accident, but ultimately broke his hand. Prior chemical spills and accidents also occured in 2001, 2000 and 1999 at the facility.

According to BA, when an accident happens in the plant, the company tries not to file an Occupational Accident Report (CAT), and places the worker in restricted labor and puts pressure on him/her to work, even if s/he has a broken leg or arm. This is so that the statistics of labor accidents does not increase in numbers. In outsourced companies the problem is even worse. Many times the sick workers are laid off and the company does not make the CAT for the victims of an accident.

Currently, in Dupont Camaçari, the most common health problems are related to the back bone, the spine: many workers even had to undergo surgical interventions. The company also has a program establishing that any accident that occurred outside the work site has to be informed and investigated. This is a clear demonstration that there is no privacy for the workers.