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Committee on Inherently Safer Chemical Processes: The Use of Methyl Isocyanate (MIC) at Bayer CropScience Board on Chemical Sciences and Technology Division on Earth and Life Studies THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by the Chemical Safety and Hazard Investigation Board under Award No: TPD-CSB-1O-C-OOO1. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number 13: 978-0-309-25543-1 International Standard Book Number 10: 0-309-25543-0 Cover image: Bayer CropScience. Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http:// www.nap.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a man - date that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examina - tion of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON INHERENTLY SAFER CHEMICAL PROCESSES: THE USE OF METHYL ISOCYANATE (MIC) AT BAYER CROPSCIENCE Elsa REichmanis (Chair), Georgia Institute of Technology Paul amyottE, Dalhousie University PEtER BEak, University of Illinois at Urbana-Champaign michaEl l. P. Elliott, Georgia Institute of Technology WaynE B. GRay, Clark University DEnnis c. hEnDERshot, Independent Consultant anDREa kiDD tayloR, Morgan State University michaEl k. linDEll, Texas A&M University JacquElinE macDonalD GiBson, University of North Carolina at Chapel Hill JEffERy J. siiRola, Eastman Chemical Company (retired) John soREnsEn, Oak Ridge National Laboratory (resigned from committee on 2/28/2011) National Research Council Staff kathRyn huGhEs, Study Director DoRothy ZolanDZ, Director JEffREy JacoBs, Director, Water Science and Technology Board ERicka mcGoWan, Program Officer (until April 2011) shEEna siDDiqui, Senior Program Associate amanDa clinE, Administrative Assistant RachEl yancEy, Senior Program Assistant v

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BOARD ON CHEMICAL SCIENCES AND TECHNOLOGY PaBlo DEBEnEDEtti (Co-Chair), Princeton University c. DalE PoultER (Co-Chair), University of Utah, Salt Lake City ZhEnan Bao, Stanford University RoBERt G. BERGman, University of California, Berkeley hEnRy E. BRynDZa, E. I. du Pont de Nemours & Company Emily caRtER, Princeton University DaviD chRistianson, University of Pennsylvania maRy JanE haGEnson, Chevron Phillips Chemical Company LLC caRol J. hEnRy, The George Washington University Jill hRuBy, Sandia National Laboratories michaEl kERBy, ExxonMobil Chemical chaRlEs E. kolB, Aerodyne Research, Inc. JosEf michl, University of Colorado, Boulder sanDER G. mills, Merck, Sharp, & Dohme Corporation DaviD moRsE, Corning Inc. RoBERt E. RoBERts, Institute for Defense Analyses DaRlEnE J. solomon, Agilent Technologies JEan tom, Bristol-Myers Squibb DaviD Walt, Tufts University National Research Council Staff DoRothy ZolanDZ, Director kathRyn huGhEs, Program Officer tina m. mascianGioli, Senior Program Officer DouGlas fRiEDman, Program Officer amanDa clinE, Administrative Assistant shEEna siDDiqui, Senior Program Associate RachEl yancEy, Senior Program Assistant vi

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Acknowledgments The Committee on Inherently Safer Chemical Processes: The Use of Methyl Isocyanate (MIC) At Bayer CropScience would like to thank the many technical, chemical, and engineering experts who contributed to the integrity of this report through the submission of informative materials and attendance of committee meetings. The committee would like to acknowledge Amy McCormick and Lucy Sciallo-Tyler of the U.S. Chemical Safety and Hazard Investigation Board; Steven Smythe, Patrick Ragan, Connie Stewart, Cindi Lester, Walter Martin, and the staff of the Bayer CropScience facility in Institute, West Virginia; Scott Berger, Center for Chemical Process Safety; Randall Sawyer, Contra Costa County; George Famini and George Emmett, Department of Homeland Security Analysis Center; John Carberry, Carberry EnviroTech; Matthew Blackwood and Larry Zuspan, Kanawha Putman Emergency Planning Committee; Craig Mattheisson, U.S. Environmental Protection Agency; and Warren Woomer of Charleston, South Carolina. We would also like to thank West Virginia State University in Institute, West Virginia for hosting the committee members and National Research Council staff for an open public comment session. Our thanks to all those who participated in the comment periods and who contributed information in support of the com - mittee’s data-gathering efforts. vii

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Acknowledgment of Reviewers This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that it meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report: DaniEl a. cRoWl, Michigan Technological University chau-chyun chEn, AspenTech maRtin shERWin, W.R. Grace & Company, Retired John saWyER, MATRIC Research michaEl WRiGht, United Steel, Paper and Forestry, Rubber, Manufacturing, Energy, Allied Industrial and Service Workers International Union (United Steelworkers) scott faRRoW, UMBC Gail BinGham, RESOLVE nED hEinDEl, Lehigh University michaEl R. hoffman, California Institute of Technology Pam nixon, West Virginia Department of Environmental Protection may BEREnBaum, University of Illinois at Urbana-Champaign John h. soREnsEn, Oak Ridge National Laboratory (retired) ix

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x PREFACE ACKNOWLEDGMENTS Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recom- mendations, nor did they see the final draft of the report before its release. The review of this report was overseen by David Bonner, Stematix, Inc. and W. Carl Lineberger, University of Colorado at Boulder. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional proce - dures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution.

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Contents Summary 1 Technical Summary 13 1 Introduction 21 2 Bhopal and Chemical Process Safety 31 3 Industrial Production and Use of MIC at Bayer CropScience 43 4 The Concepts of Inherently Safer Processes and Assessment 59 5 MIC and Pesticide Production at the Institute Plant: Alternatives Assessment 83 6 A Framework for Decision Making 113 7 Process Safety Management at Bayer CropScience 131 8 Post-incident Retrospective Process Assessment 141 Appendixes A Statement of Task 155 B Carbamate Pesticide and Methyl Isocyanate Timeline 157 C Emergency Response and Emergency Preparedness 173 D Policy Context of Inherently Safer Processes 179 E Meeting Agendas 191 F Biographies of Committee Members 195 G Acronyms 201 xi

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