• DuPont’s phosgene hazard awareness program was deficient in ensuring that operating personnel were aware of the hazards associated with trapped liquid phosgene in transfer hoses.
• DuPont relied on a maintenance software program that was subject to changes without authorization or review, did not automatically initiate a change-out of phosgene hoses at the prescribed interval, and did not provide a back-up process to ensure timely change-out of hoses.
• DuPont Belle’s near-miss reporting process was not rigorous enough to ensure that the near failure of a similar phosgene transfer hose, just hours prior to the exposure incident, would be immediately brought to the attention of plant supervisors and managers.
• DuPont lacked a dedicated radio/telephone system and emergency notification process to convey the nature of an emergency at the Belle plant, thereby restricting the ability of personnel to provide timely and quality information to emergency responders.