1. DuPont relied on a maintenance software program to initiate the automatic change-out of phosgene hoses at the prescribed interval.
2. DuPont did not provide a back-up method to ensure timely change-out of the hoses.
3. A maintenance software program change was not documented or reviewed in accordance with the MOC process.
4. No person with process knowledge was in place and assigned to convey timely and useful information to Metro 9-1-1. This responsibility was consigned to the gate guard.
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5. The Belle Plant did not use the construction materials recommended by a corporate expert, the P3H standard, CGA, or the HTM manual for phosgene hoses, even though the 2006 second-party HTM audit recorded it as an observation