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CSB Investigation Report No. 2014-08-I-TX 2014 Safety Safety Environmental Environmental
DuPont La Porte Phosgene Release
DuPont La Porte Facility, Texas
Related equipment → Reactor (reactor)
4Fatalities
1Injuries
LeakageMechanism code SPO
Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
LeakageSPO
ISO functional code (as recorded)
ISO 14224:2016 functional failure code
SPO · Spurious operation
ISO SPO — Spurious operation.
1What Happened

Byproduct treatment unit reactor phosgene release (valve mispositioned + overpressure)

2Root Cause

Incorrect valve position + inadequate phosgene system isolation + insufficient training

3Reliability Lessons (from investigation root cause)
  • Incorrect valve position
  • inadequate phosgene system isolation
  • insufficient training
4Associated Failure Mechanisms (Keywords)
phosgene leak overpressure valve operator error corrosion internal thinning
About the Failure-Mode Code (click to expand)

The recorded code SPO is an ISO 14224:2016 functional failure code (describes what the equipment failed to do). The damage mechanism (how it failed) is shown in the Mapping block above. The two are distinct dimensions in ISO 14224.

5Evidence Source (transparent)
Authority:U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report:www.csb.gov ↗
Data Verification:verified_url_csb_sitemap
Related Failure Modes · Traceability
Fatigue Fracture fatigue_fractureBending bendingKeyway Wear keyway_wearCorrosion/Erosion corrosion_erosionBlade Crack blade_crackBlade Detachment blade_detachmentGlass-lining Damage glass_lining_damageGear Wear/Pitting gear_wear_pittingBearing Failure bearing_failureOil Seal Leak oil_seal_leakInternal Corrosion Thinning internal_corrosion_thinningStress Corrosion Cracking (SCC) sccWeld Crack weld_crackGlass-lining Failure glass_lining_failureCorrosion corrosionAnchor Bolt Loosening anchor_bolt_looseningFace Wear face_wearO-ring Aging o_ring_agingSpring Failure spring_failureSecondary Seal Leak secondary_seal_leakDry-running Burn dry_running_burnFlush Loss flush_lossFilter Clogging filter_cloggingGasket Aging gasket_agingFlange Face Corrosion flange_face_corrosionJacket Corrosion jacket_corrosionJacket Fouling jacket_foulingHalf-pipe Weld Leak half_pipe_weld_leakCoil Perforation coil_perforationVibration Fatigue vibration_fatigueSupport Loosening support_looseningSet Point Drift set_point_driftValve Seat Leakage seat_leakagePremature Fatigue Rupture premature_ruptureBackside Corrosion backside_corrosionRelief Line Blockage vent_line_blockageQuench System Failure quench_system_failureSensor Drift sensor_driftThermowell Corrosion thermowell_corrosionDiaphragm Failure diaphragm_failureImpulse Line Blockage impulse_line_blockageImpulse Line Blockage impulse_line_blockage_2Coating→False Reading coating_false_readingElectrode Fouling electrode_foulingCalibration Drift calibration_drift
Report No. 2014-08-I-TX · Data from CSB public investigation conclusions, compiled by Reliability AI, for reliability demonstration purposes only. This case is derived from public incident investigation reports for learning purposes only. AIM does not endorse or guarantee its accuracy.