By DAVID MERCER
Associated Press Writer

A series of explosions that killed five employees at a central Illinois chemical plant in 2004 was caused by a worker who mistakenly opened a valve on a high-temperature reactor that was in operation, a federal agency said Tuesday.

The U.S. Chemical Safety and Hazard Investigation Board also faulted the plant owner, Formosa Plastics Corporation U.S.A., for failing to address problems that made human error possible at the plant near Illiopolis, about 25 miles east of Springfield.

Investigators said New Jersey-based Formosa should have recognized that such an accident could occur because of similar incidents at one of its Louisiana plants and at the Illinois plant just two months before the fatal blasts.

"There are just so many different things that occurred here that a prudent company could have identified to prevent such a catastrophic event," investigative board Chairman Carolyn Merritt said in an interview Tuesday.

Both Formosa and investigators said the employee who opened the valve on the wrong reactor apparently became confused about which of the plant's 24 reactors he was cleaning on the night of April 23, 2004.

The reactors are three-story metal vessels that use 120-degree heat and high pressure to begin turning vinyl chloride monomer, or VCM, and other chemicals into resin used to make polyvinyl chloride, or PVC. Polyvinyl chloride is used in PVC pipe and other materials.

"He's on the top level, does the cleaning, goes down flights of stairs and he was supposed to go left to reactor 306 and open the drain valve," Thibault said in an interview. "Apparently what happened was that he went right."

When the worker opened the valve on the operating reactor, he bypassed written safety guidelines without telling a shift supervisor, a violation of the company's procedures, the investigative board found. Other workers apparently believed the reactor had failed or malfunctioned and tried to relieve pressure within the reactor, releasing the VCM inside.

The cloud of VCM that escaped the reactor exploded, according to investigators.

Four employees _ including the worker who made the error _ were killed by the ensuing explosions: Joseph Machalek, 50, Larry Graves, 47, and Linda Hancock, 56, all of Decatur, and Glenn Lyman, 49, of Cornland. Hancock's husband, Randy Hancock, 50, died three weeks later in a local hospital burn unit.

Investigators did not identify who made the error.

But they faulted Formosa for not recognizing that problems were possible after workers incorrectly bypassed safety measures to open reactor valves at the Illiopolis plant in February 2004 and at a plant in Baton Rouge, La., in 2003. Neither of those resulted in explosions, but both led to fines by the U.S. Environmental Protection Agency.

Investigators also faulted Formosa and the plant's previous owner, Borden Chemical, for not installing some means of communications _ even something as simple walkie-talkies _ to allow employees to communicate while working around the reactors. Borden is now Columbus, Ohio-based Hexion Specialty Chemicals.

Formosa bought the plant from Borden Chemical in 2002.

"How much do walkie-talkies cost?" Merritt asked. "It isn't an expensive endeavor to provide communication between employees with critical operating responsibilities."

In addition, the board's report said, workers had uncontrolled access to the reactors and could open the valve without detection. The board found that Borden as early as 1992 noted that the valve was too easily accessed and opened.

Formosa spokesman Rob Thibault said the company already has taken steps to address some of the concerns raised by the investigative board, including tightening rules employees must to follow to bypass safety procedures and adding electronic communications between reactor control rooms and other areas at the company's plants. The company continues to work on other changes, he said.

"The bottom line is we haven't waited for a report to come out from the government," he said.

A spokesman for Hexion Specialty Chemicals did not return a message left for comment.

One of the employees injured in the explosions, Bradford Bradshaw of Decatur, declined to comment about the findings. But Bradshaw, 50, said he hasn't been able to work since the accident.

"I have nightmares every night of what happened that night and I have flashbacks during the days," he said.

He and the families of the workers killed in the accident last year sued Borden and a number of contractors that worked at the plant. That suit is pending, as is a lawsuit filed by another injured worker, Christopher Havener of Decatur.

The board lacks authority to issue fines or other penalties, but can recommend that another federal agency _ such as the Environmental Protection Agency _ take action.

Formosa agreed in 2005 to pay $300,000 in federal fines and hire safety experts to evaluate what it said at the time were plans to rebuild the plant.

The April 2004 explosions destroyed several buildings at the plant and a fire burned for hours, forcing the temporary evacuation of 150 people who lived near the plant, according to the CSB report.

Although VCM is a carcinogen, pollution monitoring by the Illinois Environmental Protection Agency and Formosa did not find enough hazardous materials around the plant to cause health concerns, according to the investigative report. Some of the buildings destroyed by the explosions, however, contained asbestos, the report found.

Formosa and the Illinois EPA continue to discuss how best to clean up the site, Thibault said this week. The company hopes to reopen the site at some point, he said, though not as a PVC plant.

On the Net:

The U.S. Chemical Safety and Hazard Investigation Board's report is available at http://www.CBS.gov. A video recreation of the accident can be viewed by clicking on "Video Room."

Formosa Chemical Corporation U.S.A.: http://www.fpcusa.com/

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