Synthron Final Report1

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CASE STUDYRunaway Chemical Reaction and VaporCloud Explosion

Worker Killed, 14 Injured

Synthron, LLCMorganton, NC

January 31, 2006

KEY ISSUES:

Reactive Hazards and Safeguards

Corporate Oversight

Safe Operating Limits

Evacuation Planning and Drills

No. 2006-04-I-NC

July 31, 2007

This Case Study describes arunaway chemical reaction andsubsequent vapor cloudexplosion and fires that killedone worker and injured 14 (two

seriously). The explosiondestroyed the facility anddamaged structures in the nearbycommunity. The incidentoccurred at the Synthron, LLCfacility in Morganton, NorthCarolina, on January 31, 2006.

The CSB issues this Case Studyto emphasize the importance ofimplementing comprehensive

safety management practices tocontrol reactive hazards.

INSIDE . . .

Incident Description

Synthron Operations

Incident Analysis

Lessons Learned

Recommendations

References


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Synthron Case Study July 31, 2007

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1.0 Incident Summary

This incident occurred at Synthron, LLCsMorganton, North Carolina, facility. Thecompany manufactured a variety of powdercoating and paint additives by polymerizing

acrylic monomers in a 1,500 gallon reactor.

The company had received an order forslightly more of an additive than the normalsize recipe would produce. Plant managersscaled up the recipe to produce the requiredlarger amount of polymer, and added all ofthe additional monomer needed into theinitial charge to the reactor. This more thandoubled the rate of energy release in thereactor, exceeding the cooling capacity of

the reactor condenser and causing a runawayreaction.

The reactor pressure increased rapidly.Solvent vapors vented from the reactorsmanway, forming a flammable cloud insidethe building. The vapors found an ignitionsource, and the resulting explosion killedone worker and injured 14. The blastdestroyed the facility (Figure 1) anddamaged off-site structures.

The U.S. Chemical Safety Board (CSB)found that the reactor lacked basicsafeguards to prevent, detect, and mitigaterunaway reactions, and that essential safetymanagement practices were not in place.

1.1 The Incident

The production department began preparinga 6,080 pound acrylic polymer batch the day

before the incident, approximately 12percent more material than would normallybe made in a single batch. The plantsuperintendent determined the quantities ofsolvent, monomer, and initiator needed for

the batch.1 The day shift operators thenblended the solvents and used some of theblend to prepare the initiator solution. Theyadded the balance to the 1,500 gallonreactor. The second shift operators, inaccordance with written instructions, added

some of the monomer to the reactor and heldback the remainder for use later in thereaction sequence.

The day shift arrived on the morning ofJanuary 31 and added steam to the reactorjacket (Figure 2) to heat the reactor to thetemperature specified on the batch sheet,then shut off the steam.

The senior operator took the final step to

start the reaction by pumping initiatorsolution into the reactor. He then visuallychecked the flow of condensed solventthrough the condenser sight glass to monitorthe rate of reaction. While the reactioninitially did not proceed as vigorously as heexpected, the condensed solvent flow laterincreased and appeared to be in the normalrange.

Several minutes later, the senior operator

heard a loud hissing and saw vapor ventingfrom the reactor manway. The irritatingvapor forced him out of the building.

Three other employees were also forcedfrom the building by the release. Joined bythe plant superintendent and the plantmanager, the employees gathered outside anupper level doorway (Figure 3). The senioroperator re-entered the building wearing arespirator, and was able to start emergency

cooling water flow to the reactor jacket.However, the building exploded less than 30seconds after he exited.

1 Refer to section 2.2 for an explanation of thechemistry involved.


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Photo courtesy of Morganton Department of Public Safety

Figure 1. Synthron facility after the explosion

The blast knocked down the personnelgathered outside the doorway. All wereinjured, and one required helicoptertransport to hospital. Administrativepersonnel working in an onsite trailer alsosuffered minor injuries.

The maintenance supervisor was near the labon the lower level when the explosionoccurred (Figure 3). He was severelyburned over most of his body and wastransported by helicopter to a regional burncenter, where he died five days later.

The blast damaged structures in the nearbycommunity. Two church buildings and ahouse were condemned, and glass was

broken up to one-third of a mile from thesite. Two citizens driving by the site wereslightly injured.

The Environmental Protection Agency(EPA) federalized the site under theCERCLA (Superfund) regulation,remediated the site and eventually razed the

heavily damaged structures at Synthronsfacility.

1.2 Community EmergencyResponse

The Morganton Department of Public Safetyresponded rapidly and called in mutual aidsupport from Burke County and nearbymunicipalities. Employees and PublicSafety officers assisted injured employees.

The fires following the explosion generatedthick smoke, and local residents wereaskedto shelter-in-place for several hours.2 Thefires were extinguished the next day.

2 Shelter-in-place can protect people in emergenciesby reducing their exposure to toxic substances.People should take refuge in a small interior room,close windows, seal openings, and shut off heatingand air conditioning systems.


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Liquid solvent drained from the bottom ofthe condenser back into the reactor.6 Theoutlet of the condenser vented to theatmosphere through a small pipe, keepingthe pressure in the reactor very nearatmospheric under normal operation. In an

emergency, water could be manuallydirected through the reactors jacket toincrease cooling.

A complete manufacturing cycle couldinclude several reaction steps. The finishedliquid polymer was stripped of solvent,cooled, and packaged into drums forshipment to customers.

Figure 2. Reactor M1

6 Operators could monitor the condensed solventflow, known as reflux, through a sight glass(Figure 2).

3.0 Incident Analysis

The CSB investigators determined that thekey factors leading to this incident included

a lack of hazard recognition,

poorly documented process safetyinformation,

ineffective control of product recipechanges,

a lack of automatic safeguards toprevent or mitigate the effects of lossof control over the reaction,

improper manway bolting practices, poor operator training, inadequate emergency plans drills,

and

inadequate corporate oversight ofprocess safety.

3.1 Hazard Identification

When performing reactive chemistry,companies should maintain a high degree ofawareness of the hazards involved.Synthron combined monomers and reactioninitiators in the presence of flammablesolvent to produce polymer products, but

failed to identify the hazards associated withthis type of chemistry.

Texts such as Loss Prevention in theProcess Industries (Mannan, 2005) andBrethericks Chemical Reaction Hazards(Urban, 2000) describe appropriate meansfor characterizing industrial chemicalreactions. These include determining theheat generation rate as a function oftemperature, the available heat removal

capacity, and the potential for excessivemonomer or initiator accumulation in thereactor. Failure to control these criticalcharacteristics can lead to severe upsets,including runaway reactions.

Managers can detect hazards by askingWhat can go wrong? to identify the


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potential consequences of inappropriatemixing, recipe changes, greater- and lower-than-normal heating, lack of mixing, etc.The answers can be used to developimprovements or changes that can preventreactive upsets or mitigate their

consequences.

Synthron had not identified the hazards ofits reactive chemical operations. No formalhazard review (also known as a processhazard analysis, or PHA) was conducted toaddress What could go wrong? duringreactor operations.7

Furthermore, most of the management andoperations personnel at Synthron had been

on the job for less than a year, in some casesmuch less (Table 1), and lacked previouspolymer manufacturing experience.8 Inaddition, Synthrons training program wasinformal and did not include reactivehazards training.

EmployeeTime at

SynthronPolymer

Experience?

Manager 9 months No

Superintendent 8 months No

Vice President 5 months No

2nd Shift Op-1 3 months No

2nd Shift Opt-2 3 months No

Chemist 3 weeks No

Table 1: Management and operations

personnel tenure at Synthron

7

Guidance on conducting hazard assessments isavailable from the Center for Chemical ProcessSafety (CCPS):, Guidelines for Hazard EvaluationProcedures, 2nd ed., and other CCPS publications.8 Synthrons president had replaced the managementteam in an attempt to increase sales. A variety ofcauses had simultaneously contributed to highoperator turnover. The senior operator had beenbrought back from retirement to provide a degree ofcontinuity.

Personnel, including site managers, werethus poorly prepared to recognize potentiallyhazardous changes to product recipes, or torespond to an incipient runaway reaction.

Additionally, Synthron had no chemical or

other engineers on staff, and none had beencontracted to evaluate the hazards associatedwith reactive operations at the site.

3.2 Lack of Process SafetyInformation and Training

Synthron had minimal safety information onits polymerization process, even though thiswas the core of its manufacturing business.Synthron optimized product formulations to

meet customer specifications. However,reaction characterization and calorimetry9were not performed to establish processequipment performance requirements andoperating limits for safe operations.

When scaling-up new products from thelaboratory, the previous Synthron plantmanager had typically estimated initialproduction batch sizes based on pastexperience. He then gradually increased

batch quantities until the sight glass in thecondensate return line showed that thecondenser was close to flooding,10 or thatanother performance limit was beingapproached (e.g., the reactor pressure

9 Reaction calorimetry uses specialized instruments tomeasure heat flow from a laboratory-scale reacting

mixture under controlled conditions. Calorimetryresults can be extrapolated to full-scale processes.10 Condensers flood when vapors condense fasterthan the liquid produced can flow back to the reactor.Liquid begins to fill the condenser, blocking off theheat transfer area. The resulting loss of cooling canresult in a sharp increase in pressure and possible lossof reaction temperature control. The M1 condenserwas located only slightly above the reactor, whichmade it prone to flooding.


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Figure 3. Synthron facility layout

increased). Polymerization scale-up to theirstandard batch sizes had historically beendone by simple trial-and-error. Thecondensers cooling capacity was not

documented, nor could the cooling loadplaced on the condenser be determined withthe available instrumentation. As a result,information essential to the safe operation ofthe reactor was not available.Polymerization reactors can runaway withdisastrous consequences if they are notcarefully controlled.11

Based on interviews the CSB conducted,Synthron employees and managers had little

or no understanding of reactive hazards.

11 In a runaway reaction, the pressure, and thus theboiling temperature, in the reactor increases, furtherincreasing the rate of reaction, and leading to higherpressures and heating rates.

They had not been trained on,12 and did notunderstand, the margin of safety needed oravailable in their polymerization operations.Furthermore, they had little knowledge of

the sensitivity of the reactor to changes inproduct recipes, batch sizes, or reactionconditions.

Synthrons employees were thus unpreparedto recognize and respond to the reactivehazards they faced the day of the incident.

3.3 Batch Recipe Changes

In planning the MFP-BH batch, Synthron

managers made several changes that greatlyincreased the heat released by the reaction inreactor M1 and the potential for a runaway

12 Synthrons training program was informal, relyingon unstructured on-the-job training. Testimonyindicated that reactive hazards were notsystematically addressed.


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reaction. However, the changes were noteffectively reviewed and the hazards wentunrecognized. Synthron:

increased the total amount ofmonomer to be charged to the reactor

by 12 percent. The additionalmonomer, with a Normal BoilingPoint Temperature (NBPT13) of147

oC (297

oF), was placed in the

initial reactor charge. reduced the amount of aliphatic

solvent, with an NBPT of 81oC

(178oF), charged to the reactor by 12percent.

increased the amount of aromaticsolvent, with an NBPT of 111oC

(234o

F), by 6 percent.

The customer had ordered 12 percent moreMFP-BH than a standard batch wouldproduce. To avoid the additional time andeffort of running two half-size batches, thesuperintendent scaled up the recipe toproduce the order in a single batch.

MFP-BH was produced in two stages. Inthe first, an initial charge of acrylic

monomer and solvent was loaded intoreactor M1, heated, and then reacted byadding an initiator over a brief period. Inthe second, the remaining monomer andinitiator were co-fed into the reactor over anextended period. Unfortunately, thesuperintendent placed almost all of theadditional monomer for the larger batch intothe initial charge of chemicals loaded intothe reactor.

According to the batch sheet, roughly equalamounts of aromatic and aliphatic solventshould have been added to the reactor.However, there was not enough of the lowerboiling temperature aliphatic solvent

13 NBPT is the boiling temperature at 1 atmosphereabsolute pressure.

available in storage. To compensate, thesuperintendent and manager decided tomake up half the shortfall using the higherboiling aromatic solvent, and to run thebatch with slightly less total solvent thanspecified in the recipe.

Together, these changes: increased the total amount of

monomer in the reactor by 45percent,

increased the concentration ofmonomer by 27 percent, and

increased the atmospheric boilingpoint temperature of the mixture byalmost 5oC (9oF).14

Each of these changes would be expected toincrease the rate of heat release in thereactor. When asked to review the changesin the solvent quantities, the plant chemistestimated that the boiling point of thesolvent mixture would increase about 1

oC

(1.8o F). However, the chemist, manager,and superintendent did not recognize oraddress the potential impact of the increasedmonomer amount and concentration on themixture boiling point, reaction rate, or total

rate of heat release.

The combined effect of the changes was toincrease the maximum heat output from thereaction to at least 2.3 times that of thestandard recipe. Figure 4 illustrates theresults of reaction calorimetry performed tosimulate the early stages of the incident.

14 The CSB measured the boiling points of laboratorymixtures with the same compositions.


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Figure 4. Reaction calorimetry heating curves for standard (lower) and modified (upper) recipes

The lower curve shows the heat release rate

(thermal power) versus time for the standardrecipe, while the upper curve shows the heatrelease rate for the modified recipe.15 Thelower solid horizontal line is the estimatedcooling capacity of the reactor condenser onthe day of the incident (see section 3.6 for adiscussion of condenser fouling). Once theheating curve exceeded the condensercooling line, control of the reaction was lost,resulting in a runaway reaction.

15 Each curve was generated isothermally at theNBPT of the mixture, closely simulating theoperation of the reactor up to the time when controlwas lost. Heat generation rates during the subsequentrunway reaction were higher.

3.4 Chemical Process

SafeguardsThe incident occurred before the second,continuous feed phase of the manufacturingprocess could begin.Synthron relied primarily on a proceduralsafeguard to prevent loss of reactor control:the batch sheet, which was used as anoperating procedure at the site. Proceduresare essential for safety in chemicalprocessing operation, but are the least

reliable form of safeguard for preventingprocess incidents (CCPS, 2004).

Failures with potentially severeconsequences, such as runaway reactions,should have multiple independentsafeguards.


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Examples of safeguards that could haveprevented or mitigated this incident, butwere not installed at Synthron, include:

high pressure alarms to notifyoperators of problems early in the

incident when action to control thereaction might still be possible,

automatic emergency cooling waterflow to the reactor jacket,

automatic shut-off of initiator feed, automatic or remotely operated

injection of short stop solution tostop the polymerization reaction,16and

automatic or remotely operatedventing or dumping of the reactor to

a safe location.

Good practice is to review the adequacy ofsafeguards on chemical reactors using astructured method such as Layers ofProtection Analysis (CCPS, 2001). Suchreviews can help ensure that runawayreactions are prevented or are rapidly andreliably detected and controlled.

3.5 Manway Bolting Practice

Operators opened the reactor manway afterevery batch cycle to clean the reactor.Long-standing practice at the facility was tothen close the manway and secure it usingonly four of the 18 clamps specified by themanufacturer (Figure 5).17 The risk posed bythis practice had not been recognizedbecause the reactor normally ran at near-

16 Chemicals, such as phenothiazine, can be injectedinto a reactor to slow or stop free-radicalpolymerizations such as the reaction at Synthron.17 The reactor manufacturer specified 18 clamps tomaintain a tight seal at the reactor maximum workingpressure of 75 psig. The clamps were notpermanently attached to the manway, and nomarkings on the manway indicated the requirednumber of clamps.

atmospheric pressure, for which four clampswere thought to be adequate.

Photo courtesy of Morganton Department of Public Safety

Figure 5. One of four installed manway

clamps

The CSB investigators calculated that, withonly four clamps installed, the manwaybegan to leak flammable solvent vaporswhen the reactor pressure reachedapproximately 23 psig, well below thereactors maximum allowable working

pressure (and likely relief valve set point) of75 psig.18 The vapor leak path is clearlyvisible in Figure 6 (arrow).

18 The reactor M1 relief valve could not be recoveredfrom the debris, and the relief valve records weredestroyed in the explosion and subsequent fires.Other relief valves examined were set at the ratedoperating pressure of the vessels they protected.


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Figure 6. Damaged manway gasket, showing

vapor release path

3.6 Process Equipment

Fouling

Synthron failed to establish procedures tomaintain the performance of the M1condenser, an inclined shell-and-tube heatexchanger essential to safe operation of thereactor.

In the condenser, solvent vapors flow insidethe tubes and are cooled and condensed bycooling water flowing through the shell

(Figure 2). Inspection of the cooling waterside of the condenser after the incidentrevealed that it was badly fouled, likelyreducing condenser capacity at least 25percent (Figure 7).

The condensers design, with the tubespermanently bonded to plates at both ends ofthe condenser, made inspecting or cleaningthe water side difficult.

19Furthermore, the

19 The condenser was a Tubular ExchangerManufacturers Association (TEMA) type BEM,fixed tubesheet exchanger with the process fluid onthe tube side and cooling water on the shell side. Thetubes could not be removed for inspection orcleaning. This design may require periodic chemicalcleaning of the shell side to maintain good thermalperformance.

company had no program to systematicallymonitor and control water side fouling.20The CSB found no evidence that the waterside of the condenser had ever beeninspected or cleaned to remove the scale,rust, and sediment that had accumulated

during 30 years of service. Synthronsemployees lacked the expertise andexperience to recognize the risk posed bywater side fouling of the condenser.

Figure 7. Deposits fouling the water side of

the M1 reactors condenser.

A clean condenser, combined withautomatic emergency jacket cooling (Figure

4, upper dashed line), would likely haveprevented the runaway reaction andsubsequent explosion.

3.7 Emergency EvacuationProcedures and Training

Effective evacuation plans are important forminimizing injuries and fatalities inchemical emergencies.

During this incident, none of the productionemployees evacuated to a safe location. Atthe time of the explosion, six employees,

20 Chemical treatment of the cooling water is almostalways required to prevent biological growth,fouling, and/or corrosion. The cooling water atSynthron was not treated.


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including the manager and superintendent,gathered outside a doorway on the upperlevel while a seventh was on the lower levelby the lab. The employee on the lower levelwas killed, while all the employees outsidethe doorway were injured, two seriously.

Synthron was unprepared for an emergency;specifically,

The facility Emergency Action Plandid not list events or describesituations that might necessitate aplant evacuation.

Operating procedure did not specifyemployees actions in the event of achemical release or loss of reactor

control. Employees were not trained on the

Emergency Action Plan andevacuation drills were not conducted.

The facility was not equipped withan emergency alarm system.

In this incident, there was sufficient timeafter the release began to evacuateemployees to a safe location. Adequateemergency response planning by Synthron

could have prevented the death and seriousinjuries caused by the explosion.

3.8 Corporate Oversight

Synthron was part of Protex International, amuch larger organization. However, theparent company provided little safetyoversight or support to Synthron.

While Synthron performed quality controltesting and limited product developmentwork in Morganton, the procedures,equipment, and trained personnel needed tocharacterize reactive hazards were not inplace.

However, Protex had the ability to performdetailed reaction characterization work,

including reaction calorimetry, at itsEuropean facilities. It is good practice(CCPS, 2003) to ensure that reactive safetyprograms at small facilities are adequatelysupported by technically qualified resources.Protex did not provide adequate reactive

safety support to Synthron.

Furthermore, in the summer and fall of2005, Synthrons president (also thepresident of Protex) hired a new vicepresident, plant manager, and plantsuperintendent for the Morganton site.While two of these key managementemployees had degrees in chemistry, theyhad no previous polymerization experienceand were not trained on the parent

companys process safety procedures or itstesting capabilities. Having little reactivechemistry background or training, they didnot recognize the reactive hazards at theMorganton site.

CCPS (1995) stresses that expertise inmanaging process safety must be ensuredwhen making staffing changes. Synthronspresident failed to ensure that the new teamhe installed at the Morganton site had the

requisite training, knowledge, andexperience to operate the facility safely.

Finally, Protex did not comprehensivelyaudit or review Synthrons safety program.Such a review should have identified theabsence of an effective reactive hazardcontrol program.


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4.0 Regulatory Analysis

Synthron had not implemented a ProcessSafety Management (PSM) systemconsistent with the requirements of theOccupational Safety and Health

Administrations (OSHA) PSM regulation(29 CFR 1910.119). 21 The site had lastbeen inspected by North Carolina OSHA(NC-OSH) in 1996. No PSM citations wereissued following that inspection. Followingthe explosion, NC-OSH proposed numerousPSM citations, which Synthron contested.

The batch being processed at the time of theexplosion, had it been completed, wouldhave contained in excess of the OSHA PSM

threshold of 10,000 pounds of flammableliquid. However, only 4,500 pounds ofmaterial were in the reactor at the time ofthe incident, well below the PSM thresholdquantity. Nonetheless, a catastrophicincident occurred. Synthrons experiencedemonstrates that companies working withreactive chemical quantities less than thePSM flammables threshold still need toconsider and guard against potentiallycatastrophic accidents.

21 OSHA Process Safety Management regulation, 29CFR 1910.119, is a performance-based process-safety regulation requiring manufacturers toimplement certain management practices onprocesses containing greater than threshold quantitiesof toxic or flammable chemicals.

5.0 The CSB ReactivesStudy

In its comprehensive 2002 report,Improving Reactive Hazard Management(CSB, 2002), the CSB found that reactiveincidents are a serious problem in the UnitedStates, and that both management systemand regulatory improvements are needed tohelp facilities control reactive hazards. Thisreport studied reactive incidents, causalfactors, and preventive measures,22 andoutlined the screening, hazard identification,hazard review, operating procedures, andtraining needed to prevent reactive incidents.

The report documented 167 serious reactive

incidents in the United States betweenJanuary 1980 and June 2001 that resulted in108 deaths, hundreds of injuries, andsignificant public impacts. Ongoingmonitoring by the CSB indicates thatreactive incidents, such as the Synthronexplosion, continue to occur.

The CSB report also found that 70 percentof reactive incidents occurred in thechemical manufacturing industry, with 35

percent due to runaway reactions, such asthat which occurred at Synthron.23 While 42percent of reactive incidents resulted in firesand explosions, another 37 percent causedtoxic emissions. Many reactive incidentsoccurred at small manufacturing sites suchas Synthron.

More than 50 percent of the 167 incidentsdocumented in the CSB report involvedchemicals not covered by existing OSHA

PSM (29 CFR 1910.119) or EPA RiskManagement Program (40 CFR Part 68)regulations. The CSB recommended better

22 Available for download at http://www.csb.gov.23 Of reactive incidents, 25 percent originate inreactors, with the rest occurring in a wide range ofequipment.


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coverage of reactive hazards by theseregulations. EPA now requires reporting ofreactive chemical incidents under RMPreporting rules. OSHA has taken steps toincrease industry awareness of reactivehazards, but has not fully implemented the

CSB recommendations.

The CSB report identified many valuablesources of good practices for managingreactive hazards. Since the reportspublication, additional guidance has becomeavailable. The Center for Chemical ProcessSafety (CCPS) publishedEssential Practicesfor Managing Chemical Reactivity Hazards(CCPS, 2003), which can be downloaded atno cost from http://info.knovel.com/ccps/

(January 2007). This book lays out the basicsteps manufacturers should take to protectagainst reactive hazards.

Other valuable sources of guidance areavailable. The EPAs Chemical EmergencyPreparedness and Prevention web pagehttp://yosemite.epa.gov/oswer/ceppoweb.nsf/content/ap-book.htm (May 2007) containsuseful links. The United Kingdoms Healthand Safety Executive also offers an

informative web page,http://www.hse.gov.uk/pubns/indg254.htm(May 2007) and the comprehensive booklet,Designing and Operating Safe ChemicalReaction Processes (HSE Books, 2000).

6.0 Lessons Learned

This incident provides important lessons formanufacturers with operations involvingreactive chemistry.

6.1 Identify and ControlReactive Hazards

Manufacturers should take a comprehensiveapproach, and:

identify and characterize reactivehazards;

systematically evaluate what can gowrong, including mis-charging ofreagents, loss of cooling, instrument

malfunction, and other crediblefailure scenarios; and

implement, document, and maintainadequate safeguards against theidentified failure scenarios.Multiple, independent safeguardsmay be needed to reliably ensure thesafety of the reactive process.

6.2 Control Change

Chemical manufacturers and others withreactive chemistry operations should controlchanges to batch recipes, including keyoperating conditions, such as:

the quantities, proportions, andsequencing of reactor feeds,

reaction temperature, conditions that could cause initiator

or monomer accumulation, and conditions that could affect the

deactivation of monomer inhibitorsor stabilizers.
http://info.knovel.com/ccps/http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/ap-book.htmhttp://yosemite.epa.gov/oswer/ceppoweb.nsf/content/ap-book.htmhttp://www.hse.gov.uk/pubns/indg254.htmhttp://www.hse.gov.uk/pubns/indg254.htmhttp://yosemite.epa.gov/oswer/ceppoweb.nsf/content/ap-book.htmhttp://yosemite.epa.gov/oswer/ceppoweb.nsf/content/ap-book.htmhttp://info.knovel.com/ccps/


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8.0 References

Health and Safety Executive (HSE) [Online], 2007. Chemical Reaction Hazards and the Risk ofThermal Runaway, www.hse.gov.uk/pubns/indg254.htm, London, UK: HSE.

HSE.Designing and Operating Safe Chemical Reaction Processes, Rugby, UK: HSE Books, 2000.

Center for Chemical Process Safety (CCPS). Guidelines for Hazard Evaluation Procedures - WithWorked Examples, 2nd ed, New York: American Institute of Chemical Engineers (AIChE), 1992.

CCPS. Plant Guidelines for Technical Management of Chemical Process Safety (Revised Edition),New York: AIChE, 1995.

CCPS. Layer of Protection Analysis - Simplified Process Risk Assessment, New York: AIChE,2001.

CCPS.Essential Practices for Managing Chemical Reactivity Hazards, New York: AIChE, 2003.

CCPS.Inherently Safer Chemical Processes, A Life Cycle Approach, New York: AIChE, 2004.

Mannan, S., LeesLoss Prevention in the Process Industries, 3rd ed., Burlington, MA: ElsevierButterworth-Heinemann, 2005.

Urban, P. G., Ed. Brethericks Handbook of Reactive Chemical Hazards, 6th ed., St. Louis, MO:Elsevier Science and Technology Books, 2000.

The United States Chemical Safety and Hazard Investigation Board (CSB). Improving Reactive

Hazard Management, Washington, DC: CSB, 2002.
http://www.hse.gov.uk/pubns/indg254.htmhttp://www.hse.gov.uk/pubns/indg254.htm


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The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal agencywhose mission is to ensure the safety of workers, the public, and the environment by investigatingand preventing chemical incidents. The CSB is a scientific investigative organization; it is not anenforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB isresponsible for determining the root and contributing causes of accidents, issuing safetyrecommendations, studying chemical safety issues, and evaluating the effectiveness of othergovernment agencies involved in chemical safety.

No part of the conclusions, findings, or recommendations of the CSB relating to any chemicalaccident may be admitted as evidence or used in any action or suit for damages. See 42 U.S.C. 7412(r)(6)(G). The CSB makes public its actions and decisions through investigation reports,summary reports, safety bulletins, safety recommendations, case studies, incident digests, specialtechnical publications, and statistical reviews. More information about the CSB is available atwww.csb.gov.

CSB publications can be downloaded at

www.csb.govor obtained by contacting:U.S. Chemical Safety and Hazard

Investigation BoardOffice of Congressional, Public, and Board Affairs

2175 K Street NW, Suite 400Washington, DC 20037-1848

(202) 261-7600

CSB Investigation Reports are formal,detailed reports on significant chemical

accidents and include key findings, root causes,and safety recommendations. CSB Hazard

Investigations are broader studies of significantchemical hazards. CSB Safety Bulletins are

short, general-interest publications that providenew or noteworthy information on

preventing chemical accidents. CSB CaseStudies are short reports on specific accidents

and include a discussion of relevant preventionpractices. All reports may include safety

recommendations when appropriate. CSBInvestigation Digests are plain-language

summaries of Investigation Reports.
http://www.csb.gov/http://www.csb.gov/

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