May 17, 2018

Human error and Human factor incident

Reaction containing flammable mixture was completed. The batch was transferred to another kettle. Inerting was carried out. As soon as the nitrogen gas was admitted, an explosion took place in the system. Two operators were killed & five injured. Root Causes: Instead of inert gas, air was admitted, by mistake. There was no system to ensure the specific inert gas or air in the cylinder.

Courtesy: A.G.Shingore, National Safety Council

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