January 4, 2025

Are you discussing domino effects in your HAZOP?

At approximately 5:50 p.m. on March 25, 1988, the leacher autoclave (#2) in building #1, which had been in service for about three weeks, reached a temperature of about 490 degrees Fahrenheit and a pressure of 400 psi. At this point the single locking (locating) pin sheared (the second pin was missing) allowing the cover to rotate against the locking ring, which was not fully engaged. The cover was released with explosive force, tearing a large hole in the roof and rupturing a 2 in. high-pressure gas line. As the head fell, a second hole was made in the roof about 25 yards northwest of the original location. Approximately 120 gallons of 28 percent sodium hydroxide solution was instantly vaporized into a cloud of caustic fumes that drifted over the area, causing eye, lung, and throat irritation to approximately 25 people, including the police who responded to the emergency. Employees #1 through #12 required medical attention. The gas line was promptly shut off by plant maintenance personnel who responded to the explosion. This action prevented further serious fire and explosion damage and possible loss of life.

Source: OSHA.gov

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