"This report investigated the causes of a chemical release accident caused by an abnormal reaction and recommended certain safety steps to prevent the reoccurrence of similar accidents. An abnormal reaction occurred during the input of raw materials (t-BuOH, KMnO4, and H2O), and some foreign impurities (4% MeOH, 13% glycerin) that may have influenced the reaction were identified. The MeOH may have entered the reactor during t-BuOH reuse or the cleaning of mechanical parts, and glycerin was released from the seal oil reservoir to enhance lubrication with the agitator in the reactor. The pilot test carried out to reproduce the abnormal reaction revealed a rapid reaction, with an increase in the mixture temperature when the KMnO4 and glycerin (13%, released from the broken seal oil reservoir) were added to the mixture that contained 96% t-BuOH and 4% MeOH (impurity). Furthermore, some deficiencies in the safety system and some human errors were discovered. The reactor was not equipped with either a safety instrumental system or an automated emergency shutdown system, and the workers did not wear PPE. These factors could have had a significant impact on the accident".
Read the report in this link
