At 9:20 a.m., a rupture disc of a reactor used to produce an organomagnesium compound burst when the reactor’s internal pressure rose too high. The incident was caused by a nonconforming mixture that had formed in the reactor. First, the ambiguous instructions led a technician to add an insufficient amount of initiator. Then, seeing that the reaction had not yet started, a second technician added more reagents. The process sheet indicated that the reagent could be added after, but only after receiving the supervisor’s approval.
The operation took place on a Saturday and the chemical engineer belatedly informed the on-duty engineer. This lack of communication between the workers of both shifts and the technicians’ lack of experience are what set the stage for the incident.
The operator subsequently implemented a number of changes : tracking of technicians who are accredited to carry out synthesis operations has been reinstated ; the process sheet now indicates the amounts of reagent to be added and includes hold points for the start of the reaction ; the reaction may no longer be carried out over the weekend and it must be scheduled at the beginning of a shift so that workers may monitor it from start to finish. In addition, the operator conducted an in-depth review of organomagnesium compound synthesis in order to establish production standards and problem-management guidelines applicable at all its similar production sites.
Source:Aria database
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