Event
- Event ID
- 235
- Quality
- Description
- The incident occurred at a silane production plant. A ‘neutralization container’, part of the "Contact Mass Preparation" process unit, exploded. The bursting was caused by the accidental production of hydrogen, causing an over-pressurisation and failure of the tank, the release of hydrogen and a second explosion following ignition. The explosion caused significant property damage (plant equipment, buildings), but no serious personal injuries.
The production of hydrogen was due to an overdose of caustic soda in a silicon dust suspension tank, which caused its pH value to increase beyond a value of 11. This allowed a large amount of hydrogen to evolve in a very short time. - Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- Macro-region
- Europe
- Country
- Germany
- Date
- Main component involved?
- Chemical Storage Tank
- How was it involved?
- Internal Explosion (H2-Air Mixture)
- Initiating cause
- Accidental Hydrogen Formation
- Root causes
- Root CAUSE analysis
- The INITATING CAUSE was the accidental production of hydrogen from a run-away reaction.
There was no interlock which could have prevented the run-away reaction. The plant had been designed to operate on a manual basis. The pH probe was not used as a risk-monitoring tool. On top of that, the personnel forgot to activate the probe, probably due to malfunctioning of process components, catching their whole attention.
The ROOT CAUSE was a lack of proper risk assessment design and lack of proper personnel training during emergencies.
Facility
- Application
- Chemical Industry
- Sub-application
- Inorganic chemicals production
- Hydrogen supply chain stage
- All components affected
- silicon dust container
- Location type
- Confined
- Location description
- Industrial Area
- Operational condition
- Pre-event occurrences
- The process conditions were: alkaline solution with Si sludge,
pressure <= 300 mb, temp. approx. 50° C
Emergency & Consequences
- Number of injured persons
- 1
- Number of fatalities
- 0
- Currency
- Euro
- Property loss (onsite)
- 2000000
- Post-event summary
- Two people with minor injuries were taken to hospital (ZEMA mentions only 1).
Damage to adjacent buildings, to cars in surrounding area.
Damage outside of plant: Damage to pergola
Lesson Learnt
- Lesson Learnt
This incident example of lack of proper process variable monitoring and of interlocks system able to bring automatically the system to a safe state.
In the absences of these, the whole responsibility is shifted to personnel. In case of unexpected (thus not tested, exercised) series of events, the personnel has great difficulty in (i) understanding what is happening, (ii) focussing on the most critical emergency actions required to manage the emergency.- Corrective Measures
A ‘plausibility check’ was introduced as operative risk assessment tool. for those parts of the system which were not the object of a systematic safety-related testing beyond design and needed to be assessed regarding possible generation of unacceptable energy releases. This check is based on the logical concept that inadmissible energy conditions can occur only if:
(i) energy generated as intended cannot be dissipated,
(ii) energy potentials deactivated as intended are suddenly released,
(iii) or energy is introduced from outside.
Moreover, the company modified the process of ‘contact mass’ processing, particularly the neutralization stage relevant to the event.
Event Nature
- Release type
- gas
- Involved substances (% vol)
- H2 100%
- Actual pressure (MPa)
- n.a.
- Design pressure (MPa)
- n.a.
- Presumed ignition source
- Run-away reaction
References
- Reference & weblink
Event from German database ZEMA<br />
https://www.infosis.uba.de/index.php/de/site/2854/zema/index/3324.html<… />
(accessed December 2024)Event description in the European database eMARS<br />
https://emars.jrc.ec.europa.eu/en/emars/accident/view/4185fec7-e046-34f… />
(accessed December 2020)<br />
JRC assessment
- Sources categories
- ZEMA