Event
- Event ID
- 846
- Quality
- Description
- The accident occurred during the first phase of the batch synthesis of tricarbonyl compound (methylcyclopentadienyl) manganese (TMCM), while the reaction mixture in the reactor consisted of more than 0.5 t of sodium and organic compounds. Reaction runaway with hydrogen production caused a large increase in pressure and temperature leading to a rupture of the reactor (above 100 bar).
The ignition of the released flammable cloud led to the formation of a fireball and generated a large heat flux. A fragment of more than 100 kg from the upper part of the reactor were found 400 m from the site of the explosion.
The fire mobilized about 70 firefighters; a safety perimeter of 800 m was set up; a cloud of mushroom-shaped black smoke rose more than 600 m above the site.
The plant was employing 12 people. 4 employees died and 33 were injured, most of them outside the site, by projectiles from buildings impacted by the blast of the explosion. The damages were important, observed up to 300 m from the place of the explosion (breakage of windows, damages of the structures ...).
An investigation was conducted by a federal agency to determine the exact causes of the accident. The runaway of the reaction was due to a lack of cooling of the reactor. The reactor cooling system was sensitive to point failures due to the lack of redundancy of safety equipment during reactor design. In addition, the safety system was not able to evacuate the pressure generated by the runaway reaction. - Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- Macro-region
- North America
- Country
- United States
- Date
- Root causes
- Root CAUSE analysis
- The INITIATING cause of the runaway reaction was the lack of cooling of the reactor.
The ROOT CAUSE was that fact that the plant operator did recognize the runaway reaction hazard associated with the MCMT. This could be associated o lack of training of lack of diagnostic capacity of the installation.
CONTRIBUTIGN CAUSES were deficiencies in the safety design. The cooling system was susceptible to single-point failures due to a lack of design redundancy. The MCMT reactor vessel relief system was incapable of relieving the pressure from the runaway reaction.
Facility
- Application
- Chemical Industry
- Sub-application
- fuel additives manufacturer
- Hydrogen supply chain stage
- All components affected
- chemical reactor for TMCM synthesis
- Location type
- Confined
- Location description
- Industrial Area
- Operational condition
- Description of the facility/unit/process/substances
- DESCRIPTION OF THE PROCESS
The tricarbonyl (methylcyclopentadienyl) manganese (TMCM) is an organomanganese compound with formula (C5H4CH3)Mn(CO)3. It is used as fuel supplement, in gasoline, specifically in unleaded gasoline to increase the octane rating.
The accident occurred during the first phase of the synthesis of the TMCM, while the reaction mixture in the reactor consisted of more than 0.5 t of sodium and organic compounds.
According to the normal operation procedure, hydrogen is among the reaction products and is vented to the atmosphere via a pressure relief valve. The reaction becomes self-sustaining and need to be cooled.
Short before the accident the operator reported a cooling problem.
Emergency & Consequences
- Number of injured persons
- 33
- Number of fatalities
- 4
- Post-event summary
- 4 employees were dead and 33 injured, most of them, outside the site, by projectiles from buildings impacted by the blast of the explosion. The material damages were important, they were observed until 300 m of the place of the explosion (breakage of windows, damages of the structures ...).
Lesson Learnt
- Lesson Learnt
In a previous analysis of the accidents related to reactive hazard, the CBS had issued the following general recommendations (HAZARD INVESTIGATION Report No. 2001-01-H Issue Date: October 2002 IMPROVING REACTIVE HAZARD MANAGEMENT):
1. Identify and thoroughly evaluate reactive hazards in their processes
2. Implement appropriate emergency pressure relief devices and other design safeguards
3. Develop effective operating procedures and training programs
4. Carefully manage changes to existing processes
5. Plan for possible accidents, including evacuation drills and emergency response exercises
These recommendations can be applied also to this specific accident. Moreover, one of the findings of the dedicated report (see references) is the lack of reactive chemistry experience.
Therefore, the CBS issued the following additional recommendations to the American Institute of Chemical Engineers:
6. To add reactive hazard awareness to baccalaureate chemical engineering curricula requirements.
7. To inform all student members about the Process Safety Certificate Program and encourage program participation.
Event Nature
- Release type
- gas
- Involved substances (% vol)
- H2 100%
- Actual pressure (MPa)
- 10
- Presumed ignition source
- Run-away reaction
- High pressure explosion
- Y
- Flame type
- Fireball
References
- Reference & weblink
U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD(CSB )<br />
Investigation report NO. 2008-3-I-September 2009<br />
https://www.csb.gov/userfiles/file/t2%20final%20report.pdf <br />
(accessed July 2020)<br />ARIA database event no. 34193<br />
https://www.aria.developpement-durable.gouv.fr/accident/34193/<br />
(Accessed December 2023)
JRC assessment
- Sources categories
- CSB