Event
- Event ID
- 745
- Quality
- Description
An employee was preparing a batch of glycol stearate emulsifier in a vessel. Upon completion of product, the quality control lab reported that the pH was too high and the product needed to be bleached.
When the employee reached the step of adding the sodium borohydride, he decided to relieve the pressure in the vessel by opening the valve used to introduce sodium chlorite. As he opened the valve, sodium chlorite (liquid) residue discharged, spraying the grating and the plastic bucket which contained sodium borohydride. The sodium borohydride reacted with the sodium chlorite, producing hydrogen gas which flashed into the employee's face. He was wearing splash goggles as face and eye protection, but nevertheless he experienced burns.- Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- fire
- Macro-region
- North America
- Country
- United States
- Date
- Component involved
- unknown
- Failure mode
- unknown
- Initiating cause
- unknown
- Root CAUSE analysis
Accidentally produced hydrogen due to human error.
- Root causes
- Date entry in HIAD
- 01/01/2020
Facility
- Application
- Chemical industry
- Sub-application
- Pharmaceutical production
- Hydrogen supply chain stage
- All components affected
Chemical reactor vessel (glycol stearate emulsifier)
- Location type
- Unknown
- Location
- industrial area
- Operational condition
- Pre-event occurrences
The event occurred during a manually operated chemical process. It is assumed that this operation was part of the normal production cycles.
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 1
In-depth data
- Release type
- Gas-liquid mixture
- Involved substances (% vol)
- H2,
NaClO2,
NaBH4 - Probable IGNITION SOURCE
- Flame type
References
- Sources categories
- OHSA
- Reference & weblink
Occupational Safety and Health Administration (OHSA) Inspection 112128152,
https://www.osha.gov/pls/imis/establishment.inspection_detail?id=112128…,
(accessed November 2020)
