Event
- Event ID
- 916
- Quality
- Description
A explosion occurred in a chemical manufacturing plant for the pharmaceutical and cosmetics industries, classified as high level Seveso), and affected its hydrogenation reactor.
At end of the hydrogenation cycle, the catalyst needed to be reactivated by explosure to hydrogen at high temperature. After that, two buffer tanks belonging to the hydrogenation unit were opened for cleaning, when the explosion occurred.The operator initiated the emergency plan, evacuated personnel and secured the area. Two operators were injured.
- Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- Macro-region
- Europe
- Country
- France
- Date
- Component involved
- reactor / oven / furnace / test chamber
- Failure mode
- rupture & ignition
- Initiating cause
- inadequate or no purge
- Root CAUSE analysis
INITIATING CAUSE of the explosion was the presence of hydrogen when opening to air the buffer tanks.
According to the ARIA report, the explosion was probably be due to the presence of hydrogen in the reactor, because the nitrogen purging was not performed despite the procedures in place.
The flammable mixture created by the entrance of air at the opening of the tanks was then ignited by a hot spot formed by a catalyst deposit (ruthenium on coal), which probably had become pyrophoric after activation.Contributing to the ROOT CAUSE was the failing to apply the procedure to purge the tank with nitrogen. This failure could be attributed to a human error, possibly triggered by lack of training or lack of clarity of the procedures.
ROOT CAUSE is unknown, because it is not known why the procedure was no followed.
- Root causes
- Date entry in HIAD
- 01/01/2018
Facility
- Application
- Chemical industry
- Sub-application
- pharmeceutical and cosmeticals manufacturer
- Hydrogen supply chain stage
- All components affected
hydrogenation reactor, buffer tank
- Location type
- Confined
- Location
- industrial area
- Operational condition
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 2
- Post-event summary
Two operators in the vicinity of the reactor at the time of the explosion were injured.
The system was not damaged.- Emergency action
Following the explosion, the operator initiated the emergency plan, evacuated personnel and secured the area.
Lesson Learnt
- Lesson Learnt
An additional measure, not mentioned in the ARIA report, would come from answering the question on why the procedure was not followed, and what can be put in place to guarantee/monitor that they are followed in the future.
- Corrective Measures
The operator introduced the following two improvements
1. Review and re-assessment of the operative procedures
2. new training of the workers.
In-depth data
- Release type
- gas
- Involved substances (% vol)
- H2 100%
- Probable IGNITION SOURCE
- Explosion type
- Detonation
References
- Sources categories
- ARIA
- Reference & weblink
Event 52794 of the French database ARIA
https://www.aria.developpement-durable.gouv.fr/accident/52794/
(accessed September 2020)