Event
- Event ID
- 784
- Quality
- Description
The loss of control of a reaction caused a fire in a pharmaceutical plant caused a reaction runaway and the rupture of a 6 m³ reactor. A cloud containing sodium borohydride and hydrogen was released.
The production manager evacuated the installation. When the cloud reached electrical equipment, an explosion occurred. The cooling circuit was damaged. The thermal oil leaked and ignited. The fire spread to a large part of the plant.
Firefighters intervened. The water of extinction was confined in basins. Storage tanks that were not affected by the fire were emptied. During the accident, 30 t of oil burned. 50% of the installations were destroyed, representing a damage of 12 M €.- Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- Macro-region
- Europe
- Country
- Spain
- Date
- Component involved
- reactor / oven / furnace / test chamber
- Failure mode
- rupture & ignition
- Initiating cause
- run-away reaction
- Root CAUSE analysis
INITIATING cause was a reaction runaway cause explosion of the reactor.
The runaway of the reaction was due to a change in the reaction temperature. In order to increase reaction efficiency, the temperature had been lowered from 50 ° C to 20 ° C. The accident occurred during the first production under these conditions. No risk analysis of this operative change had been made beforehand. The standard procedures of the group to which the plant belongs did not take into account the risk of runaway exothermic reactions.
ROOT CAUSE was a modification of the process parameters, without performing a risk assessment.
- Root causes
- Date entry in HIAD
- 01/01/2020
Facility
- Application
- Chemical industry
- Sub-application
- Pharmaceutical production
- Hydrogen supply chain stage
- All components affected
unspcified chemical reactor
- Location type
- Unknown
- Location
- industrial area
- Operational condition
- Pre-event occurrences
Reaction temperature in the reactor containing NABH4 and H2 was lowered from 50C to 20C.
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 0
- Post-event summary
During the accident, 30 t of oil burned. 50% of the installations were destroyed, representing an damage of 12 M €.
- Emergency action
The production manager evacuated the installation.
The fire spread to a large part of the plant. Firefighters intervened. The water of extinction was confined in basins. Storage tanks that were not affected by the fire were emptied.
Lesson Learnt
- Corrective Measures
After the accident, the operator modified the Management of Change procedures.
This event was at the origin of an evolution of the regulations to integrate this experience feedback.
In-depth data
- Release type
- gas mixture
- Involved substances (% vol)
- H2,
NaBH4 - Probable IGNITION SOURCE
- Explosion type
References
- Sources categories
- ARIA
- Reference & weblink
ARIA data base
event no. 50441Event of the European database eMARS
https://emars.jrc.ec.europa.eu/en/emars/accident/view/c6df8789-b814-856…
(accessed May 2026)