The incident occurred before the second, continuous feed phase of the manufacturing process could begin.
Synthron relied primarily on a procedural safeguard to prevent loss of reactor control: the batch sheet, which was used as an operating procedure at the site. Procedures are essential for safety in chemical processing operation, but are the least reliable form of safeguard for preventing process incidents (CCPS, 2004).
Failures with potentially severe consequences, such as runaway reactions, should have multiple independent safeguards.
Examples of safeguards that could have prevented or mitigated this incident, but were not installed at Synthron, include:
¾ high pressure alarms to notify operators of problems early in the incident when action to control the reaction might still be possible,
¾ automatic emergency cooling water flow to the reactor jacket,
¾ automatic shut-off of initiator feed,
¾ automatic or remotely operated injection of “short stop” solution to stop the polymerization reaction, and
¾ automatic or remotely operated
venting or dumping of the reactor to a safe location.
Good practice is to review the adequacy of safeguards on chemical reactors using a structured method such as Layers of Protection Analysis (CCPS, 2001). Such reviews can help ensure that runaway reactions are prevented or are rapidly and reliably detected and controlled.
The incident occurred before the second, continuous feed phase of the manufacturing process could begin. Synthron relied primarily on a procedural safeguard to prevent loss of reactor control: the batch sheet, which was used as an operating procedure at the site. Procedures are essential for safety in chemical processing operation, but are the least reliable form of safeguard for preventing process incidents (CCPS, 2004). Failures with potentially severe consequences, such as runaway reactions, should have multiple independent safeguards. Examples of safeguards that could have prevented or mitigated this incident, but were not installed at Synthron, include: ¾ high pressure alarms to notify operators of problems early in the incident when action to control the reaction might still be possible, ¾ automatic emergency cooling water flow to the reactor jacket, ¾ automatic shut-off of initiator feed, ¾ automatic or remotely operated injection of “short stop” solution to stop the polymerization reaction, and ¾ automatic or remotely operated venting or dumping of the reactor to a safe location. Good practice is to review the adequacy of safeguards on chemical reactors using a structured method such as Layers of Protection Analysis (CCPS, 2001). Such reviews can help ensure that runaway reactions are prevented or are rapidly and reliably detected and controlled.
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