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The Incident

An ester was being reduced by sodium borohydride.  During the reaction several errors were made, and several warning signs were ignored, with the result that, eventually, the reactor contents completely ran away, with temperatures far exceeding 300°C.

The Investigation

Immediate on-site investigation was carried out

Findings:

Lessons Learnt

Ignoring the human error of sending to the doser, there were two obvious places where warnings were ignored, which could have prevented this runaway

This shows that operators must be trained into correct following of process, and not try to do changes to correct mistakes of others. Plus to try to observe the unusual and report it immediately to a senior person.

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