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The Incident

An epoxide intermediate polymerized leading to a drum rupture. The intermediate was thought to be stable.

The Investigation

It was shown that the polymerization was base catalysed.  Normally the compound was purified by a silica treatment prior to drumming up.  In this particular case less silica was available to carry out the purification.  The process change was not perceived as significant.

Conclusions

Lessons Learnt

Once again we see a minor "insignificant" process change being the main cause of an incident.  All process changes, however minor must be properly assessed, starting with laboratory trials.

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