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Thermal runaway with gas evolution

A gas evolution incident occurred which resulted from a thermal runaway.

Aliquots of material were being charged and even though no reaction was apparent 4 aliquots were added.  The cooling was stopped and the batch ran away.

The investigation showed that the operator was not fully trained, the incident occurred at the shift changeover, the process instructions were poor and it was the first time the operator had worked on this process

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