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Failed Controller causes Incident

The Incident

During a polymerization reaction (poly acrylates), a runaway reaction occurred and the vessle pressurized and relieved via the emergency relief system.  Four tones of material were released to the roof, and some blown off-site.  No one was injured.

The Reasons

It was found that a feed controller had failed, and added three toms of material in 45 minutes rather than 3 hours.  As the plant was old there were no catch tanks for any release.  The temperature alarms which were once in place had been removed as the plant was now "multi-purpose".

The Changes

All the interlocks have been re-instated, but with greater consideration of all products manufactured in the plant
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