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19871 Chemical accident in Sweden with toluene
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General accident information
Class/Quality * * *
Year 1992
Summary Toluene was stripped off unintentionally from
A reactor containing mono nitrate ester causing
Runaway reaction, explosion, badly damaged
Building and at least 6 casualties
Country S
Activity PROCESSING
Location CHEMICAL FACTORY
Chemicals Mono nitrate ester, Toluene (toluol/Methylbenzene)
Cause Human-failure
Fatalities/Injuries 1 / 5-7
Occurrences or events Burst/Rupture, Chemical reaction, Defective-working, Explosion,
Ignition, Mix, Overheating, Overpressure,
Release, Run-away-reaction, Vaporize
 
 
Full accident information 
download accident report Click here to view a document containing the full accident information

Country: SWEDEN (S)
Date : 1992 0211


Just a few minutes before midnight, a reactor at a chemical plant for production of active pharmaceutical ingredients exploded killing 1 worker and slightly injuring at least 5 other workers.
Six operators were working in the plant at the time, one was killed and the other five miraculously survived and managed to get out of the badly damaged building.
The root cause was the overheating of a reactor containing approximately 300/kg of a mono nitrate ester in toluene.
When, unintentionally, all of the toluene was stripped off, the temperature of the remains in the reactor reached the temperature of the jacket and a thermal decomposition was initiated.
A huge amount of heat and gases were evolved, along with a rapid pressure build-up. Within a few tens of milliseconds the reactor burst and a second explosion occurred due to auto-ignition of the hot gases blowing out. The second explosion wrecked a major part of the building.
The accident really shocked the whole organization and jeopardized the business activities as well. Very soon after the accident the Board of Directors decided to restore the plant, and started an extensive and intense work to save all business commitments and to learn the most of this event.
From that day process safety and many other related safety areas became daily issues and handled with more respect than before the accident.
Over the years a deeply rooted safety culture has been developed in the company.
From early trial of new product developments in lab-scale to full scale production, it is a serious and natural matter for us to follow the policy statement form our management: Safety prior to production.

Lessons learned
1.
Learning from experiences of accidents from others is important, but demands a great portion of humility.
2.
The importance of top management attitude and engagement with respect to safety issues.
3.
A thorough investigation of causes down to its deepest root pays. Incorporate external expertise, even if you feel competent enough yourselves.
4.
An accident may deteriorate the self-confidence of an organisation due too strong focus on defects. Highlight strengths as well.
5.
An accident is not just a technical matter. The management system must be reviewed as well - organisation, policy, procedures, competence, training, etc.
6.
Do not overdo things, when implementing correcting measures. Blindness to other areas can be the effect and new accident may occur.
7.
The importance of strict and adapted risk analysis procedures in daily work.




 
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