Case Ditails

Scenario
Case Name Rupture and fire of a measuring tank caused due to an incompatible reaction from transport of a different chemical to a tank containing a chemical
Pictograph
Date August 6, 1998
Place Iwakura, Aichi, Japan
Location Chemical factory
Overview At a chemical factory, an explosion occurred at a measuring tank for chemicals. When an operator transferred chemicals contained in a drum to the measuring tank with a pump, the drum was placed and left near the pump. From the appearance of the drum, a third person guessed the name of substance and transferred it to an incorrect measuring tank with good intentions. Due to an incompatible reaction of two chemical materials, it exploded and a fire occurred.
Incident Diethylenetriamine was accidentally transferred to a measuring tank containing epichlorohydrin. Consequently, the pressure of the measuring tank rose due to a reaction, the tank ruptured, and a fire occurred.
Processing Manufacture
Individual Process Transfer
Process Flow Fig2.Unit process flow
Substance Diethylenetriamine, Fig3
Epichlorohydrin, Fig4
Type of Accident Rupture, explosion, fire
Sequence Past 10:40 on August 6th, 1998. An operator was carrying a drum in front of the feed pump from a drum can storage place.
10:50. Another operator started transfer work to a measuring tank to assist the operator voluntarily. The contents were judged to be epichlorohydrin from the color of the drum. A pump was attached to the drum and transfer started. The transfer was checked with a level meter in the control room.
Transfer of the 2nd drum can started.
10:57. When the 1st empty drum can was carried to the empty drum storage place, the measuring tank exploded and a fire occurred. As the letter "diethylenetriamine" was written at the upper part of the drum can, the operator noticed the error after the explosion.
11:00. The public fire department was notified. 14 fire engines and 62 fire fighters turned out.
The transfer pump was stopped. Valves were closed. The fire was not extinguished by initial fire extinguishing using a powder fire extinguisher.
11:08. The fire was extinguished.
Cause As diethylenetriamine was transferred to the measuring tank for epichlorohydrin, the tank swelled due to the reaction, and ruptured. The source of ignition is assumed to be electric sparks at the time the electric equipment was broken by the rupture.
Response The transfer pump was stopped and the valve was closed.
Initial fire extinguishing using a powder fire extinguisher was done, but failed.
Self-protecting fire fighters sprayed water from an outdoor fire hydrant.
Water was sprayed by public fire fighters with a tank car.
Countermeasures Strengthening of a check system for receiving work.
A transfer pump and a tank were moved to another place.
Sufficient safety education.
Knowledge Comment Even if a third person was working in good faith, it is a violation of safety rules to handle a hazardous material without confirmation. It is also a problem that a person not in charge handles a hazardous material.
The measure for preventing a mistake in judgment of similar objects by the color of the container may be effective, if one by one correspondence is taken. However, if two or more colors are used for the same objects, it only leads to confusion. It is better to stop such a measure.
Background There were two fundamental problems. The first is that a third person worked without contacting a person in charge, although he was trying to assist. Such work is prohibited and is a violation of order because a hazardous material was being used. The second problem was not having checked the substance's name. Although it is also a problem that the appearances of containers of completely different chemicals were similar, the contents need to be checked before use. The reason for not having carried out a contents check was that the appearance of the diethylenetriamine drum usually used was different, and at that time, the appearance of the diethylenetriamine drum resembled the appearance of an epichlorohydrin drum which was used generally at the site. Therefore, diethylenetriamine was taken for epichlorohydrin. It was an easy mistake to make and is not desirable from the viewpoint of human engineering.
Incidental Discussion Distinction by color is problematic. The same product might differ according to the manufacturer in its color and form. Consequently, different products may have the same color of the container. For example, colors of chemical gas cylinders are not universal.
Reason for Adding to DB Example of fire caused due to an incompatible reaction from a mistake in judgment of a third person in good faith
Scenario
Primary Scenario Organizational Problems, Inflexible Management Structure, Insufficient Education/Training, Poor Value Perception, Poor Safety Awareness, Inadequate Risk Recognition, Misjudgment, Misperception, Convincement, Regular Movement, Careless Movement, Work without Confirmation, Malicious Act, Rule Violation, Safety Rule Violation, Bad Event, Chemical Phenomenon, Abnormal Reaction, Secondary Damage, External Damage, Rapture/Explosion, Bodily Harm, Death, Bodily Harm, Injury, 3 person injured, Loss to Organization, Economic Loss, Manetary Damage 55 million yen
Sources Fire and Disaster Management Agency, Fire caused by explosion due to chemical reaction heat. Accident cases of dangerous materials, 1998. pp.76-77.
Outlines of significant accidents. Safety yearbook 1998. p.275.
The Res. Inst. of Industrial Safety material. (closed).
Number of Deaths 1
Number of Injuries 3
Physical Damage Fire damage to the factory. Damage to a storage tank and ancillary facilities.
Financial Cost ¥ 55 million. (Fire and Disaster Management Agency).
Multimedia Files Fig3.Chemical formula
Fig4.Chemical formula
Field Chemicals and Plants
Author ITAGAKI, Haruhiko (Japan National Institute of Occupational Safety and Health)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)
Scenario