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In , at Batch 42, T2 increased the batch size by one third. There are no records of additional chemical or process analysis conducted as part of this recipe change, which may have introduced significant new risks. A greater volume of reactants increased the energy that the reaction could produce, and likely altered cooling and pressure relief requirements.

When the MCMT process yielded unexpected results in early batches, T2 did not halt production, investigate causes, and redesign the process. Instead, T2 attempted to control unexpected reaction results on-line through operator controls or minor alterations to continue running the process as it was already constructed.

As demand grew, T2 increased batch size and frequency with no additional documented hazard analysis. Unexpected exothermic reactions were managed as they occurred, 22 These exothermic behaviors were either stronger than T2 expected, or occurred at unexpected steps in the reaction. The CSB has investigated four previous runaway reaction incidents caused in part by not recognizing the reactive hazard. The incidents were an explosion at Morton International, Inc.

These incidents, summarized in Appendix E, and the one at T2 are responsible for a combined 10 deaths and over injuries. However, reactivity hazard awareness is not currently a fundamental component of chemical engineering curricula. Hence, they were illprepared to appreciate and recognize the reactivity hazards of the MCMT process. Of the universities surveyed, only 11 percent required process safety education in the core baccalaureate curriculum. An additional 13 percent offered an elective process safety course. The survey did not specifically address reactivity hazard awareness education; however, a sampling of curricula indicates that the inclusion of reactivity hazards in chemical engineering education is limited at best.

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Accreditation of U. Baccalaureate programs are accredited by the Accreditation Board for Engineering and Technology, Inc. ABET based on recommendations from profession-specific industry groups. There is no requirement for accredited baccalaureate chemical engineering programs to include process safety or reactive hazard awareness in their curricula.

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PSM applies to facility processes that include 10, pounds or more of flammable liquids or gases in one location, and to listed toxic chemicals at or above certain threshold quantities. Key elements of the management system required for covered processes include conducting PHAs, implementing and maintaining written operating procedures, conducting periodic operator training, and implementing a management of change program.

T2 did not use or store any listed chemicals subject to PSM coverage. RMP elements must specifically address potential community impact, environmental damage, and site coverage under other regulatory programs. T2 did not use or produce any RMP-covered chemicals and was not required to register with or submit plans and release analyses to EPA. EPCRA Tier II reporting requirements are designed to inform emergency responders of potential hazards should a chemical incident occur at a facility. Emergency responders should be familiar with the hazards of EPCRA-listed chemicals, but are dependent upon facilities to accurately convey which chemicals are present on their sites.

This incomplete report did not warn emergency responders of the MCMT, which is toxic by ingestion, inhalation, and skin absorption. Board Voting Copy September 15, storage tanks. The consultant informed T2 that it must develop a hazard communication program,33 which should include employee training, chemical labeling, and provision of MSDSs for all chemicals onsite. He compiled the report based upon a list of raw materials provided by T2, and was unaware that T2 was manufacturing a toxic chemical. Board Voting Copy September 15, 7. In the CSB published a comprehensive report, Improving Reactive Hazard Management, documenting the rate, types, and causes of reactive incidents and providing recommendations to improve regulatory coverage.

The American Institute of Chemical Engineers AIChE has actively promoted reactivity hazard education, operating groups specifically tailored to provide reactivity safety and design information to students and process engineers 7. The report studied reactive incidents, causal factors, and preventive measures, and outlined the screening, hazard identification, hazard review, operating procedures, and training needed to prevent reactive incidents. Ongoing CSB monitoring indicates that reactive incidents—such as the T2 explosion—continue to occur.

The report also found that 70 percent of reactive incidents occurred in the chemical manufacturing industry, with 35 percent due to runaway reactions like the one that occurred at T2. Of reactive incidents, 25 percent originate in reactors, with the rest occurring in a wide range of equipment. Board Voting Copy September 15, reactive incidents resulted in fires and explosions, another 37 percent caused toxic emissions. Many reactive incidents occurred at small manufacturing sites like T2. EPA now requires reporting of reactive chemical incidents under RMP reporting rules and OSHA has taken steps to increase industry awareness of reactive hazards, but neither has fully implemented the CSB recommendations.

The reference section of this report lists resources that are widely available to plant designers and operators. Presently more than domestic and international member companies interested in design, use, or manufacture of emergency relief systems comprise the DIERS Users Group, which meets semiannually. DIERS methodology has earned broad industry acceptance and recognition.

DIERS Users Group publications address screening and management of chemical reactivity hazards, reactivity test apparatus design and evaluation, scale-up, and design of emergency relief systems. CCPS members define, develop, and publish engineering and management best practices to prevent or mitigate catastrophic releases of chemicals. SAChE products address hazards of chemical reactivity, inherently safer design, risk assessment, simplified relief design, and other process safety topics.

RMR provides reactivity hazard recognition and management resources to companies with limited technical sophistication. RMR is developing web-based tools that use decision trees to identify potential chemical reactivity hazards.

T2 Laboratories Case Study | Free Case Study Example

Two certificate modules, in addition to the general module, address runaway reactions and chemical reactivity hazards. The program issued about certificates in its first year. Board Voting Copy September 15, 8. On December 19, , an explosion at T2 Laboratories, Inc. The explosion was due to a runaway exothermic reaction that occurred in a chemical batch reactor during the production of methylcyclopentadienyl manganese tricarbonyl MCMT.

The runaway reaction occurred during the first, metalation, MCMT process step. A desired exothermic reaction in the metalation step ran away due to a cooling system failure, leading to a second undesired exothermic reaction.

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The reactor cooling system lacked design redundancy and was susceptible to single-point failure. No emergency source of cooling existed. The T2 owners were likely unaware of the second exothermic reaction that occurred in the batch recipe at high temperatures.

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Neither of the T2 owners had prior reactive chemistry experience. Most baccalaureate chemical engineering curricula in the U.


Board Voting Copy September 15, 9. The MCMT reactor vessel relief system was incapable of relieving the pressure from the runaway reaction. CCPS, b. Fisher, H. HSE, Hendershot, D.

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O, Mannan, S. CSB, a. CSB, b. Morton International, Inc. The first step of the reaction required heating to initiate the reaction. After that, all three steps were exothermic heat-producing and required cooling. In the first step called metalation , molten metallic sodium was reacted with methylcyclopentadiene MCPD in the presence of a diethylene glycol dimethyl ether diglyme to form sodium methylcyclopentadiene and hydrogen gas. This was accomplished by adding metallic sodium to a mixture of MCPD dimer37 and diglyme, then heating the mixture.

T2 vented the hydrogen gas produced by this step to the atmosphere. MCMT metalation reaction. In the second step called substitution , T2 added manganese chloride dry powder to the reactor.