2017 PSM Moment

Process Safety Awareness

T2 LABORATORIES, INC. RUNAWAY
REACTION 10th Anniversary,
19th December 2007
 Incident Summary
At 1:33 pm on December 19, 2007, a explosion
equivalent to 1,400 pounds of TNT and
subsequent chemical fire from exothermic
reaction killed 4 employees and destroyed T2
Laboratories, Inc. (T2), a chemical manufacturer
in Jacksonville, Florida. It injured 32, including 4
employees and 28 members of the public who
were working in surrounding businesses. Debris
from the reactor was found up to one mile away,
and the explosion damaged buildings within one
quarter mile of the facility.[1].
• Key Issues:  Process Safety Culture  Process Hazard Analysis
 Management of Change  Competency Management
[1] http://www.csb.gov/t2-laboratories-inc-reactive-chemical-explosion/

2
 Incident Background

On December 19, T2 was producing its 175th batch of methyl cyclopentadienyl manganese
tricarbonyl (MCMT). At 1:23 pm, the process operator had an outside operator call the owners to
report a cooling problem and request they return to the site. Upon their return, one of the two
owners went to the control room to assist. A few minutes later, at 1:33 pm, the reactor burst and
its contents exploded, killing the owner and process operator who were in the control room and
two outside operators who were exiting the reactor area.

3
 What went wrong?
T2 did not recognize runaway reaction hazard with the MCMT it was producing
Development Phase Operation Phase
 T2 sized the reactor relief devices  T2 increased the batch size by one
based on anticipated normal third. There are no records of
operations, without considering additional chemical or process
potential emergency conditions. analysis conducted as part of this
 The reactor cooling system lacked recipe change. During scale-up, CSB
design redundancy and was found no evidence that T2 ever
susceptible to single-point failure. No performed the HAZOP.
emergency source of cooling existed.  Interviews with employees indicated
that T2 ran cooling system
components to failure and did not
perform preventive maintenance.
[1] http://www.csb.gov/t2-laboratories-inc-reactive-chemical-explosion/
4
Incident
 The runaway reaction occurred
during the first, metalation, MCMT
process step.
 A loss of sufficient cooling during the
process likely resulted in the runaway
reaction, leading to an uncontrollable
pressure and temperature rise in the
reactor.
 The MCMT reactor relief system was
incapable of relieving the pressure
from a runaway reaction. The
pressure burst the reactor; the
reactor’s contents ignited, creating
an explosion equivalent to 1,400
pounds of TNT
 What went wrong?
PTTEP 21 Process Safety Elements
Process risk Risk Management Review and
Process Safety identification/
Leadership Improvement
assessment

Leadership Operating manuals Process start-up

and procedures
Incident Reporting
Hazard and Investigation
Identification Process and Emergency
Legal/standard operational status preparedness
compliance monitoring /
handovers
Inspection and
Management of maintenance
Employee
competency / operational Audit, Assurance,
assurance interfaces Management of Management
Safety Critical Review and
Elements Intervention
Workforce Standards and
involvement practices
Documentation, Work control, PTW
Records & KM
Process Safety
Communication Contractor Event Indicators
MOC
with stakeholders management

The 21 Process Safety Elements as specified in 11038-STD-SSHE-440-007-R02;

Red: Ineffective barriers – details provided in the next slide.

5
 Elements of Process Safety Management
1. Leadership: The runaway reaction on December 19, 2007, was not the first unexpected exothermic reaction that
T2 experienced; Leaders/Company did not recognize / encourage safety awareness to employees.
2. Legal/Standards compliance: T2 did not use or produce any Risk Management Planning (RMP)-covered
chemicals to Environmental Protection Agency (EPA).
3. Employee Selection, Placement, Competency and Health Assurance: Chemists and chemical engineers who
involved in developing and operating the T2 MCMT process did not recognize runaway reaction hazard. T2
sized the reactor relief devices based on anticipated normal operations, without considering potential emergency
conditions leading to MCMT reactor relief system was incapable of relieving the pressure from the runaway
reaction
4. Workforce Involvement: Lack of Safety Awareness e.g. Although the owner/chemical engineer told employees
he thought a fire would occur, none of the T2 employees appreciated the potential for a catastrophic explosion.
5. Communication with Stakeholders: T2 summited incomplete report to Emergency Planning and Community
Right-to-Know Act (EPCRA). It did not warn emergency responders of the MCMT, which is toxic by ingestion,
inhalation, and skin absorption.
6. Hazard Identification: One of T2’s design consultants identified the need to perform a hazard and operability
study (HAZOP, a type of PHA) during scale-up. CSB found no evidence that T2 ever performed the HAZOP.
7. Documentation, Records & KM: There was no additional documented hazard analysis when increased batch
size and production frequency.
8. Operating Manuals and Procedures:.
9. Process and Operational Status Monitoring and Handovers:
6
 Elements of Process Safety Management
10. Management of Operational Interfaces:
11. Standards and Practices:
12. Management of Change: In 2005, at Batch 42, T2 increased the batch size by one third. There are no records
of additional chemical or process hazard analysis conducted as part of this recipe changed, which may have
introduced significant new risks.
13. Operational Readiness + Process Start-Up:
14. Emergency Preparedness: T2 did not recognize the runaway reaction hazard associated with the MCMT both
design and production.
15. Inspection and Maintenance: Interviews with employees indicated that T2 ran cooling system components to
failure and did not perform preventive maintenance.
16. Management of Safety Critical Elements:
17. Work Control, Permit to Work and Task Risk Management:
18. Contractor Selection and Management:
19. Incident Reporting and Investigation: 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.
20. Audit, Assurance, Management Review and Intervention:
21. Process Safety Event Indicators:
7
 Lesson Learned
In this case, T2 did not recognize the runaway reaction hazard associated with the
MCMT leading to an explosion. then
“ Process Hazard Analysis - HAZOP in the development phase helps establish
operating limits and identify operating strategies to prevent runaway reactions.”

Additionally, T2’s process safety information was inadequate, product recipes were
changed without an evidence of systematic review,
“ Implementing a Management of Change Program in the operation phase
helps to manage the hazards involved and take action to minimize potential
consequences of all identified hazards. “

Process Safety: Keep oil and gas in the pipe !

8