Drum burst due to runaway reaction and the limits of MOC - issue 259

Issue Number: 259


A small process change was made due to a pump failure, which meant that a solvent and a process reactant were mixed for an extended period inside a drum. The change was evaluated according to the organisation’s management of change (MOC) procedures and no significant hazard was identified. A runaway reaction later occurred which resulted in a drum burst. Fortunately, there were no injuries as a result. Data showing that the mixture between the reactant and the solvent could exhibit dangerous behaviour was available but would not be widely known beyond experts in the field, who may not be systematically involved in assessing small process changes during operations.

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