Pesticide Chemical Runaway Reaction `

Pressure Vessel Explosion

Background
Bayer CropScience is one of the world's leading innovative crop science companies in the areas of seeds, crop protection and non-agricultural pest control. On August 28, 2008, at about 10:35 p.m., a runaway chemical reaction occurred inside a 4,500 gallon pressure vessel known as a residue treater, causing the vessel to explode violently in the methomyl unit. This highly flammable solvent sprayed from the vessel and immediately ignited, causing an intense fire that burned for more than 4 hour. The incident occurred during the restart of the methomyl unit after an extended outage to upgrade the control system and replace the original residue treater vessel. Incident resulted in fatal incident of two company employees, toxic chemical exposure to six volunteer fire fighters and evacuation of about 40,000residents up to 12 km of area. Primary reasons of the runaway chemical reaction and loss of containment of the flammable and toxic chemicals resulted from deviation from the written start-up procedures, bypassing of critical safety, inadequate pre-startup safety review, inadequate operator training on the newly installed control system and insufficient technical expertise available in the control room during the restart.

Incident Details
Date Location Incident : 28 August 2008, 10:35 p.m. : Bayer CropScience , Virginia, US : Runaway Reaction & Explosion

Consequences : 2 company employees fatal, 6 volunteer fire fighters toxic exposures, 40,000 residents evacuation and 7500 liters of toxic and flammable liquid sprayed in atmosphere.

Bayer CropScience Runaway Reaction

CSB Video

Residue treater vessel after explosion

PSM Element Failures

Operating procedures & Safe Work Practices: o Several required SOP steps were not completed during the methomyl unit startup like The residue treater was not pre-filled with solvent. The solvent was not circulated and heated to the minimum operating temperature. Daily residue treater liquid sample was not collected and analyzed for methomyl concentration. Safety interlocks bypassed on the residue treater bottom feed valve allowing concentrated methomyl.

Training & Competency: o Operations personnel were inadequately trained to operate the methomyl unit with the new DCS control system.

PSM Element Failures

Process Hazard Analysis: o o The residue treater layers of protection to prevent a runaway reaction were inadequate. PHA team failed to validate critical assumptions used in their analyses. (e.g. PHA team concluded that a high residue concentration in the flasher feed was an operations issue having no consequence.)

Pre-Startup Safety Review:

o o The PSSR did not include a formal process of involving multiple discipline member team. The PSSR did not verified the completion of modifications in the field, including toxic gas monitoring system which were not in service, verification of the functionality of critical DCS control and instruments installed before the restart.

OD Element Failures
Practice Consistence with Procedures: o Non adherence to safe operating practices & safety interlocks

Active Lines of Communication: o o Inadequate operator awareness on newly installed DCS system A number of key items were inadequately addressed in the shift changeover log book.

Leadership By Example: o o Inadequate safety checks before start up Failure to identify protection factors for chemical runaway reaction

Take home for Reliance

Inherently Safer: The Future of Risk Reduction
Bayer has taken specific action to reduce the risk of MIC. The company did not rebuild the damaged methomyl unit and discontinued production of two of the MIC based pesticides. The company also made an investment of more than $25 million to redesign and modify the MIC production unit to significantly reduce the on-site inventory.

The company announced it would eliminate the production of the two remaining Carbamate pesticides, Aldicarb and Carbaryl, during 2012 and end all production, use, and storage of MIC.

Thanks