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ANALYSIS OF DISTILLATION FLASK EXPLOSION
AT “X” LABORATORY, FACULTY OF “ABC”“YZ” UNIVERSITY
ZULKIFLI DJUNAIDIPresented at The 2nd Asian Conference on Safety and Education in Laboratory
December 2nd, 2015
Depok, Indoesia
Introduction
Distillation is one of important competence that has tobe achieved by under-graduated student at Faculty“ABC”. Chemicals, instrumentations and experimentactivities involved in distillation experiment containsignificant hazards that need to be assessed andcontrolled beforehand. Failure of identifying andtreating the risk will lead to an unexpected event.
Objectives
Analyze the incidence of distillation flask explosion in Qualitative Chemical Laboratory, Faculty of “ABC”
Arrange recommendations of control measures, so the same accident will not occur in the future.
Take lesson learned from the incident that occurred.
Methods
Desk-top review
• Study the results of investigation that has been conducted by OHSE Team of “YZ” University
• Collect secondary data
Discussion and Site Visit
• Held a meeting to discuss with management of faculty
• Conduct Laboratory visit
Data Analysis
• Fault Tree Analysis (FTA)
• Event Tree Analysis (ETA)
• Bow Tie Analysis
Report and Recommendation
• Report of analysis results
• Recommendation for improvements
Chronology of Event
Source: Press release of Faculty, 2015
Group A5 has a mixture of benzoate acid, resorcinol, isopropanol, and water. The experimental procedure was performed as follows:
The distillation flask which already containing the mixture boiled over asbestos gauze using a spirit lamp. Based on one of group member information, before distillation flask exploded, the contents of the flask was running out while the spirit lamp still on fire. That member does not inform the temperature of distillation flask before exploded. The distillation flask of Group A5 exploded, then the activity was stopped.
The procedure of
experiment
incompatible with
the safety aspect
There is no
hazard
communicati
on
The
procedure
has not
prepared
by
considerin
g the
potential
risks
OHS induction
has not been
done before
the
experiment
Distillation Flask Explosion
Over pressure
Heating time over the limit
Over heating
The heater is not equipped
with the process temperature
control proses
Using an open
flame to warm
up
There is no
warning
system at the
time of
hazardous
process
condition
The students and supervisors did not
control the heating process according to
specified time and temperature
The condition of
Lab environment
not appropriate
There is no
safety sign
The room
capacity did
not based on
the number of
students
Poor lighting
in the
Laboratory
Lack of
supervision
The
number of
supervisors
incompatib
le with the
number of
students
Lack of
understanding of
critical hazard
Safety briefing has
not been done
before the
experiment
Performed a week
before the
experiment
The response
of student is
less than
optimal
Fault Tree Analysis (FTA)
Event Tree Analysis
(ETA)
EXPLOSION Laboratory
Damage
Facility
Damage
Flask distillation
damage
The image of
University
dropped
Media
publication
Newspaper
TV
Internet
INJURY
Serious: 2
person
Minor: 13
person
Hospital cost:
70.766.410
The cessation
of experiment
activity
The experiment
using open flame is
stopped
The activity of
distillation is stopped
The experiment
activity
suspended for 2
weeks
Bow Tie Method
PREVENTION MITIGATION
Distillation Flask
Explosion
THREAT 1: Human
Resources
THREAT 2: Facilities and Infrastructure
THREAT 3: Procedures
THREAT 4: Work
Environment
THREAT 5: Material
CONSEQUENCES 1: SPILL
CONSEQUENCES 4: FIRE
Bow Tie AnalysisThreat Barrier
T1.2 Lack of supervision as
result of the ratio
between the number of
students and
supervisors
(experiment assistant,
lab assistant, and
lecturer) inadequate.
B1.2 Ensure the presence of supervisors in the
Laboratory.
Ensure that supervisors conduct supervision.
Ensure the ratio of students and supervisors.
Bow Tie Analysis (2)Threat Barrier
T1.3 Unsafe act of Human
Resources, such as lack
of concentration
during experiment, not
follow Standard
Operating Procedure
(SOP), etc.
B1.3 Develop and communicate Standard Operating
Procedure (SOP) in the Laboratory.
Bow Tie Analysis (3)Threat Barrier
T2.2 The heater is not
comply with safety
standards.
B2.2 Ensure to use the heater that has a process
temperature control.
Bow Tie Analysis (4)Threat Barrier
T2.4 Human resources
(students) do not use
appropriate PPE.
B2.4 Provide and ensure that HR use appropriate
PPE. The PPE in distillation experiment are:
1. Lab coat
2. Safety gloves
3. Safety goggles
4. Chemical mask
Bow Tie Analysis (5)Threat Barrier
T3.3 Emergency response
procedure and hazard
communication
procedure are not
available.
B3.3 Ensure that safety procedure in the Laboratory
is available and has been communicated
through safety briefing or induction before
conduct the experiment.
Bow Tie Analysis (6)Threat Barrier
T4.3 Lack of
housekeeping
B4.3 Ensure that the chemicals are placed in
the chemical storage room and the
student bags are placed in the locker,
etc.
Consequences Recovery Measure/Mitigation
C1 Chemical spills M1 Decontamination and handling spills procedure
M2 The availability of spill kits
M3 The availability of chemicals or contaminatedmaterials disposal.
C2 Inhaled chemical/ poisoning
M2 Emergency response procedure in the Laboratory
C3 Injury M3.1 The availability of first aid box in accordance withstandard medicine
M3.2 Emergency response procedure in the Laboratory
C4 Fatality M4 Emergency response procedure in the Laboratory
C5 Fire C5.1 The availability of fire extinguisher whichappropriate to chemical in the Laboratory.
C5.2 Emergency response procedure in the Laboratory
Bow Tie Analysis (7)
Recommendation
Attention to the design of Laboratory, include:
• The spacious of Laboratory:
<70 m2 for <25 person
85 m2 for 30 person
• The minimum of bench wide (lab table) per practitioner = 0.30 m2, The minimum of table length per practitioner = 600 mm.
• There is a space under the table for the knee when the student works while sitting.
• The minimum of roof height = 2,7 m from floor
• Have the locker to store bags, books, etc.
• The minimum of lighting = 300 lux
• There are eye and body shower
• There is a fire extinguisher according to the chemicals
• There is the spillage kit
• Well ventilated
Recommendation (2)
• Arrange and communicate:
– Safe work procedure in the Laboratory
– Chemical spills handling procedure
– Emergency response procedure
Recommendation (3)
• Improve the housekeeping :
– Store the chemicals in separated place
– Move the materials that are not used in the Laboratory
Recommendation (4)
• Implement chemical safety, such as:
– MSDS
– Proper labelling
– Waste disposal
– Chemical storage
Recommendation (5)
Work procedure:
– Review of safety aspect
– List of the maximum temperature which is allowed during distillation.
Recommendation (6)
• Heating flame with bunsen/spirit lamp is not recommended.
• Use the ceramic cavity heater, steam coils, hot water, non-flammable liquid bath/ electric heating mantle.
• Ensure that the surface of coil on the heating mantle is not damaged.
• Do not use hot plates, unless “spark-proof”.
• The addition of boiling chips to ensure homogeneous heating and not bumping.
• Thermometer – to measure the reaction of temperature, and installed near the solvent.
Recommendation (7)
The materials should be used:
– Not to do the distillation of organic compounds, or evaporate dry organic compounds because organic compounds can form explosive peroxides.
– For example: alcohol compounds, unsaturated hydrocarbons can form peroxides compounds when heated.
Recommendation (8)
• Personal Protective Equipment (PPE) should be used:
– Laboratory coat
– Closed shoes
– Safety goggles
– Neoprene gloves
– Safety mask
Recommendation (9)
Thank You