analysis of distillation flask explosiondrrc.ui.ac.id/acsel/lister/oral presentations/a23_acsel 2015...

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