15T2实验室公司反应失控.docxVIP

INVESTIGATION REPORT REPORT NO. 2008-3-I-FL SEPTEMBER 2009 Board Voting Copy T2 LABORATORIES, INC. RUNAWAY REACTION (Four Killed, 32 Injured) 调查报告 编号：2008-3-I-FL 2009年9月 T2实验室公司反应失控 （4死32伤） 1 Incident Description 1.1 December 19, 2007 Incident On the evening of December 18, 2007, a night shift process operator cleaned and dried the reactor in preparation for a new MCMT batch. At about 7:30 am on December 19, the day shift process operator began manufacturing Batch 175 from the control room adjacent to the process line. He likely followed the routine batch procedures, loading the reactor with the specified quantities of raw materials using an automated process control system. An outside operator hand-loaded the reactor with blocks of sodium metal, then sealed the reactor. At about 11:00 am, the process operator began heating the batch to melt the sodium and initiate the chemical reaction, while monitoring the temperature and pressure on the process control screen. 1、突发事件 1.1 2007年12月19日突发事件 2007年12月18日晚，夜班工艺操作员清洗并干燥了反应器，为生产新一批的甲基环戊二烯三羰基锰（MCMT）做准备。12月19日上午七点半，白班工艺操作员在工艺线旁边的控制室开始生产第175批次产品。他像往常一样按照程序操作，使用自动化制程控制系统加载装有一定量原料的反应器。外部操作员往反应器中手工装载金属钠块，然后密封反应器。大约上午11点，工艺操作员开始加热反应器使钠块熔化开始反应，同时在工艺控制显示器上监测温度和压力。 Once the sodium melted, at 210°F (98.9°C), the process operator likely started the mixer (agitator). Mixing the raw materials increased the reaction rate, creating heat. Heat from the reaction and the heating system continued raising the temperature in the reactor. At a reaction temperature of about 300°F (148.9°C), the process operator likely turned off the heating system as specified in the procedure, but heat from the reaction continued increasing the mixture temperature. At a temperature of about 360°F (182.2°C), the process operator likely started cooling, using the process control system, as specified in the procedure. However, the mixture temperature in the reactor continued to increase. 当温度达到98.9℃时，钠开始熔化，工艺操作员启动了搅拌机。搅拌原料可以提高反应速率，产生热量。反应产生的热量和加热系统的热量提升了反应器的温度。当温度为