Citation

Wang W, Liu Y, Zhao D, Chen J, Wang Y, Dong H. Process Saf. Progr. 2020; 39(1): e12099.

Copyright

(Copyright © 2020, American Institute of Chemical Engineers, Publisher John Wiley and Sons)

DOI

10.1002/prs.12099

PMID

unavailable

Abstract

On July 12, 2018, a devastatingly incident occurred in Yibin City at Hengda Technologyin Sichuan Province of China, which resulted in 19 deaths and 12 injuries. During the dehydration, the operator replaced butyramide with the unlabeled sodium chlorate and fed it into the reactor, which caused an explosion and fire because of the reaction of sodium chlorate with butyramide. The incident reflects the general deficiencies of process safety management in small and medium-sized companies. This article presented a systematic analysis of the incident. The Fishbone Diagram Model was used to identify the influencing factors from six perspectives: people, design, management, environment, safety prevention, and materials. Furthermore, the main elements of process safety management, which include process hazard analysis, prestartup safety review, operation procedures, training, and emergency plan and response, are considered to analyze the incident to learn the lessons from the incident.

Language: en

Keywords

fishbone diagram; incident investigation; process safety management