(164a) Friday Night in the ER

A single process safety event can significantly influence one’s career trajectory as a chemical engineer, while for others, a series of events may shape their path. For both, it is certain that process safety events affect people and change lives.

This paper describes the first of a series of events influencing an early career engineer’s future. The event began with the success of being part of a team that developed a new process to increase production. The process was invented prior to management of change and therefore no formal procedure existed to identify and mitigate hazards. In the rush to commercialize the process, early warning signs regarding hazards were not recognized. Failure to identify reactive chemistry hazards led to a toxic gas release of phosgene resulting in my Friday Night in the ER.

There was no formal investigation to understand the hazards, and therefore little learning resulted from the incident. The focus on production was successful, but lack of understanding of the reactive chemistry hazards and failure to correct underlying reliability plant problems ultimately led to other unintended consequences including a large accumulation of reactive material over ten years. Accumulation eventually led to off-site disposal and ended with a rail car explosion. This paper will describe the events leading up to my Friday Night in the ER, and how failure to learn from the incident had repercussions in the years following the incident. This incident was the first of many that defined my career path in process safety.