Text For Citation: 01 Item/Group: 001 Hazard: HEAT

Section 5(a)(1) of the Occupational Safety and Health Act of 1970: The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed to: the hazard of a runaway reaction and uncontrolled release of confined gases and reactants: a) On or about 11/9/92 one research technician was seriously hurt during a step in the pilot production of DMHA (dimethyl hydroxyl amine). During the quaternization step of the process in a 30 gallon reactor vessel, a sudden unexpected pressure rise resulted in the rapid uncontrolled release of confined gases. This event resulted in the attending technician suffering a broken arm. The employer did not adequately investigate or otherwise account for the effect of the separation and neutralization on the thermal sensitivity of O-MBDO and any possible subsequent effect on the quaternization phase of the DMHA process prior to its use in a pilot plant production level reaction. b) The most appropriate methods were not utilized to safely heat the O-MBDO and dimethyl sulfate mixture thereby increasing the risk of a runaway exothermic reaction during the quaternization phase of the pilot plant DMHA production. Among other methods, feasible and acceptable abatement methods to correct the hazard include: 1. Conduct a complete stability and process hazard analysis of the quaternization phase of DMHA production. This analysis must account for the effects of isolation and neutralization and subsequent use of "acidwashed" O-MBDO in the quaternization phase of DMHA production. 2. Completely re-evaluate the way the O-MBDO/DMS mixture is heated, with appropriate consideration given to its "strong exothermic reaction" and with emphasis on the use of the safest heating method available, e.g. hot water bath. Ref: Discussion Section of Dust-Tech Inc. 1992 Report Section "D".