Safety analysis.

So I asked Mark what he thought about what I mentioned in my last post, the analysis of that 2007 chemical plant explosion in Florida (summary here; full report including awe-inspiring post-explosion photos is  here).  Bottom line, the owners of that plant — T2 Laboratories of Jacksonville, Florida — were seriously, severely, fatally negligent (one, the engineer, paid for it with his life, plus the lives of three employees).  

But we concluded that the board recommendations for increased "reactive hazard awareness education" in the undergraduate chemical engineering curriculum miss the point entirely.  Even had the chemist-owner and the chemical-engineer-owner had specific undergraduate training in runaway reactions or in failed cooling systems, I doubt it would have made a difference.

Why do I think so?  Because they didn't follow the recommendations of their own hired consultants, and they didn't make reasonable modifications after experience taught them that their desired reaction had the potential to run out of control.  Clearly the root cause wasn't a knowledge problem, but an attitude problem and a company culture problem.  In fact, the reason they didn't know about the runaway reaction was BECAUSE they ignored a consultant's recommendation.

Consider the following facts gleaned from the report:

• "One of T2's design consultants identified the need to perform a hazard and operability study [HAZOP]… CSB found no evidence that T2 ever performed the HAZOP."
• "The runaway reaction on December 19, 2007 was not the first unexpected exothermic reaction that T2 experienced; three of the first 10… batches resulted in unexpected exotherms [that is, they got hotter than they were supposed to]…. T2 did not repeat batch recipes to isolate the problem."  
• "As demand grew, T2 increased batch size and frequency with no additional documented hazard analysis"… and indeed with no other changes to the process.  Scale-up IS something that is included in the standard engineering curriculum and the engineer-owner knew better.
• T2 submitted the reports required by the Emergency Planning and Community Right-to-Know Act, but they left off required information about the chemical they were manufacturing.
• "T2 hired a consultant to analyze regulatory programs that might apply… The consultant informed T2 that it must develop a hazard communication program, which should include employee training, chemical labeling, and provision of MSDSs… The consultant listed other OSHA [Occupational Safety and Health Administration] requirements … the consultant recommended that T2 hire an additional consultant with OSHA expertise… There is no documentation that T2 further addressed potential OSHA requirements."

Because of this evidence, I conclude that it's bulls#!t that the root cause is, as identified by the board, that T2 did not recognize the runaway reaction hazard.  Equally bulls#!t, the idea that adding reaction hazard analysis to undergraduate education would have fixed the problem.  The root cause here was, in my opinion, a corner-cutting culture in which T2 didn't follow the advice of the experts it hired to tell it how to build a safe process — especially, omitting the HAZOP analysis.  The owners weren't ignorant because their professors omitted to teach them about runaway reactions; the owners were ignorant because they were to cheap to pay for HAZOP analysis they knew they were supposed to have.

* * *

The problem isn't that all undergraduates should receive formal reactive hazard analysis training.  The problem is that all engineers should follow the recommendations of  the experts who HAVE received formal hazard analysis training — hazard analysis of all kinds, from the hazards of specific chemical reactions to ordinary workplace hazards.  If we need more undergraduate training — and quite possibly we do — it should be as general as possible, an attempt to inculcate an expectation of a culture of safety and general hazard awareness in every newly minted engineer, so that we're all always looking for ways to make the workplace safer for everyone.

UPDATE.  Mark pointed out something I didn't catch:  their cooling system was guaranteed to foul and occlude, because it constantly boiled municipal water and vented steam, thereby concentrating minerals inside the system.  According to the report, the owners never did any preventative maintenance, and it was indeed a failure in the cooling system that precipitated (no pun intended) the accident.  

 Now I know that fouling of heat transfer equipment is something that was covered in my undergraduate chemical engineering education!  Could it be that more undergraduate technical education is not the answer?