A rapidly growing small chemical company had established a strong niche market in preparing food-grade aqueous solutions of citric acid and phosphate salts, and detergent solutions for oil-well drilling applications. The company was asked to toll-blend a 25% aqueous solution of sodium chlorite from the technical-grade powder. The company developed a procedure to produce 1000-gallon batches and ran a test batch. Several months later, they did a production run of five batches.  As the consequence of a series of <i>ad hoc</i> changes to the procedure, the fifth batch resulted in a fatal detonation. The events leading to this incident will be discussed and are a case-study in ignoring Management of Change MOC) and lack of management leadership in safety.<br/>

Scale-up to fatality: Case study of ignoring MOC

ACS Fall 2020 Virtual Meeting

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