U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BO ARD
INVESTIGATION REPORT
REPORT NO. 2008-3-I-FL
SEPTEMBER 2009
T2L ABORATORIES ,I NC .
R UNAWAY R EACTION
(Four Killed, 32 Injured)
KEY ISSUES:
R EACTIVE H AZARD R ECOGNITION
H AZARD E DUCATION
E MERGENCY P REPAREDNESS
P ROCESS D ESIGN AND S CALE -U P
J ACKSONVILLE ,F LORIDA
D ECEMBER 19,2007
T2 Laboratories Inc. September 15, 2009 Contents
EXECUTIVE SUMMARY (1)
1.0INTRODUCTION (3)
1.1Summary (3)
1.2Investigative Process (4)
1.3T2 Laboratories, Inc (5)
1.4Advanced Fuel Development Technologies, Inc (6)
1.5Methylcyclopentadienyl Manganese Tricarbonyl (6)
1.6City of Jacksonville (7)
2.0INCIDENT DESCRIPTION (8)
2.1December 19, 2007 Incident (8)
2.2Emergency Response (10)
2.3Injuries and Community Damage (12)
3.0T2 MCMT PROCESS (17)
3.1Process Development (17)
3.2Manufacturing Process (18)
4.0INCIDENT ANALYSIS (23)
5.0REACTIVE HAZARD ANALYSIS (26)
5.1T2 Research and Development (26)
5.2Process Hazard Analysis (27)
5.3T2 Incident History (28)
5.4Reactive Hazard Recognition (28)
5.5Hazard Education (29)
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T2 Laboratories Inc. September 15, 2009
6.0REGULATORY ANALYSIS (31)
6.1Occupational Safety and Health Administration (31)
6.2Environmental Protection Agency (32)
6.2.1Risk Management Planning (32)
6.2.2Emergency Planning and Community Right-to-Know (33)
6.3T2 Regulatory Compliance (33)
7.0REACTIVE HAZARD RESOURCES (35)
7.1The CSB Reactives Study (35)
7.2Reactive Hazard Reference Materials (36)
7.3American Institute of Chemical Engineers (37)
7.3.1Design Institute for Emergency Relief Systems (37)
7.3.2Center for Chemical Process Safety (38)
8.0KEY FINDINGS (39)
9.0ROOT AND CONTRIBUTING CAUSES (40)
9.1Root Cause (40)
9.2Contributing Causes (40)
10.0RECOMMENDATIONS (41)
American Institute of Chemical Engineers (41)
Accreditation Board for Engineering and Technology, Inc (41)
REFERENCES (43)
APPENDIX A  MCMT PROCESS CHEMISTRY (45)
APPENDIX B  EXPLOSIVE SEVERITY AND DAMAGE CHARACTERIZATION (48)
reaction in the shaft
APPENDIX C  MCMT CHEMICAL TESTING (52)
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T2 Laboratories Inc. September 15, 2009
1.0TEST DESCRIPTION (53)
2.0TEST DATA (57)
APPENDIX D  MCMT-RELATED PATENTS (61)
APPENDIX E  SIMILAR INCIDENTS (65)
1.0MORTON INTERNATIONAL, INC. EXPLOSION AND FIRE (66)
2.0CONCEPT SCIENCES INC. HYDROXYLAMINE EXPLOSION (66)
3.0MFG CHEMICAL INC. TOXIC GAS RELEASE (67)
4.0SYNTHRON, LLC CHEMICAL EXPLOSION (68)
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T2 Laboratories Inc. September 15, 2009
List of Figures
Figure 1.  Aerial Photograph of T2 taken December 20, 2007 (3)
Figure 2.  Control room after the incident (10)
Figure 3.  JFRD responders in SCBA battle fire (11)
Figure 4.  Injury and business locations (13)
Figure 5.  Portion of the 3-inch-thick reactor (14)
Figure 6.  Agitator shaft pieces (15)
Figure 7.  Trucking company trailer adjacent to T2 (16)
Figure 8.  Reactor cross-section (20)
Figure 9.  Process control system screen (21)
Figure 10.  MCMT metalation reaction (46)
Figure 11.  MCMT substitution reaction (47)
Figure 12.  MCMT carbonylation reaction (47)
Figure 13.  Free-Field Pressure Contours for Estimated TNT Yield of Explosion (50)
Figure 14.  Free-Field Impulse Contours for Estimated TNT Yield of Explosion (51)
Figure 15.  New VSP2 Test Cell (54)
Figure 16.  Burst VSP2 Test Cell (56)
Figure 17.  Sodium Diglyme Test Results (59)
Figure 18.  MCPD Diglyme Sodium Test Results (60)
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