Lessons In Chemical Process Safety

Lessons In Thermal Process Safety


On December 19, 2007, a catastrophic explosion and fire occurred at the T2 Laboratories in Jacksonville, FL. The explosion was caused by a runaway reaction, which caused a massive release of chemicals and a subsequent blast, resulting in multiple fatalities and significant damage to the surrounding area. Learn critical safety lessons from this incident and preventative measures you can take for reducing risk.

T2 Laboratories was a small chemical company specializing in the production of gasoline additives and other chemical compounds. The fatal incident took place in their facility, located in an industrial area in Jacksonville. The reaction involved the production of methylcyclopentadienyl manganese tricarbonyl (MCMT), a gasoline additive, in an exothermic reaction that also produces hydrogen. The process was designed around a 1-liter reactor, which was scaled up directly to a 2,500-gallon reactor. After 41 batches, T2 increased the reaction load by an additional third. During subsequent runs, unexpected temperature rises occurred.

How the Incident Occurred

On the day of the incident, cooling water could not be sent into the jacket of the vessel possibly due to a blocked supply pipe or valve failure, resulting in an uncontrolled rise in temperature and pressure in a runaway reaction. The owners of the facility were called, and when they arrived, they told employees to move away from the reactor. The pressure continued to build, eventually bursting the rupture disk. Ten seconds after the disk burst, the vessel exploded.

This explosion was extremely powerful, causing widespread damage to the facility and nearby structures. The blast wave shattered windows, collapsed roofs, and sent debris flying over a significant area. The shockwave was felt several miles away from the site, and the resulting fire burned for hours.

Injuries and Damages

Tragically, the explosion claimed the lives of four employees and injured many others, including the first responders who rushed to the scene. Two of the fatalities occurred inside the facility's concrete masonry control room. The incident also had severe environmental consequences, as toxic chemicals were released into the air and nearby waterways. The surrounding community was deeply affected by the explosion, both physically and emotionally. The facility was destroyed.

Incident Investigation

The U.S. Chemical Safety and Hazard Investigation Board investigation determined that the root cause of the explosion was that T2 Laboratories did not recognize the runaway reaction hazards associated with the gasoline additive MCMT. It was discovered that their cooling system was susceptible to single-point failures owing to a lack of design redundancy and that the reactor relief system was incapable of relieving the pressure from the runaway reaction.

Furthermore, investigations revealed several safety lapses and regulatory violations at T2 Laboratories. The company was found to have neglected proper safety protocols, including inadequate staff training, insufficient process controls, and poor hazard assessment. These findings prompted increased scrutiny of chemical manufacturing facilities and emphasized the importance of adhering to strict safety regulations.

Lessons Learned

The lessons learned from the T2 Laboratories explosion led to significant changes in the chemical industry and safety practices. The incident highlighted the importance of rigorous adherence to safety regulations and the need for robust process control systems. It brought attention to the necessity of comprehensive hazard assessments, proper training, and ongoing monitoring of potentially dangerous chemical reactions.

Several measures could have been implemented to prevent the thermal runaway explosion and fire:

Process Hazard Analysis (PHA)

The company should have conducted a thorough Process Hazard Analysis (PHA) of the reaction and implemented appropriate safety measures based on the identified risks. This includes having effective process controls, such as automated monitoring systems, to ensure that temperature and pressure remain within safe limits. According to the incident report, the CSB found no evidence that T2 Laboratories ever performed a hazard and operability study (HAZOP).

A PHA in the development phase is invaluable for establishing operating limits and identifying operating strategies to prevent runaway reactions. A PHA during scale-up is also needed for identifying testing needs to determine the thermodynamic and kinetic nature of a reaction, as well as any limitations of cooling and relief systems.


A lack of knowledge of the hazards associated with a chemical reaction can also lead to a thermal runaway reaction. According to the Florida Times-Union, U.S. Chemical Safety and Hazard Investigation Board investigator Robert Hall said, “The owners had these warning signs. They had these near misses. But the reaction was not to investigate what caused the problem... Just to make another batch.”

Training is essential for safety. Proper training on the hazards would have informed the company of the importance of performing runaway reaction testing, addressing emergency relief, and identifying the causes of process disruptions. It is vital that employees working at facilities where toxic chemicals are handled be safety competent. Read this article for a review of what safety competency is and ways you can improve safety competency at your workplace.

Management of Change (MOC)

The CSB investigation found that product recipes were changed without systematic review at T2 Laboratories. Changes such as production increases or scale-up, changes in formula, or changes in suppliers of one or more process inputs have all been cited as factors in past runaway incidents.

Any process or equipment changes at T2 Laboratories should have undergone a Management of Change (MOC) procedure. A facility's management of change program (MOC) can identify critical safety equipment for special maintenance, testing, or inspection as part of a facility's asset integrity program.

We Can Help

The T2 Laboratories incident served as a sobering reminder of the potential dangers associated with chemical reactions and the critical importance of maintaining rigorous safety standards. ioMosaic has the service, training, and software solutions to help you prevent incidents. You can count on us for guidance that not only satisfies regulatory requirements but delivers peace of mind to you. Contact us at 1.844.ioMosaic or send us a note via our online form. We would love to hear from you.