YASHASHWI RASAYAN PRIVATE

LIMITED
INCIDENT REPORT
 DESCRIPTION OF THE INCIDENT
As per the information received,
---Incident happened due to mixing of Dimethyl Sulphate and
Concentrated Nitric Acid.
--- Nitric acid tanker unloaded in the tank of Dimethyl Sulphate
by mistake on 02.06.2020.
---Management decided to tackle this emergency on next
morning, till that they were spraying water on tank
continuously to control the temperature.
 DESCRIPTION OF THE INCIDENT
---The explosion was so severe that the RCC building of the
plant observed cracks.
---Near by village Luvara evacuated to safe place immediately
after this incident.
---The incident resulted in death of 8 people and 40-50 injured.
 DESCRIPTION OF THE INCIDENT
---On 03.06.2020,they decided to dispose the material by
taking out it in tankers.
---Before taking mixture of Dimethyl Sulphate and Nitric Acid in
tanker, they started circulation through unloading pump as
per the seniors instruction.
---During circulation, within no time the tanker exploded.
---Hydrogen trolleys were standing near to this tanker and
hydrogen also caught fire and exploded.
 POSSIBLE CAUSE AND CONTRIBUTING FACTORS
Medium
• Mixing of nitric acid with dimethyl sulphate which are
incompatible with each other. Dimethyl sulphate reacted
exothermically with nitric acid resulting in increase in the
pressure in the tank which caused to explosion.
Man
• The workers failed to indentify the tank of nitric acid. Casual
approach of management is work from contract workers
• The workers did not know that nitric acid and dimethyl
sulphate were incompatible and should not be mixed.
 POSSIBLE CAUSE AND CONTRIBUTING FACTORS
Management
• Hydrogen trolley were kept near the storage tank farm.
• Failed to handle the incident.(Did not treat as a emergency)
• Evacuation not done before starting the scenario handling.
• The management failed to carry out a thorough Hazard and
Operability (HAZOP) study and a Quantitative Risk
Assessment (QRA) on the tank and associated process lines.
 Casue Analysis
Evaluation of 8 workers died and 40-50 were injured.
Loss

Type of Explosion and fire.

Contact
Immediate mixing of Dimethyl Sulphate and Concentrated Nitric Acid.
cause
Basic cause Dimethyl Sulphate and Concentrated Nitric Acid are incompatible with each other.

Failure to • Process safety information

EHSMS • Hazard identification, risk assessment and risk control
• Plant layout
• Operating procedures and safe work practices
• Training, awareness and competence
• Control of hazardous substances
• Emergency preparedness and response
 Recommendations and Learning Points
• Carry out risk assessment prior to any work involving
hazardous chemicals and develop safe work procedures to
include all control measures used to address the identified
risks.
• Provide competency training to ensure that the workers
understand the process flow and the risks associated with
mixing of incompatible chemicals.
• Skilled man power in hazardous process
 Recommendations and Learning Points
• Ensure positive isolation of process lines through the use of
double block valves and bleed with spading to prevent
accidental mixing of incompatible chemicals.
• Proper implementation of recommendations of the plant
siting and layout.
 What we can do
• Hazard identification, risk assessment and risk control
• Plant siting and layout
• Employee selection
• Operating procedures and safe work practices.
• Follow the tanker loading and unloading permit.
• Control of hazardous substances by following the Chemical
Management Plan.
• Emergency preparedness and response.
• Training, awareness and competence.