Chemical fume release from fermentation reactor R-202 during pH adjustment. Ammonia gas released when operator added acidification agent to reactor containing residual ammonia-based buffer. Three operators evacuated area. No injuries - air monitoring showed levels returned to normal within 20 minutes.

Human Factors

Lack of training or knowledge, Fatigue or impairment, Complacency or shortcuts, Communication failure, Failure to follow procedure

Materials

Hazardous substance exposure, Improper material handling, Incompatible materials, Material degradation, Mislabeled materials

Process

Process deviation, Inadequate process control, Start-up / shutdown error, Abnormal operating conditions, Insufficient process monitoring