Pollution
Humain
Environnement
Economique

During delivery of dimethyl ether (DME) at a cosmetics plant, a transfer hose swelled around the fitting leading to the stationary installation and leaked due to incompatibility between the hose material and the product being delivered. The control operator noticed the leak and alerted the truck driver, who promptly closed the tank bottom valve and turned off the truck engine. Pressing the emergency shutoff button activated the transfer station security response, and the plant was evacuated for 20 minutes as a precautionary measure. The accident cause focused on an inoperable gas detection device due to component defect in the electronic cards of the central processing unit (the cards had not been changed since 2001). The sensors quickly saturated, emitting an «off-scale» signal that was interpreted as «sensor malfunction», without triggering any special action (even though the «off-scale» notification should normally activate safety procedures).The card manufacturer had in fact identified this potential risk of malfunction back in 2008 and remedied the situation (by changing cards and updating the software). However, all potentially flawed cards at this plant had not been recalled or updated. The plant management proceeded by replacing all cards used on-site.