At around 9:40 a.m., a fire broke out on a pharmaceutical packaging line that had been shut down for the weekend. The alert was given by an automatic detection system. The operator alerted the firefighters.

The firewater was confined and then treated at the plant’s wastewater treatment plant. The packaging line was down for several months. The employees were reassigned elsewhere at the facility. A specialist company was called in to clean the facility, which had been contaminated by smoke and fumes from the fire. Several clean rooms were cleaned, decontaminated, and requalified.

The fire originated in the vacuum unit of the packaging line’s thermoforming machine. A power outage had occurred the previous day. When the power was restored, the vacuum unit (which had been left on for a cleaning operation) automatically started back up. However, the operating personnel did not notice this as they were busy securing the production line. In addition, as the power was restored shortly before the end of the shift, the employees immediately left after completing the securing operations. As a result, the thermoforming machine’s vacuum unit ran for 12 hours. This, combined with a design defect or fouling (impossible to verify due to the fire), caused the vacuum unit (made of many plastic parts) to overheat and then start the fire. The flames then spread to the thermoforming machine’s other plastic parts.

The operator implemented the following corrective actions:

• it installed an emergency power supply to take over in the event of a complete power outage;
• it replaced equipment fitted with thermal and electrical safety cut-outs and controlled by the operator;

it implemented a procedure to prevent malfunctions that could lead to a fire. If a power outage occurs, no system may restart without human intervention and after a series of checks have been carried out. Operators will also systematically complete a checklist at their workstations at the end of their shifts.