An investigative communication notes that "mechanical integrity programs at refineries repeatedly emphasize inspection strategies rather then the use of inherently safer design to control the damage mechanisms that ultimately cause major process safety incidents." Regarding the similarity of this accident to others, it is also noted that "while sulfidation is a well-known damage mechanism at refineries that requires regular inspection and monitoring, the segment that failed has no record of ever being inspected."

NOTE: This record is based upon an investigative report and related communications and will be updated, as appropriate, when additional investigative reports are completed, released and reviewed. Additional details regarding mechanical integrity programs and procedures in place at the time of the accident are expected.

The researcher's failure to pull the fire alarm was an oversight of required facility practice. The alarm should have been triggered in consideration of the potential for greater harm to personnel and facilities.

Hot, reacting ammonia borane produces hydrogen as well as other pyrophoric impurities. Reactions should be carried out in inert atmospheres or purged with inert gases. Furthermore, efforts should be made to prevent oxygen from coming in contact with the material while hot.

As a consequence of this incident, an updated procedure was put in place to check critical fittings before each subsequent test and to purge the apparatus with argon in the area surrounding the reactor/fittings.

The procedure for disposal of spent or partially spent AB has been modified so that it does not include the use of water. Instead, the AB is removed from containers and transferred for disposal by rinsing with mineral oil, silicone oil or other similar inert materials. It is then disposed of as a slurry.