A pump explosion killed two workers during the mixing process of nitroglycerine with various polymers to manufacture heart patches. The pump fragments were recovered and carefully analyzed.
Rapperport Associates was retained to determine the cause of the accident. A detailed examination of the fragment damage yielded clues to the failure sequence and ultimately to the cause of the failure. A pump redesign was proposed and built, eliminating the design flaw that resulted in collection of fugitive nitroglycerine setting the stage for the explosion.Return to Case Studies