“The strange movements and attitudes of (two workers of the Fármaco Uruguayo laboratory) allow us to suppose that they acted maliciously, even though it has not been possible to collect elements that demonstrate malicious act,” states the criminal complaint filed by the company sponsored by the criminal Gonzalo Fernández together with his partner Renato Echevarría. For this reason, they ask the Prosecutor’s Office to investigate them for the crime of culpable havoc, according to the document they agreed to. The Observer.
The explosion and fire of the laboratory that produces serum for almost the entire country, located in Flor de Maroñas, occurred on the morning of December 10 last year. The fire caused damage to machinery, walls, ceilings and glass, and put the lives of some 60 employees who were in the plant at risk. But the surveillance cameras and the computer system remained undamaged, so the company was able to reconstruct the performance of the two workers: the grade 2 specialized trainer; and his brother, a specialized operator.
The complaint, which was reported by El País, and which is in charge of the Flagrancia prosecutor Patricia Rodríguez, maintains that the accident “clearly endangered public health, because the suspension of the company’s activities affected all the health clinics dialysis to which (the laboratory) provides serum as well as to most of the hospital network in the country”. The crime of havoc punishes with sentences of twelve months in prison to twelve years in penitentiary whoever endangers the safety of the persons or property of others by the use of powerful means or agents of destruction.
The company informed the Prosecutor’s Office that the preparer had been working for four years and had multiple instances of training in the handling and operation of the whey manufacturing system, while his brother was appointed to the task that day by his boss in substitution of another person and it was the first time that he fulfilled it. According to firm sources, he has about 250 employees, of which 17% are unionized. The two accused were.
As stated in the complaint, there are six successive stages in the preparation of the whey and “under normal conditions, none of the components, either in isolation or in the mixtures of the global process, constitutes a chemical risk per se.” The first stage is performed in automatic mode, the next two stages in manual mode and the other two in automatic mode. The reaction that caused the explosion occurred in the final phase of the preparation.
The “strange moves”
From the review of the cameras, the company’s investigation concluded that “even when the aforementioned irregularities are not the cause of the harmful event, they do reliably demonstrate the reckless and negligent nature of both, acting with indifference and incurring in irregularities that violate the protocolized practices.
According to the images, provided to the Prosecutor’s Office, they indicate that at 5:00 the preparer used the area telephone inside the manufacturing room without a mask. At 5:06 a.m., the assistant entered the manufacturing area through the materials lock and not the personnel lock, as it should have been, using the wrong flow, which puts the products that are manufactured at risk of contamination.
At that time, it was found that her brother entered the manufacturing area wearing a white general circulation uniform instead of the special uniform, as required, which involved risks of microbiological and/or chemical contamination, not acceptable in the pharmaceutical industry.
At 5:27 am, the preparer began the preparation process and both he and his brother used the protection elements.
At 6:26 a.m., the preparer opened the extraction valve located on the mouth of the reactor and five infractions of good practices were observed, reported Fármaco Uruguayo. He also stated that an hour later he threw an empty container of acetic anhydride from the manufacturing area into the materials lock on his brother.
The complaint described that from 07:46:10 to 07:46:43 the preparer loaded the automatic prescription, without having completed the transfer step of the acetic anhydride loaded in the dissolver, so he had to return to manual mode to complete the transfer.
At 7:48:15, he began to carry out various operations on the control panel “unnecessary and it is not known what they obey, activating commands that should not be activated at that stage of the process.”
Three seconds later a dense vapor was observed and the operator continues to operate on the control panel screen.
At 7:48 and 26 seconds, as soon as the coach pressed the last button, “they quickly left the room.” At 7:49 and three seconds the trainer pressed the panic button. When they left the place, none gave an alert of what had happened, the complaint stated, adding that they seemed very calm.
One minute later, the explosion occurred due to the accumulation of gases outside the reactor and a fire was observed in the room. Shortly after, a second explosion was verified. The complaint stated that one minute and 39 seconds passed from when the first gas leak began until the explosion occurred.
The explanations
The complaint concluded that an incorrect alternative outlet was generated, causing a visible accumulation of steam in the environment that led to the explosion, and that two valves that should have been closed were open. “The release of gas into the environment caused the explosion of the gaseous mixture due to excessive pressure inside the enclosure, causing in turn an expansive wave that caused the reactor to fall and the lid to detach and the consequent explosion of the mixture that was still contained. within it,” the complaint stated.
The company maintained that “the event responds entirely to the human factor” and pointed out that this leak “does not correspond to the manufacturing process” and was warned by the preparer, “who is trained, qualified and has sufficient experience.” He further stated that the two workers did not notify anyone else to evacuate the building.
The Engineering and Maintenance manager warned that if the emergency stop had been pressed when the product began to come out, it would have stopped coming out, preventing a gaseous cloud from forming in the enclosure, which caused the explosion.
The preparer stated in the investigation carried out by the company that the pressure gauges were turning nonstop, stating that this was indicative of a very significant increase in temperature and pressure, but the complaint signed by Fernández stated that “it does not match the facts real observed”.
