Disclaimer: The Lessons Learned Database includes the incidents that were voluntarily submitted. The database is not a comprehensive source for all incidents that have occurred.
The simplicity of this situation has made us aware that increased consideration must be given to all aspects of the workplace when preparing preliminary hazard assessments. Some hazardous situations appear so trivial that they can be easily…
Hazard assessment is critical during the design, fabrication, and installation of system modifications to ensure hazards and potential hazards are addressed prior to system start-up and operation.
Personnel should be aware that items requiring special receiving inspections should still be verified/examined by the end user prior to use.
Given that the anaerobic chamber and associated nearby electrical equipment were not designed or…
All chemicals, including gases, should be clearly labeled and expiration dates (if applicable) identified. Incidents are more common when incompatible chemicals are mixed or when chemicals are stored/transferred using incompatible equipment.…
The manufacturer will be notified of the failed parts identified as a result of the follow-up testing plan. These results may be useful to them for their information and forwarding to others with the same equipment.
Designs for high-tech systems/components evolve based on operating experience. The design changes should resolve identified deficiencies and are part of a continuous improvement process to increase reliability and productivity.
Laboratory accidents can happen despite the best preparation and careful attention to procedures. However, the lesson to be learned here is that employees must always be sure they understand the hazards of the activities, and that they know how…
Diligence needs to be practiced when performing assigned work tasks. To guard against complacency, it is necessary to emphasize adherence to established procedures, including appropriate reviews of preventive maintenance instructions (PMI) and…
The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed…
On-site personnel performing treatment of reactive metals/chemicals must continue to exercise caution. Although there is an inherent risk in treating reactive metals/chemicals, personnel must adhere to conduct of operations principles to include…
Thoroughly plan and schedule work such that the correct tools are at the job site. If activities take place that take the job supervisor away from the job location while critical steps are to be performed, the work should be temporarily stopped.…
Utilize a Six Sigma Black Belt to statistically evaluate LFL monitor reliability and determine the failure rate based on the existing technology.
Revise the tank uncertainty calculation and surveillance to include a wider "Required…
In the future, the laboratory will issue a memorandum about this incident to illustrate the need to wear safety glasses with side shields, store chemicals compatibly, take care when placing chemicals in the refrigerators for storage, and keep the…
Implementing and enforcing the laboratory's stop work and restart policy and procedures in conjunction with peer reviews for new processes and experiments should help prevent future accidents due to a lack of recognition of potential reactions…
Frequently inspect and maintain all elements of hydrogen-related systems.
A flammable gas explosion is an analyzed hazard and gas detection/shut off is a safety significant control system that requires a limiting condition for operation (LCO). The rigor of the evaluation of flammable gas systems was inadequate. There…
Recommended Actions:
Facilities should review their process systems to determine if they have valves installed that may be subject to this hazard. If so, facilities should conduct a detailed hazard analysis to determine the risk of valve failure. Detailed internal…
Cause and effect can sometimes be predicted by observing abnormal behavior even when the behavior is within specifications. Operators log equipment data and inform shift management when specifications are exceeded or when unusual equipment…
Key:
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