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.
No Lessons Learned, Specific Suggestions for Avoidance, or Mitigation Steps Taken.
This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…
All safety devices worked as designed thereby protecting the environment and laboratory personnel. Researchers involved in the experiment acted properly and with the parameters set forth in operational procedures.
Follow up: Stops have…
This occurrence demonstrated the use of data by engineering to evaluate equipment problems. As the data changed, highlighting a problem with one-half inch PVC ball valves, the facility redesigned the valve extension and valve handle to prevent…
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…
In this case, failure to recognize a run of tubing still maintaining pressure could have been avoided if such information was provided in a safety briefing. Knowledge of any job is the utmost importance in promoting and maintaining a safe working…
This incident highlights the need to ensure that the performance of special procedures does not place facility equipment in a condition that could lead to entry into a LCO.
A gas detector was added in close proximity to the compressor shaft and a vibration switch is under consideration. Additional predictive measures are being considered to predict bearing failure. In addition, the manufacturer has been contacted…
The fitting was an SAE straight thread and was likely loosened by torque applied to the fueling hose. After the incident, these fittings had additional means applied to restrict loosening, a cover installed to deflect any leakage, and means taken…
Mounting hardware incorporated polymeric braces not suitable for long-term exposure to sunlight and temperature extremes. With time, the polymeric materials had disintegrated, allowing the mounting brackets to become loose. In addition, the…
The SS 24-inch pipe that failed was replaced with 1-1/4 Cr 1/2 Mo alloy pipe that is corrosion-resistant to SCC. A revised HTS bypass piping layout was installed to prevent the hazardous conditions that lead to the failure. A detailed hazard…
Installation
The manager in charge acknowledged that, while he made relatively recent modifications to the high-pressure gas storage side of the system and had directed a major rebuilding of various units, the moderate-pressure interconnecting system (the…
This incident occurred due to moisture in the sample line monitoring system. Removing moisture from the sample line increases the reliability of the equipment. Further evaluations are being considered for improving system reliability.
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…
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