No Lessons Learned, Specific Suggestions for Avoidance, or Mitigation Steps Taken.

• Unprotected hoses are susceptible to glass shards, abrasion, and burns during normal use. This leak was formed from a glass shard penetrating the tube wall.
• Flexible hoses require protective sheaves to avoid cuts, abrasions and…

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…

• Equipment that is designed to provide a safety barrier must be stringently tested upon installation.
• A procedure requiring annual testing of both excess flow valves, which includes proper seating for closure and proper flow, has…

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…

1. Parallel-path design activities require an increased level of management oversight and control to mitigate the risks inherent in this process.
2. Schedule pressure cannot be allowed to compromise the integrity of the design process…

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.

Installation

1. Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
2. Research staff are responsible for communicating system specifications [gas type,…

Hydrogen distribution lines should be designed and carefully inspected to ensure process equipment in the area is correctly and safely installed. Equipment subject to vibration should not be placed in contact with hydrogen lines or with other…

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…

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…

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…