[Hallb-engineering] Fwd: Lesson Learned "Improperly Marked Compressed Gas Cylinder Delivered to South Access � Thomas Jefferson National Accelerator Facility"

[Douglas Tilles]

Please read     Doug

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From: mbailey at jlab.org
To: mbailey at jlab.org
Cc: robertl at jlab.org
Sent: Tuesday, August 27, 2013 11:00:04 AM
Subject: Lesson Learned "Improperly Marked Compressed Gas Cylinder Delivered to South Access � Thomas Jefferson National Accelerator Facility"






	Improperly Marked Compressed Gas Cylinder Delivered to South Access � Thomas Jefferson National Accelerator Facility 	
Statement of Lessons Learned 
When opening a cylinder of nitrogen, an operator noticed an unusual odor.  He immediately halted his work and proceeded to lock the cylinder out. Discussion of Activity 
On July 31, 2013 four nitrogen gas cylinders were delivered to the South Access.  On August 14 an operator open one of the cylinders and noticed an unusual odor.  He proceeded to check the other cylinders and found that two of them had a similar odor.  He halted work, locked out all the cylinders and contacted the purchaser for vendor verification. Analysis 
The vendor was contacted regarding the delivery.  It was confirmed that only nitrogen could have been inserted into those particular cylinders because both the source and cylinders have a unique thread pattern that is only compatible with each other.  A possible explanation is that some customers request a trace �odor� be added to nitrogen so leaks can be detected.  TJNAF may have received cylinders with residual "odor." Recommended Action 
The vendor has removed the offending cylinders.

TJNAF to provide a �lessons learned� to others who work with gas.

It is noted that though it was good that immediate action was taken upon initial detection that something was wrong with the nitrogen.  The concern that purposefully smelling compressed gases from other cylinders, when the content is suspect, is highly risky and should not be done. 
Comments 
8/27/2013 10:46:21 AM by Bailey, Mary Jo 
Submitted to those with current �SAF129: R&D Chem Room Safety
�SAF150: WELDING SAFETY Training 	
Summary 	Lesson ID: 	745 
	Status: 	OK 
	Doc ID: 	2013-JLAB-745 
	Priority: 	Best Practice 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	8/27/2013 10:41:19 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	8/27/2013 10:46:21 AM 
	Source: 	TJNAF Other 
	Location: 	TJNAF 
	Cost Savings: 	
	Contact: 	Tina Johnson, TJNAF Notable Events Coordinator (757)269-7611 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	2 times Attachments 

Hazard Issues 

    * Gas - Compressed and Liquified 
Skills 

    * SAF129: R&D Chem Room Safety 
    * SAF150: WELDING SAFETY 
Distribution/Notification 

    * *Division Safety Officers (DSOs) 
    * *Safety Wardens 
    * *DOE Notification 
    * *ESH&Q Liaisons