[Hallb-engineering] Fwd: Lesson Learned "Handling of an Extremely Heavy Gas Cylinder Results in Injury - Lawrence Berkeley National Laboratory"

[Douglas Tilles]

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Subject: Lesson Learned "Handling of an Extremely Heavy Gas Cylinder Results in Injury - Lawrence Berkeley National Laboratory"






Handling of an Extremely Heavy Gas Cylinder Results in Injury - Lawrence Berkeley National Laboratory 
Statement of Lessons Learned 
For a copy of the full report and pictures, see Attachments on Lessons Learned page.

A gas cylinder fell and rolled onto a graduate student�s foot causing multiple broken bones.  This incident re-enforces the importance of understanding all the hazards associated with handling compressed gas cylinders including that related to size, shape and weight. Discussion of Activity 
On April 24, 2013, a student lost control of a large compressed gas cylinder while trying to transfer it between the gas storage rack and a gas cart.  The cylinder fell and then rolled onto the graduate student�s foot, pinching it between the cylinder and the ground. Emergency medical assistance was called and the student was treated at the scene and transported to a local facility for further treatment and X-rays. Analysis 
Three factors contributed to the accident:
1.	The configuration of the cylinder rack, including an angled transition or "ramp" (see photograph #1) which the cylinder tipped on. 
2.	Recognition that the weight of the cylinder was 341.5 lbs (2.6 times heavier than a typical cylinder).  (See photograph #2).
3.	Markings, stamped on the top sides of the cylinder (see photograph #3), were not noticed. Recommended Action 
None for Jefferson Lab at this time.

None for Jefferson Lab at this time.

1.	Enhance existing training by producing a training video.  The training video will address such subjects as how to identify cylinders by markings, how to handle cylinders safely, which carts and equipment to use, and how to recognize when assistance is needed (e.g. heavy cylinders, handling on sloped surfaces).
2.	Distribute a series of additional Lessons Learned Briefings in the coming months covering these topics plus additional gas cylinder safety issues.
3.	Develop procedures to track 6K cylinders onsite and to provide additional "Heavy" labels (see photograph #4) for 6K type cylinders while they are present at LBNL facilities. 
Comments 
7/16/2013 11:49:10 AM by Bailey, Mary Jo 
Submitted to those current in �SAF129: R&D Chem Room Safety
and �GEN006: HOSTING FOREIGN NATIONALS training 	
Summary Lesson ID: 	447 
Status: 	OK 
Doc ID: 	2013-JLAB-447 
Priority: 	Best Practice 
Safety Related: 	YES 
Originator: 	Bailey, Mary Jo 
Issued: 	7/16/2013 11:47:32 AM 
Approved By: 	Bailey, Mary Jo 
Approved On: 	7/16/2013 11:49:10 AM 
Source: 	DOECRD 
Location: 	LBL 
Cost Savings: 	
Contact: 	510-486-7401 
Queued Emails: 	0 
Sent Emails: 	0 
Viewings: 	1 times Attachments 

    * DOE Lessons Learned - MentorPic1.pdf 
    * DOE Lessons Learned - Mentor1.pdf 
Hazard Issues 

    * Gas - Compressed and Liquified 
    * Other: Student Mentor 
Skills 

    * SAF129: R&D Chem Room Safety 
    * GEN006: HOSTING FOREIGN NATIONALS 
Distribution/Notification 

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