[Hallb-engineering] Fwd: Lesson Learned "Welding Material Causes Floor Insulation to Start on Fire - FERMI National Accelerator Laboratory"

[Douglas Tilles]

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From: mbailey at jlab.org
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Sent: Tuesday, October 21, 2014 11:00:08 AM
Subject: Lesson Learned "Welding Material Causes Floor Insulation to Start on Fire - FERMI National Accelerator Laboratory"






	Welding Material Causes Floor Insulation to Start on Fire - FERMI National Accelerator Laboratory 	
Statement of Lessons Learned 
Ensure all flammable material is identified and secured prior to commencement of Hot Work. Discussion of Activities 
During the finishing of a TIG weld on a piece of stainless steel pipe above the MicroBooNE detector at the LArTF facility, molten material was blown out of a weld due to pressure caused by the argon purge gas.  The molten material fell down to the floor (approximately 25 ft.) landing on the floor�s foam board insulation lining.  A couple minutes later an odor was noticed. The welder looked over the side of the vessel and noticed a small charred area with small flames. The welder quickly exited the area and notified others in the area.  One of the technicians working on the topside of the detector area phoned [security] and reported the emergency. A precautionary evacuation was conducted.  

An engineer conducting work on the electronics noticed the fire, grabbed a fire extinguisher and put out the fire. An area of approximately 3 sq. ft. of foam board was consumed. The fire department cleared the area. The local alarm system functioned properly, but did not communicate appropriately to the communication center. No personnel were injured as a result of this incident. The investigation is ongoing. Analysis 
Fermilab's Particle Physics Division is conducting a thorough investigation that will include Human Performance Improvement (HPI) fundamentals and establish meaningful corrective actions and lessons learned. Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

All hotwork was stopped in the building.  Pieces of the insulation and other debris in the area of the fire was fire tested by the Fermilab Fire Safety Engineer. Hazard analyses were updated to reflect the possibility of molten material falling from TIG welding and other welding operations.   

The FIRUS connection from the building to the communication center was repaired and tested, verified operational immediately after the event. HPI investigation initiated. JLab Preventive Measures 
Jefferson Lab prevents incidents such as this by requiring a hot work permit for ��any work activity that requires an open flame (greater than a BIC lighter); welding or brazing activities; and/or spark producing grinding or cutting operations, unless � performed in a designated area established by an Operational Safety Procedure (OSP).�  (See ES&H Manual Chapter 6900 Appendix T1 Fire Protection: Hot Work Permit � Instructions.)  Hot Work Permit requirements are reviewed and inspected daily to ensure compliance. 
Comments 
10/21/2014 10:18:02 AM by Bailey, Mary Jo 
Submitted to those current in SAF 150 Welding Safety 	
Summary 	Lesson ID: 	855 
	Status: 	OK 
	Doc ID: 	2014-JLAB-855 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	10/21/2014 10:16:04 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	10/21/2014 10:18:02 AM 
	Source: 	OTHER 
	Location: 	Fermilab 
	Cost Savings: 	
	Contact: 	Timothy Meyer, Facility Manager, (630) 840-6650 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	3 times Attachments 

Hazard Issues 

    * Welding, Cutting, Brazing, and Grinding (i.e. Hot Work) 
Skills 

    * SAF150: WELDING SAFETY 
Distribution/Notification 

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