[Hallb-engineering] Fwd: Lesson Learned "PHY-16-0516- Brief Exposure to Pungent Odor (oil vapor), Results in Days Away"

[Douglas Tilles]

----- Forwarded Message -----
From: "Tina Johnson" <cjohnson at jlab.org>
To: "Tina Johnson" <cjohnson at jlab.org>
Sent: Thursday, June 23, 2016 10:00:02 AM
Subject: Lesson Learned "PHY-16-0516- Brief Exposure to Pungent Odor (oil vapor), Results in Days Away"

Jefferson Lab Lessons Learned : Print Lesson 
	PHY-16-0516- Brief Exposure to Pungent Odor (oil vapor), Results in Days Away 
	
Statement of Lessons Learned 
1.Small tidbits of historical information about equipment and material used during a build may be helpful to others.  Try to share this type of information with others. 
Discussion of Activities 
Superconducting magnets are constructed with a vacuum space between the outer shell and the very cold part of the magnet. This is called the insulating vacuum and it helps to prevent the warmth on the outside of the magnet from reaching the minus 300 degree or so temperature on the inside of the magnet.  On May 16, 2016 at approximately 11:00 am a technician was working to remove an insulating vacuum pump out tube in preparation for removing the Q1 (number 1 Quadrupole magnet from a High Resolution Spectrometer).  As the tube was removed from its connection on the magnet, the technician observed a strong odor of burnt oil which can backstream from the pump used to establish the insulating vacuum and another plastic-like odor, possibly G10 or Mylar which are used in the construction of these type of magnets.  Over the course of the day, the employee experienced a headache, runny nose, scratchy throat, stomach pains, and coughing.  The employee was out of work for two days and returned to work on May 19, 2016.  He was evaluated by Dr. Chandler on May 20, 2016, at which time he returned to work with no restrictions. 

Technicians covered the opening with foil after sensing the odor, and the supervisor instructed the technicians to stay out of the area until Industrial Hygiene (IH) could evaluate. IH was notified and responded to the request on May 18, 2016. 
Analysis 
Root Cause:  	A3 Human Performance LTA, B2 Rule Based Error, CO4 Previous Success in use of rule reinforced continued use of rule.  Similar work on this and other magnets without incident gave the workers the confidence to complete without further hazard evaluation.** There was no way to predict that an employee would react to the smell in such a manner. 
Recommended Actions 
Extent of Condition: When a magnet is pumped on, oil vapors can back stream into the magnet.  This can cause a burnt oil smell on an old magnet.  During the construction of this magnet G10 was used as an isolator between the super insulation and the welds and was mostly likely burnt at that time.  When performing this type of work on super conducting magnets (containing G10 or super insulation and welding the magnet could have burned the insulation or G10) workers shall have a local exhaust to ensure that the area is well ventilated and no one else is potentially exposed to this odor.

Corrective Action:
Conduct a Hall Coordinator Meeting to raise awareness about this event and encourage the sharing of pertinent historical data and IH consultation in the future when performing similar work on superconducting magnets. 
JLab Preventive Measures 
See Corrective actions. 
Comments 
6/23/2016 8:25:50 AM by Johnson, Tina 
SME approved.  Please share this within your work areas. 
6/22/2016 3:32:30 PM by Johnson, Tina 
Please share this lesson learned within your work areas. 
	
Summary 	Lesson ID: 	954 
	Status: 	OK 
	Doc ID: 	2016-JLAB-954 
	Priority: 	Info 
	Safety Related: 	NO 
	Originator: 	Johnson, Tina 
	Issued: 	6/16/2016 3:40:00 PM 
	Approved By: 	Johnson, Tina 
	Approved On: 	6/23/2016 8:25:50 AM 
	Source: 	TJNAF NE 
	Location: 	TJNAF 
	Cost Savings: 	
	Contact: 	Ed Folts 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	261 times Attachments 


Hazard Issues 

    * Other: Pungent Odor- Body Reaction 
Skills 

Distribution/Notification 

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




Do you have a lesson learned you would like to contribute? Contact the Lesson Learned Coordinator .