[Hallb-engineering] Fwd: Lesson Learned "PHY-16-0516- Brief Exposure to Pungent Odor (oil vapor), Results in Days Away"
tilles at jlab.org
Thu Jun 23 10:12:02 EDT 2016
----- 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.
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.
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.
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.
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
Doc ID: 2016-JLAB-954
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
Contact: Ed Folts
Queued Emails: 0
Sent Emails: 0
Viewings: 261 times Attachments
* Other: Pungent Odor- Body Reaction
* *Division Safety Officers (DSOs)
* *Safety Wardens
* *DOE Notification
* *ESH&Q Liaisons
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