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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=812">Stopper Ejected during Heating of Non-Hazardous Sample - UT-Battelle, LLC / Oak Ridge National Laboratory (ORNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see Attachments on Lessons Learned page.
When heating a liquid in a sealed container, the potential for vessel rupture must be considered and appropriate safety precautions taken. An estimate of the maximum pressure needs to be made and compared with the pressure rating of the container assembly and safety release mechanism.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On January 23, 2014, a researcher placed a 10ml autoclave glass vial, containing a nonhazardous material in 3ml of water adjusted to a pH of 10, and sealed with a butyl rubber stopper and foil crimp seal in a heating block with the temperature set to 150 degrees Celsius (C). The heating block was on a bench top. The researcher left the lab, and the e Lab Space Manager (LSM) discovered that, due to pressure buildup, the butyl rubber cap of the vial had popped off and some of the contents had sprayed (see Figure 1 in Attachment) . There were no personnel in the immediate vicinity when this happened, and no one was hurt or directly affected by the event.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The experiment was set up to reproduce results from a previously published experiment. However the published paper did not contain any details regarding sample containment during heating or any safety information. The risks of heating a liquid in a closed vial were not discussed in the paper, and consequently not considered by the researcher during planning.
The selected vial (with rubber stopper and crimp seal) was not designed for use outside an autoclave for heating liquids (see Figures 2 and 3 in Attachment).
Changes made during experiment planning were not adequately analyzed for safety. The initial plan was to heat the samples in an autoclave (steam sterilizer). When the plan changed a hazard analysis was written specifying that the work was to be done in a fume hood using a pressure-rated vial. A subsequent change by the researcher moved the experiment to a bench top heater in a different laboratory. This was not discussed with a Superviosr. (The work control policy for the laboratory the experiment was moved to, dictated that researchers are responsible for analyzing the hazards of their work. A written analysis, authorized by a supervisor was not required for the area.)
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Below are the consequences of the above event. They are provided for information and discussion purposes only.
1. A written job hazard analysis (JHA) will be required for the laboratory when work involving a new process or non-standard procedure is planned. A Supervisor will be consulted for the new JHA to ensure that the proposed work is within the scope of the Research Safety Summary (RSS) and the JHA will be approved by the supervisor.
2. A change in experiment plans will require a new look at potential changes in hazards and mitigation method.
3. Heating devices should also be labeled as "hot" when in use.
4. Heating of sealed vessels needs to be done in a fume hood with the sash closed. A hood with a closed sash provides all-direction containment of flying liquids and debris. Depending on the level of hazard, it may be advisable to place a safety shield in front of the apparatus to protect the operator when it is necessary to open the sash (adding or removing samples, etc.) during the procedure.
5. Prior to heating any sealed container, an estimate of the maximum pressure needs to be made and compared with the pressure rating of the vessel and safety release mechanism. This analysis should be part of the JHA (or Standard Operating Procedure/notebook entry if operating under an RSS).
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<h2>Comments</h2>
<h5 style="white-space:nowrap">4/17/2014 2:06:42 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
•SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">812</td>
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<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-812</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
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<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
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<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">4/17/2014 2:05:37 PM</td>
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<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">4/17/2014 2:06:42 PM</td>
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<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
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<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">ORNL</td>
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<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
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<td class="label" nowrap>Contact:</td>
<td class="dataval">Paul Langan, langanpa@ornl.gov</td>
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<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">3 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=2961">M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - Pressure Pic2.pdf</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=2962">M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - Pressure2.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Pressure Systems</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS</li>
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<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
</ul>
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