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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=874">Pressure Vessel Leak results in Sulfuric Acid Burns – Lawrence Livermore National Laboratory (LLNL)</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.
On February 12, 2013 three LLNL workers suffered inhalation and dermal exposures when the contents of a 100-liter reaction vessel sprayed into their work area. Two employees closest to the vessel experienced first- and second-degree burns from a direct acid splash. The third was exposed to sulfuric acid mist but suffered no visible injuries.
The event prompted a DOE investigation by the National Nuclear Security Administration (NNSA).
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Based on the investigation’s LLNL received a Preliminary Notice of Violation (PNOV), citing four Severity Level I Violations and two Severity Level II Violations and a contract fee reduction of $365,000.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Severity Level I Violations:
1. Hazard Identification, Assessment, Prevention, and Abatement
The Process Hazard Analysis did not fully address all the hazards associated with the equipment design.
The vessel lacked the proper chemical dispensing equipment and an adequate number of ports. The ports available were neither adequately sealed nor oriented.
Conflicting work control documentation requirements led to confusion over the purpose and expectations of work procedures.
Peer review procedures, intended to ensure the objectivity of the process, did not identify hazards nor adequate controls.
2. Safety and Health Standards
Identified PPE and engineering controls were not adequate to protect workers.
3. Emergency Response
Emergency response protocols did not identify what to do in case of over pressurization or chemical release.
4. Pressure Safety
The vessel did not include a pressure relief device or an adequately designed pressure relief system to safely address the potential for elevated pressure.
Severity Level II Violations
1. Industrial Hygiene
It was not identified that the method of manually adding chemicals to the vessel exposed workers to a carcinogen.
2. Management Responsibilities
Research staff, responsible for determining when new hazards required management review, did not identify that the equipment and its subsequent hazards needed a more thorough management review and safety analysis.
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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.
LLNS is being monitored by the NNSA Livermore Field Office until this matter is fully resolved.
LLNL underwent a DOE investigation and is now obligated to submit a written reply to the PNOV. After reviewing the response NNSA will determine if further action is required to ensure compliance with worker safety and health requirements.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab has a robust experimental / work control review process. Management is integrated into the system resulting in a thorough review and consistent approval process.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">1/29/2015 3:41:24 PM by Bailey, Mary Jo</h5>
<pre>Submitted to Chemical Workers and Pressure System Workers.</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">874</td>
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<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2015-JLAB-874</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">1/29/2015 3:37:33 PM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">1/29/2015 3:41:24 PM</td>
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<td class="label">Source:</td>
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DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">LANL</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">Steve Smith, QA/CI Manager TJNAF, 757-269-7007</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Viewings:</td>
<td class="dataval">2 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3700">LLNL 10CFR851 PNOV.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Chemicals</li>
<li>Pressure Systems</li>
<li>Acids & Bases</li>
<li>Pressurized Tanks, Containers, and Vacuum Vessels</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF129: R&D Chem Room Safety</li>
<li>SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS</li>
<li>SAF130B: PRESSURE SYSTEMS SAFETY DESIGN AUTHORITY</li>
<li>SAF130kd: PRESSURE SYSTEMS QUALITY PROCEDURE</li>
<li>SAF137: Chem Room Safety</li>
<li>SAF137KD: CHEMICAL SPILL CLEANUP PROCEDURE </li>
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<legend>Distribution/Notification</legend>
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<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
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Do you have a lesson learned you would like to contribute? Contact the <a href="mailto:cjohnson@jlab.org,sjsmith@jlab.org,mbailey@jlab.org">Lesson Learned Coordinator</a>.