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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=932"> Failure to Recognize Combustible Material inside Piping Causes Small Fire - Facility Stabilization Deactivation, Piketon, OH</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Failure to evaluate unique circumstances during work planning led to
unforeseen hazards and resulted in a small fire in a cell process pipe.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On September 29, 2015, at approximately 10:00pm, a fire broke out inside
a cell process pipe which had previously been connected to a compressor
discharge line and was being prepped for removal. The removal team was
tack welding a flat plate onto the pipe using the Gas Metal Arc Welding
(GMAW) process when hot weld spatter ignited combustible material inside
the pipe.
This particular cell presented many challenges due to a previous fire
that had occurred in the cell in December of 1998. Since then, the cell
had remained dormant. Plans for removing the cell involved several
hundred man-hours and multiple organizations. A Nuclear Criticality
Safety Evaluation had to be revised to allow for the removal of
compressors prior to the cell being removed. An engineering evaluation
was completed on the overall facility¿s structural integrity to ensure
adequate support for personnel and equipment. In addition, other
precautionary measures were taken which included spraying lockdown on
cell components, a comprehensive radiological survey, and added
Industrial Hygiene monitoring.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The root cause of the fire was determined to be failure to recognize and
plan for combustible material inside the piping. Even though significant
work was done to prepare for the pipe's removal, the overall planning
process was similar to all previous work, with the exception of how the
pipe capping was performed. There was no recognition that residual
materials from the 1998 fire would be flammable. Substantial analytical
data from samples collected after the previous fire were reviewed and
interpreted, but not fully understood. Personnel, who were knowledgeable
of the potential existence of the combustible material were not utilized
effectively. Their expertise was heavily relied upon for resolution of
personnel safety, industrial hygiene, and chemical safety hazards, but
not for analysis of the residual material.
Contributing causes also identified that the piping's interior could not
be seen when performing hot work walk downs. The hot work procedure
provided clear guidance on evaluating piping interior surfaces for
flammable gases and combustible materials, but this guidance was not
included in the hot work permit. The permitting process included
cleaning and purging if necessary, however, this step is interpreted as
being a pre-treatment process only.
Another contributing cause was the changed methodology of capping the
pipe. The prescribed method had rarely been implemented over the
duration of the project (nearly four years). In spite of the time and
effort that went into preparations to ensure personnel were not exposed
a physical, radiological, or inhalation hazards, no time was given to
considering the change in the pipe capping evolution. Evaluation of this
change would have eliminated the potential for hot spatter to enter the
pipe and contact the combustible material.
Once the piping system was opened the material was clearly seen. Had the
condition been recognized and evaluated, additional hazard controls
would have been implemented to prevent the hot weld spatter from
contacting the material.
</pre>
<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.)
* Stop Work was initiated pending additional evaluation and hazard
analysis.
* A standing Order was implemented providing interim compensatory
measures for performing hot work on process gas systems that were
shut down for an abnormal reaction such as exothermic reaction.
* The Job Hazard Analysis procedure was revised so that when work
scope or conditions change there are procedural requirements to
document the hazard analysis review along with including more
pointed questions in the Hazard and Control Identification Checklist
(HCIC) relative to hazard identification to ensure proper subject
matter experts are utilized to establish proper controls.
* Job Field Instructions were revised to require a process cap
configuration that prevents weld spatter entry into systems being
capped when capping is necessary.
* The hot work process and procedure were evaluated for potential
enhancements as well as evaluating the hot work permit to determine
the need to more clearly address internal pipe inspections.
* Training will be provided to applicable issuing authority personnel
on the hot work process as it relates to evaluating and determining
if combustible materials are present in process gas systems pursuant
to hot work process procedure.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab's Subject Matter Expert has read the above and provided the following:
Jefferson Lab has a stringent procedure for identifying potential fire situations. "ES&H Manual Chapter 6900 Appendix T1, Fire Protection: Hot Work Permit - Instructions" requires detail inspections of the hot work area before a Hot Work Permit is actually issued and while the operation is being performed. Pay close attention to Section 4.0, Hot Work Permit Preparation, for details of the inspection process. Having a retired Fire Marshal on staff with numerous years of fire investigation experience has contributed to our successful Hot Work Permit Program.
Tim Minga
Fire Protection</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">2/23/2016 8:52:01 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with:
SAF108: FIRE SAFETY
SAF150: WELDING SAFETY </pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">932</td>
</tr>
<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
</tr>
<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2016-JLAB-932</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
</tr>
<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">2/23/2016 8:42:03 AM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">2/23/2016 8:52:01 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">OTHER</td>
</tr>
<tr class="row">
<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
</tr>
<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Dwayne McCloskey, Process Equipment Deactivation Manager, (740) 897-3856</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">1 times</td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=4322">DOE - Fire1.pdf</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Hot Work</li>
<li>Fire Potential</li>
<li>Welding, Cutting, Brazing, and Grinding</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF108: FIRE SAFETY</li>
<li>SAF150: WELDING SAFETY</li>
</ul>
</fieldset>
<fieldset>
<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>
</fieldset>
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