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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=958">PHY-16-0531- Propane Torch Caught Fire Around Bottle Neck, Requiring Use of Fire Extinguisher</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. Although you may be semi familiar with a piece equipment (use it at home from time to time), you should consider investing a few extra minutes into re-familiarizing yourself with that equipment and recommended uses of the equipment before using it. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On May 31, 2016 around 1:30 an employee was attempting to use a hand held propane torch in Hall B when the neck of the tank caught on fire. After attempting to install one Trigger-Start Torch head, he noticed that it was significantly misshapened, and he discarded that one. He grabbed another one and installed the head. Once installed he partially unscrewed the head and tightened it down again. After lighting the propane torch he noticed that the flame was rather small. He then noticed a flame around the neck of the bottle. After several attempts to extinguish the flame, he put down the propane torch and called for assistance.
An employee walking into the area, grabbed a fire extinguisher from the wall and put out the fire.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause: There was a failure to follow previously identified corrective actions and lesson learned which were to follow manufacturer¿s guidelines before using the hand held propane torch with Trigger-Start Torch. Specifically the manufacturer¿s guideline states to attach the torch device and check for leaks with soapy water before igniting the propane torch for use.
Contributing Causes:
A2 Equipment Material Problem, B3 Inspection/testing LTA -The incident investigation determined that the cause of the fire was a worn insertion pin on the torch which allowed propane to leak between the bottle and the torch. The manufacturer¿s instructions states that after the bottle is attached to the torch ¿With valve closed, without lighting, test all connections with soapy water. If bubbles appear, gas is leaking and the torch must be repaired or replaced.
A5 Communication LTA, B4 Verbal Communication LTA, C01 Communication between work groups LTA: Communication between Hall Coordinator and other qualified personnel was LTA Less than adequate. When the employee asked if there was a hot work permit, there was no dialogue or read back to ensure that the work that was being done matched the permits and the users that are indicated on the permits.
A4 Management Problem, B3 Work Organization and Planning LTA, C11 Inadequate work package preparation. The Hot work Permit procedure was not followed entirely. The hot work permit did exist. However it did not cover open flame work nor did it cover this particular worker. The employee failed to follow Hot work processes and procedures which decreased his preparedness for this type of work.
A3 Human Performance LTA, B1 Skill Based Error, C04 Infrequently performed steps were performed incorrectly. The employee does not typically perform this type of work. The project is behind schedule and manpower from other areas is being used to supplement the workforce.
A3 Human Performance LTA, B1 Skill Based Error, C04 Previous success in use of rule reinforced continued use of rule. Previous experience with this device gave the employee the confidence use the device for the task of softening epoxi.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Extent of Condition: All Halls will inspect all Propane bottles and torches for damage and discard any suspect bottles and torches and report back to the Division Safety Officer.
Corrective Actions:
1. Share the Lessons learned from this event within the local and DOE Lessons Learned Databases.
2. Torches that do not have factory labels for the type of gas to be use will be discard and replaced with ones that do
3. Provide a punchlist of items to do before using a propane torch. This punchlist should be posted on the cabinets where the items are stored within the hall
Evidence of completion: Pictures of the cabinets with signs posted
Conduct meetings in each of the halls to share this event and the expectations for the future handling of such devices.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">8/10/2016 1:46:32 PM by Johnson, Tina</h5>
<pre>SME reviewed and approved. Please share this lessons Learned within your work groups. Also a good lesson learned that you can apply to use of this equipment at home as well. </pre>
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<legend>Summary</legend>
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<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">958</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">2016-JLAB-958</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</td>
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<td class="label" nowrap>Safety Related:</td>
<td class="dataval">NO</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Johnson, Tina</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">8/10/2016 9:49:17 AM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Johnson, Tina</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">8/10/2016 1:46:32 PM</td>
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<td class="label">Source:</td>
<td class="dataval">
<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/PHY-16-0531%20Propane%20Torch%20Use%20Requiring%20%20Fore%20Extinguisher.pdf" target="_blank">TJNAF NE</a>
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<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</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">Ed Folts</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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<td class="label" nowrap>Viewings:</td>
<td class="dataval">3 times</td>
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<legend>Attachments</legend>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=4508">IMG_2621.JPG</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4509">IMG_2622.JPG</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4510">IMG_2610.JPG</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4511">IMG_2611.JPG</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4512">IMG_2612.JPG</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4513">IMG_2613.JPG</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4514">IMG_2614.JPG</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4516">BZ_manual_TS3000(1).pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Gas Cylinders</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF110: HALL A SAFETY KNOWLEDGE</li>
<li>SAF111: HALL B SAFETY AWARENESS</li>
<li>SAF112: HALL C SAFETY AWARENESS</li>
<li>SAF113: Hall D Safety</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:mbailey@jlab.org,sjsmith@jlab.org,cjohnson@jlab.org">Lesson Learned Coordinator</a>.