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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1045">Acid Splash in Lab Provides Valuable Lessons - Oak Ridge National Laboratory</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Consider what can go wrong before performing seemingly routine activities. When conditions are not as expected, re-evaluate identify additional hazards. Troubleshooting is a non-routine activity, consider worse case scenarios and perform another mitigation evaluation before proceeding.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On May 25, 2017, two Environmental Sciences Division Researchers were performing post-experiment clean-up on a 30-vial distillation system. Both researchers were wearing safety glasses and gloves but no lab coats. Researcher 1 (R1) noticed that the friction slip connection, supplying nitrogen gas to the Vial-1, was disconnected and approximately 10 mL of acid solution had leaked onto the lab benchtop. R1 reconnected the line and Researcher 2 (R2) assisted with the acidic solution clean up.
The researchers then noticed that the reconnected gas line had re-filled with acid solution. This was a malfunction even under normal operating conditions. They were troubleshooting the issue, when the friction slip connection again disconnected and hot, acidic solution released onto the forearm of R1 and a mist sprayed onto the neck of R2.
R1 flushed the exposed skin in the lab sink; R2 used the lab's eyewash station. Medical staff treated R1 for three small thermal burns; R2 had no visible injury. Both were released without restrictions.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>A post-event management discussion identified corrective actions, along with other considerations
1. Workers are reminded to stop and re-evaluate changed conditions when performing routine tasks. Troubleshooting and other non-routine activities require additional hazard identification and personal protective equipment (PPE) before proceeding.
2. Consider the effectiveness of your work controls. Tribal knowledge verses the development of a Standard Operating Procedure (SOP). An SOP eliminates person-to-person variation in process steps.</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Prior to commencing experiments researchers are to review equipment to verify that it is working properly, and are to develop scheduled maintenance periods.
Researchers will review work controls. Determine the process steps that require PPE and identify what type.
Existing equipment SOPs will be modified and linked to the Research Safety Summary (RSS) to ensure they are routinely reviewed and evaluated.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab has determined that working with chemicals carries an unmitigated Risk Code > 2. At a minimum, all tasks requiring chemicals are discussed with the supervisor prior to commencement of work. An Operational Safety Procedure (OSP) is written for work considered to be Risk Code >2. ES&H Manual Chapter 6610 Chemical Hygiene Program provides the minimum requirements for chemicals use at Jefferson Lab. Additional control measures, up to and including a work control document, may be required during certain operations, or for work within specific areas, as identified by a Task Hazard Analysis (THA). Safety training is required for all chemical workers.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">1/31/2018 3:22:44 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with SAF125: FIRST AID FOR CHEMICAL EXPOSURES</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1045</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">2018-JLAB-1045</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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<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">1/31/2018 3:18:23 PM</td>
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<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">1/31/2018 3:22:44 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">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">Mike Watkins / (865)241-3341</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">229</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">1 times</td>
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<legend>Hazard Issues</legend>
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<li>Chemicals</li>
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<legend>Skills</legend>
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<li>SAF125: FIRST AID FOR CHEMICAL EXPOSURES</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>.