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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1147">Expiring Uninterrupted Power Supply Batteries Lead to a Potential Oxygen Deficient Exposure - Nevada National Security Site (NNSS)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Batteries found overheating and off-gassing in a closed room resulted in low oxygen levels. An odor was noticed by a maintenance worker when entering the room. The worker paused to discuss potential hazards and a path forward with the supervisor. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On the morning of March 1, 2021, a NNSS maintenance worker entered the A-1 Uninterrupted Power Supply (UPS) battery room as part of a routine morning inspection. As the maintenance worker entered the room, a slight "rotten egg" odor and heat seemed to be coming off some of the units. The worker reported the condition to the supervisor.
Two maintenance personnel returned to the battery room to look at the UPS. The workers determined the batteries had overcharged and took actions to open the battery cabinet doors for ventilation and cooling. Later that afternoon the UPS was put on bypass.
Industrial Hygiene (IH) was notified and performed air monitoring in the hallways and the UPS room. Inside the UPS room the monitoring instrument alarmed at 19.5% oxygen, which is considered an atmosphere "immediately dangerous to life or health" (IDLH) per U.S. Occupational Safety and Health Administration (OSHA) definitions.
Due to the instrument readings, IH instructed the maintenance representatives to open the UPS room doors and vent the room overnight before resuming work the next day. Maintenance personnel placed barricades in the A-1 building hallway intersections and opened east and west hallway doors for enhanced airflow/ventilation.
IH performed air monitoring twice the next morning (2-hour intervals) with no detectable readings.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre></pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>The UPS batteries involved in this incident were scheduled to be replaced by maintenance workers, with support from a subcontractor, prior to March, 2021. However, the replacement was delayed due to a lack of clarity as to exactly which department was responsible for the cost. This delay is considered the root cause of the events. </pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Identify clear accountability and authorities for battery replacement.
Use historical data and preventive maintenance programs to determine conservative battery replacement intervals.
Identify every UPS/battery room and location within each facility.
Label, review, and track UPS battery expiration dates and historical data to determine if similar conditions exist.
Install appropriate non-explosive gas sensors for battery and UPS rooms.
Inform workers that when they are exposed to unknown concentrations of gases they are to seek prompt medical evaluation even if no symptoms are evident as some materials may have delayed effects.
Distribute a "rapid knowledge share" to NNSS staff to highlight the potential hazards associated with UPS battery off-gassing and remind them to stop work if they perceived something off normal.
</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">6/4/2021 10:16:19 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in
GEN150: Property Custodian</pre>
</div>
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<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1147</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">2021-JLAB-1147</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</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">6/4/2021 10:04:49 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">6/4/2021 10:16:20 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">NNSS</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">Contact Michele Kelly, Infrastructure, Facilities and Maintenance, 702-295-7600, KellyML@nv.doe.gov </td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">757</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>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=5964">NNSS - Battery Overheating.pdf</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Chemicals</li>
<li>Confined Space</li>
<li>Oxygen Deficiency Hazards (ODH)</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>GEN150: Property Custodian</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>
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