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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1156">Oxygen Deficient Atmosphere Hazards at DOE Facilities - Operating Experience Level 3 (OE-3) Report</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>This Operating Experience Level 3 (OE-3) Report (see attached) is provided by the Office of Environmental, Health, Safety and Security to raise awareness of the potential for worker exposure to oxygen deficient atmospheres and to promote exchange of operating experiences at other DOE facilities.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Several documented events demonstrate the need for vigilance in operating practices and facility maintenance. Workers are reminded to respect the alarms that are installed to detect hazards, and perform activities that will prevent adverse consequences. Due to the severity of some of the events described Worker Safety and Health enforcement actions were initiated by the DOE.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>On June 14, 2021, a maintenance worker at the Kansas City National Security Campus opened the side panel on a Remstar Shuttle XP500 cabinet that was filled with an inert nitrogen atmosphere. The subsequent exposure to nitrogen resulted in the worker having a momentary loss of consciousness which caused them to fall backward and strike their head and neck on nearby equipment. The fall resulted in a bump on the lower head/neck and a mild concussion.
On March 5, 2021, while performing routine maintenance, a worker at the Nevada National Security Site noticed and reported a rotten egg smell in the A-1 Uninterrupted Power Supply battery room. Machine Shop personnel, responding to the incident, also reported the odor and burning eyes. The cause was determined to be batteries overheating and off-gassing. Industrial hygiene monitoring confirmed a low oxygen atmosphere coupled with the presence of carbon monoxide and hydrogen sulfide. The workers entering the area did not understand the hazardous condition or follow safe practices when the odor was recognized.
On November 4, 2019, at Los Alamos National Laboratory, an alarm was sounding in a room. After ten minutes of searching, a worker identified the alarm as a low oxygen alarm and exited the room. The worker then consulted their Integrated Work Document (IWD) which instructed them to return to the room and reset the alarm. The event investigation later showed that the oxygen monitor was malfunctioning, however, the IWD did not contain appropriate alarm response instructions.
On August 12, 2019, Los Alamos National Laboratory while a low oxygen alarm was activated workers entered the high bay room to isolate a liquid nitrogen leak from a vent pipe, which they believed to be the cause of the alarm. The oxygen monitor did indicate an oxygen level of about 19%, thus confirming that the workers had entered an oxygen deficient area.
On September 13, 2017, a Los Alamos National Laboratory Subject Matter Expert entered a room while a low oxygen alarm was activating. They had determined that a relief valve in the room was releasing liquid nitrogen so they entered the room to turned off the supply valve and placed the system in a safe configuration. The low oxygen alarm stopped within twenty minutes. These actions were opposed to work requirement documents which specified that if alarms are activated personnel are to evacuate, close the valve on the liquid nitrogen tank located outside of the building, and then contact Emergency Management and Response (EM&R). EM&R was not contacted because the situation was thought to have been mitigated.
In 2015, Environmental Management's Moab Uranium Mill Tailings Remedial Action project found carbon monoxide and volatile organic compound build-up in a tightly enclosed tent structure being used as a mechanics shop. The resulting oxygen deficient atmosphere was attributed to solvent-containing rags stored too close, too long, near a ventless infrared propane-fired heater.
In 2014, during a testing evolution, the Brookhaven National Laboratory (BNL) Collider-Accelerator Department found that an Oxygen Deficiency Hazard monitoring and alarm unit would not enunciate at a low oxygen condition using its alarm relay output if the oxygen level went too low. The manufacturer reproduced and confirmed BNL's results. An external system (relays or PLC) with a different power source was required to enunciate alarms if the unit failed to activate its alarm (low O2 or had a system failure (power loss, O2<5%, low flow, etc.).
On October 13, 2011, an initial evaluation by a Los Alamos National Laboratory industrial hygienist determined that a catastrophic failure of the nitrogen supply system at the Weapons Engineering Tritium Facility could result in a potential asphyxiation hazard in certain rooms of the facility. The potential hazard had previously been identified in 2002 and 2008 however, oxygen monitors were never installed. The Weapons Facility Operations Director declared this situation to be a management concern.
In October 2010, a liquid nitrogen (LN2) valve leak resulted in a drip from the ceiling into the basement of a building at Sandia National Laboratory resulting in oxygen levels below 14%. Oxygen monitor alarms activated and the event was properly reported to management, the safety coordinator, and Emergency Management. The investigation identified that a faulty LN2 purge valve had opened, the leaking LN2 had entered an exhaust duct, found its way into the ducting and leaked out resulting in the low oxygen levels.
On March 31, 2009, a nitrogen purge was being planned for the beam line located in the Linear Coherent Light Source Front End Enclosure when an oxygen deficiency alarm sounded. The investigation found that fire dampers in the supply air duct were in the closed position and there was no make-up airflow to necessary to prevent the oxygen deficient atmosphere.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>* Recognize that oxygen deficient atmospheres can be dynamic and exist outside determined spaces. Analyze all potential facility conditions and implement protections with the hierarchy of controls.
* Design and engineer facilities to prevent or control oxygen deficient atmospheres using interlocks, ventilation, gas controls and robust monitoring and alarms.
* Ensure facilities are designed so workers can hear and/or see alarms and lights at a safe distance from the hazardous condition.
* Conduct routine facility inspections to ensure engineered systems function properly and as expected (e.g., ventilation, valves, and alarms are set correctly and are functional).
* Track and confirm the implementation and effectiveness of controls to address deficiencies and support continuous improvement.
* Stop work when unexpected conditions are encountered. Exit potentially hazardous areas until confirmed safe.
* Ensure all procedures and postings, including building Emergency Plans, are correct and consistent regarding informing workers of the actions to be taken when an alarm is activated.
* Train affected employees on response procedures including awareness of the visual and/or audible signals produced by each alarm and actions to take when an alarm activates.
* Conduct emergency drills to reinforce response to abnormal/alarm conditions.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/29/2021 2:27:27 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
SAF103: Oxygen Deficiency Hazard</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1156</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-1156</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</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">9/29/2021 2:20:52 PM</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">9/29/2021 2:27:27 PM</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>
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<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">Maria Dikeakos, Office of Environmental, Health, Safety and Security, 631-574-0220 or maria.dikeakos@hq.doe.gov.</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">1039</td>
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<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>Oxygen Deficiency Hazards (ODH)</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF103: Oxygen Deficiency Hazard</li>
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<legend>Distribution/Notification</legend>
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