Appendix B Lessons Learned - hdbk11392002vol20061

DOE-HDBK-1139/2-2002

Appendix B

LESSONS LEARNED

The following lessons learned are extracted from DOE Operating Experience (OE) Weekly Summary and

Occurrence Reporting and Processing System (ORPS) reports and are included in this Appendix as

potential learning and training tools for the reader.

Safe storage of chemicals.

Students discovered a cylinder containing hydrogen fluoride (HF) that had ruptured inside a storage

room next to a laboratory. Following the cylinder failure, investigators learned of a letter DuPont

Fluoroproducts sent to its customers two and a half years earlier about the potential over-pressure

hazard associated with the long-term storage of Anhydrous HF in carbon steel cylinders. The

cylinder was a lecture bottle that had been stored at the university for 22 years. (OE Weekly

Summary 99-25)

Three reactor auxiliary operators were exposed to trimethylamine above the short-term (15-minute)

exposure limit while recharging an ion exchange resin in a demineralizer tank. Investigators believe

that the excessive off-gassing of trimethylamine resulted from the drums of resin being stored at a

higher temperature than that recommended on the MSDS. (ORPS Report ID--LITC-ATR-1998-

0014)

Facility chemists found five sealed containers of lithium metal stored inside a nitrogen glove box

instead of an adjacent argon glove box. Lithium reacts with nitrogen and can result in highly

exothermic reactions when exposed to water or oxygen. (ORPS Report ID--LITC-ERATOWNFAC-

1998)

A cleaning subcontractor employee became nauseous and vomited while spraying a chemical cleaner

in a restroom in the administration building. Investigators determined that the spray bottle was

mislabeled "Crew," which is a chemical manufactured for cleaning toilet bowls and sinks. The label

did bear the manufacturer's warnings, but the bottle actually contained nearly full strength Lysol

liquid cleaner. (ORPS Report ORO--MK-WSSRAP-1998-0040)

A maintenance crew discovered a small vial labeled "picric acid" in a crawl space while they were

performing a pre-job walk-down for maintenance on some steam lines. Picric acid is normally used

as an aqueous solution and an explosive mixture results when the solution crystallizes. Eight similar

occurrences involving picric acid were found dating back to 1990. In these events, explosive safety

specialists removed the acid and either chemically neutralized it or detonated it in a safe area. (OE

Weekly Summary 98-05)

Inadequate control of chemical hazards.

The Type A investigation of a sodium potassium (NaK) accident that occurred at the Y-12 plant on

December 8, 1999, identified a lack of understanding of the hazard from NaK and its reactive by-

products as one of the root causes of the accident. The investigation found that personnel involved in

planning the task, the safety documentation for the facility, the procedure for the task, and the

procedures supporting hazard identification and analysis did not address the complete NaK hazard.

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