Inadequate control of chemical hazards.

DOE-HDBK-1139/1-2006

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)

On March 5, 2002, at Rockey Flats Environmental Technology Site, facility personnel found

approximately 14 containers of combustible liquids that were not stored in flammable liquid storage

cabinets as required. Spark-, heat-, and flame-producing activities were curtailed in affected areas

until the combustibles were removed form the facility. Facility management identified this

occurrence as a programmatic deficiency because the applicable program requirements for controlling

flammable/combustible liquids were not met. (ORPS Report RFO-KHLL-371OPS-2002-0014)

In January 2003, at the Lawrence Livermore National Laboratory, a researcher's mixture of 2 percent

potassium dichromate in concentrated sulfuric acid leaked from its container, wetting adjacent

containers, soaking into the wood floor of a cabinet, and spilling out onto the floor of the room. The

leaking chemicals presented a safety hazard in the laboratory that could result in injury, illness, fire,

or property damage. (SELLS Identifier LL-2003-LLNL06)

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. The investigation also determined that detailed hazard identification data supported

by accident analysis and appropriate control information was readily available.

On September 27, 2003, five Los Alamos National Laboratory (LANL) workers cutting a glovebox

coolant line became ill from toxic vapors caused by thermal decomposition of refrigerants in the line.

All workers were wearing personal protective equipment including Level II anti-contamination

clothing. Investigators determined that the potential hazard had not been identified before work

B-2