Lessons Learned - DOE-HDBK-1139-1-20060048

DOE-HDBK-1139/1-2006

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)

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