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DOE-HDBK-1139/1-2006
A high- pressure carbon dioxide (CO2) fire suppression system unexpectedly actuated, resulting in
one fatality, several life-threatening injuries, and significant risk to the safety of the initial rescuers.
Investigators determined the inadvertent operation of electric control heads released CO2 into the
occupied space without a discharge warning alarm. In addition, the CO2 system was not physically
locked out as was required. The procedure that required this barrier had not been updated or used for
this work. The requirement to train workers in the hazards of emergency response to CO2 discharges
had not been incorporated into trai ing programs. A contributing cause for the accident was the
n
failure to take corrective actions and apply lessons learned from previous accident investigations,
particularly in work planning and control. (ORPS Report ID--LITC-TRA-1998-0010)
A subcontractor employee was sprayed with acid when he inserted a hydrochloric acid pump into a
drum of sulfuric acid. When the two acids mixed, a violent chemical reaction caused acid to be
sprayed from the drum approximately 10 feet to the ceiling and onto the employee. (ORPS Report
ORO--MK-WSSRAP-1999-0004)
A technician working in a laboratory discovered a ruptured 1-liter polyethylene bottle of acid on the
floor of a chemical hood. Laboratory personnel had heated it to approximately 140 degrees, capped
it, and placed it in the hood to cool down. Chemists believe that off-gassing of the acid mixture at an
elevated temperature built up sufficient pressure to rupture the bottle. (ORPS Report SR--WSRC-
FSD-1998-0004)
Hazardous waste workers discovered a ruptured 1-liter glass bottle labeled "Used Nitric Acid" in a
waste room. Investigators determined that the unvented bottle had accumulated pressure over time,
causing it to burst. (ORPS Report CH-BH-BNL-NSLS-1996-0002)
A building was evacuated due to fumes generated by mixing a solution of nitric acid, hydrogen
fluoride, and acetic acid with a solution of ethanol, hydrofluoric acid, and water. Investigators
determined that the fumes resulted from a reaction between incompatible materials being mixed for
waste disposal by a technician. (ORPS Report SAN--LLNL-LLNL-1997-0037)
A researcher was adding methanol to two vials containing sodium permanganate and polychlorinated
biphenyls when an unexpected energetic reaction caused the mixture to spray from the vials and onto
the researcher's gloves. Investigators determined that there was an inadequate evaluation of chemical
compatibility. (ORPS Report ORO--ORNL-X10ENVIOSC-1996-0001)
B-4


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