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began and that the situation was exacerbated by performing work in a tent that had limited air flow.
(ORPS Report ALO-LA-LANL-TA55-2003-0022; update/final report filed April 16, 2004)
On July 28, 2003 at the Nevada Test Site, technicians found the bottom head from a 110 gallon
testing cylinder that apparently burst the previous weekend. The cylinder contained 55 gallons of
hydrochloric acid, which was sprayed over a 50-foot radius when the vessel ruptured. The acid spray
damaged some equipment, and personnel would very likely have been injured had the cylinder burst
during working hours. (ORPS Report NVOO--BN-NTS-2003-0011)
Training. These events underscore the importance for chemical worker training to include hazard
information and lessons learned from accidents, previous studies, and similar events involving the same
chemicals and chemical work practices
A chemical tank explosion caused significant localized damage to a facility. Personnel failed to
recognize the phenomenon that was being created inside the tank. Concentration by evaporation of a
dilute solution of hydroxylamine nitrate and nitric acid occurred to the point where an autocatalytic
reaction created a rapid gas evolution that over-pressurized the tank beyond its physical design
limitations. Similar hazards were identified as early as 1970, and reports of various accidents were
available to the facility. However, these hazards were not included in training and qualification
programs to heighten awareness of the chemical hazards. (ORPS Report RL--PHMC-PFP -1997-
0023, Final Report 05-17- 99)
An explosion occurred when a chemical operator performing lithium hydride recovery operations
submerged a high-efficiency particulate air (HEPA) filter embedded with lithium hydride residue into
a salvage vat containing demineralized water. Lithium hydride reacts exothermically with water to
form caustic lithium hydroxide and flammable hydrogen gas. The exothermic reaction produced
enough heat to begin burning the filter's wood framing, even though the filter was submerged.
Investigators believe that oxygen from air trapped in the filter combined with the hydrogen generated
from the reaction caused the explosion. Investigators also determined that it had once been a skill- of-
the-craft practice to perforate a filter with holes before cleaning to more efficiently liberate entrapped
air and hydrogen during the reaction. This past practice had been lost over time, owing to the attrition
of experienced operators, and had not been captured in the procedure for cleaning the filters. (ORPS
Report ORO--LMES-Y12NUCLEAR-1999-0031)

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