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Change Notice No. 1
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)
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 training programs. A contributing cause for the accident was the
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)

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