From: "Secretary, ACS Division of Chemical Health and Safety" <secretary**At_Symbol_Here**DCHAS.ORG>
Subject: [DCHAS-L] DOE Safety & Health Daily Lessons Learned
Date: Fri, 25 Aug 2017 08:01:25 -0400
Reply-To: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**PRINCETON.EDU>
Message-ID: 392BE419-212E-47AF-ABEC-C0BB837A3BC8**At_Symbol_Here**

A couple of interesting events from the DOE Lessons Learned Digest this week.

Subject: DOE Safety & Health Daily Lessons Learned
Date: August 24, 2017 at 6:00:36 AM GMT-4

The following DOE Lessons Learned ( is/are distributed for utilization and evaluation. Please direct any questions to Ashley Ruocco at ashley.ruocco**At_Symbol_Here**

New Lessons Learned that fit your current user profile:

? Near Miss to an Occupational Injury: Glovebox on Casters Tips over and Falls during Relocation Activities
(Source: User Submitted - ID: LANL-2017-409)
It is important to carefully evaluate every equipment move even if you have successfully moved the same or similar equipment in the past. Previous success can lead workers to an incorrect conclusion that every hazard has been addressed. Past success does not guarantee that there will not be any problems. For non-routine and complex equipment moves, subject matter experts should be consulted evaluate the move, analyze hazards and plan the move. In some cases, the best choice may be using a hoisting/rigging crew to perform the move.

? Pyrophoric Event in a LANL Plutonium Facility Lab (A Housekeeping Day Event)
(Source: User Submitted - ID: LANL-2017-428)

On the day of the event the Los Alamos National Lab (LANL) Plutonium Facility paused operations to support a Housekeeping Day. One of the Tenant Groups engaged in what they believed to be low hazard work. Under the Housekeeping effort they decided to discard unneeded equipment from one of their laboratories. All of the equipment/components being discarded were assumed to be chemically inert. The event was initiated when the team decided to empty the contents of several tube shaped metal vessels thought to have contained activated charcoal. The vessels actually contained an active metal/metal-hydride powder. When exposed to air it triggered a pyrophoric reaction, resulting in a metal fire and a burn to one of the worker's hands. The fire was extinguished by the Worker with a Class D Fire Extinguisher.

Multiple factors contributed to the onset of the incident, the most prominent of which are discussed below:

- Labeling and Hazard Identification: The metal hydride beds were legacy material and had not been used for over ten years. The vessels were not clearly marked. The vessels were once components of a larger legacy system, once separated from the parent system, proper identification of the internal hazard could possibly have prevented the incident from occurring.

- Questioning Attitude: This incident exemplifies the importance of a questioning attitude. Multiple opportunities were present where a questioning attitude could have prevented this incident. These opportunities existed in the management of the organization, and in the work planning, work authorization, and work execution phases of the task.

- Identification of Error Precursors: The team of workers and their First Line Manager (FLM) did not a have a predefined scope of work for their part in the Housekeeping day. They decided to clean up their lab {housekeep it} by discarding items and equipment they no longer needed. They assumed the vessel contents were non-hazardous, based on their process knowledge and beliefs. Multiple error precursors were present leading up to the incident (departure from normal routine, unexpected equipment condition, assumptions, etc.). Timely identification and discussion of these error precursors by either the workers on the floor or line management, could have prevented the incident.

- Latent Organizational Weaknesses: Management had allowed the vessels to be stored in the lab for over ten years, without the proper permanent labelling to communicate the hazards associated with the material contained within. A management team with a healthy questioning attitude and solid "what if" mindset could have seen these items as needing to be properly labeled, and/or properly discarded, back when the contents were well known.

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