lessons learned from a liquid nitrogen injury · lessons learned from a liquid nitrogen injury....
TRANSCRIPT
Lessons Learned from a Liquid Nitrogen Injury
Alyssa BrandEFCOG IH&S Task Team MeetingApril 17, 2019
Outline
I. Overview of the IncidentII. Compensatory Actions TakenIII. Lessons Learned – Cryogenic LiquidsIV. Lessons Learned – The Bigger PictureV. Corrective Actions in Progress
Background
• Thursday June 7th, 2018• Graduate student – first-time liquid nitrogen user• Online cryogen training completed in May 2017
• No annual refresher required for cryo training
• Injury occurred during on-the-job training• Worker transported via ambulance to emergency
services• Remained admitted until June 10th, 2018
Right Hand Left Hand
Note: Photographs were taken after the incident.
Dewar
Conflicting Signage for Procedures
Compensatory Actions
Engineering and Design Improvements
Engineering and Design Improvements
OJT, SOPs, and PPE
Investigation by External Team
Team Members:• James Tarpinian, Independent Consultant• Andrew Peterson, EHS Assurance Manager, LBNL• Kurt W. Dreger, Assurance Manager, LLNL• Allen House, Pressure Safety Manager, LLNL
Investigation by External Team
Root Causes Determined: There was no engineering or safety review of the modification
of the cryogen delivery process (e.g., the use of the funnel) There is no process or accountability to ensure the OJT trainer
was able to perform this training adequately to protect the worker from this level of hazard.
There is no central authority or control to reinforce the proper procedure to be used for this shared fill station.
Relating to Cryogenic LiquidsLessons Learned
Lesson Learned:Cryo Burns Don’t Necessarily Hurt
The worker later described feeling a cold sensation in their hand during the filling but
did not think it was unusual.
Lesson Learned:Limitations of PPE Are Not Always Communicated
… experienced users reported that cryogen glovesare not designed or intended for prolonged contactwith surfaces at cryogenic temperatures. Instead,
cryo gloves are designed to protect the handsagainst brief contact with these surfaces.
The Bigger PictureLessons Learned
Lesson Learned:Shared Equipment = Someone Else’s Problem
One user had reported [the leak] in a budget meeting as a potential waste of money. Other than that, the leak in the hose had not been
reported to the Building Manager, to Facilitiesor to EHS representatives.
Lesson Learned:Uncontrolled OJT Leads to Significant Drift
Lesson Learned:A Culture of Blind Compliance Can Be Dangerous
Interestingly, at least one user reported thatthe use of the funnel seemed unsafe which is why they did not use the funnel. In this case,
the user reported feeling somewhat guiltythat they were not following the “required”
procedure as posted.
In ProgressCorrective Actions
Training and Authorization
• Evaluate the authorization process for fill station use• Evaluate the rigor of OJT for high hazard work• Update training and policy documents• Reassess risk grading in WPC Activity Manager
Responsibility and Ownership
• Identify responsibility for preventive maintenance• Evaluate current state of shared space and
equipment
Communication
• Review avenues of communication for process changes and seek improvement
• Conduct a Listening Tour to assess reporting mechanisms and barriers
• Seek additional methods of encouraging feedback• Raise awareness and communicate expectations for
mentoring and supervision of students
