incident
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INCIDENT. i n g. Lessons Learned. Learning Lessons. Most Hazardous Waste Folks. Have some responsibility for responding to incidents (chemical, biological, fire, radiological, etc.) Have this as an additional duty – it ain’t their full time nor primary job. . Mercury Spill Response - PowerPoint PPT PresentationTRANSCRIPT
i n g
Most Hazardous Waste Folks Have some responsibility for responding to
incidents (chemical, biological, fire, radiological, etc.)
Have this as an additional duty – it ain’t their full time nor primary job.
Mercury Spill
ResponseMason,
Civil Engineerin
g
Explosion in
HoodMoSE 2285
President’s Wife Complains that a
Fox is Drinking
out of the pool
and chasing her cat
10 PM: Recover Materials fromDorm Drug Bust
Let’s get this over with and:
a. Get Back to Work
b. Go Home
c. Get a Beer
So… We Weren’t Addressing
Could we have done it better
Is there a way to prevent recurrences
About 5 Years Ago
One Hour (9-10 AM) 1st Friday of the
MonthMandatory For Hazardous Waste and
Chemical Safety Personnel
Voluntary for Every One Else
GEORGIA TECH POLICE
FACILITIES O&M
COMMUNICATIONS & MARKETING
ATLANTA FIRE & RESCUE
EMERGENCY PREPAREDNESS
MEDICAL SERVICES
OUTSIDE CONTRACTORS EH
S
BUILDING MGR
EHSGA Tech EHS
Non-OSHAAll Exempt
Currently “HAZWOPER”Qualified
Not OSHA RegulatedAll Full-Time Exempt
Hazwoper Qualified
24/7 On-Call Personnel
Not OSHA RegulatedAll Full-Time Exempt
2nd: Mercury Spill (Boggs 2-52)
15th Needle stick w/ Baboon Cells
20 Jun: Street Sweeper/Hydraulic oil release
27 Jun: Trash Can Fire (North Ave Apartments)
Where We Are Now
Power Point “Blank” Posted to Shared Drive at Beginning of the Month
Events Posted as they Occur
THE RULES Whoever had the action
briefs it NO recriminations Try to answer:
What could we have done different/better
What can be done to prevent recurrences
WHAT DO WE GET OUT OF IT
Nothing Earth Shaking Have we reduced incidents?
For at Least One-Hour per Month we’re focused on this one subject
Many/Most of the Actions Taken May have been accomplished anyway (But presenting them in public and having the Boss write them down – adds emphasis)
Good Material for Use with “Safety” Committees and answering “what have you done for me lately?”
WHAT DO WE GET OUT OF IT
Reinforce things we already know (or should know).
24 JUNE: ACID SPILL AWPL Leaking Sulfuric Acid Bottle Discovered During CHEMATIX Reconciliation
Recovered Same Took to HazMat Bldg
AFR Response Vehicles
Incident Command
Evacuees
Oct 2011: Student Assistants prepping for Freshman chemistry lab, mixed the wrong materials.
Alarm pulled: Bldg Evacuated
About a 4 ½ hour exercise
AND THEN………
Distraught co-ed in parking lot reported
“40 students trapped in building!”
Attempted to re-enter to sweep and air test
Door locked-no one had access
WHAT DO WE GET OUT OF IT
Reinforce things we already know (or should know).
Training for EHS Personnel.
21 May: Trenching IssuesGlen/Towers
No one from General Safety on Campus =
Refresher on Trenching Rules and Procedures.
14 Mar: Gas Line BreakBobby Dodd and Power Plant
Contractor Busted Gas Line GTPD/AFR/AGL/EHS
Responded Minor leak that was barely
discernible Fire Alarm Pulled in Old CE
Building Library Building Manager and
Area 4 Facilities Maintenance contacted.
Gas to Crossland Tower shut off and left off at meter until next morning.
Should have contacted Utilities & Engineering.
WHAT DO WE GET OUT OF IT
Reinforce things we already know (or should know).
Training for EHS Personnel. Identify Training Needs of Campus
Constituents
March 9: Ladder Fall, 711 Marietta
Worker trying to access roof hatch from 8-ft. ladder
Lost balance causing ladder to “kick-out” from under him
Fell to mezzanine floor
April 25: IBB ME Capstone Student was clean up after
the previous day’s research. The needle was contaminated with
rhesus monkey blood from the CDC that was infected with Plasmodium coatneyi. The student was recapping the needle
after removing it from the trash beaker and placing into a bleach solution. The student was pricked in the right
index finger She washed with soap and
water and then waited at least an hour to call Student health Services
The CDC was contacted and the monkey was determined to have a clean bill of health.
The student’s blood was tested by the National B virus lab and was free of typical monkey illnesses
25 Feb: Nitrogen Tank VentingIBB
GTPD Dispatch – Student reported Leaking Nitrogen Tank in an equipment corridor
Pozniak Responded Did not find GTPD on site,
but did locate the cylinder Was about to call dispatch
when searched out both by
phone and in person. Was unaware that AFR
had been called and that GTPD had established a Command Post
Convinced AFR that evacuation was not necessary.
WHAT DO WE GET OUT OF IT
Reinforce things we already know (or should know).
Training for EHS Personnel. Identify Training Needs for Campus
Constituents Change EHS Procedures/Capabilities
NOV 9: THF STILL, ES&T 2365
THF still explodes, activating sprinkler system.
One injury (sprained wrist)
Full (AFR++) Response
GTENS alert to “Evacuate Campus”
EHS personnel inundated with calls.
28 June:Dangerous Gas Monitoring Alarm
Bunger-Henry Carbinization Lab Reported by monitoring Company as a fire. Sep 5: H2S: Bunger Henry 439, Attributed
to “bad "Regulator. Aug 15: Determined to be an
electrical glitch Electrical problem continues but no
more alarms being sent
System only accessible from on-campus.
EHS had to come to Campus to reset.
Have 4 people with Tech issued and programmed laptops that allow access and resets from home.
Jan 19 (+) CRC Emergency Generator
Took 2 ½ Hours to Get HVAC and Electrician Support
EHS Managers Now Have Facilities O&M on-call roster at home.
Emergency Generator brought in to supply power to Campus Rec Center due to a pool leak into an electrical room
Parked under major air intakes 1,000 children and adults at swim
meet w/diesel fumes.
2 April: Nitric AcidEHS
Package rejected by FEDEX Brought Back Upstairs by Shane Discovered to be Leaking Acid Burns and Loss of Trousers Seen at Concentra For Discussion:
■ Proper Packaging?■ Handling out of ordinary shipments■ Ventilation Fan did not work
Shipping of “large amounts” moved to HAZMAT
Installed Drench Hose at EHS
Got the adapter to make the fan work
WHAT DO WE GET OUT OF IT
Reinforce things we already know (or should know).
Training for EHS Personnel. Identify Training Needs for Campus
Constituents Change EHS Procedures/Capabilities Examine Questionable Procedures
1 FEB: NITRIC ACID/DIETHYL ETHER MIXTURE
Student working added nitric acid solution to solution of diethyl ether and lignin.
Mixture reacted violently and erupted into student’s face
Student not working in fume hood – fume hood was full of “stuff” that could have been located elsewhere
Student not wearing safety glasses (but did not get any in eyes)
Student did not use eyewash in lab, instead went down hall to men’s room.
Student treated at Stamps - received 1st and 2nd degree chemical burns to face
June 22: Mercaptan Release MoSE(Chapter 2)
GTPD contacted EHS approx 6PM; 4th Floor MoSE reported odor similar to that of the night before.
Culprit was inappropriately discarded container.
Research Suspended Pending Review.
WHAT DO WE GET OUT OF IT
Reinforce things we already know (or should know).
Training for EHS Personnel. Identify Training Needs of Constituents Change EHS Procedures/Capabilities Examine Questionable Procedures Initiate Corrective Actions
24 May: Odor & Visible Emissions Love 372
Identified a small amount of smoke protruding from a t-joint where a couple tubes exhaust into one line
Main tube was exhausting vacuum pump near the bottom of the glove box
Looked to be a visible amount of
smoke inside the tube
Pump was sitting below glove box on near side (from angle of picture)
Dr. Thadhani also came in and helped guide us on what was reported
Area 1 Facilities Maintenance came and helped us trace/check exhaust lines in 372
Jan 21: Sulfide Release, Love 372
Original report was “gas leak” Led to evacuating building,
AFR response, and shutting off of all gas to the building. Lithium sulfide in THF sample
being dried in vacuum chamber of glove box
AHU and large exhaust fans shut down due to freezing temps (“freeze stat”) causing sulfide odors to release into room and hallway
Lab closed until Tuesday EHS returned on Tuesday to
open lab and check for lingering odors (Area I and Building Managers coordinated return of gas service)
Love 372: FOLLOW UP Inspected Lab:
■ Many Findings to including 8 Separate Devices Vented Though Building
HVAC System, some connected w/ Duct
Tape Meet w/ Lab Personnel, Maintenance, and
Department Chair Redesign of Ventilation System for 372
(and another lab) in Progress
19 June: Flood 433 Bunger-Henry
Lab Personnel Shut off Water During Change out of Filtration System.
While Water was Off, Someone Turned on a faucet in a non-draining sink
When the water came on….. Lab Personnel, Building
Services cleaned up – but, no one checked the chase – which was leaking water to 3rd Floor.
This lab is snake-bit, need checklist procedures
Water Leaking ThruFire caulk?
June 22: Acid Treatment System Malfunction: Bunger Henry 433
In preparation for maintenance, 2 x 50 gallon acid filled tanks were to be brought to neutral.
Added ½ of a 30 gallon drum of 50% Sodium Hydroxide.
Machine emitted a heavy foam covering ~ 50 sq feet. Foam pH’d at 11; Ammonia Release: Draeger’s Pegged.
HEPACO performed clean-up; completed at 3:45 AM Saturday.
Don’t have HEPACO cost; disposal cost for clean-up and maintenance will be over $3,000.
Spill Response: 17K
SUMMARY We Like What We Do Improvements
Incident Log/Record Capture It All (we generally ignore IAQ, slips-
trips-and falls, etc) Procedures Book/Checklist
Guidelines for Repeating Incidents Sloooowly
Periodic AARs with All the Players
Closing Thoughts No Matter How
Busy you are Take the time to
review your response(s)
It pays off And……
Buzz agrees w/ Mr. Santayana
“Those who fail to learn the lessons of history are doomed to repeat them.”