lessons learned from a liquid nitrogen injury · lessons learned from a liquid nitrogen injury....

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

Thank You!

abrand@lbl.gov(510) 486-7246