REG NASA-LLIS-1181--1999 Lessons Learned - Interim Solutions Can Hide Defective Conditions Resulting in Catastrophic Loss.pdf

1、Lessons Learned Entry: 1181Lesson Info:a71 Lesson Number: 1181a71 Lesson Date: 1999-05-04a71 Submitting Organization: JSCa71 Submitted by: Gordon M. Bowling/Ronald A. MontagueSubject: Interim Solutions Can Hide Defective Conditions Resulting in Catastrophic Loss Description of Driving Event: A 55-ga

2、llon drum of paint wastes subsequently ruptured after being overpacked into an 85-gallon salvage drum due to leakage from the original drum. Pressure had built up inside the drums to the point where both the inside drum and recovery drum burst, propelling the drums 26 feet in the air, at which point

3、 it dented the roof and spilled hazardous waste into the containment area. The incident occurred late at night and no personnel were injured or exposed.Primary Cause: The waste stream contains a mixture of solvent-base paints and cleanup solvents. None of the vapor pressures of the waste components

4、were great enough to cause failure of the drum. The pressure build-up was likely due to a chemical reaction producing a gaseous product. Polyurethane paint components of the waste stream contain isocyanate compounds which react with water to produce carbon dioxide. Although there were no accounts of

5、 water-based paints being added to the drum, the generator also uses latex paints, and some may have been accidentally added to the drum. The drum was routinely opened and closed during waste accumulation allowing release of the pressure. It was only when the drum was sealed for storage that pressur

6、e increased to deform and eventually rupture the drum.Contributing Factors: The bulging condition of the original 55-gallon drum was first noticed at a hazardous waste storage facility. The drum was overpacked into an 85-gallon recovery drum to correct the container condition deficiency, but the fac

7、ility operator was unaware that the drum was continuing to build pressure. The 85-gallon salvage drum then obscured the condition to the hazardous waste shipper, transporter, and offsite receiving facility.Root cause: 1) Commingling reactive paint chemicals in a sealed, nonpressure vessel container.

8、Contributing causes: 2) Lack of root cause analysis and corrective action implementation upon initial Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-discovery of bulging 55-gallon drum. 3) Obscuration of problem progression due to overpacking of bul

9、ging container.Lesson(s) Learned: Ensure that interim solutions do not simply hide unstable, defective conditionsRecommendation(s): Paint waste generators need to be aware of the potential for reaction between polyurethane and latex-based paint compounds or any other incompatible combinations. Preca

10、utionary warnings will be added to the technical instructions for paint waste streams. The routine practice of overpacking paint waste drums into salvage drums will be discontinued. This will facilitate detection of pressure buildup within drums. Salvage drums for paint wastes will be scrutinized to

11、 determine defects to the inside packaging. The new Waste Management Handbook, KHB 8800.7B, includes a requirement for generators to annotate salvage drums to alert personnel of bulging containers. Any salvage drums that contain buldging drums will be monitored for pressure. The use of gauges and/or

12、 relief valves on suspect drums is being examined.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Disposala71 Energetic Materials - Exp

13、losive/Propellant/Pyrotechnica71 Hazardous/Toxic Waste/Materialsa71 Logisticsa71 Packaging Handling StorageProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Parts Materials & Processesa71 Risk Management/Assessmenta71 Safety & Mission Assurancea71 TransportationAdditional Info: Approval Info: a71 Approval Date: 2002-04-17a71 Approval Name: Ron A. Montaguea71 Approval Organization: JSCa71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-