1、Lessons Learned Entry: 0580Lesson Info:a71 Lesson Number: 0580a71 Lesson Date: 1998-01-12a71 Submitting Organization: JSCa71 Submitted by: Sean KeprtaSubject: Adherence to Manufacturers Recommendations and to Established Procedures for Hazardous Operations (Plastic Cryogenic Tissue Storage Vial Burs
2、t Hazard) Description of Driving Event: A small plastic vial stored in liquid nitrogen burst while laboratory workers were inventorying and transferring vials from one dewar to another. During the transfer a vial burst, causing superficial cuts on the hands of two laboratory workers.The vial manufac
3、turer had updated catalog and shipping documents to alert customers that the vials were not recommended for storage in the liquid phase of cyrogenically stored nitrogen. Instead, the manufacturer recommends that the vials be stored only in the gaseous phase of cryogenic nitrogen. The seal on the via
4、ls is not adequate to protect against seepage of liquid into the vial which could then burst following removal from the liquid unless adequate precautions were taken to allow the liquid to evaporate and escape slowly.Workers were not wearing the selected PPE at the time of the mishap. The PPE had be
5、en removed because it was too bulky to permit manipulation of the small vials. This directly exposed the personnel to low temperature hazards as well as the burst hazard from the cryogen stored vials.Lesson(s) Learned: 1. Read and implement manufacturers warnings on products.2. PPE must be worn when
6、 required and must fit the tasks to be performed.3. Periodic reviews of hazard analyses are capable of revealing any inconsistencies between planned operations and manufacturers recommendations, protective safeguards, etc., prior to commencement of operations.Recommendation(s): Provided by IHSNot fo
7、r ResaleNo reproduction or networking permitted without license from IHS-,-,-Hazard analyses be performed and updated, periodic safety reviews be conducted with all personnel working in the area, and standard operating procedures be checked against the warnings (including updates) provided by equipm
8、ent vendors. Manufacturers tend to update warnings in their literature, both in catalog and on the data sheet shipped with the equipment when they discover hazards not previously known; such literature needs to be reviewed systematically for such new information. Identify and use suitable protective
9、 equipment to allow handling small cryogenic vials that might burst when removed from storage.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Cryogenic Systemsa71 Industrial Operationsa71 Occupational Healtha71 Personal Protective EquipmentAdditional Info: Approval Info: a71 Approval Date: 1998-01-16a71 Approval Name: Ronald A. Montaguea71 Approval Organization: JSCa71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
