1、Lessons Learned Entry: 1382Lesson Info:a71 Lesson Number: 1382a71 Lesson Date: 2003-10-23a71 Submitting Organization: GSFCa71 Submitted by: Paul GibbonsSubject: Chemical Overexposure During Thermal Vacuum Cleaning Abstract: Evening and night shift personnel were required to vacuum and wipe the inter
2、nal surfaces of three thermal vacuum chambers with Isopropyl Alcohol (IPA). A technician completed the two smaller facilities (3-foot diameter by 3-foot deep) and was in the process of surface wiping with IPA the third chamber (7-foot diameter by 8-foot deep horizontal chamber), when the shift leade
3、r found the technician unconscious in the chamber (with feet facing the opening). The shift leader pulled him out of the chamber. It was noted that the employee was breathing but unconscious and the supervisor contacted 911. The technician regained consciousness and fully recovered without medical t
4、reatment.Description of Driving Event: The employee used rags saturated with IPA obtained from an open IPA container to clean the three thermal vacuum chambers. After use, the rags were left on the chamber floor. No supplemental ventilation or personal protective equipment (PPE) was utilized resulti
5、ng in unsafe levels of IPA vapor within the chamber. The cumulative effects of prolonged exposure without sufficient breaks were not considered.Lesson(s) Learned: 1. Employees and supervisors must consider that commonly used laboratory chemicals such as IPA can be a health hazard if inhaled in unsaf
6、e quantities by multiple short term exposures without sufficient recovery time, or used with insufficient ventilation.2. 3. Supervisors and employees must recognize that even simple operations such as cleaning must be evaluated for potential hazards prior to the start of the operation.Provided by IH
7、SNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Recommendation(s): The following procedure will be used for future thermal vacuum chamber cleaning operations: 1. Verify that proper ventilation is hooked up to the chamber and is providing adequate airflow to the ch
8、amber.2. Rope off the area immediately in front of the chamber and post signs to indicate hazards.3. Notify safety personnel that cleaning of a chamber is to begin so that the chamber can be equipped with a chemical monitor.4. Verify the appropriate respirator is utilized.5. Place the chemical monit
9、or at floor level at the back of the chamber since IPA is heavier than air.6. The clean wipe saturation tank should never be placed inside the chamber.7. After the wipes become soiled remove them from the chamber and obtain three or four more saturated wipes.Evidence of Recurrence Control Effectiven
10、ess: N/ADocuments Related to Lesson: NPG 8715.3 NASA Safety ManualMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Accident Investigationa71 Cryogenic Systemsa71 Emergency Preparednessa71 Energya71 Environmenta71 Faci
11、litiesa71 Ground Equipmenta71 Ground Operationsa71 HardwareProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Hazardous/Toxic Waste/Materialsa71 Human Factorsa71 Medicala71 Mishap Reportinga71 Occupational Healtha71 Personal Protective Equipmenta71
12、Risk Management/Assessmenta71 Safety & Mission Assurancea71 Spacecrafta71 Test & Verificationa71 Test Facilitya71 Training EquipmentAdditional Info: Approval Info: a71 Approval Date: 2004-02-09a71 Approval Name: Al Galloa71 Approval Organization: GSFCa71 Approval Phone Number: 301-286-3756Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
