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INCIDENT

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

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INCIDENT

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  1. INCIDENT i n g Lessons Learned Learning Lessons

  2. 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.

  3. Mercury Spill Response Mason, Civil Engineering

  4. Explosion in Hood MoSE 2285

  5. President’s Wife Complains that a Fox is Drinking out of the pool and chasing her cat

  6. 10 PM: Recover Materials from Dorm Drug Bust

  7. Let’s get this over with and: • Get Back to Work • b. Go Home • c. Get a Beer

  8. So… We Weren’t Addressing • Could we have done it better • Is there a way to prevent recurrences

  9. About 5 Years Ago MONTHLY INCIDENT REVIEW One Hour (9-10 AM) 1st Friday of the Month Mandatory For Hazardous Waste and Chemical Safety Personnel Voluntary for Every One Else

  10. COMMUNICATIONS & MARKETING FACILITIES O&M GEORGIA TECH POLICE EMERGENCY PREPAREDNESS ATLANTA FIRE & RESCUE BUILDING MGR OUTSIDE CONTRACTORS MEDICAL SERVICES EHS

  11. EHS GA Tech EHS Non-OSHA All Exempt

  12. Currently “HAZWOPER” Qualified Hazwoper Qualified Not OSHA Regulated All Full-Time Exempt

  13. 24/7 On-Call Personnel Not OSHA Regulated All Full-Time Exempt

  14. 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)

  15. Where We Are Now • Power Point “Blank” Posted to Shared Drive at Beginning of the Month • Events Posted as they Occur

  16. THE RULES • Whoever had the action briefs it • NOrecriminations • Try to answer: • What could we have done different/better • What can be done to prevent recurrences

  17. 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?”

  18. WHAT DO WE GET OUT OF IT • Reinforce things we already know (or should know).

  19. 24 JUNE: ACID SPILL AWPL • Leaking Sulfuric Acid Bottle Discovered During CHEMATIX Reconciliation • Recovered Same • Took to HazMat Bldg AWPL IS A CESQG - CAN'T MOVE STUFF FROM THERE

  20. Oct 2011: Student Assistants prepping for • Freshman chemistry lab, mixed the • wrong materials. AFR Response Vehicles Incident Command Evacuees • Alarm pulled: Bldg Evacuated • About a 4 ½ hour exercise

  21. 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 Keep People Informed

  22. WHAT DO WE GET OUT OF IT • Reinforce things we already know (or should know). • Training for EHS Personnel.

  23. 21 May: Trenching IssuesGlen/Towers No one from General Safety on Campus = Refresher on Trenching Rules and Procedures.

  24. 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.

  25. 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

  26. 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

  27. 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 TRAINING FOR "VISITORS"

  28. 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. TRAINING FOR POLICE

  29. 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

  30. 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. ONE CALL - GETS ALL

  31. 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.

  32. Jan 19 (+) CRC Emergency Generator • 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. • Took 2 ½ Hours to Get HVAC and Electrician Support • EHS Managers Now Have Facilities O&M on-call roster at home.

  33. 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

  34. 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

  35. 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 1 FEB: NITRIC ACID/DIETHYL ETHER MIXTURE PROCESS REVIEW REQUIRED

  36. 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.

  37. 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

  38. 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

  39. 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)

  40. 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

  41. 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 Thru Fire caulk?

  42. 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

  43. 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

  44. Closing Thoughts • No Matter How Busy you are • Take the time to review your response(s) • It pays off • And……

  45. Buzz agrees w/ Mr. Santayana “Those who fail to learn the lessons of history are doomed to repeat them.”

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