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I included the web page summary of this event in the headlines, but I think that the larger story points out several factors that many labs, particularly academic labs face, and it occurred to me that this Lesson Learned could be a good safety moment for scientists in many disciplines we serve.
- Ralph
Assumptions Made About Changes to Experiment Leads to Rupture of Tubing Line
Date Published: March 21, 2019
Work planning and control documentation were not in place for changes to experimental parameters
Summary
In August 2018, a tubing line ruptured on a bench-scale coolant system in a lab in the Physical Science Laboratory (PSL) building. The tubing contained 250 ĺˇF radiator coolant fluid which sprayed onto a chair, the ceiling and the floor around the system. The spill caused minimal damage to the lab and no one was hurt, but the event was considered a ‰??near-miss‰?? due to the proximity of staff to the uncontrolled hot fluid.
Prior to the incident, the project team had successfully performed 12 tests on the coolant system. During a weekly team meeting, the Principal Investigator (PI) suggested that it would be interesting to test an additional hypothesis related to the existing experimental setup. One of the junior researchers believed the PI‰??s comments amounted to a directive and implemented the changes to the experiment outside of what the system components were designed to handle, leading to the failure of the tubing.
After an investigation into the event, it was discovered that work planning and control documentation, including an SOP (Standard Operating Procedure) were not in place as requested and the project team was operating outside the approved boundaries and limitations of the experiment.
Details
The project team‰??s work consisted of conducting experiments on coolant fluid to ascertain the characteristics of various gelling agents that may have the potential to plug small leaks in a simulated engine system. Several iterations of this bench-scale cooling system have been in place in PSL over the past two years.
There was a gap of several months between when the first system was designed and built and when funding materialized; project team members disbanded to work on other assignments in the interim. Although the project team engaged with the appropriate Subject Matter Experts to assist with hazard identification and the initial conversation of the system design, parameters, and mitigations that would need to be incorporated into the SOP, it was never developed because the PI indicated that he was waiting for additional funding to continue the experiment. Additional distractions were created by the on-again, off-again nature of the work and further ambiguity existed as the lines between proof of concept and experimental work were blurred, and some of the team members were not clear as to who was authorized to provide direction and communicate expectations.
During a weekly project team meeting prior to the event, the results of the team‰??s testing were being discussed, as well as objectives for future testing. At that time, the PI mentioned that it would be interesting to see if the coolant plug could be melted and recirculated in the system and considered his comment just ‰??thinking out loud‰?? for possible future project work. One of the junior team members, a newly graduated Supervised Researcher, mistook this to be direction from the PI for the next experiment.
In subsequent testing, the junior researcher changed the parameters of the experiment to match what he heard the PI say. The changes pushed some of the system‰??s components beyond what they were rated for and the tubing ruptured. Work was formally shutdown until work planning documents could be implemented and reviewed.
Lessons Learned
The rupture of the tubing represented the failure to assure appropriate work planning and control documents were in place, including an SOP, and a lack of clear lines of authority. In the next year, a new tool will roll out to laboratories without radiological work. The tool will force the identification of an activity lead and activity document; no work may be performed until the lead assigns and approves the activity and the applicable training has been completed by those performing the work. As part of the hazards analysis, the tool also identifies clear boundaries and limitations for work.
‰?˘ Changes to an experiment should trigger a reexamination of hazards. Although the PI had no intention of changing the experimental parameters and performing additional testing in a different manner, the junior researcher had an opportunity to note that the hazards had not been reexamined due to the change in the work being performed.
‰?˘ Be aware of the role distractions can play in missing required steps. Because of the distractions that arose between designing this experiment‰??s system and the work being performed and the lapses in funding, the team did not assure that all documentation was in place and approved before experimental work began.
‰?˘ Clearly communicate roles, responsibilities, and expectations with all team members. Without clear expectations communicated at the beginning of a project, project teams open themselves up to risk. Junior researchers and those who have recently graduated from their status as Supervised Researchers will benefit from additional guidance around Roles, Responsibilities, Accountabilities, & Authorities.
If you have questions about this article or have a lesson to share, please contact the Operating Experience / Lessons Learned Program Manager, Shannon Cartier at 375-4316.
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