By David W. Muehleisen, USACRCApril 26, 2017
FORT RUCKER, Ala. (April 26, 2017) - An explosion occurred in a research laboratory resulting in the researcher losing an arm and sustaining burns to her face. The explosion occurred when the researcher, who was electrostatically charged, ignited a pressurized tank that contained a hydrogen/oxygen gas mixture. A static charge transfer occurred when the researcher touched the metal housing of a gauge on the pressure tank, causing an electrical (brush) discharge within the gauge stem.
The laboratory involved in the accident was researching the use of hydrogen (a highly flammable gas), oxygen and carbon dioxide for the green production of bioplastics and biofuels. The process used a closed gas system bioreactor. The three gases were pre-mixed in a ratio of 70 percent hydrogen, 20 percent oxygen, and 10 percent carbon dioxide. Prior to mixing, the compressed gasses were stored in a 13-gallon gas storage tank.
This accident, like many others, was the result of several casual factors combining which contributed to the accident occurring.
A significant circumstance worth mentioning in this case was the near miss that occurred in a different lab with the same experimental conditions and research methods. That research experiment also produced an explosion; fortunately, it was contained in the pressure vessel system (not within the gauge) and did not cause any reported injuries or damage. The near miss went unreported within the laboratory and university as there was no standard operating procedure or reporting requirement to identify the incident. Due to the relaxed safety culture of the lab, it did not recognize the value in a near miss reporting requirement.
Several other causal factors that led to the accident are relative to the relaxed safety culture of the laboratory. These factors range from missing risk assessments to outdated SOPs and failure to follow manufacturer's warnings on equipment use and capabilities. All the contributing factors to this accident could have been identified and thus the accident avoided if a structured process existed in the laboratory and university.
Another accident with similar casual factors occurred in a government laboratory just months later. In this accident, research was being conducted using lasers during which an intern's eye was injured. The nature of the research was different but the circumstances, which caused the accident, are very similar.
Training, a well-documented process and a safety culture, which mandated checks and balances with clear and precise language, were deficient. Although the injuries in this accident were not as severe as the lab explosion, the laser lab's contributing factors, which caused the laser accident, were preventable.
The lab explosion and the laser incident are distinctly different yet very much the same. Both instances should encourage a thorough review of our workplace safety practices.
The Army Safety Management System has five core interrelated and interacting functions.
When performed as one coherent structure and integrated into the day-to-day activities, the safety program elements of the system can maximize safety and occupational health performance and assist leaders at all levels in protecting Army personnel, equipment and facilities.
The five core functions for the Army Safety Management System are program management, training and promotion, inspections/assessments, mishap investigation reporting and analysis and hazard analysis and countermeasures. See DA Pam 385--10, para 3--3c for prescribed guidelines for the Army Safety Management System.
Aligning each organization's goals and objectives is important to execute the Army Safety Management System in the most effective manner possible. An organization with a strong safety culture invests time incorporating the Army Safety Management System at every level. Investing time to reinvigorate it into your organization will help foster a climate of understanding while promoting workplace safety across your organization.