The Great Gas Leak Incident of 2007 LABS: Tip of the month… Be prepared for unexpected situations! But if it’s unexpected, how will I know to prepare for it? Learn from the experiences of others Case in point… The Great Gas Leak Incident of 2007

Our lab uses flammable gas with our instrumentation The instrument room is locked, well ventilated, and equipped with a flammable gas monitor with local and remote alarm Well-trained personnel follow SOP for changing tanks as part of everyday routine Ensure gas tank is properly secured Shut gas flow off at the tank valve Loosen gas hose fitting (non-sparking wrench) Unscrew fitting by hand & remove gas hose Secure cylinder cap on gas cylinder Label cylinder EMPTY to ensure pick-up by vendor

What could possibly go wrong?!

Shut gas flow off at the tank valve Loosen gas hose fitting with spark-resistant wrench Unscrew fitting by hand & remove gas hose Secure cylinder cap on gas cylinder Label cylinder EMPTY to ensure pick-up by vendor Ensure gas tank is properly secured Shut gas flow off at the tank valve Loosen gas hose fitting with spark-resistant wrench Unscrew fitting by hand & remove gas hose Secure cylinder cap on gas cylinder Label cylinder EMPTY to ensure pick-up by vendor Ensure gas tank is properly secured Shut gas flow off at the tank valve Loosen gas hose fitting with spark-resistant wrench Unscrew fitting by hand & remove gas hose Secure cylinder cap on gas cylinder Label cylinder EMPTY to ensure pick-up by vendor

Shut gas flow off at the tank valve Ensure gas tank is properly secured Loosen gas hose fitting with spark-resistant wrench Unscrew fitting by hand & remove gas hose Secure cylinder cap on gas cylinder Label cylinder EMPTY to ensure pick-up by vendor

Shut gas flow off at the tank valve Tank valve was turned by several rotations in the proper direction When it would no longer turn, gas flow was assumed off, so moved on to loosening the gas hose fitting However, the valve had actually jammed only about half-way closed, so the gas flow had NOT been closed-off

After a couple turns with the wrench, the gas fitting snapped loose with a jarring “POP” and a white cloud of pressurized hydrogen gas began spraying from the loose connection with a deafening hiss (SURPRISE & PANIC LED TO POOR CHOICES) Unable to re-tighten the connection, the individual left the instrument room to get help from colleagues, both of which tried to further close the tank valve but failed (NO ATTEMPT MADE AT RE-TIGHTENING GAS HOSE) The group called Operations, reported an uncontrolled hydrogen leak, requested help, and then hung up to deal with the problem (OPERATIONS NOT GIVEN ALL THE DETAILS OF THE SITUATION) Operations immediately dispatched a technician who retightened the gas hose fitting onto the tank, stopping the gas leak – crisis averted – all was well… Not having been given all of the details, Operations had to assume the worst and contacted the Boston Fire Department to report the leak – BFD notified BPD Evacuation of Bldg 1 & 2 Shut down of Huntington Ave & Green “E” Line Fire & Police Chief call Jeremy to “chat”

How could this have been prevented or mitigated?

How could this have been prevented or mitigated? SURPRISE & PANIC LED TO POOR CHOICES As part of training, any and all potential adverse situations related to a protocol should be identified and discussed, as well as the proper way to deal with the situation should they arise. Drills should be run periodically so workers can learn to respond to problems in real time where they will actually occur. Preparation will allow individuals to remain calm and be able to make the proper choices to handle the situation. NO ATTEMPT MADE AT RE-TIGHTENING GAS HOSE Proper training would likely have prepared the RAs to recognize that retightening the gas hose was a viable alternative to further closing the tank valve. OPERATIONS NOT GIVEN ALL THE DETAILS OF THE SITUATION During an emergency, Operations should be provided with all of the details needed to make appropriate decisions regarding how to handle a situation The lab should have worked with Operations BEFORE discuss all potential adverse situations establish SOPs to follow in event of a leak

Thank you! Good from the bad Take home messages Lab staff training expanded to dealing with adverse outcomes Worked with Operations to develop SOPs for dealing with flammable gas leaks in this space Preventive engineering safeguards proven effective – despite the leak the room’s ventilation system kept the level of hydrogen in air at less then 10% of the LEL Take home messages Consider all possible adverse situations in all aspects of work Take all possible measures to prevent them from happening Develop SOPs and best practices for dealing with these Train everyone that may play a role on what to do RAs performing the protocol / using the instrument RAs present in the space Those who respond to the adverse situation Thank you!