This is an investigative report of the March 16, 2016 hydrogen/oxygen explosion at the University of Hawaii at Manoa campus (UH), in which a postdoctoral researcher lost her arm and sustained burns to her face and temporary loss of hearing. The postdoctoral researcher was working in a laboratory at the Hawaii Natural Energy Institute in the Pacific Ocean Science and Technology (POST) building. The University of California Center for Laboratory Safety, in its capacity as an independent third party review team, was contracted to investigate the circumstances that led to this laboratory accident. The report is separated into two sections. The immediate cause of the accident was traced to the digital pressure gauge which acted as a path to ground for a static charge that ignited the hydrogen/oxygen gas mixture contained within a 13 gallon (50 liter) pressure tank. Extensive analytical testing of an identical gas tank/pressure gauge system did not reproduce a stray electrical current within the digital pressure gauge suggesting that the initiation event was due to a static discharge generated in the tank or the researcher. The explosive gas mixture was most likely ignited when the statically charged researcher touched the metal housing of the gauge and a charge transfer occurred causing a corona or brush discharge within the gauge stem. While the likely point of initiation of the explosion was determined to be due to static discharge through the digital pressure gauge, it should be emphasized that there are numerous means by which a hydrogen/oxygen gas explosion can be initiated. It is imperative that, hydrogen/oxygen gas mixtures in the explosive range should not be stored, and experiments using hydrogen/oxygen gas mixtures, such as the culture of hydrogen-oxidizing bacteria, should undergo rigorous hazard analysis and mitigation efforts to eliminate possible sources of ignition.
The Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA) urge employers (owners and operators) to conduct a root cause analysis following an incident or near miss at a facility.1 A root cause is a fundamental, underlying, system-related reason why an incident occurred that identifies one or more correctable system failures.2 By conducting a root cause analysis and addressing root causes, an employer may be able to substantially or completely prevent the same or a similar incident from recurring.
OSHA Process Safety Management and EPA Risk Management Program Requirements
In my upbringing in the chemical industry I had the opportunity to work with some outstanding engineers; too many to mention by name. These men and women took time out of their busy schedules to teach me process safety. One of these engineers was very strict about his process piping and every engineer in the units that were PSM (and then RMP later on) were expected to be intimately familiar with their process piping. So much, that the engineering manager would walk out to the unit, walk up to a run of pipe, touch it and the unit engineer would have to provide all the facts about that run of pipe. Could you answer these questions WITH DOCUMENTED PSI/MI data to support your answers?
Enforcement Delay Notice Note: OSHA is NOT implementing the July 2015 memo on the retail exemption. The Department is considering its options in light of the D.C. Circuits decision in Agricultural Retailers Association et al. v. United States Department of Labor and OSHA (D.C. Cir. Case Nos. 15-1326 and 15-1340).
Metrics are measures that are used to evaluate and track the performance of a facility’s process safety management program. For facilities that handle highly hazardous chemicals, metrics can be used to quantify how a process has performed historically, how it might perform in the future, and where improvements can be made to keep workers safe.
This document provides employers with examples of metrics that are tracked by facilities that are enrolled in OSHA’s Voluntary Protection Program (VPP). Because VPP sites have achieved a high standard of safety excellence, tracking these metrics can make a positive contribution to the effectiveness of an employer’s process safety management program. Two types of metrics—lagging metrics and leading metrics—are often used to track safety performance in process safety management:
Earlier this year, the Department of Homeland Security (DHS) temporarily suspended the requirement to submit Chemical Facility Anti-Terrorism Standards Top-Screens and Security Vulnerability Assessments (SVA) in order to allow for a phased rollout of the new Chemical Security Assessment Tool (CSAT) 2.0 surveys and enhanced risk tiering methodology. On October 1, 2016, the requirement to submit Top-Screens was reinstated. Chemical facilities of interest that have not previously submitted a Top-Screen, but which have come into possession of reportable amounts of COI, MUST submit a Top-Screen within 60 days. Additionally,