TOXIC FUME INHALATION

Purpose: To prevent recurrence, not place blame.

Report Date: 07-07-2015

Start Date: 07-07-2015
Report Number: NC- 150703

I. Problem Definition
What: Toxic Fume Inhalation
When: 3 July, 2015 at 10am
Where: Lab 3
Significance: Low
Safety: Reportable incident but no medical treatment required; Potential lung
irritation
Environment: Slight release of SO2 gas (air pollution)
Revenue: Production delayed 20 minutes while lab evacuated and source
identified
Cost: Minor administration
Frequency: 3rd reported incident in 2015

II. Report Summary

Toxic fume inhalation was caused by SO2 fumes entering Lab 2 via one of three drains.
The drains service the fume cupboard, a floor waste and an eyewash station in Lab 2.
The fumes originated in the sump when the product, NA2S2O5, mixed with water when
the dosing pump was flushed out. This flushing occurred because the pump was hosed
out in Lab 1 to remove a blockage. The blockage was caused by the accumulation of
the product on the inside of the pump chamber and connections. The flushed material
entered the drain and thence to a common sump servicing both labs.

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III. Solutions
Causes Solutions Solution Owner Due Date

Implement weekly flushing schedule for

pumps in this process/product, measure
Chemical built up Warren Gibbs 10-07-2015
effectiveness and recommend adjustments
as required

Doors closed Install additional ventilation in the room Shane Consent 24-07-2015

Install airlock/trap on each plumbing drain

Drains unplugged from both labs to prevent fumes emanating Warren Gibbs 14-08-2015
from sump or connected drains

IV. Team Members

Name Email Member Info

Lloyd Smith lsmith@chemlab.com Mechanical Engineer

Shane Consent sconsent@chemlab.com Electrical Engineer

Ian Stephens istepphens@chemlab.com Chemist

Warren Gibbs wgibbs@chemlab.com Maintenance Coordinator

William Metz wmetz@chemlab.com Maintenance Supervisor

V. Notes
1. Realitychart Status: The Realitychart is in draft form and the Incident Report has not been
finalized.
2. NB: possible chemical could crystallise in here at low temps
3. Some causes have been purposefully left off the chart.
4. Rules Check Status: Missing Causes Resolved.
5. Rules Check Status: Conjunctions Resolved.

VI. References
1. Operator statement
2. Floor plan
3. Reference removed
4. Lab maintenance schedule

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 CRYSTALS
Action ACCUMULATE
NA2S2O5
ACCUMULATED IN Action
PUMP PRODUCT
Condition Desired Condition
FLOWED
NA2S2O5 THROUGH PUMP
PRESENT
Condition

PUMP MOVES Desired Condition

PRODUCT

Condition

HOSING RELIEVES Other Cause Paths More

BLOCKAGE Productive

Condition Action Condition

Other Cause Paths More
SULPHUR DIOXIDE PUMP HOSED OUT PUMP CAVITIES Productive
(SO2) FUMES IN IN ROOM 1 AVAILABLE
SUMP Action
Condition
Action PUMP HEAD
CRYSTALS Lack Of Control
WATER APPLIED BECAME
BLOCKED ACCUMULATE
Root Cause (A)
Condition Condition
CHEMICAL BUILT Lack Of Control
WATER IS Desired Condition LOW
UP
FLUSHING FLUID TEMPERATURE
Action
Condition Action
CHEMICAL
FLUSHED Desired Condition CRYSTALLISED DOSING RATE SET Desired Condition
MATERIAL GOES Action
TO SUMP
CHEMICAL FLOWS
Action Condition
SLOWLY
DOSING Other Cause Paths Mo
FUME CUPBOARD Desired Condition
Action DETERMINES Productive
EXHAUST FAN
Action FLOW
AIR CURRENT TURNED ON
TOXIC FUMES GENERATED IN
ENTERED ROOM 2 ROOM Root Cause (C)
Desired Condition
DOORS CLOSED
Action Condition
FUMES ESCAPED FUMES IN Lack Of Control
FROM SUMP DRAINAGE
SYSTEM

Root Cause (C)

STANDARD
DRAINS ARRANGEMENT
UNPLUGGED
Primary Effect

TOXIC FUME
Condition
INHALATION Desired Condition
FLOOR DRAIN

Condition

Condition EYEWASH Desired Condition

THREE DRAINS IN STATION DRAIN

ROOM 2 CONNECT
Condition
TO SUMP
FUME CUPBOARD Desired Condition
DRAIN
Condition
Other Cause Paths More Action
PERSON Productive
BREATHING EACH FACILITY Desired Condition
CONNECTED

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