Lessons Learned Database



Title:

Health and Safety Concerns During Floor Tile Installation

Identifier:

Y-1998-OR-LMESY12-0302

Date:

1998-03-11

Lesson Learned Statement:

PRIOR to beginning work involving chemicals or materials which can release fumes or vapors, building managers and supervisors should ensure that employees with respiratory problems and/or increased sensitivity to chemicals, such as those with Chronic Beryllium Disease, are informed of the use of the chemicals and that accommodations are made.

Discussion:

On September 15, 1997, a task was initiated to replace floor tiles in the halls of building 9737 at the Y-12 Site. This task involved the use of an adhesive with mineral spirits glue derivative. During the day, several employees began to feel nauseous and light-headed as the result of the vapors from the adhesive materials used to lay the tiles. Employees were evacuated from the area and most reported feeling better after they were in an area with fresh air. Several employees reported to the medical center for evaluation and returned to work the following day.

An employee in the area who has been diagnosed with Chronic Beryllium Disease (CBD) experienced additional effects from the inhalation of the vapors. This employee experienced additional problems breathing for several days which were determined to be related to the vapors from the tile adhesive. With CBD, inflammation and scarring of the lungs make it more difficult for the lungs to get oxygen to the bloodstream and body, a condition which can be further aggravated by the inhalation of chemicals. A second employee with pre-existing respiratory problems also experienced additional respiratory aggravation.

Analysis:

The causal analysis of this incident concluded that Personnel Error - Communication Problem, was the direct and root cause. This analysis also noted that the building manager was not aware of the respiratory health problems of the employees at the time the work was planned. Had the building manager been aware of these health problems, the work could have been scheduled during an off-shift, or the employees reassigned to a different area during the time the work was in progress.

Recommended Actions:

PRIOR to beginning work involving chemicals or materials which can release vapors or fumes, building managers and supervisors should ensure that employees with respiratory problems and/or increased sensitivity to chemicals, such as those with Chronic Beryllium Disease, are informed of the use of the chemicals. Medical advice to determine the potential impact on these employees should be obtained prior to beginning such work, so that employees may be relocated to other work areas as necessary or work performed during off-shifts. Employees should ensure that their supervision and the medical department are notified of medical conditions that may be affected by their work environment.

This lesson learned should be placed in the required reading for building managers and supervisors to emphasize the need for effective communication with the occupants of their buildings of potential health and safety concerns prior to the initiation of a task.

Originator:

Lockheed Martin Energy Systems; A. G. Bell, (423)574-2712

Validator:

Mark McKinney, Safety & Health Organization

Contact:

Mark McKinney, Safety & Health Organization

Name Of Authorized Derivative Classifier:

M. W. Sherrill

Name Of Reviewing Official:

n/a

Priority Descriptor:

Yellow / Caution

Keywords:

BERYLLIOSIS, BERYLLIUM, RESPIRATORY, ADHESIVE, FUMES, VAPORS, MSDS, WORK PLANNING

References:

DOE Chronic Beryllium Disease Prevention Program Home Page, http://tis-nt.eh.doe.gov/be

Beryllium Support Group Home Page, http://www.dimensional.com/~mhj ORPS Report ORO--LMES-Y12SITE-1998-0008, I0035097
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DOE Function / Work Categories:

Maintenance - Facility
Operations - Facility
Occupational Safety & Health - General

ISM Category:

Analyze Hazards

Hazard:

Personal Injury / Exposure - Beryllium
Personal Injury / Exposure - Hazardous Material (General)

End of Lesson!

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