Lesson Learned Statement:PPE should be carefully inspected prior to use.
Discussion:On 6 July 2000, at Mound, the HEPA filter fell off of a full-face respirator worn by a mechanic while he was working in a radiological area. The work in question had the mechanic lying on his side and removing equipment by hand from a tight location. In order to see what he was doing he was obliged to push his head into tight areas and his mask had brushed against various objects during this process. Upon exiting from beneath the equipment and standing up, the filter and housing fell from the mask. The mechanic immediately exited the room and doffed his PPE with the assistance of a Radiological Controls Technician. He was surveyed for contamination with a portable monitor, wipes and a nasal smear were taken, and he exited through the Portal Contamination Monitor. No contamination was discovered.
Analysis:The respirator was inspected and no apparent reasons for the filter falling from the respirator were found. There were no obvious signs that the equipment had structurally failed or that the filter was pulled from the mask by snagging it on something. When disassembled, the respirator was found to have one filter gasket missing. A review of respirators in inventory discovered three additional respirators with similar problems. The demolition technician responsible for respirator maintenance had been on vacation and upon return found 100-150 respirators waiting to be processed. Because of work schedule and concern about possible work shut-downs, the respirators were processed as quickly as possible. The assembly errors were the result of a rushed job.
Safety equipment maintenance should not be compromised by a percieved urgency for production. In this instance, management should have anticipated the maintenance worker's vacation and arranged alternate coverage instead of allowing respirators to accumulate.
An opportunity to detect the faulty assembly was evidently missed when it was not found in a pre-use inspection by the user. Mound wrok practice makes it the wearer's obligation to inspect the assigned respirator prior to use. This inspection has always required that the HEPA filters be removed, the gaskets inspected, and the filters reinserted. A check list has been prepared to guide the wearer on what aspects of respirators to check before they are worn. Mound requested their managers brief employees on this event and recommended that their Industrial Hygiene group conduct spot inspections of assembled respirators.
Contact:Dr. George F. Nafziger firstname.lastname@example.org, 937-865-4598
Name Of Authorized Derivative Classifier:Ron Mahan
Name Of Reviewing Official:Danny Punch
Priority Descriptor:Yellow / Caution
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DOE Function / Work Categories:Conduct of Operations - Work Planning
Occupational Safety & Health - Personnel Protective Equipment
ISM Category:Develop / Implement Controls
Hazard:Personal Injury / Exposure - Radiation / Contamination
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