UVLIGHT EXPOSURE INCIDENT

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UV-LIGHT EXPOSURE INCIDENT

• August 14, 2006

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UV-Light Exposure Narrative

• On Monday, August 14, 2006, _at_ 1200 PM a TD-MDTL
  employee took several digital photographs (close
  shots) of the Nb plate in a UV-light
  equipped-biological laminar hood.
• Employee used the UV-Light equipped hood to
  minimize glare of the highly reflective Nb plate.
• The employee spent 10 minutes in the hood and
  was exposed to x10 rated high intensity
  disinfecting UV-light.
• Same evening, about 1000 PM, the employee
  developed redness of the face, severe redness in
  his eyes, blurred vision and severe irritation of
  his eyes (feeling of sand in the eyes).
• The employee subsequently went to the emergency
  room at Edward Hospital not sure of the exact
  cause

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The MDTL Biological Laminar Hood

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MDTL Biological Laminar Hood (cont.)

• Warning Signage By The UV-Light Switch

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MDTL Biological Laminar Hood (cont.)

• UV-Light Warning Signage

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Immediate Actions Taken

• August 15, 2006 AM - Technical Division Suspended
  any Acid Processes in MDTL Facility.
• August 15, 2006 - TD Secured the UV Hoods in MDTL
  and IB3 and suspended the use of any UV-Light
  equipment in the Technical Division.
• August 16, 2006 Fermilab Director, Pier Oddone
  Suspended the Etching Activities involving HF.
• August 16, 2006 Removed the UV-Lamp and
  Fixtures from the two hoods (MDTL IB3)
• Secured All Known UV-sources in TD

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TD MDTL Biological Laminar HOOD With UV-Light
Lamp Removed
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The MDTL Biological Laminar HOOD (cont.)

• Correct Application New Signage

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TD UV-Sources Secured

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Two UV Sources In MDTL Cabinet Presently Under
Lock Tag
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TD UV HOOD

• UV Warning Signs
• On Storage Cabinet
• Doors
• UV Rated Safety Glasses
• To be used when/if authorized

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The Fall-out

• Immediate suspension of MDTL Acid Activities
• Suspension of Usage of UV-Light hoods and other
  UV-Light Sources.
• Suspension of Nb Electro-Polishing and any use of
  HF.
• Category-2 Occurrence Reporting Processing System
  (ORPS) to DOE.
• Internal Review Ordered Through an Internal
  Independent Panel by the Director.

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Injury Root Causes

• Not reading the warning sign next to the UV light
  switch that states Ultraviolet light will injure
  your eyes. Avoid direct viewing at all times.
  Personnel should be present when ultraviolet lamp
  is on.
• Lack of Equipment Knowledge and the Hazard
  Associated with

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Several Opportunities Missed

• Failure to recognize the facts that this is a
  Biological Laminar UV-Light Equipped Bacteria
  Disinfecting Chemical Hood.
• No NEPA review was requested or done (DOE Excess
  List Item)
• Readily available Operating Manual was not
  acquired and studied before installing/operating
  the hood.
• No Equipment Operating or Safety Training was
  provided.
• No Commensurate PPEs were identified or supplied
  to operate this hood.
• No Operational Readiness Clearance (ORC) was
  requested or secured which would have caught all
  of the deficiencies above with the exception of
  NEPA Review. A Violation of the TD Policy 1140,
  requiring an Operational Readiness Clearance.

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Additional Corrective Actions Taken/Planned

• TD Procurement Policy 4100 has been revised to
  include NEPA Review and Approval for all
  DOE/Government Excess Items.
• The UV lights and fixtures from the MDTL and IB3
  laminar hoods have been removed and replaced with
  neon lamp fixtures.
• The Proper PPE (UV goggles) for the two seized UV
  sources has been provided.
• A Matrix has been developed for the MDTL
  processes to list the Equipment/Process,
  Associated Hazards, Required PPEs, Trained
  Employees, and written Training Module and
  Procedures in use.
• The Operational Readiness Clearance Process has
  been launched for the UV light hoods and other
  MDTL processes

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In Summary (Bottom Line)

• The ESH NEPA Procurement Review TD-Policy 4100
  has been revised to require a NEPA review of
  requested Government Excess List items.
• Set aside all opportunities missed this incident
  was preventable if the existing Operational
  Readiness Clearance, TD-Policy 1140 was followed.