Lesson Learned Briefing


TitleNot Recognizing UV Hazard Results in Eye Injury

EventLBNL Event

Event Date01/28/2019

CategoryESH-Non-Ionizing Radiation - UV Equipment

Lesson Learned Statement
During planning and execution of experiments, consider the following actions to assure work is performed safety throughout the life cycle of an experiment.

1. Perform Integrated Safety Management (ISM) for all new experiments and tasks. Even quick test experiments that are not part of ongoing research must be planned using ISM principles.
2. Always wear proper personal protective equipment (PPE) for all tasks. Seek out information on the hazards of the chemicals, items, or equipment to be used and follow the safety data sheet (SDS) or manufacturer recommendations.
3. Refer to work authorizations regularly to insure one does not stray outside of the scope of the authorized work, and review the work authorization when planning new work to insure the new work is in scope of the authorization. If not, edit the existing authorization or construct a new authorization following ISM principles.
4. Review all activities and equipment regularly to insure proper labeling is in place and that labels are serviceable.
5. Perform regular reviews of the work authorization and insure all relevant hazards are selected and controls are implemented.
6. Although interlocks are not required on this instrument, interlocks are very effective controls that should be considered for control of hazardous energy, and should never be purposefully defeated.
7. If external responsibilities demand more time from research oversight, consider delegating critical laboratory tasks to a responsible lab manager or lab safety lead.

On January 28th, 2019, an employee at Lawrence Berkeley National Laboratory was conducting an experiment which included exposing aqueous samples in quartz cuvettes to ultraviolet (UV) light. The equipment contained three functional 40 watt germicidal lamps with 11 watts of UV-C (254 nm) output each. This experiment required the worker to open a protective cover, insert or remove a cuvette and close the cover. This process was repeated nine times resulting in approximately 50 seconds of total UV exposure to the worker. The three UV lamps were on during the opening and closing of the equipment, and the employee was not wearing protective eyewear during this activity. That night the employee experienced an intense burning sensation in both eyes with loss of vision and sought medical attention at a local emergency room.

An accident investigation team determined that 7 items caused or contributed to the injury occurring.
1. The hazard of the UV light was not recognized (failure of ISM principle #2). The researcher considered that the few seconds of exposure achieved from this lamp would be similar to going outside in the sun light.
2. Safety glasses, or any other PPE, were not worn. This issue is directly related to not recognizing the hazard of the UV light. By not recognizing the hazard the researcher did not realize PPE was needed.
3. The scope of the work changed without evaluation. The UV lamps and enclosure were designed to study samples in a flow tube with the lamps fully enclosed. Studying samples entered through the open lid of the light box was a new idea that was not evaluated.
4. There were no signs or warning labels to warn about the UV exposure on the instrument.
5. The UV light hazard was not selected in Work Planning and Control (WPC) Activity Manager. Had the UV hazard been selected, controls would have appeared in the control section of the activity including, labeling, use of PPE, and evaluation by the Non-Ionizing Radiation (NIR) subject matter expert (SME).
6. There were no switches or interlocks on the enclosure lid.
7. Oversight of research activities was limited. At the time of this incident, the principal investigator (PI) was very busy with administrative tasks and also serving jury duty. The experiment was discussed with the PI, but not specific detail about how the experiment would be conducted. Further discussions could have identified the hazards involved.

Lessons Learned are part of the ISM Core Function 5, Feedback and Improvement. Applicable Lessons Learned are to be considered during working planning activities and incorporated in work processes, prior to performing work.
Please contact the following subject matter experts if you have any questions regarding this briefing.

Uploaded documents/attachments:
Germicidal lamp safety tips.pdf

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