Lesson Learned Briefing


No.LL19-0008

TitleReceipt of Leaking Hydrofluoric Acid Containers

EventLBNL Event

Event Date12/07/2018

CategoryESH-Chemical - Chemical Hygiene-General, Corrosives, Hydrofluoric Acid, Toxic Compounds (Highly Acute Toxic Only)

Lesson Learned Statement
Over the past two years, a purchaser at the Molecular Foundry (the Foundry) received several compromised shipments of 48 wt.% hydrofluoric acid (HF), an acutely toxic and corrosive chemical. In each incident, the Lab purchaser was aware of the hazards posed by HF and had the proper controls in place when opening the containers. An investigation of the probable cause was conducted and a response delivered to the vendor to prevent recurrence. This lesson learned highlights the importance of continued diligence when a safety concern is presumed to be solved and the need to be persistent when an issue has not been fully addressed.

Discussion
The subject shipments arrived at Lawrence Berkeley National Laboratory (Berkeley Lab) showing evidence of leakage, including small droplets of liquid, staining on the label, and specks of an unidentified white powder (pictures attached). The droplets in the most recent shipment received 12/07/2018 subsequently tested positive for the fluoride ion. Fortunately, the inner packaging contained the leakage, and no exposure occurred. In each case described above, the Berkeley Lab purchaser was aware of the hazards posed by HF and had the proper controls in place when opening the containers.

While all leaking chemical containers should be taken seriously, leaking containers of HF are of particular concern given this chemical's acute toxicity. HF exposure can cause severe burns and even systemic toxicity resulting in death. The purchaser conscientiously reported the initial incident in 2017 to the Lab's Government Scientific Source (GSS) Sales Manager. GSS asked the vendor to investigate the issue, however, the vendor's Product Manager indicated that there was no history of this issue and it was believed to be a one time defect. The purchaser did not need to reorder this product until 2018, when signs of leakage were again observed. The Foundry involved Berkeley Lab's Environment Health and Safety (EHS) group to help escalate the safety concern with GSS and the vendor.

Following the most recent incident, GSS's Quality Assurance Representative submitted a formal Supplier Corrective Action Request (SCAR) to the vendor in late January 2019. During the same time frame, EHS communicated this issue both internally and externally to raise awareness and collect feedback. The vendor's Quality Services worked with GSS, as well as with Berkeley Lab EHS directly, to complete a formal investigation of this issue.

While no additional leakage events have been reported, a vendor stock check revealed darkening/discoloration of product labels similar to that reported by Berkeley Lab, and acid was likely present at low levels outside of the primary container. The probable cause was determined to be relaxation of the bottle caps and/or cap liners over time, which may be further aggravated by the pressure differential resulting from a vacuum sealing step during packaging. The vendor is further evaluating the vapor seal of the cap as well as testing the permeation of aged HF. Corrective actions may include a combination of adding an HF desiccant packet to absorb HF vapors, modifying the vacuum sealing process used, and/or limiting inventory storage time to less than six months.

This lessons learned highlights some key takeaways:

- Appropriate actions taken by the purchaser prevented any exposure or injury. Before opening and removing chemicals from shipping materials, anticipate the hazards, don all proper personal protective equipment, and implement appropriate controls.

- Don't hesitate to contact chemical manufacturers such as the vendor directly about any issues. Multiple communication venues may be necessary to reach a satisfactory resolution for quality issues such as leaking containers.

- Be alert for recurring issues and persevere. Throughout this ordeal, the purchaser showed exemplary diligence regarding chemical safety and they remained committed to resolving this serious issue.

Please contact the following subject matter experts if you have any questions regarding this briefing:
- Evelyn Davies, Chemical Safety Specialist, [email protected]

- Alyssa Brand, Lab Safety Specialist, [email protected]



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:
Leaking HF_03.JPG
Leaking HF_02.JPG
Leaking HF_01.JPG

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