As part of the “Lessons Learned” Program, a recent glovebox glove failure incident is examined to provide feedback and continuous improvement of the Safe Work Practices (SWPs) work-control process. While slowly evaporating liquid from solutions in trays on hot plates, a glovebox became pressurized and a glove ruptured resulting in widespread contamination of equipment, work surfaces, and the floor. Based on the post-analysis of the solution and residues of the incident, several contributing causes of the overpressurization were ruled-out, including exposure to strong shock, organic materials, and inorganic species. Evaporation of an ammonium nitrate solution was postulated as the cause of the incident glovebox breach. Since ceramic-top stirring hotplates heat from 150°C to 590°C and are controlled by a voltage power controller, the temperature to reach rapid decomposition conditions (210°C) was possible. The risk of these types of incidents is control to acceptable level by replacing voltage power controlled hotplates with temperature controlled ones. In addition, a still pot thermometer is required to prevent the solution from evaporating to dryness. Using a heating device designed such that 210°C cannot be reached under any circumstances further minimizes the risk. In summary, a primary objective of the Integrated Safety Management program is to minimize hazards associated with materials whenever possible. Implementing “Lessons Learned” not only maintains SWPs, but also contributes to an organization’s scientific and technological excellence. As with all other elements of business, there are costs associated with implementing an effective “Lessons Learned” Program. Using a cost-benefit analysis for another category of reportable occurrences, radiation exposure, it was estimated that over $50,000 could be spent on “Lessons Learned” to reduce the likelihood of this type of unusual occurrences and still be cost-effective. While the cost saving may not be immediately apparent, feedback in the form of incident reports provide continuous improvement in day-to-day operations.

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