March 16, 2020 | Susan Napier-Sewell

Fire Extinguished by a Questioning Attitude + Best Practices + Principles

A researcher noticed an acrid odor and employed a questioning attitude, instinct, best practices, & principles to address a fire

What would you do if you noticed a smell out of the ordinary but could write it off to electricians doing their work? 

In January 2020, a Pacific Northwest National Laboratory (PNNL) researcher was pulling data from a Thermogravimetric Analyzer – Mass Spectrometry (TGA-MS) computer in a lab in the LSL2 building while electricians were replacing the lab’s light bulbs. The researcher noticed an acrid smell he attributed to the work the electricians were performing. However, because the smell was out of the ordinary, the researcher decided to check the heating elements on the TGA manifold. At that moment, the researcher heard a clicking sound coming from the water chiller used to cool the TGA manifold and then noticed sparks and small orange flames coming from the side grill of the chiller. He alerted the electricians, unplugged the chiller power cord and pulled the fire alarm, while the electricians called the PNNL Security Operations Center.

Although the fire extinguished itself once the power cord was unplugged, the Richland Fire Department arrived on the scene to assist in restoring the building back to normal service

After the chiller was taken out of service, it was determined a hole had burned through the bottom of the chiller component. The chiller manufacturer later informed PNNL there were no recalls or any other concerns regarding this line of circulating chillers.

The PNNL staff response to this event could not have been any better.

  • The researcher instinctively used the Safe Conduct of Research (SCoR) principles “A questioning attitude is cultivated” and “A healthy respect is maintained for what can go wrong” by questioning the source of the smell until it was located.
  • The electricians’ immediate Single Point of Contact notification assured the fastest possible emergency response.
  • In addition, the staff did not have any combustible material stored around the chiller; this is a PNNL best practice.

Lessons Learned

• Staff should always be observant in a laboratory environment and never assume that off-normal events are correlated with normal activities.

• Staff should always deploy best practices in a laboratory environment as you just never know what could go wrong.

• Inspect all circulating chillers (Model AD 7L R-20) periodically for anomalies.

This Lessons Learned is from OPEXSHARE, U.S. Department of Energy. Published by Pacific Northwest National Laboratory (PNNL; Richland, Washington) 2/18/2020 “How SCoR Principles helped to extinguish the fire.”

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Accidents, Human Performance, Root Cause Analysis
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