Protecting Our Hands
9/8/2020
It was on a Friday. It was cold and dark…..no, no, no, this is not a mystery novel! But it was on a Friday; and in the morning. One of our employees was working in the field, performing a specific test to analyze for high explosives. The reason for this activity was that in the past, our designated work area was used for explosive testing. And now TPMC was tasked to characterize the soils.
The test being performed involved opening small vials (aka ampoules) that contained a chemical reagent that when mixed with a soil sample, would react with a specific explosive material (the suspected contaminant of concern) and when placed in a portable spectrometer, the readings would specify whether the soil sample contained the specific contaminant along with providing a concentration.
The ampoules are glass and are shaped in such a configuration that they have a neck where the ampoule is to be broken. To help ensure the ampoule neck is broken cleanly, it is etched or scored by the manufacturer; thus, by applying a little torque or wrist strength, the ampoule will not shatter or splinter; a potential for causing sharp edges.
As an additional control, for hand/finger lacerations, a device known as a “cracker” is supplied by the manufacturer, which envelops the entire ampoule neck and used to assist in breaking the ampoule in a safe manner.
Apparently, for some unknown reason, the required etching on the ampoule neck was not present; thus, creating a potentially higher risk for a cut (regardless of the ampoule cracker) due to the chance of the glass having a jagged edge.
Employees wore nitrile gloves as prescribed in the manufacturer operations manual. As we should all be aware, nitrile gloves are designed to protect the wearer from chemical skin exposure and typically do not offer any cut resistance.
Nevertheless, while all protocol was followed, the worker suffered a considerable thumb laceration requiring medical treatment beyond first aid (first aid was administered which controlled the bleeding, but the laceration was substantial).
In order to ensure this type of incident would not occur again, an investigation was performed to determine root causes as well as contributing factors. Corrective actions were discussed and while the all instructions were followed, the manufacturer protocol did not consider that the etching would not be properly embossed.
If a procedure cannot be followed verbatim due to a procedure not properly written or the procedure is not written to address a particular situation or unforeseen condition, it is important to pause work.
Other actions to be considered include wearing leather (or similar material) gloves or cut-resistant gloves during the process to remove the ampoule neck – even though the operations manual did not specify this. This would require placing cut-resistant gloves over the nitrile gloves while breaking the ampoule neck. Once this task is completed, the cut-resistant gloves can be removed.
Another possible control is to find a hand tool that can help cut the ampoule neck in a safe manner – whether the neck is properly etched or not.
Another control would be to place any ampoule aside when inadequate etching is noticed, followed by returning to the vendor. It should be noted that up until this incident TPMC never received an ampoule with inadequate etching. In addition, it was noted that TPMC received a number of kits that contained ampoules with this condition for our current order. This suggests that the manufacturer may have undergone a new process or has recently had a personnel change that involved inadequate training or other short-coming. Thus, contacting the manufacturer to inform them of our recent incident would be appropriate. Maybe with this information, the manufacturer might identify a glitch in their process, leading to correcting their current practice and thus, prevent a similar occurrence; whether with TPMC or with another customer.
Everyone thinks of changing the world, but no one thinks of changing himself
Leo Tolstoy