Potential Chemical Burn: Lack of Communication

Danger! Wear chemical googles, face shield & rubber gloves when handling chemicalsToday’s potential injury from What Went Wrong? by Trevor Kletz involves a simple change that could happen anywhere combined with our tendency to go into “auto-pilot” with routine tasks.

A plant used sulfuric acid and caustic soda in small quantities, so the two substances were supplied in similar plastic containers called polycrates. [Two polycrates of acid were kept on one side of the tank and two polycrates of caustic were kept on the other side]. While an operator was on his day off, someone decided it would be more convenient to have a polycrate of acid and a polycrate of alkali on each side. When the operator came back, no one told him about the change. Without checking the labels, he poured some excess acid into a caustic crate. There was a violent reaction, and the operator was sprayed in the face. Fortunately, he was wearing goggles.

In this case, the book suggests that people should be told about changes made while they are away, and that containers for different chemicals should vary in size, shape, or color. What other measures might be taken to prevent this kind of incident?

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