External LER - Lucky to be alive

Title

Monday, May 23, 2016

Situation

An experienced professional was to perform a demonstration in front of 100+ people. He noted some deviations but decided to ignore them and proceed with his silane demo that he has done many times in the past without incident.

An uncontrolled silane vent/fire of 1600 psig occurred.

"This 15 sec event seemed like 20 minutes as I desperately tried to shutoff the flow. The 3 ft flame was at the cylinder valve and the radiant heat was intense as I reached for the alternate shutoff valve, I was worried that the aluminum nitrogen purge cylinder was going to explode due to the heat."

The fire torched his Nomex coveralls, hood and faceshield. (image attached)

"My PPE saved me from burns. I was fortunate to have turned and ducked as the flames came over my head at one point."

In his own words:

"I am ashamed that I ignored (warning signs) ..

I have been campaigning for silane safety for more than 10 years and yet I ignored some basic rules. 44 years of handling silane under many conditions and still I was so stupid. God saved me for another day

Luck should not be part of the safety program. Yes, please share. While I am embarrassed, I survived. PPE is absolutely critical to safety"

The experienced professional publicly shared his mistake on the ACS division of Chemical Health and Safety List serve. His credentials are available here.

Suggestions

Everyone, even experienced professionals can make mistakes when under pressure. It is important for experienced individuals to share their mistakes to help beginning professional learn that experience does not negate the need for safety controls or provide immunity from mistakes.