Document Yr1pYywopJOx2jg5NmKyj1zjO

f<?5 .5 e INTEROFFICE MEMORANDUM Date: From: Dept: Tel NO: 22-Sep-1995 05:57pm EDT FLETCHERT FLETCHERT@SCTVAX@MRGATE@CLE Use RDL option to see message distribution. Subject: High PEL Board of Review From: TO: CC: Subj; SCTVAX::HUNTERC FLETCHERT,LAMBLES, POLIQUINJ,MCDONALDB,FRASERJ HUNTERC Hgh PEL Board of Inquiry SUMMARY : Jim Poliquin and Shawn Lamble had exposures greater than lppm without breathing air on Aug. 10/95 Jim Poliquin - 1.36ppm Shawn Lamble - 1.56ppm BOARD OF INQUIRY : Bill McDonald Tom Fletcher Jim Fraser Carole Hunter Plant Manager S.H.E./H.R. Manager Operator Acting Shift Supervisor Occupational Health Coordinator NARRATIVE : =========== #i Autoclave which was charged at 0515 hr. was left down for repairs once the batch was complete. East end sleeve on #1 Autoclave was repaired. Jim inspected #1 A/C east end packing because high readings had been observed but at the time did not see any light indicating readings over lppm. prepared the autoclave east end for packing sleeve repairs. FACTS SURROUNDING THE INCIDENT : l. The average VCM reading in the background for the same period was 0.62 ppm. There were high peaks of 10 - 15 ppm occuring around the time the work was being done. MANAGEMENT SYSTEM : 1. No deviation from the normal established work procedures. Respiratory protection was not normally required for the work they were doing. redacted NQC 13669 2. Both Jim and . have been site employees for 15 years and are certified thesa areas. PROBABLE CAUSES : 1. It was most probable that the high concentration of VCM came from a pinhole leak on compressor degas line on #4 A/C located some distance away. The leak was located and patched two days later. CORRECTIVE ACTIONS : 1. Pin hole leak was immediately patched and the line replaced at a later date. 2. GC#l checked and found to be performing properly. 3. East end sleeve on #1 A/C repaired. Distribution: CLE::PATIENTB ALTC::MARESCAL CLE::MARTINELLIE CLE::HIGBYG CLE::KNECHTGESD CLE: : RUTMANG CLE::CANELLAJ CLE::DAVISR LNB280::RADTKER SCTVAX::FLETCHERT LPT: :HINSOND PED26 : *. JOHNSONM HNY::JOHNSONS ALTC::KELLINGM PED26::KIELJ SCTVAX::LAMBLEN PLQADM::NOTOJ CLE::ORSBORNC DPK100::REYNOLDSM LVLC::THOMPSONM CLE::ARCHERJ HNY::CALDERR PLQADM::COMEAUXM DPK100::DESJARDINSR CLE::DONATACCIOP ALTC::GRIFFINJ LVLC::MARTINR PSD26::OKEEFED NIAVAX::KELLYC NIAVAX::WAHERM CLE::WALTEMATEH LPT::WILLIAMSS NGC 13670