From: BEE micocrocoorosem Sent: Friday. February 13. 2009 5:14 PM To: Chandler. George George. This just came in from team that was in the laboratory at the time of the dif?culty. Thought you might find it helpful. El :3 of Incident Regards. [b}l3}:42 use. 2622mm OSEP Customer Satisfaction Survey. This document is intended for the use of the recipientts] named above. It may contain sensitive information that is protected. privileged. or con?dential. and it not be disseminated. distributed. or copied to persons not authorized to receive such ll?yuu are not the intended any dissemination. distribution. or copying is strictly pruhihited. ll? tun [hinlt ynu have received this document in error, please notify the sender immediately and destroy the original. is Incident February 12, 2009 ?3:131:42 U.S.C. 5 262301;: On February 12, 2009, the above listed laboratorians along with the I M3342 use. 252m: I [ti-?3?42 - entered into the ME: "mm; space of building ?52,453] room to conduct an of?cial inventOIy of mg? . After successful completion, the laboratorians attempted to exit U-S'bl 2 hrough the chemical shower where the-following events occurred: All four persons entered the chemical shower. The gasketed door from the I [mar-:42 use. a 262%: Iwas properly closed and sealed by evidence of the light indicator turning from green to red. 2. Pets onncl then pressed the ?door open? button next to the gasketed door leading from the chemical shower tothe suit room in order to initiate the automatic chemical shower. 3. The-automatic chemical shower did not start and the light indicator turned from red to yellow indicating the gasket of the door from the chemical shower to the suit room was beginning to deflate. Upon noticing this, personnel physically held the door shut between the chemical shower and the suit room until the door gasket rein?ated and the light indicator turned from green to red. While the gasket was de?ated, light from-the suit room was visible in the I chemical shower however the door was never open. 4. After ensuring the gasketed door from the chemical shower to the suit room was properly sealed, personnel attemptedto initiate the automatic chemical shower by pressing the ?door open? button next to the gasketed door between the chemical shower and the I ?33342 U-S-C- i Ei?? Again, the automatic chemical shower did not start and the light indicator turned from red to yellow indicating the gasket of the door from the chemical shower to th imp: was begimiing to de?ate. Upon noticing this, personnel physically held the door shut between the chemical shower and the until the door gasket reinflated and'the light indicator turned from green to red. 5. After ensuring the gasketed door from the chemical shower to was properly sealed, personnel began using the emergency- deluge Microehem). 6. Approximately 20 30 seconds into the 5% Misroehem delu 3e, the gasketed door from the chemical shower to ?13'333342 U-S-C- i 2523i?? burst open forcefully. Personnel physically shut the door between the chemical shower and thel miter? U-S-C- 252mm land held it shut until the door gasket rein?ated and the light indicator turned from green to red. 7. After ensuring the gasketed door from the chemical shower to the m;:r3;;:42 l? was properly sealed, personnel again used the emergency uge Microchem). Immediatelv, the gasketed door from the chemical shower to th rbj:r33::42 :urst open force?illy again. Personnel I and held it shut until the door gasket reintlated and the light indicator turned from green to red. 8. After ensuring the gasketed door from the chemical shower to the "i was properly sealed, personnel again used the emergency eluge Microchem). Immediately, the gasketed door from the chemical shower to thel Iburst open forcefully for a third time. Personnel shut the door between the chemical shower and the containment [motto uses 2623 and held it shut until the door gasket reintlated and the light indicator turned from green to red. 9. After ensuring the gaskcted door from the chemical shower to the was properly sealed, personnel again used the emergency deluge Microchem). Personnel attempted to physically hold the gasketed door from the chemical shower to the shut but it burst open with enough force that personnc could not keep the door shut. 10. Personnel entered the Ito call Four Seasons about the problem. At this time. the gasketed door from the chemical shower to the WW 2523f? was left open while we tried to address the issue. 1 1. Personnel attempted to communicate the issue to Four Seasons. th (more U.S.C.?2528thl 5 2:523 '1 ?523 .5 and the Occupational Health and Safety representative a. At this time. personnel noted that the air pressure ala light) were blinking. Also. the monitor screen showed the main laboratory and procedure rooms and chemical showe I The autoclave room. animal room, andmot USO-CE stayed blue. i. The alarm message on the monitor screen read animal room humidity non-critical alarm?. ii. All four personnel moved into the main 523'?; and closed the gasketed door between the [more and the chemical shower in an effort to normalize pressure within the laboratory. The main laboratory then quickly changed from ?red? to ?green" on the monitor screen according to the pressure color chart. I ?erring, called personnel within the and suggested: a. Personnel exit two at a time i. Four Seasons would activate the automatic chemical shower while the ?rst two were within the chemical shower. ii. After the ?rst two exited into the suit room. the second two would enter the chemical shower 1. Personnel would activate the chemical shower bypass From the suit room. 2. Personnel would repeat this activation two more times and then exit the chemical shower. 13. The ?rst two personnel entered the chemical shower and ensured the gasketed door was sealed. Four Seasons attempted to activate the automatic chemical physicall shut the door between the chemical shower and th ??szagti' I shower through the Building Automation System (BAS) but only the water cycle occurred. a. Personnel used the emergency deluge Mi crochem) two times b. Personnel then pressed ?door open? button next to the gasketed door leading from the chemical shower to the suit room to exit the chemical shower but then the automatic chemical shower initiated. c. After completion of the full automatic chemical shower cycle (7 minutes), personnel exited into the suit room. '14. The second two personnel then entered the chemical shower and ensured the 15 gasketed door was sealed. The chemical shower bypass was then activated by personnel from the suit room. Following the short 2 minute cycle, personnel attempted to activate the automatic chemical shower by pressing the ?door open? button next to the gasketed door between the chemical shower and the suit room (since the automatic chemical shower cycle had just previously worked). Theautomatic chemical shower did not start and the light indicator turned from red to yellow indicating the gasket of the door from the chemical shower to the suit room was beginning to de?ate. Upon noticing this, personnel physically held the door shut between the chemical shower and the suit room until the door gasket rein?ated and the light indicator turned from green to red. .- The chemical shower bypass was again activated for a second time by personnel from the suit room. During this cycling, personnel also used the emergency deluge Mieroehern) as an extra precaution. 16. Following completion of this cycling, personnel exited the chemical shower to personal showers. I Cha Je?ernyen. I have been in conversation with Geor Chandler this afternoon regarding the airflowldecon shower issue in the yesterday afternoon. Them mrcoorocoorosw) Friday, February 13. 2009 5:19 PM Williams, Jeffery Bowen. Ken L. Iggw?f ge Porter, William (CDCIOCOOIOSEP) ssue lousy.? 989mm Program has developed the attached first-hand account of what occurred. George has asked that I pass this along to you for your information. IWor - Incident . .. Sincerely, I uses 252mm DSEP Customer Satisfaction Survev. this document is l'or th? i-wclmiic use ul?lhv rvcipicullal numcd show: may contain :?cnsitiw information Ilmi is protected. prii or con?dential. and Il should not be disseminated. or Copied to to rcuciw such If jmu an: not lln: all} dialiihlltinll, or cup} ing is strictly prultihilcd. if I'mnl. 3.1m hm this ducun?lcul Ill umr. plums: nulil'} lilc scmlu imnludlaloly and [he nriginal.