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Key Lessons for Preventing Incidents from Flammable Chemicals in Educational Demonstrations

Overview

On September 3, 2014, a flash fire occurred during a science demonstration at The Discovery in Reno, Nevada. Thirteen people were injured. Eight children and one adult were transported to the hospital. The incident involved a Fire Tornado demonstration using methanol. The poured methanol ignited, flashed back into the bulk container, and produced a large flash fire that spread burning methanol toward the audience.

Incident Snapshot

Field Value
Facility / Company Terry Lee Wells Nevada Discovery Museum (“The Discovery”)
Location Reno, NV
Incident Date 09/03/2014
Investigation Status The CSB's safety bulletin was released at a news conference in Denver, CO on October 30, 2014. Three accidents involving methanol which injured children during lab demonstrations are examined by the CSB.
Accident Type Community Impact Investigation
Final Report Release Date 10/30/2014

What Happened

  • An educator was performing the Fire Tornado demonstration for a group of visitors consisting primarily of young children.
  • The visitors were seated on the floor approximately 15 feet away from the demonstration.
  • The first two variations of the demonstration were performed without incident.
  • During the third variation, the educator held the lighter flame to the cotton ball, but the expected fuel flame did not rise.
  • The educator realized that methanol fuel had not been added to the cotton ball.
  • The educator attempted to pour a small amount of methanol from a four-liter bulk methanol container onto the cotton ball.
  • Although there had been no sign of flame from the cotton ball, it is likely that the lighter had actually ignited the cotton, and it was smoldering.
  • The poured methanol ignited immediately, and then flashed back into the methanol container.
  • The methanol inside the container then ignited, resulting in a pressure rise that expelled a large flame from the mouth of the container, causing a large flash fire.
  • The educator dropped the methanol container after it caught fire.
  • The container spilled, and burning methanol spread toward the audience, catching some members of the audience on fire.
  • Two of The Discovery employees extinguished the fire using a nearby fire extinguisher and fire blanket.

Facility and Process Context

  • Educational demonstrations involving flammable materials are often performed at schools or museums to engage students and visitors and stimulate their interest in science.
  • The Discovery has approximately 14 demonstrations that its educators perform on a regular basis.
  • Five of these demonstrations involve the ignition of flammable chemicals such as methanol, hydrogen, and methane.
  • The Discovery has a storage cabinet for flammable chemicals in the basement of the facility where the methanol was intended to be stored.
  • Prior to performing the Fire Tornado demonstration, the methanol was originally brought upstairs to an adjacent room near the demonstration area in order to provide educators more convenient access for filling the beaker.
  • When demonstrations were over, the bulk methanol container would be returned to the basement cabinet.

Consequences

  • Fatalities: None reported.
  • Injuries: Thirteen people were injured, including eight children and one adult who were transported to the hospital as a result of the fire. One child was kept overnight for treatment and additional observation.
  • Environmental Release: None reported.
  • Facility Damage: Not specified.
  • Operational Impact: Not specified.

Key Findings

Immediate Causes

  • The poured methanol ignited immediately, and then flashed back into the methanol container.
  • The methanol inside the container then ignited, resulting in a pressure rise that expelled a large flame from the mouth of the container, causing a large flash fire.

Contributing Factors

  • The educator attempted to pour methanol from a four-liter bulk methanol container onto the cotton ball.
  • The written Fire Tornado demonstration procedure did not contain a requirement to first pour the methanol from the bulk container into a small beaker in a separate room.
  • The written Fire Tornado demonstration procedure did not require the use of a beaker for methanol transfer.
  • The written Fire Tornado demonstration procedure provided no warnings about storing the methanol container outside of the flammables cabinet, or about using it directly during the demonstration.
  • No effective hazard review was ever carried out by The Discovery for any of the demonstrations.
  • The training provided to the educators did not effectively emphasize the inherent methanol flammability hazards.
  • Insufficient emphasis was placed on the safe use of methanol and other flammable materials during the demonstrations.
  • Periodic evaluations focused on presenting an engaging demonstration rather than ensuring good safety practices during demonstrations.
  • The Discovery did not emphasize the importance of the use of a small container with a minimum amount of methanol during the demonstration.
  • The CSB determined that only a few milliliters of methanol were actually needed to perform the Fire Tornado demonstration.
  • The quantity of methanol could have been minimized by pre-moistening the cotton balls with methanol prior to the demonstration.
  • Educational demonstrations involving flammable materials
  • Use of bulk containers of flammable chemicals in educational demonstrations when small quantities are sufficient
  • Handling hazardous chemicals without strict safety controls
  • Lack of written procedures
  • Lack of effective training
  • Lack of required use of appropriate personal protective equipment for all participants
  • Lack of a comprehensive hazard review prior to performing any educational demonstration
  • Lack of a safety barrier between the demonstration and the audience

Organizational and Systemic Factors

  • The CSB learned that neither The Discovery educators nor their managers had experience or were expected to perform hazard analyses.
  • The lack of an effective hazard analysis and formal safety procedures resulted in a normalization of the improper use of the four-liter bulk methanol container during the Fire Tornado demonstrations.
  • The Discovery staff’s lack of understanding and appreciation for the flammable hazards of methanol affected the demonstration procedures and training.
  • Employers and organizational leaders are responsible for ensuring strict controls and effective safety programs are in place to prevent incidents.

Failed Safeguards or Barrier Breakdowns

  • Do not use bulk containers of flammable chemicals in educational demonstrations when small quantities are sufficient
  • Implement strict safety controls when demonstrations require handling hazardous chemicals — including written procedures, effective training, and the required use of appropriate personal protective equipment for all participants
  • Conduct a comprehensive hazard review prior to performing any educational demonstration
  • Provide a safety barrier between the demonstration and the audience
  • no effective hazard review
  • written procedure for the Fire Tornado demonstration did not contain such a requirement
  • written Fire Tornado demonstration procedure did not require the use of a beaker for methanol transfer
  • written Fire Tornado demonstration procedure provided no warnings about storing the methanol container outside of the flammables cabinet, or about using it directly during the demonstration
  • training provided to the educators did not effectively emphasize the inherent methanol flammability hazards
  • periodic evaluations focused on presenting an engaging demonstration rather than ensuring good safety practices during demonstrations
  • The Discovery did not emphasize the importance of the use of a small container with a minimum amount of methanol during the demonstration
  • safety barrier between the demonstration and the audience

Recommendations

  1. Recommendation ID: not provided. Recipient: Employers. Status: not provided. Summary: implement strict safety controls when demonstrations necessitate handling hazardous chemicals — including written procedures, effective training, and the required use of appropriate personal protective equipment for all participants
  2. Recommendation ID: not provided. Recipient: not provided. Status: not provided. Summary: Conduct a comprehensive hazard review prior to performing any educational demonstration
  3. Recommendation ID: not provided. Recipient: not provided. Status: not provided. Summary: Provide a safety barrier between the demonstration and the audience

Key Engineering Lessons

  • Do not use bulk containers of flammable chemicals in educational demonstrations when small quantities are sufficient.
  • Use only the minimum amount of methanol needed for the demonstration; the CSB determined that only a few milliliters were actually needed for the Fire Tornado demonstration.
  • Prepare a written procedure that describes all of the activity details and all of the required safety precautions.
  • Conduct a thorough hazard review prior to performing any activity with flammable chemicals.
  • Provide a safety barrier between the demonstration and the audience.
  • Any person inside the barrier during a chemical demonstration activity, such as the person performing the activity, must wear all appropriate personal protective equipment.

Source Notes

  • Priority 1 final report information was used as the primary authority.
  • The incident involved a flash fire during a science demonstration at The Discovery in Reno, Nevada on September 3, 2014.
  • The CSB safety bulletin was titled 'Key Lessons for Preventing Incidents from Flammable Chemicals in Educational Demonstrations.'
  • Some schema fields in the source documents were not explicitly provided and are left blank.
  • https://www.csb.gov/key-lessons-for-preventing-incidents-from-flammable-chemicals-in-educational-demonstrations/

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