Investigation of a light fixture fire

Abstract

Metal-halide lamps produce light by discharging an electric arc through a gaseous mixture of vaporized mercury and metal halides. Metal-halide lamps for use in spaces with lower mounting heights can produce excessive visual glare in the normal, higher field-of-view unless they are equipped with prismatic lenses. Should the bulb fail, high internal operating pressure of the arc tube can launch fragments of arc tube at high velocity in all directions, striking the outer bulb of the lamp with enough force to cause the outer bulb to break. This article reports an investigation of a light fixture fire and reviews a case study of a metal-halide lamp fire. Causal analysis of the metal-halide lamp fire uncovered contributing factors that created the environment in which the incident occurred. Latent organizational conditions that created error-likely situations or weakened defenses were identified and controlled. Effective improvements that reduce the probability or consequence of similar metal-halide lamp fire incidents were implemented.

Investigation of a “Sharps” incident

“…The use of cause-and-effect diagrams in the analysis of glove breaches and failures and air-purifying respirator, drum handling, and metal-halide lamp fire incidents, have been previously reported in this journal. 9 In this incident, replacement of a razor blade with a utility knife was the active error that triggered the immediate, undesired consequence: a cut to the thumb requiring three stiches, as shown in Figure 1. In the causal analysis, engineering, equipment, human performance, and management issues were uncovered.…”

“…With the advent of 3D printing, 11 The previous papers in this series published in this journal discussed the value of a Lessons Learned Program. 3,9 As the causal node, A4B1C06, in Table 1 demonstrates, the Lessons Learned Program used was not effective. Four incidents of fingers and thumbs getting cut with sharps were documented during the last ten years.…”

“…Using an approach similar to that presented in the "Light fixture fire" paper, 9 the fact finders identified the following steps that can be taken to ensure implementation of Lessons Learned related to fingers and thumbs getting cut with sharps:…”

A Fuzzy Petri-Net Approach for Fault Analysis Considering Factor Influences

“…Causal analysis can reveal the importance of each factor to an event and thus can help us to prevent the event or to investigate the event. There have been some studies on causal analysis of various events [35]- [38].…”

Turning Outsiders into Insiders: A Call for Papers to Expand the Reach of National Laboratories’ Safety Successes, Challenges, Research, and Approaches

“…In the Laboratories’ never-ending quest to learn more, understand better, and advance scientific discovery further, this VSI seeks to glean safety insights from my colleagues across the DOE National Laboratories networkfrom both the professionals with safety in their job titles and those creating safety in their day-to-day work. Innovators at the Laboratories have previously published fundamental chemical safety research and data analysis, negative outcome case studies, chemical health and safety warnings, chemical safety and security risk assessments and management, emergency response, and health and safety education . Yet this collection of work leans heavily on a limited number of the 17 Laboratories from before 2018, suggesting there is much more to share.…”