Investigation of drum pressurization incident in the 331 Building, Room 175 on January 10, 1995

On January 10, 1995, a pressurized drum incident occurred at the 331 Building, Room 175. On January 12, 1995, the Manager of the Life Sciences Center appointed members to an Investigation Board to investigate the incident (see Exhibit A). This incident was initially categorized as an Off-Normal Occurrence, but was later elevated to an Unusual Occurrence by the Occurrence Classifier. The scope of this investigation was to employ a formal method of root cause analysis, identify the methodology, and report the results of the analysis, fully explaining the technical elements of the causal sequence along with a description of the barriers that should have or could have prevented the occurrence. During the course of the investigation, the scene of the event was not accessible. Therefore, the investigation relied primarily on testimony from staff members directly involved and their management. In addition, other outside professionals were also consulted. The Investigation Board visited the previous location of the drum, 331A Building, Room 9; Room 173, which fronts room 175, was also visited. The Investigation Board reviewed selected documents, which are also listed