When adding elemental sulfur to a process line that once contained elemental mercury, it was expected that the vapor concentration of mercury would be reduced due to the mixing of mercury with the sulfur. What was not expected, or considered, was the reaction that could occur if the elemental sulfur came in contact with hot metal particles or shavings from the subsequent cutting operation that was performed after adding it to the inside of a pipe. Lessons Learned: Expected outcomes from an intentional change are important to understand. What is more important to understand is that an unexpected condition could occur when a changed condition is implemented if all aspects of the work are not considered and evaluated beyond the expected intentional change.
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