Strengthening today's laboratory safety culture through better management
Because the Safety Guys write about this stuff all the time, you know that laboratory workers are exposed to numerous hazards spanning biological, chemical, physical, and radioactive risks. Repetitive tasks of production labs and high-volume analytical labs as well as the challenges of handling research animals can also lead to musculoskeletal disorders. The diverse and serious potential hazards faced daily by laboratory workers begs two questions: Are our labs safe enough? Are we doing our best to protect our laboratory workers? Sadly, given some examples below, the answer is definitely not.
Research laboratories conduct work on the forefront of technology and innovation. This often entails working with dangerous materials and unknown reactions. Progress demands that this research continue and thrive. However, it must be done with effective safety management in place and within a strong safety culture at the institution. This is not always the case, particularly in academic settings. A rash of recent serious accidents sheds light on the fact that we could and should be doing better. Granted, these are taken primarily from academic labs, but that is only because that is where we Safety Guys practice in our day jobs. We are sure that if we looked long and hard enough, we could find similar incidents in nonacademic settings.
Making the case for stronger safety culture and management programs
During the past few years there have been a number of very serious laboratory accidents that have resulted in severe injuries, extensive facility damage, and even fatalities. Given the facts, the labs may have been lucky that damages and injuries were not worse. We present a brief summary of a few recent events and findings by the Chemical Safety Board (CSB) to make our case for needing a stronger safety culture and better management programs.
2010, Texas Tech University2
Two graduate students were conducting research for the Department of Homeland Security on explosive compounds. They were given the task of synthesizing and testing a new compound, a nickel hydrazine perchlorate (NHP) derivative. The faculty principal investigators believed they had verbally established a limit of 100 milligrams for production of the material. Through interviews of graduate students on the project, the CSB found that initially the compound was made in small batches of 300 milligrams. The two graduate students decided to scale up the production to 10 grams to make one batch of material for all their testing. The senior member of the team noted the large batch contained clumps, which he thought needed breaking up prior to conducting their testing. The students believed that keeping the compound wet with a solvent would prevent it from exploding. As the project lead graduate student started to break up the clumps, the material detonated. The student was severely injured, losing three fingers of his left hand, having his eye perforated, and sustaining cuts and burns on the rest of his body.
The CSB investigation following the incident found that there was no formal system for communicating or documenting the limit on compound synthesis. Nor was there any auditing by the principal investigators to verify compliance. Further, the CSB discovered there had been two near misses with similar causes in the laboratories of the same principal investigators since 2007. However, due to the lack of a reporting system for auditing, documenting, and reviewing incidents, these important lessons were not passed on to project members.
June 2010, University of Missouri3
The biochemistry lab involved in this incident conducted research on anaerobic bacteria, organisms that cannot live in the presence of oxygen. The bacteria were cultured in a microbiologic anaerobic growth chamber that was about two cubic meters in size. During routine setup of the growth chamber, the standard operating procedures called for initially purging the chamber with nitrogen. Then small amounts of pure hydrogen were introduced to remove any remaining oxygen by combining to form water. The source of the hydrogen was a standard 55- inch-tall K-size cylinder. Apparently, the student researchers were not very familiar with the setup and operation of the gas delivery system. Following a check for leaks in the hydrogen gas lines, the valve for the hydrogen cylinder was inadvertently left open. Hydrogen introduced into the chamber reached an explosive level and was ignited by a source in the chamber, according to investigators. Four researchers were injured, and the lab was destroyed.
Fortunately, none of the injuries in this incident were serious. One student who was admitted to the hospital was released the following day after treatment for burns. The lab was a total loss, but the building’s sprinkler system put out the resulting fire, limiting damage to adjacent areas. The hydrogen cylinder did not explode, and secondary impacts were minimal. Even so, building repairs ran to several hundred thousand dollars, and the cost to repair and replace equipment will probably double that figure.
December 2008, University of California, Los Angeles4
This widely publicized incident occurred in an organic chemistry lab in the UCLA Molecular Science Building. A newly hired but experienced research associate was planning to scale up a reaction using tert-butyllithium (t-BuLi), a pyrophoric material, meaning it ignites spontaneously on contact with air. The research associate intended to add three 54-milliliter aliquots of t-BuLi in pentane to a reaction flask placed in a dry ice/acetone bath, and then combine them with vinyl bromide to create vinyllithium, the first part of a multistage process.
Handling pyrophorics is tricky. Normally it is done using inert gas, such as nitrogen or argon, and prepared glass syringes with one-to-two-foot-long needles. For reasons unknown, the research associate was using a plastic syringe with a two-inch needle, requiring tipping the reagent bottle up in order to fill the syringe. In addition, she was wearing only nitrile gloves, safety glasses, and street clothes, including a synthetic sweater. No lab coat was used. The syringe and plunger separated during the first attempt at filling the syringe, and the t-BuLi and pentane spilled on her hands and sweater, immediately bursting into flames. In the ensuing panic the associate ran from the area, although a safety shower was just six feet from the hood where she was working. A fellow postdoc working in the same lab was able to smother the flames with his lab coat—but not before the research associate sustained third-degree burns on her hands and second-degree burns on her arms and abdomen, covering about 40 percent of her body. After she spent 18 days in a specialized burn center, her organs began to fail and she succumbed.
This horrific fatal accident has garnered much media attention. UCLA was fined about $32,000. But most of the attention is due to the fact the local district attorney has filed felony labor code violations against the principal investigator, the first criminal prosecution of an American academic for a lab accident. Was the principal investigator grossly negligent, or was he following standard protocol for academic research? The trial is under way and should help answer these and other questions.
Moving toward a better safety culture
“The most difficult thing to do is change a culture.” That quote is from Bill Tolman, the chair of the chemistry department at the University of Minnesota.4 Looking at the examples presented above, the need for a better safety culture, especially in academia but also in general industry, cannot be denied. How do we do this? What steps are necessary to move us closer to safe and healthy research laboratories and workplaces? Below are our answer, opinion, and plan.
Prevention = Training
As Safety Guys, we believe prevention is the best medicine and that it starts with training. However, we would venture to say that most of us consider training just another item to check off, a small headache that we have to deal with and perform in order to comply with regulations. Granted, many regulations do address training, and a few go as far as to make it mandatory. The Safety Guys have covered (and will continue to write about) these mainstays of safety: the OSHA Lab Standard and Hazard Communication Standard and specific chemical standards that are common to research laboratories. Add OSHA respiratory protection and hearing conservation standards plus EPA hazardous wastes regulations and you have a very full complement of routine or annual training requirements.
If we truly want to move training away from the mundane and advance toward real prevention, we need to make good training a priority and put most of our effort into ensuring that it is done well and that employees take it to heart. To do this, incorporate a wide variety of training methods and use everything at your disposal. Online, computer-based training can reach large numbers of employees with computer access. Videos are very helpful, especially if well done, but should be updated or replaced every so often or they will become stale. In-person training is still probably the most effective, but don’t let those PowerPoint presentations go too long without updating and tailoring them to your specific audience or topic. Try inserting short video clips (YouTube videos) to make important points and maintain interest. We Safety Guys are also big fans of short tests administered immediately following the training session to demonstrate understanding and comprehension. Consider the use of even briefer pop quizzes given unannounced to see whether employees are retaining the most critical information. And finally, retrain whenever the need arises, such as when a breach in protocol, a near miss or close call, or, heaven forbid, an accident or injury occurs.
Prevention = Observing
What do we mean by this, you ask? Think about it. How busy are you in your day-to-day activities? Dealing with all the little things that come up while trying to finish your must-do list, maybe you feel overwhelmed. When did you last take the time to observe your employees performing their work?
By observing we mean conducting regular inspections of the lab, chemical storage room, and other areas under your supervision. And performing occasional audits. Checking the chemical inventory, safety data sheets, training records, and standard operation procedures, sure. But mostly we would ask that you simply watch. Are the proper procedures being followed? Does it look and feel right? Is there anything that could be done differently or changed to flow better, be more efficient, or, most important, performed more safely? In addition to watching, ask employees for feedback. Perhaps they have ideas on improving certain procedures or operations. They perform the tasks daily; what better source is there for positive change? Finally, we want to stress documentation. Record your observations, employee input, training needs, and anything else that you feel needs attention. Set definite dates for follow-up and completion of corrective actions.
Prevention = What if … ?
Statistics on the differences between academic and industrial safety are sparse, to say the least. But nobody seems to dispute that safety culture at universities is widely divergent from safety culture in private, industrial, and production facilities. The reasons for this are far-ranging and complex and beyond the scope of this article yet perhaps the topic of a future one. However, one reason may be a program referred to as Process Safety Management.
Process Safety Management, or PSM, is an OSHA regulation that applies only to certain facilities that handle specific chemicals classed as highly hazardous and in large quantities above the standard’s published thresholds.5 The emphasis of this OSHA standard is management of the hazards associated with these very dangerous chemicals to prevent unexpected releases that create the real possibility of disaster if not properly controlled. The relatively substantial threshold quantities mean that the standard generally applies only to large production facilities. However, we feel that PSM and especially the major components have much wider applicability and should be considered for all laboratories handling hazardous materials.
The purpose of PSM is succinctly summarized as preventing or minimizing the consequences of catastrophic releases that may result in toxic, fire, or explosion hazards. Given that catastrophic is defined as “a major uncontrolled release that presents serious danger to employees in the workplace,” we can all agree this is easily applied to most research labs handling hazardous materials.
The main component is the process hazard analysis (PHA); all hazards involved in the process are identified, evaluated,and (hopefully) controlled. In industry the PHA is performed using a number of different methodologies such as hazard and operability studies, failure mode and effects analysis, fault tree analysis, or simple checklist/what-if scenarios as appropriate to the complexity of the process. We think the latter what-if method is a perfect one to use in most laboratory situations. In developing your standard operating procedures, take the time to ask “What if ?” for each step of the operation. As you work through each “deviation”—considering the worst-case scenario and its causes, consequences, possible safeguards, and recommendations—you very likely will uncover appropriate controls, both engineering and administrative, that will greatly improve safety. We challenge you to play “What if ?” and see whether your safety culture is stronger for it.
1. Safety and Health Topics: Laboratories, Occupational Safety and Health Administration, US Department of Labor. Washington, D.C. April 2014. https://www.osha.gov/SLTC/laboratories/
2. “CSB Releases Investigation into the 2010 Texas Tech Laboratory Accident,” Chemical Safety Board. Washington D.C. October 2011. http://www.csb.gov/csb-releases-investigationinto-2010-texas-tech-laboratory-accident-case-study-identifies-systemic-deficiencies-in-university-safety-management-practices/
3. “Investigation of Schweitzer Hall Explosion Complete,” University of Missouri News Bureau. Columbia, MO. July 2010 http://munews.missouri.edu/news-releases/2010/0709-investigation-of-schweitzer-hall-explosion-complete/
4. “A Young Lab Worker, a Professor and a Deadly Accident,” Kate Allen, Toronto Star. March 30, 2014. http://www.thestar.com/news/world/2014/03/30/a_young_lab_worker_a_professor_and_a_deadly_accident.html
5. Process Safety Management of Highly Hazardous Chemicals, Occupational Safety and Health Administration, US Department of Labor. Washington, D.C. February 2013. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9760