Lessons Learnt from a Tragic Chemistry Laboratory Accident
A fatal accident happened in an organic chemistry laboratory at the University of California, Los Angeles (UCLA) in late December, 2008. A research assistant was using a syringe to transfer about 50 mL of a pyrophoric chemical (a substance that catches fire spontaneously once exposed to air), tert-butyl lithium, dissolved in pentane, a flammable solvent. The plunger suddenly came apart from the syringe barrel, causing the pyrophoric chemical to spew onto the hands and body of the researcher and catch fire. Even though the fire was finally put out by other laboratory workers, the researcher suffered second to third-degree burns to over 43% of her body. She died in January 2009 due to the burns and the resulting complications, after 18 days in the hospital.
Accident investigations were conducted by the university and the government. A fine of more than US$31,000 was imposed by the State of California to the university in early May, 2009 for civil violation of multiple safety regulations. Criminal investigation is still ongoing. The findings so far highlighted a number of deficiencies in the chemical safety management and practices in the laboratory in question. These can serve as sobering reminders for all laboratory chemical users everywhere:
Adequacy of risk assessment. The appropriateness of using a syringe to transfer pyrophoric liquid in the experimental procedure was questionable. There was no record of any risk assessment conducted of this critical operation involving a highly hazardous chemical.
Adequacy and record of safety training. The deceased research assistant was a fresh graduate, and had joined the research group for only three months. It was unclear how much training was given to her, or whether it included any specific and hands-on training related to handling pyrophoric chemicals and emergency response procedures. The fact that the victim ran in the direction away from the nearest emergency shower after the accident might indicate there was inadequate safety training. A family member of the deceased person alleged that no safety training was ever provided. In any case, there was no safety training record available.
Proper use of fume hood and other safety devices. The victim was conducting the chemical transfer inside a fume hood, however, the sash of the fume hood was apparently raised too high to prevent the chemical from spewing onto the body of the victim. If the sash was at a lower position, or if a blast shield or a similar barrier had been placed between the body and the chemical, it might have restricted the injury to the hands and forearms.
Lack of protective clothing. The victim was wearing a pair of rubber gloves, which were not flame-proof, and she was not wearing a laboratory coat when the accident occurred. It also happened that she was wearing a sweater that was made of highly flammable synthetic material at the time. These factors combined to create a highly unfavorable situation when the pyrophoric material caught fire.
Inadequate supervision and unsatisfactory safety management. The laboratory in question was inspected two months before the accident and was found to be lacking in various aspects of chemical safety, such as improper storage of hazardous chemicals, missing first aid kits and chemical spill kits, personnel not wearing personal protective equipment such as eye protection, laboratory coats and gloves. The situation was not corrected after the due date for corrective actions. These all pointed to lack of supervision from the professor in charge of the research laboratory.
Links to Los Angeles Times articles:
In HKUST, at the beginning of each safety training class offered by HSEO, participants are reminded that the training class only covers chemical safety principles, while each supervisor has the responsibility to provide specific safety instructions and hands-on safety training to staff and students working under him or her. Moreover, science and engineering departments that use hazardous materials and potentially dangerous operations in their laboratories also have a departmental safety clearance procedure, which individually assesses and documents the needs of specific safety training, personal protective equipment of each new laboratory worker. The safety clearance form also documents the completion of safety induction in the laboratory environment, including showing the new worker where key safety features, such as fire alarm, emergency eye wash and shower, are located. These are important tools for us to systematically ensure proper hands-on safety training is given to new laboratory workers, and to document such effort for inspection by university management and relevant government authorities.
We would like to take this opportunity to remind all HKUST laboratory supervisors and workers, and in particular, faculty members who are principal investigators of research projects, that risk assessment and hands-on safety training are crucial to chemical safety in laboratories. Besides, these crucial elements can only be accomplished by the initiative of laboratory supervisors and faculty members. This is a good time for departmental management and faculty members to review how well these procedures are being implemented in their departments and laboratories, and whether proper records are available to document these efforts.
We must rely on the continuous efforts of laboratory supervisors and workers, the management oversight of department heads, and the support of relevant campus units including HSEO, to achieve and sustain a safe research environment.