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Posted on October 10th, 2016 by Mike Schmidt in Chemical R&D
“Once trained, the hazard often becomes a routine part of their experimentation and researchers perceive themselves to be experts in handling the hazard. Perceived familiarity can shift the awareness level from cautiousness to complacency.” University of California Center for Laboratory Safety, June 29, 2016
It didn’t get much press. Science reported on it, as did Chemical & Engineering News, but neither journal considered it their cover story. At the end of June, the UCCLS published their two part Report to University of Hawaii at Manoa on the Hydrogen/Oxygen Explosion of March 16, 2016. Report 1 is a 73 page technical analysis of the accident; Report 2 is a 38 page description of recommendations for improvements in UH laboratory safety programs. These reports speak volumes about changes that need to occur in research settings to improve process safety, not just at the University of Hawaii, but throughout the research community—academic, government, and industrial.
What Happened at UH?
The experiment at UH used a mixture of hydrogen, oxygen, and carbon dioxide. Not surprisingly, the mixture was flammable. For much of the program, the components were stored separately and mixed at the point of use. Just prior to the March explosion, however, the researcher reconfigured the experiment to use premixed gas supplied from a 50 liter pressure tank. Reportedly, the mixture was 55% hydrogen, 38% oxygen, and 7% carbon dioxide, at 120 psig. (The flammable limits of hydrogen in air at atmospheric pressure is 4 – 75%. Increasing the concentration of oxygen and increasing the pressure both have the effect of increasing the flammability as well as increasing the intensity of the energy released.) A static discharge ignited the flammable mixture, causing an explosion that destroyed the lab and dismembered the post-doc running the experiment, who lost an arm.
Both the post-doc and the principal investigator to whom she reported had consistently expressed interest in lab safety. Nonetheless, there was no hazard assessment before the experiment was reconfigured, no management of change. Undoubtedly, the change was intended to address a problem associated with operability or control, but the first time the modified process was used it had catastrophic results.
Interest in Safety
This incident, and most laboratory incidents for that matter, did not result from a willful disregard for safety. The record clearly shows that the researchers involved cared about safety. Caring about safety, however, does not confer expertise in safety.
We have worked with hundreds of clients leading safety reviews performed. Of those, we have been engaged to work only a handful of academic projects. In each case, it was because the researchers had industrial partners that insisted on formal hazard reviews as a condition of providing funding. In each case, the academic researchers were unconvinced prior to the review that it would discover anything of interest. In each case, after the review was completed, the team of academic researchers agreed with their industrial partners that it had been a valuable exercise and their research facilities were safer as a result. More importantly, the grad students and post-docs that would actually be operating the facility had a sense of what they needed to do to keep themselves safe.
Written in Blood
The UCCLS report shared faculty “trepidations” that “the University would impose broad requirements on faculty and research groups as a result of the incident that do not directly impact actual laboratory safety.” This is almost always the response to increased regulation: the regulated community expresses concern—trepidations—that formal requirements will pose a burden and not actually do any good. No one wants more rules. In the communities that have already accepted these requirements, however, there is no push to go back to the previous status quo.
There is a saying in the safety community: “Safety regulations are written in blood.” The adage acknowledges that safety regulations are only written after a catastrophic incident or series of incidents have made it painfully clear that something must be done, that the status quo is unacceptable.
The idea that the research environment is somehow immune to the hazards that haunt the rest of chemical enterprise is firmly embedded in our culture. Even the standards that regulate chemical safety accommodate this notion. The EPA’s Risk Management Planning Rule (RMP) explicitly excludes activities in laboratories [ 40 CFR 68.115(b)(5) ]. OSHA’s Hazard Communication standard makes an exception for laboratories to have a written hazard communication program [ 29 CFR 1910.1200(b)(3) ]. Too many researchers have come to believe that they are too smart to let something bad happen. Yet these incidents continue to happen.
A Fool for a Client
Kemsley quotes Craig Merlic, UCCLS executive director and chemistry professor at UCLA: “The message to other researchers is that they need to do a better job of educating themselves about the hazards of the materials they’re working with.” The issue is not just with the materials, but with the processes and the equipment. Moreover, education by self-study is unlikely to be adequate. Lawyers are fond of saying that a man who represents himself has a fool for a client. The same can be said for process safety. There is a reason that most industrial organizations insist on third party evaluations, even if the third party comes from elsewhere in the organization.
In the Mean Time
The comments here are addressed specifically at academic laboratories, but they also apply to other laboratory environments, especially those staffed with highly educated chemical professionals. Most of us are interested in safety, but many of us are inclined to give ourselves more credit for being safe than is warranted. Lab safety, like all process safety, should never be an afterthought. It should be integral to all that we do, from the moment we begin conceiving our experiments and processes. The application of safety principals to the laboratory is not an innate ability but a learned skill. Learning to be safe requires teachers that know how to be safe.
If you are responsible for safety in a laboratory, make sure that you are qualified to teach others how to be safe. A PhD in chemistry, unfortunately, is not necessarily a qualification. If, on honest self-examination, you determine you are not qualified, make sure you seek out someone who is.
If you are an organization where laboratory safety is a concern, make sure that qualified resources are available. It is unfair to the personnel actually working in the lab to do any less. Then make sure they are used. In an environment where there is always too much to do and too little time to do it, shortcuts will always be a temptation.
Finally, if you work in a laboratory, insist on being trained on the hazards with which you work. It is your right. Do not be cowed or shamed into ignoring hazards. When a finger, or an eye, or a life is lost, it will be yours.
 Benderly, B.L., “Report on UH lab explosion reveals deep, systemic safety failures,” Science, AAAS. 7-Jul-2016. Accessed on 11-Jul-2016 at http://www.sciencemag.org/careers/2016/07/report-uh-lab-explosion-reveals-deep-systemic-safety-failures.
 Kemsley, Jyllian, “University of Hawaii lab explosion likely originated in electrostatic discharge,” Chemical & Engineering News, ACS, 94:28, p. 5.
 Merlic, C., E. Ngai, I. Schroeder, and K.Smith, “Report to the University of Hawaii at Manoa on the Hydrogen/Oxygen Explosion of March 16, 2016, Report 1: Technical Analysis of Accident, UCCLS, 29-Jun-2016, Accessed on 11-Jul-2016 at https://cls.ucla.edu/images/document/Report%201%20UH.pdf .
 Merlic, C., E. Ngai, I. Schroeder, and K.Smith, “Report to the University of Hawaii at Manoa on the Hydrogen/Oxygen Explosion of March 16, 2016, Report 2: Recommendations for Improvements in UH Laboratory Safety Programs”, UCCLS, 29-Jun-2016, Accessed on 11-Jul-2016 at https://cls.ucla.edu/images/document/Report%202%20UH.pdf
All opinions shared in this post are the author’s own.
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Principal, Bluefield Process Safety, LLC
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