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Web Date: September 23, 2016

University of Hawaii fined $115,500 for lab explosion

State occupational safety and health agency found 15 workplace safety violations associated with blast that severely injured a researcher
Department: Science & Technology
Keywords: lab safety, hydrogen, oxygen, explosion
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The explosion shattered fume hood sash windows and knocked over equipment.
Credit: Honolulu Fire Department
Laboratory at the University of Hawaii after an explosion of gases occurred.
 
The explosion shattered fume hood sash windows and knocked over equipment.
Credit: Honolulu Fire Department

The University of Hawaii faces a total $115,500 fine for 15 workplace safety violations after a laboratory explosion in March on the university’s Manoa campus. Postdoctoral researcher Thea Ekins-Coward, who worked for the Hawaii Natural Energy Institute, lost one of her arms in the explosion.

Ekins-Coward was preparing a gas mixture of 55% hydrogen, 38% oxygen, and 7% carbon dioxide when an electrostatic discharge likely ignited the mixture, according to an investigation report issued in July by the University of California Center for Laboratory Safety. The gas mixture was to be used to feed bacteria to produce biofuels and bioplastics. The gases were combined in a 49-L steel tank designed for compressed air and not electrically grounded.

The safety violations cited by the Hawaii Occupational Safety & Health Division (HIOSH) include failing to do the following: reduce employee exposure to potential explosion and fire hazards, ensure safety practices were followed, perform periodic inspections to identify hazards, ensure employees wore appropriate personal protective equipment, make use of standard operating procedures, and require suitable exits from the laboratory.

HIOSH labeled all 15 violations as “serious” and assessed the maximum state penalty of $7,700 to each. The university must fix the violations by Oct. 21.

The university “will be requesting an informal conference with HIOSH to clarify the citations and discuss adjustments of the citations, as provided for in the HIOSH citations process,” according to a statement from the university. “Safety officers and leadership have been working diligently to further strengthen the culture of safety on the Manoa campus and foster an environment where hazard recognition and risk assessment are the standard of care for all activities,” the statement adds.

Both the Center for Laboratory Safety report and HIOSH findings show that the incident was avoidable, says Ekins-Coward’s attorney, Claire Y. Choo of the firm Danko Meredith. She and Ekins-Coward are evaluating whether to file a lawsuit against the university, Choo says.


University of Hawaii workplace safety violations identified by HIOSH

1. The employer failed to provide a safe workplace by reducing employee exposure to potential explosion and fire hazards.

2. The employer did not ensure that its safety practices were followed by employees and underscored through training, positive reinforcement, and a clearly defined and communicated disciplinary system.

3. The employer did not ensure periodic in-house inspections were being performed in Hawaii Natural Energy Institute laboratories to determine new or previously missed hazards.

4. Laboratory personnel working under the principal investigator did not use the required personal protective equipment at all times.

5. Two exit routes were not available in the laboratory to permit prompt evacuation of employees and building occupants.

6. The exit door did not swing out in the direction of exit travel.

7. The employer’s emergency action plan(s) did not list the evacuation meeting point nor a way to account for the evacuees.

8. The employer did not review the emergency action plan when employees were initially assigned.

9. A fire prevention plan did not include specific provisions to address potential ignition sources in the presence of hydrogen and other flammable gases.

10. Activities performed in the laboratory by researchers with the potential exposure to explosion and fire hazards were not assessed for appropriate personal protective equipment.

11. Activities performed in the laboratory by researchers with the potential exposure to explosion and fire hazards were not assessed for appropriate glove protection to guard against static discharge and flame-retardant laboratory coats to guard against fire.

12. Where hazardous chemicals were used in the workplace, the employer did not carry out the provisions of a written Chemical Hygiene Plan, which were capable of protecting employees from health hazards associated with hazardous chemicals in that laboratory.

13. The employer’s Chemical Hygiene Plan did not include the standard operating procedures relevant to safety and health considerations to be followed when laboratory work involved the use of hazardous chemicals.

14. The employer’s Chemical Hygiene Plan did not include criteria to determine and implement controls relevant to the gas mixing operation (engineering controls, personal protective equipment, administrative).

15. The employer failed to review and evaluate the effectiveness of the Chemical Hygiene Plan at least annually and update it as necessary.

Source: Hawaii Occupational Safety & Health Division Citation and Notification of Penalty to the University of Hawaii, issued Sept. 16, 2016.


UPDATE: The story was updated on Sept. 29, 2016, with a comment from Ekins-Coward’s attorney.

 
Chemical & Engineering News
ISSN 0009-2347
Copyright © American Chemical Society
Comments
William Smith (Mon Sep 26 01:19:12 EDT 2016)
Without knowing specifics of the accident, it is difficult to judge how appropriate these findings are. I am assuming that the explosion was external to the compressed air tank (used as a mixing tank) If not, then the pressure relief of the tank has failed.
The lab includes a lot of electrical equipment that does not appear to be intrinsically safe. The criticality of grounding a pressure vessel is much lower than the criticality of having intrinsically safe light fittings and electrical equipment.
The gas ratios were virtually stoichiometrically matched. Judging by the equipment in the lab, I dont think that this was a consideration for the personnel involved. I am guessing that their qualifications were probably in biology.
If my suspicions are correct, then addressing the 15 violations would not prevent such an explosion from happening. The violations are written in such a way that seem contrived to identify a false root cause. I believe them to be misleading.
Unfortunately, many personnel working in pure research are so specialized that they are not well equipped to assess or even recognize some potential hazards. Safety officers with engineering qualifications may help to bridge this gap.
Daniel Hall (Tue Sep 27 14:34:43 EDT 2016)
"If my suspicions are correct, then addressing the 15 violations would not prevent such an explosion from happening. The violations are written in such a way that seem contrived to identify a false root cause. I believe them to be misleading."

I don't agree with this assessment.

9.A fire prevention plan did not include specific provisions to address potential ignition sources in the presence of hydrogen and other flammable gases.

An investigative report indicates the ignition source was inside the compressed air tank. It seems as if #9 had been addressed with proper engineering controls then the potential for explosion from a ungrounded tank with a pressure gauge not rated as intrinsically safe would have been greatly reduced.

Andrei Novikov (Wed Sep 28 16:52:48 EDT 2016)
Well, the first thing the safety managers should have say aloud - it's a very bad idea to mix hydrogen and oxygen! If you got them together in 49-L steel tank, then missing arm might be considered still a lucky output.
All these citations most probably were intended to remind about the dangers, but they effectively obscure the main simple point: don't mix hydrogen and oxygen!
Jyllian Kemsley (Thu Sep 29 13:20:55 EDT 2016)
The UC Center for Laboratory Safety went more into the root causes. From that report: "the overall underlying cause of the accident was failure to recognize and control the hazards of an explosive gas mixture of hydrogen and oxygen."

http://cen.acs.org/articles/94/i28/University-Hawaii-lab-explosion-likely.html

https://www.documentcloud.org/documents/2942734-2016-07-01-U-Hawaii-CLS-Report-Technical-amp.html
Phil (Mon Oct 03 15:43:23 EDT 2016)
"The overall underlying cause of the accident was failure to recognize and control the hazards of an explosive gas mixture of hydrogen and oxygen."
How the heck did Prof. Yu manage to parrot facts all the way through grad school and to a professor position if he doesn't understand something this fundamental? Shame on the Hawaii hiring committee for not detecting this.
Carol Sampson (Tue Nov 15 12:56:17 EST 2016)
If you had read the story of this lab accident when it first occurred, I believe that the woman injured in the explosion had brought concerns of the apparatus she was using to the attention of her PI, who basically waved her off, instead of investigating, or contacting EHS. I would think a huge part of the responsibility of the accident rests there.
Dennis Leppin (Thu Sep 29 11:41:23 EDT 2016)
It is OK to mix hydrogen and oxygen but then immediately react them (combust them) just as we mix methane and air in a furnace. Pre-mixing them and keeping a stockpile around is what is the "bad" idea here. Why would that be necessary? You can have hydrogen and oxygen in compressed cylinders, and kept separate per OSHA regulations, and mix them on demand. If there is an explosion the amount of the gases involved is then minimal by comparison to 49 L.

In this case the particulars of this incident aren't important except to highlight the completely unacceptable safety culture that exists at this workplace. This is not atypical of University labs, it seems, at least until they have had an incident and injuries to personnel, who usually are students. If anything, the fine is a joke considering the nature of the injury to the student, but it will buttress a very strong civil case at which I am sure millions in damages will be awarded. I think it likely that the University is contesting the findings of HIOSH for that reason, not to weasel out of the $7K fines per violation cited.
K.N. Krishna Prasad (Fri Sep 30 15:13:22 EDT 2016)
It is not mentioned whether a lab scale experiment had already been conducted and a SOP had been formulated. A 49 liter steel cylinder has been used for mixing the gases. It means it is not a lab scale experiment. It appears the place of work is clutter-red.
The researcher, Thea, was working alone. Also, there was no supervisor nearby? Serious violation of common rules and regulations,I am afraid, has made the matter worse.

K.N.Krishna Prasad, Chemical engineer and OSH professional, Mysuru, India.
Pickles (Wed Oct 05 12:21:59 EDT 2016)
In a previous article, which was released closer to the time of the incident, it was reported that the researcher had performed the experiment previously and had a small explosion in the hood. She reported the event to her professor, and also expressed her unease with the experiment. She was told that everything was fine, not to worry, and she should continue on with her experiments. I'm not sure about an SOP being drafted, or if there was anyone else in the lab (I don't think there was) but all safety violations aside, she shouldn't have been working in the lab until the initial small explosion was investigated.
Jyllian Kemsley (Thu Oct 06 15:14:17 EDT 2016)
From the Center for Laboratory Safety report:

"One day before the accident, on March 15, 2016, the postdoctoral research reported a “cracking sound” within the 1 gallon pressure vessel to her PI. The reaction occurred when the postdoctoral researcher depressed the On/Off button of the vessel’s digital gauge. The researcher opened the vessel and discovered that the petri dishes inside were singed and cracked. The gauge had a smaller error range and had been added to the experimental set-up in February 2016; it allowed the researcher to more accurately follow gas consumption by the bacterial cultures over time. The gauge was not rated as intrinsically safe. After reporting the incident, the PI strongly advised the researcher not to use the vessel again."

To be clear: The vessel that she was not to use again was the 1 gal (3.8 L) one. They didn't appear to think that the explosion in the smaller one was indicative of a problem with the bigger one.

Quote from page 7 of this document: https://www.documentcloud.org/documents/2942734-2016-07-01-U-Hawaii-CLS-Report-Technical-amp.html
Ronald Myers (Wed Oct 05 07:56:30 EDT 2016)
The basic underlying cause of this tragic incident is simply a very poor (seems to be almost non-existent based on the list of violations) safety-minded culture at University of Hawaii (UH) ! We can argue all we want about the use of an explosive mixture of gases, but that argument completely misses the crucial point. Unless UH takes heed and makes huge corrections to its safety training and safety adherence, this type of incident, I fear, will happen again. In my opinion, the monetary fines should be multiplied in cases such as this, where an obvious disregard of employee safety seems to have been demonstrated !
Pedro Arrechea (Wed Oct 05 12:38:16 EDT 2016)
I really think these citations missed the point. They built a bomb by mixing a large quantity of hydrogen and oxygen and were then surprised it found an ignition source and exploded.

They could have corrected all the deficiencies (15) listed but these would not have addressed the underlying lack of common sense.

As cited by one of the above commentators:
"the overall underlying cause of the accident was failure to recognize and control the hazards of an explosive gas mixture of hydrogen and oxygen."

David Mendenhall (Wed Oct 05 15:25:53 EDT 2016)
Everyone is blaming a deficient "safety culture" whatever that is, failure to follow tedious bureaucratic procedures, or the professor. I filled a balloon with hydrogen from zinc and sulfuric acid when I was about 11 years old, and then set fire to it. I blame the female postdoc for being incredibly ignorant of the properties of simple gases. Good candidate for the Darwin Award. The standards for getting an advanced degree in chemistry have apparently become very very low.
Jyllian Kemsley (Thu Oct 06 15:54:41 EDT 2016)
There is some evidence that the postdoc was aware of the hazards of the gases and questioned the PI about them, but we don't know how he responded. See pages 9-10 of https://www.documentcloud.org/documents/2942734-2016-07-01-U-Hawaii-CLS-Report-Technical-amp.html.
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