A fire at one university that led to a researcher’s death and an explosion at another that seriously injured a graduate student are among several incidents in the past few years that have turned a spotlight on safety practices in academic chemistry laboratories.
Since 2001, more than 120 university lab accidents have caused injuries, millions of dollars in damages, and one death, according to the federal Chemical Safety & Hazard Investigation Board (CSB). In a report released on Oct. 19, CSB presents details of one of them—a Jan. 7, 2010, accident in a Texas Tech University chemistry department lab in which a graduate student lost three fingers on his left hand, burned his hands, and injured his eyes.
The Texas Tech investigation is CSB’s first examination of an accident involving a university laboratory. But the board emphasizes that its recommendations are applicable to all academic research settings and could protect the more than 110,000 students and postdoctoral researchers working in hundreds of U.S. academic labs. Also, CSB last week released a safety video directed to researchers working in academic labs.
CSB identifies a long list of parties responsible for the accident at Texas Tech. They include the graduate student, the faculty members and administrators who allowed safety gaps that led to the accident, and the Department of Homeland Security (DHS), which funded the energetic materials research project that detonated.
The report makes a host of suggestions to improve academic lab safety. Additionally, CSB has advice for the American Chemical Society, which publishes C&EN. The 163,000-member organization of chemical professionals, the board urges, should develop “good practice guidance that identifies and describes methodologies to assess and control hazards” that occur in academic research labs. CSB notes there is no such guidance now that is specific to the “unique cultural and dynamic nature of an academic laboratory.”
The Texas Tech accident occurred when fifth-year graduate student Preston Brown, under a DHS-funded contract, synthesized an explosive compound as part of a search for methods to detect energetic materials that could pose a security threat (C&EN Online Latest News Jan. 20, 2010 ).
Brown had started working with energetic materials a year prior to the incident but received no formal training for working with such compounds, CSB says. In preparation for his research, Brown conducted his own literature review to familiarize himself with energetic compounds.
On the day of the accident, Brown and a first-year graduate student he was training synthesized a 10-g batch of nickel hydrazine perchlorate. Brown took half of the batch, noted it was lumpy, and put it in a mortar. Believing that the compound would not ignite or explode when “wet,” he added hexane and then used a pestle to try to break up the chunks. The compound detonated in Brown’s hands; Brown was not wearing eye protection. The other student was not injured (C&EN, Aug. 23, 2010, page 34).
Brown made mistakes, but CSB investigator Mary Beth Mulcahy bristles at claims that he was at fault. “If you take Preston out of the situation, it wouldn’t matter,” Mulcahy says. She and CSB team leader Cheryl MacKenzie headed the board’s investigation of the Texas Tech accident. “All of this would have still happened with or without him, and unless something is done, this kind of accident will happen again,” Mulcahy says.
Mulcahy points to a string of safety gaps that led to the accident. For example, the laboratory had no written protocols or procedures for synthesizing energetic materials. And there were no written policies regarding safety precautions—including how much material the students could make. Synthesis of explosive compounds was to be limited to 100 mg, but the principal investigators (PIs), chemistry professor Louisa J. Hope-Weeks and chemical engineering professor Brandon Weeks, had only expressed the limit verbally to some students. None of the students interviewed by CSB, including Brown and his partner, were aware of the 100-mg limit.
Texas Tech as an institution further lacked a safety management oversight and accountability system, the report says. The university’s Environmental Health & Safety (EH&S) office was treated as a “consultant,” advising departments on how to improve safety rather than having the power to change conduct or shut down a lab. The office was not even required to report the results of its safety inspections to those with administrative authority over faculty, according to the report.
The university also had no formal mechanism to document, track, or communicate lessons learned from similar incidents. In fact, two near-misses had occurred within the same research group. One involved an erroneous scale-up of a synthesis to 30 g and was witnessed by Brown but not documented by the university.
The experiment’s funding agency also dropped the ball, CSB says. Although the funding agreements included stock language regarding research involving human and vertebrate subjects, they “included no particular provisions for the safety of researchers working with energetic compounds, with the exception of a general condition making researcher safety the university’s responsibility,” the CSB report says. CSB calls this “a missed opportunity to influence positive safety management and behavior,” noting that DHS is one of some 19 federal agencies that provide more than $25.3 billion to academic institutions for scientific research. Those agencies could exert great power to influence safety behavior of researchers they support.
During the nearly two years since the incident, Texas Tech has made many changes to its safety programs, says Alice Young, the university’s associate vice president for research in charge of research integrity. To begin, the EH&S office, which formerly fell under the vice president for administration and finance, was moved under the aegis of the vice president for research and now reports to Young.
The university is also incorporating responsible scholarship and research—including safety-related activities—into faculty annual reports and is discussing ways to consider safety in tenure and promotion decisions, Young tells C&EN. EH&S representatives are becoming involved in hiring decisions and participated in lab renovation planning for a new chemistry professor this year. The result was a change in the physical layout of the lab to separate computer and bench work, Young says.
Texas Tech is also setting up a faculty chemical safety committee, with powers and responsibilities similar to other oversight committees, such as its Biosafety Committee, Animal Care & Use Committee, and Institutional Review Board for research on human subjects. Chemical safety had previously been managed through the Biosafety Committee, but the dual purpose diluted its impact on chemical safety, says T. Taylor Eighmy, Texas Tech’s vice president for research.
Eighmy believes creation of a new, stand-alone committee focused on chemical safety offers a better chance to engage faculty, departments, and colleges in a dialogue to improve the safety culture at the institution.
CSB has six key lessons for the academic research community:
1. Laboratory safety management plans must include physical as well as chemical exposure hazards.
2. Institutions should ensure that research-specific hazards are evaluated and mitigated.
3. Laboratory researchers need guidance documents to help manage hazardous chemicals that are unique to their research environments.
4. Research-specific written protocols and training are necessary to manage laboratory research risk.
5. Academic institutions must ensure that safety inspectors report directly to those with authority to implement improvements.
6. Incidents and near-misses should be documented, tracked, and communicated.
SOURCE: Adapted from Texas Tech University Laboratory Explosion Case Study, CSB No. 2010-05-I-TX
TTU has also made safety part of its responsible conduct of research training, which is required for students supported by National Science Foundation grants, and Texas Tech is mandating this training for all students working in labs that get NSF funds.
This past September, the university brought in the Laboratory Safety Institute, a lab safety training organization, to give seminars to senior administrators and anyone else on campus who wanted to attend. Students could get NSF training credit for attending, Young says, but they had to apply the safety material by writing a description of how the content presented at the seminar affects their research. Additionally, a new cumulative exam required for chemistry graduate students will cover responsible conduct of research topics, including laboratory safety.
For its part, in response to the incident, DHS has introduced a research safety plan requiring contractors to identify research hazards and ensure that processes and protocols conform to safety principles and parameters.
Beyond those changes, CSB has several key lessons aimed at the academic research community as a whole. One of those is to recognize that the Occupational Safety & Health Administration’s laboratory standard, on which many academic institutions base their laboratory safety plans, is directed at health hazards of chemical exposure and does not address physical hazards of chemicals. That is a gap that should be addressed by institutions, CSB says.
On Oct. 13, OSHA released new educational materials, a portion of which is intended to protect lab workers from physical hazards. However, CSB’s MacKenzie says an important gap remains since the new document still does not emphasize physical hazards of chemicals, particularly those that are pyrophoric, energetic, or explosive. In regard to “physical hazards,” the document focuses instead on ergonomics, noise, and ionizing hazards.
Generally, according to CSB, “academic institutions should ensure that practices and procedures are in place to verify that research-specific hazards are evaluated and mitigated.” But CSB says that guidance on how to manage hazards in academic labs is lacking. Although tools are available for industrial settings, the board says, they cannot be easily transferred to the academic environment.
Consequently, CSB is calling on ACS to put together models for how to assess and control hazards in academic labs—ideally in a way that can be tailored to meet the specific needs of a particular lab or research project. “Without this, it is sort of ‘every man for himself,’ doing what he thinks is best,” MacKenzie says. “We need common guidance to have a conversation with others doing academic research.”
Other key lessons in the CSB report include the need for laboratories to have research-specific written protocols and training; the means to ensure that safety inspectors report to someone with the power to implement improvements; and reporting systems to document, track, and communicate laboratory incidents and near-misses.
The report overall presents “a nice blueprint for developing a good safety culture at academic institutions” and highlights the holes that need to be filled, says Laurence J. Doemeny, chair of the ACS Committee on Chemical Safety.
Although it’s helpful to acknowledge the lack of OSHA guidance on physical hazards, in practice, most schools probably already have that covered, says Peter C. Ashbrook, director of the Division of Research Safety at the University of Illinois, Urbana-Champaign. “I would be surprised if most universities don’t have some guidance that addresses physical hazards,” Ashbrook says. “Usually fires and explosions are the first things that come to my mind when I worry about labs.”
But developing good ways to do hazard and risk assessments is a real need in the community, Ashbrook adds. “A lot of us are coming to the realization that that is where we need to give our folks some help.”
A hazard assessment tool is something that ACS is already developing, says Robert H. Hill Jr. Hill is chair of a new Safety Culture Task Force that involves members of the Committees on Chemical Safety, Professional Training, Education, and Younger Chemists.
At the ACS Council meeting in August, the task force sought suggestions from councilors on additional ways ACS could promote lab safety. One suggestion was to establish a database for incident or near-miss reporting, akin to CSB’s recommendation. Because the number of events at any one institution is likely to be small, a national database would be valuable, says Charles A. Wight, a chemistry professor and dean of the graduate school at the University of Utah. The challenge, he notes, will be to provide incentives to encourage institutions to participate.
And although the institutional aspects—such as organizational structure, best practice guidance, and databases—are important, ultimately the PIs have to step up, says Kenneth P. Fivizzani, chair of the ACS Division of Chemical Health & Safety. The nature of academic research labs, with people always working on new projects, is that there is a limited amount that outsiders can contribute. PIs, Fivizzani continues, “have to take responsibility for primary instruction in laboratory safety and especially research-specific safety.”
To that end, reports and analyses such as CSB’s on the Texas Tech incident are helpful, says James Whitesell, a chemistry professor and chair of the Chemical Safety & Surveillance Committee at the University of California, San Diego. Whitesell calls CSB’s report “right on the mark” for emphasizing that safety is an intrinsic part of laboratory operation.
Noting the personal devastation that occurs with a lab accident, Whitesell adds, “You want to do whatever you can to avoid being in that situation.”