‘Systemic Failures’ Cited In UCLA Lab Fatality | Chemical & Engineering News
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Web Date: January 24, 2012

‘Systemic Failures’ Cited In UCLA Lab Fatality

Lab Safety: State investigator’s report alleges a breakdown in safety and training
Department: Science & Technology
Keywords: Sangji, UCLA, Harran, Cal/OSHA, safety, lab safety, tert-butyllithium, tBuLi
Sangji was using a 60-mL plastic syringe to transfer more than 50 mL of tBuLi when she pulled the plunger out of the barrel.
Credit: UCLA
Sangji was using a 60-mL plastic syringe to transfer more than 50 mL of tBuLi when she pulled the plunger out of the barrel.
Sangji was using a 60-mL plastic syringe to transfer more than 50 mL of tBuLi when she pulled the plunger out of the barrel.
Credit: UCLA

New details of the circumstances surrounding the 2009 death of University of California, Los Angeles chemistry researcher Sheharbano (Sheri) Sangji are outlined in a report by the California Division of Occupational Safety & Health (Cal/OSHA). The report says a “systemic breakdown of overall laboratory safety practices” contributed to the fatal accident. Cal/OSHA sent the report to the Los Angeles County District Attorney, who filed felony charges in the case on Dec. 27, 2011 (C&EN, Jan.2, page 7).

The report—obtained by C&EN but first made public by the Los Angeles Times on Jan. 20—describes a seemingly ineffective environmental health and safety program at UCLA in which fixing problems identified during lab safety inspections and wearing personal protective equipment were viewed as optional.

UCLA administrators assert that the report is biased. It “reached the conclusion that the [state’s] investigator set out to reach,” says Kevin S. Reed, vice chancellor for legal affairs.

An attorney representing chemistry professor Patrick G. Harran, who faces prison time for the charges against him, alleges the report contains “numerous errors” but declined to give examples. The lethal accident occurred in Harran’s lab.

The report provides insight into how Sangji, who was 23 at the time, was trained to handle the pyrophoric chemical tert-butyllithium (tBuLi). On the day of the accident, she was using a syringe to remove tBuLi from a container when the syringe plunger came out of the barrel. She was not wearing a flame-resistant lab coat, and the chemical set her clothes on fire. She died from her burns 18 days later, on Jan. 16, 2009.

According to the report, Sangji had not previously handled pyrophoric reagents. Harran told a Cal/OSHA investigator, however, that he checked Sangji’s technique by observing her use an air-sensitive nonpyrophoric reagent.

The report goes on to say that Sangji then sought help for her first attempt with the tBuLi procedure from then-postdoctoral researcher Paul Hurley. Hurley told the Cal/OSHA investigator he could not recall his specific interactions with Sangji, but the approach he described for handling tBuLi was similar to what is known about Sangji’s actions leading to the accident. His description included details that are counter to safety recommendations for handling the hazardous chemical by its manufacturer.

The report is the second Cal/OSHA prepared on the basis of its investigations. The first report resulted in fines levied against UCLA for multiple safety regulation violations. Harran and the university are scheduled for arraignment on the felony charges on Feb. 2.

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Unstable Isotope (January 25, 2012 9:55 AM)
So much wrongness here. As someone who has handled tBuLi, I would never handle it the way that was described here. Also, testimony from Harran's own group member goes against the defense UCLA is using - that Sangji was an experienced chemist and just chose not to do things safely. The postdoc didn't even know the correct procedure and had only taught her once. I'm really not sure what the outcome of this case should be but I don't think UCLA is doing itself any favors. Perhaps they should stick with the time-honored "no comment."
Paul (January 25, 2012 1:11 PM)
What are the "recommendations for handling the hazardous chemical by its manufacturer"?
null (January 26, 2012 12:55 AM)
I am a former graduate student from UC Davis and was injured in a chemistry lab accident due to improper training and lack of safety protocol knowledge by my graduate teaching assistant. Thankfully I was able to seek immediate medical treatment and my wounds healed without any systemic side effects. However, the laboratory safety and training in the UC system needs to continue to be under investigation and monitoring.
Raman Parkesh, PhD (January 26, 2012 11:22 AM)
This clearly shows what I commented earlier when C&EN commented on Patrick G. Harran being indited. There are no rules of safety in all the universities. PI and the university administration don't really care whether PhD and Postdoc are taking care of their safety and the safety of others. They only care about the results and data. They will ask you "show me the data" but not "show me creativity or safety". This culture has to change and only way it can change if we take some lesson from it. Science should never be above life. In my view charge Harran and make him a chemistry lab in the jail so that he will 16-20 hours to do experiments and write grants. When Harran is released from prison after 4 years, he can apply for many grants and won't have problem in running his research group.

What really makes me sad that why UCLA is supporting Harran. He should have been fired next day.

Jyllian Kemsley (January 26, 2012 2:50 PM)
@Paul: Sigma-Aldrich's guidance for handling air-sensitive reagents is here:
PMP (February 1, 2012 4:12 PM)
The instructions of the Aldrich bulletin work only with all-glass syringes. However, these must be dried in oven prior to use and they are never as tight as plastic syringes. It is true that plastic syringes do not usually come with a Luer lock - but I have also witnessed leaky Luer locks several times.

The thing with plastic syringes is that in order to fill them you _do_ need to pull the plunger _gently_. This is easy to do with a fresh, small syringe for quantities up to 10 mL. More than that - especially with a tight, 60 mL syringe - is too much and leads to the consequences we are discussing here.

Someone should write a proper manual how to use plastic syringes safely. They are used safely throughout the world for transfer of pyrophorics as well. But only for reasonable quantities. The report makes it sound like the whole world should now immediately switch to all-glass syringes or else. I do not think this will solve the problem.

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