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Lab Safety

Spark from pressure gauge caused University of Hawaii explosion, fire department says

Postdoc Thea Ekins-Coward, who lost an arm in the incident, was using a gauge not specified for work with flammable gases

by Jyllian Kemsley
April 19, 2016

UPDATE: A subsequent investigation by the University of California Center for Laboratory Safety determined that the cause of the explosion was an electrostatic spark, after laboratory testing ruled out a spark from the pressure gauge. Read the full story here.

An explosion last month that caused a University of Hawaii, Manoa, postdoctoral researcher to lose an arm was caused by a spark from a digital pressure gauge that was not designed for use with flammable gases, says a Honolulu Fire Department investigation report.

Credit: Honolulu Fire Department
Debris littered a lab bench after the explosion.

Thea Ekins-Coward was combining hydrogen, carbon dioxide, and oxygen gases from high-pressure cylinders into a lower pressure tank when the incident occurred. She has not given the university permission to release information about her condition, said spokesman Daniel Meisenzahl at an April 18 press conference.

The gas mixture was “food” for bacteria being used to produce biofuels and bioplastics. Ekins-Coward was working for the Hawaii Natural Energy Institute under researcher Jian Yu. A 2013 paper by Yu indicates a set-up in which gases are plumbed through a mixing device called a gas proportioner directly into the bioreactor (Int. J. Hydrogen Energy 2013, DOI: 10.1016/j.ijhydene.2013.04.153). The gas gauge identified in the paper is an “intrinsically safe” model designed to prevent ignition.

But after Ekins-Coward started in the lab last fall, she purchased a 49-L steel gas tank, a different gauge not rated as intrinsically safe, a pressure-relief valve, and fittings, and she put them together, Yu and Ekins-Coward told fire department investigators, according to the report. Ekins-Coward would add the gases to the portable tank, which would then be connected to the bioreactor. She was using a mixture of 70% hydrogen, 25% oxygen, and 5% carbon dioxide for her experiments, the report says.

In the week before the incident, a similar set-up with a 3.8-L tank resulted in a “small internal explosion” when Ekins-Coward pressed the off button on the gauge, the fire department report says. She also occasionally experienced static shocks when touching the tank, which was not grounded. She reported the shocks and possibly the small explosion to Yu, who told her not to worry about it, the report says.

On the day of the incident, the 49-L tank exploded when Ekins-Coward pressed the off button on the gauge. “She did not lose consciousness or hit her head; she was aware that she lost her arm in the explosion,” the report says. “She couldn’t open the door to the lab, the door was stuck closed.” Security officers and a graduate student kicked in the door to help Ekins-Coward get out. Her right arm was severed just above the elbow, the report says.

The University of Hawaii hired the University of California Center for Laboratory Safety to independently investigate the incident. That report is expected to be completed by the end of this month. The Hawaii Occupational Safety & Health Division is also investigating the incident.

Disaster Scene

These photos, released by the Honolulu Fire Department, 
llustrate the force of the March 16 explosion and its consequences.
(warning: some images are graphic)

Credit: Jian Yu/U Hawaii
The steel tank that ruptured in the March 16 explosion.
Credit: Jian Yu/U Hawaii
The steel tank that ruptured in the March 16 explosion.
Credit: Honolulu Fire Department
The explosion caused damage in the hallway outside of the lab.
Credit: Honolulu Fire Department
The explosion caused damage in the hallway outside of the lab.
Credit: Honolulu Fire Department
The hallway outside the lab door after the explosion.
Credit: Honolulu Fire Department
Compressed gases in the lab included hydrogen, carbon dioxide, helium, and carbon monoxide.
Credit: Honolulu Fire Department
This steel tank ruptured during the explosion, which severed a researcher’s arm.
Credit: Honolulu Fire Department
Chemical bottles fell and glass broke in the northeast corner of the lab, next to the bioreactor for growing bacteria.
Credit: Honolulu Fire Department
The explosion knocked down ceiling panels, broke light fixtures, and scattered debris throughout the lab.
Credit: Honolulu Fire Department
The explosion knocked down ceiling panels, broke light fixtures, and scattered debris throughout the lab.
Credit: Honolulu Fire Department
The remains of the steel tank sit at the site of the explosion, near the south wall of the lab.
Credit: Honolulu Fire Department
The remains of the steel tank sit at the site of the explosion, near the south wall of the lab.
Credit: Honolulu Fire Department
The explosion also shattered fume hood sash windows and knocked over equipment in the northwest corner of the lab.
Credit: Honolulu Fire Department
An oxygen cylinder was nearly knocked over in the southwest corner of the lab, something that could have added to the damage.
Credit: Honolulu Fire Department
Possible circuit board from the pressure gauge that caused the explosion.
Credit: Honolulu Fire Department
Photo of a circuit board on top of debris.
Credit: Honolulu Fire Department
Postdoctoral researcher Thea Ekins-Coward lost an arm in the explosion.


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Tom C. (April 19, 2016 4:19 PM)
Looks like lessons were not learned from the previous small explosions in the lab. Mixing hydrogen and oxygen without proper controls and hazard assessment can always lead to a big explosion. This incident could have been easily stopped using proper controls. Big loss for the researcher! We need to look the safety culture of the lab involved in this incident plus departmental culture as a whole. Was a SOP developed by the PI of the lab for this experiment, we would like to see the same. Otherwise it only remains a forum discussion, similar to the rainbow experiment.
Robert H. Foster (April 20, 2016 1:53 PM)
Agreed with Tom C. While I was not there and do not have the benefit of the full investigation, I have combined oxygen and hydrogen and had an explosion (all I lost was the hair on both hands). The risk of explosion from a number of ignition sources is very high, and a thorough review of SOPs for all work presenting those ignition risks should be undertaken. A question is also raised about the safety equipment (such as shields or remote handling apparatus.
Greg S. (April 20, 2016 2:45 PM)
Surely I'm not the only person who's seen (and done) the oxygen, hydrogen, and oxygen+hydrogen balloon ignition demo ( As Tom C and Robert F note above, handing mixtures of hydrogen and oxygen is a _very_ hazardous operation.

As Robert H notes, I was not there, and don't know the particulars, but on reading what is reported here I'm very surprised by the use of the mixture, and would be concerned if the workers had not considered this to be highly hazardous from the start.
Mark Bricka (April 20, 2016 8:07 AM)
I can empathize with this researcher.... I work with Hydrogen, CO, and O2 in the lab and did not consider the issue with fires.... I will conduct a SAP review and modify our current working conditions. I teach a safety course and work closely with SAChE but and aware of the LFL and UFL of H2... we as researchers get tunnel vision. I am very sorry it took someone to lose an arm for me to realize the danger I put myself and my researcher at.... I know better.

I hope pray this researcher has a full recover although She lost an arm and will never fully recover... this is too high of a price to pay!... the research community must take steps to prevent such an accident from occurring in the future.

If any one has ideas for action and lesion learned documentation dissemination I raze my hand to assist.

Mark Bricka
Chemical-Environmental Engineer
Mississippi State U.
Brenna Arlyce Brown (April 20, 2016 2:12 PM)
This makes me indescribably sad. The fact that the smaller "near misses" were reported but no corrective action was taken by the laboratory management makes this accident seem like it could have been prevented.

It is frustrating that it is such a stark contrast with industry, where even something as seemingly minor as the potential of a pinched finger in a cabinet requires a report and corrective action implementation. In comparing industry and academia on safety standards, it seems that at heart, academia should be MORE strict with safety, not less. In an industry lab, many of the risks are well known, whereas in academic research, one is often pushing the boundaries of current knowledge, meaning that all of the risks are not well known or understood. This should make us MORE vigilant rather than less vigilant. What needs to be done to make a change? It seems that our collective sadness over these stories isn't encouraging change. Do we need to restrict funding until appropriate safety measures are implemented? Do we need to resort to punitive measures?

I am thankful that this accident did not result in loss of life. I wish Dr. Ekins-Coward all the best in her recovery, both physically and mentally.
Jyllian (April 22, 2016 1:22 PM)
Regarding "one is often pushing the boundaries of current knowledge, meaning that all of the risks are not well known or understood": I have yet to hear of a serious incident in which the risks were not understood. Whether it's been fires from:
* methanol,
* tert-butyllithium,

Or explosions from:
* hydrogen + oxygen, this story
* nitric acid + organics,
* nickel hydrazine perchlorate,
* azide,
* diazonium perchlorate,

Or a death from toxic:
* dimehtylmercury,

The chemicals involved behaved exactly as expected.

Jyllian (April 22, 2016 4:13 PM)
I forgot the hydrogen explosion at Tsinghua University,
Brenna Arlyce Brown (April 24, 2016 2:19 PM)
That is actually a very good point, Jyllian. One that perhaps makes these accidents, if possible, more terrible. In thinking of my own research, I did work with chemicals such as tBuLi, and therefore was well aware of the safety measures that needed to be followed, even if I was making a "new compound".

What then is the solution to these types of accidents? I always find that punitive measures, while effective to some degree, fail to get the appropriate buy-in from people. We shouldn't care about safety because we are concerned over the litigious outcomes; we should care about safety because we care about our well-being and that of our coworkers.
Michael D. Lundin (April 27, 2016 2:52 PM)
The dimethylmercury incident is actually one where the risks were not entirely understood at the time. Karen Wetterhahn was wearing protective equipment (latex gloves) thought to be sufficient protection at the time and the toxicity was also not fully appreciated. In hindsight we know better, but it would have been very difficult to foresee the risks at the time.
Jyllian (April 28, 2016 12:40 PM)
If you read the pdf that I included above, I think it's clear that Wetterhahn and then-postdoc Kent Sugden did understand and appreciate dimethylmercury's toxicity. Hopefully the incident did raise awareness about researching glove permeability--and perhaps conducting tests--before handling such a compound.

For anyone handling dimethylmercury, this is information from a safety letter that ran in C&EN on May 12, 1997:

A highly resistant laminate glove (SilverShield or 4H) should be worn under a pair of long-cuffed, unsupported neoprene, nitrite, or similar heavy-duty gloves. Latex or PVC gloves have an important role in many
laboratory activities, but they are not suitable for significant, direct contact with aggressive or highly toxic chemicals. Medical surveillance measuring mercury concentrations in whole blood or urine should be considered for repeated or extended use of alkyl mercury compounds. In all cases, the potential hazards associated with dimethylmercury and related alkyl mercury compounds must not be underestimated.
Andres Galeano (April 27, 2016 5:19 PM)
I discussed with my colleagues this accident and we realized that the awareness of risk and hazards at academy labs some times is not at the level of Industrials Labs and we recalled events related to the handling of solvents , lab glassware , exposure to harmful substace that we had when we were at the University. This event should create awareness of the risk and hazardous existing in a R&D lab and look for the implementation and leverage of best practices in Lab safety in the academy.
James Osprey (April 20, 2016 2:29 PM)
The spark energy limitations of intrinsically safe apparatus are normally assessed considering flammable component when mixed with air at atmospheric conditions. If this mixture was being prepared form pure gases, then there is a real of preparing an oxygen enriched atmosphere unless the order of mixing and the concentrations were limited to ensure the inert component (CO2) was always at least x5 the oxygen concentration (giving a similar dilution as nitrogen in air) and the oxygen concentration could never exceed 21%.
The point being that any explosion protected equipment, including Intrinsically safe apparatus would need to have been specifically approved for an oxygen enriched atmosphere. The spark ignition properties are some X10 to x20 more onerous in enriched atmospheres. NFPA 53 gives some guidance as to the risks. Managing pure oxygen or oxygen at pressure also imposes its own ignition risks without need of any spark assistance from non-explosion protected equipment.
Paul Kimmel (April 20, 2016 2:35 PM)
Think Challenger 1986. O-ring failure lead to disaster and loss of 7 lives. There was ample evidence of O-ring deterioration in previous flights, but no one did anything about it since it did not end disastrously. The model: it was OK before, it will be OK in the future--not.
Stephen T Ross, Retired Chemist (April 20, 2016 2:41 PM)
A tragic and severe loss for Ms Ekins- Coward but probably lucky to have not lost her life. Mixing Hydrogen and Oxygen is begging for an explosion and/ or fire. And the chamber should have been placed behind a barricade. Neither the researcher or her supervisor heeded obvious warning incidents. Do we not learn?
Alain Goeppert (April 20, 2016 2:46 PM)
I am not familiar with this particular experiment setup and procedure but it seems dangerous under any circumstances to mix oxygen and hydrogen within the explosion limits, which for hydrogen are very broad (~4 to 95% H2 in the gas mixture, Chem Eng,. Technol. 2004, 27, 847). This seems like a recipe for disaster in the waiting in any case, especially considering the very low energy needed to ignite this mixture (about 0.02 millijoules).
Spastic Lab Rat (April 20, 2016 3:06 PM)
It will be interesting to see if there are any consequences for the PI, ala Phil Baran at UCLA; the professors who run these labs have got to start taking responsibility for generating a culture of safety, as students and post docs do not always have a clue that what they're doing is hazardous with possible life-ending/altering consequences.
b (April 22, 2016 9:27 AM)
You mean Patrick Harran, NOT Phil Baran
Jeff (April 22, 2016 11:06 AM)
If you are referring to the tert-butyllithium lab accident at UCLA, Phil Baran (who is at Scripps) was NOT the PI involved. Please, make sure your facts are correct before erroneously implicating someone in a crime!
Linda Swihart (April 26, 2016 10:38 AM)
It will come from Hawaii OSH or maybe Federal OSHA if it comes from anywhere I suspect. It would be impressive to see U. Hawaii step up and investigate the professor and give us a report on that investigation. Is any US University truly ready to take a stronger hand in making that popular buzz-phrase "culture of safety" happen? If talking about it and having meetings with staff and graduate students would get it done, it'd be done by now.

The APLU Lab Safety Task Force guidance document just released

and it includes, demurely, as part of point 4: "Establish recognition and reward systems and integrate these into tenure and promotion, hiring, and annual performance reviews."

Until this happens, and faculty hiring and promotion are tied to their responsibility for safety, not much is going to change. And that is a *very* scary step in this day when so much money is tied to getting "good" faculty, and "good" does not seem to have a safety component. "Good" equals number of papers, number of dollars. Maybe much easier after all of the grant and contract-awarding sources are required to tie the grants and contracts to a PI's safety performance. Maybe Journals will require a safety certification before accepting manuscripts.....
Gary Carlton (April 27, 2016 2:08 PM)
As a staff-member and chemical safety officer in a busy Chemistry dept, this is my take on the issue as well. Until there are direct, immediate and tangible consequence to the research faculty, NOTHING will change in the academic environment with regards to safety. Sitting behind the defense of 'this is how we do things in college and while safety issues may be concerning, they are not that big of a deal and not my responsibility' is a foolhardy belief.
As mentioned by many others, with all these very preventable accidents and tragedies in mind, what will it take to alter the academic safety culture? I am without clue on this.
Robert J. Kobrin (April 20, 2016 4:05 PM)
I have no access to the original paper, so I can only question why Yu used an intrinsically-safe gauge but the student didn't. Did the original paper SPECIFY "intrinsically-safe", or was the valve used one that happened to be so rated? I certainly hope the paper warned readers about this seemingly mundane detail.

Regardless of why the student failed to exactly follow the original paper, this incident CLEARLY points out the typical lack of concern in educational facilities about safety--UNTIL a catastrophe occurs! Personally, I am grateful to have worked for a few years in an excellent industrial research facility before doing my thesis research. There were no exceptions to rigorous safety procedures, and all technologists had to rotate through safety inspection teams that checked all labs monthly.

Safety-wise, my grad school experience was a shock many decades ago, and it seems little has changed since. I cannot claim to be the most safety-conscious chemist in history, but even a tiny quantity of O2-H2 mixture in a pressure vessel would make me nervous. The original experiment used a gallon. It got scaled up to 13. That's a car gas tank full. Of a gas mixture with the highest energy and widest explosive range of all. OMG!
Jyllian (April 22, 2016 10:42 AM)
The paper itself did not specify that the gauge intrinsically safe, I got the information by looking up the model.
Carol Sampson (May 6, 2016 4:37 PM)
I have to say that this was entirely the PI's responsiblity. The PI should know the lab he runs, and understand the importance of safety issues with any compressed gasses, let alone the ones she was working with. He should have looked over her set-up and thoroughly examined it, or, if he was clueless, had the EHS Department look it over. And I cannot believe after she told him of the minor explosion and the static shocking events he told her not to worry about it! What the heck? He should be held accountable. Period.
Bakhtyar K. Aziz (April 20, 2016 4:19 PM)
I'm very sorry for the researcher, looks like accident happens some times regardless of safety precautions. But as I read the story, she faced some other small explosions before.. as she worked on a smaller volume.
Unfortunately in our university we don't care much about safety and security of labs and lab working, and I'm terrified of some views of dangerous or hazardous situations. In my country... unless an accident happened... no one care about safety , after disaster.... cautions will be taken but in wrong manner. If I present some photos of our labs to you .... you never believe. But fortunately.... no serious accidents happened till now.
Tomasz Dluzniewski (April 20, 2016 5:03 PM)
A mixture of 70% hydrogen, 25% oxygen, and 5% carbon dioxide seems to have a ratio of hydrogen to oxygen not far from stoichiometric, hence just needs any ignition source to cause explosion. Some time ago there was another accident, at a Texas Tech lab, in which High Energy Materials were studied. That accident was different in many respects, but a learning from it was to use limited amounts of explosive material. If applied at University of Hawaii lab, that rule would almost certainly forbid using 49L tank for the explosive gas mixture.
Jeff Baranchok (April 22, 2016 9:24 AM)
This mixture is within the explosive range of H2 and was stored in a rather large tank for a lab, possibly even under pressure, very dangerous.
It would have been a large improvement to mix these gases right at the bioreactor but even then the mixture is explosive, but in a smaller vessel most likely with a lower pressure rating an explosion would have caused much less damage and she might still have her arm. She was fortunate not to be killed!
Shankar (April 20, 2016 5:04 PM)
When will they learn? I mean the gall of it! A small fire preceeded previously before the major one with trageic loss of limb. I am a chemist by trainingand if I was the supervisor I would have done it at all. I mean mixing the rocket fuel without any consequences?
Alan O. (April 20, 2016 5:56 PM)
My time as a student versus my time in industry is night and day in regards to safety and acceptable chemical hygiene. The 'it won't happen to me' mentality gets people killed. Academic institutions need tougher and and accountable enforcement of safe and proper lab policies/SOPs or we will end up with more Thea's and Sheri's.
Susanne (April 20, 2016 7:36 PM)
That was my concern about this incident - when using a smaller set-up and the result was both the noted static shocks and the small explosion, regardless of what Jian Wu said to disregard, she should have put one and one together and came to the conclusion that if A=Explosion, then 4A=Bigger explosion, and shut down the experiment until she determined where the problem was that caused the initial explosion and did not repeat that issue (eg the presence of static electricity and the non-intrinsically-safe device).

As sad as it is she lost her arm, the most important take-away of this is to Check, Check, and Check again, make SURE everything is correct and right, if you have the wrong equipment DO NOT GO BLINDLY into your experiment but wait until you get the correct equipment, and even IF a senior research fellow says "It's OK, go ahead", if something like that happens, STOP until you fix the problem.

Thea bears the responsibility that she didn't stop what she was doing and correct the KNOWN problem before stepping up the experiment, and Wu bears the responsibility of encouraging a student to go ahead with an experiment that had blown up once, and instead of shutting it down he encouraged her to increase the experiment using larger quantities of the highly flammable mixture with the wrong equipment.

I only hope other Graduate (and undergraduate) students - and especially their faculty and advisors - remember that NOTHING trumps safety. Nothing. Ever.
Linda Swihart (April 26, 2016 10:22 AM)
"Thea bears the responsibility..." suggests (perhaps I erroneously infer) that no responsibility is borne by Professor Yu. I agree that Dr. Ekins-Coward is plenty responsible and she should have done several things *quite* differently, but I insist that Professor Yu shares a large amount of this responsibility.

Did he really tell her "not to worry about" the previous warning signs? I want to say "that's unthinkable," but, well, it's a little too easy to believe.
james francis (April 20, 2016 10:49 PM)
A mixture like that!?!?!? Not behind heavy shields? What were they thinking?

I ALWAYS assumed my reagents/mixtures/solutions would catch on fire, treated them accordingly.Should be standard assumption.
Ned Edmonds (April 20, 2016 10:57 PM)
Everyone loves to conduct research at universities vs. a private or government research laboratory due to cost. Part of the "cost savings" of university laboratories is due to the lack of environmental safety and health support, they don't have knowledgeable people to address these issues. They also don't have proper engineering support to design systems.

But keep feeding them grants, cheap science all the way.
Sam (April 27, 2016 12:28 PM)
Sorry to be disagreeable but you are probably operating under many assumptions. If you want to stereotype anyone look to the PI not EHS. The only truth is that higher education is very accommodating to the SMEs who bring research dollars to the institution.
Hannah Shelton (April 21, 2016 4:04 AM)
I am a researcher in the same building as the HNEI, although not on the same floor, and not in the same field. We felt the explosion rattle the floor and walls eight floors up - Dr. Ekins-Coward is truly lucky to be alive. The incident has prompted campus-wide laboratory safety re-certification efforts here, particularly with regard to pressurized gas cylinders, whether or not they contain flammable gases. PIs, please take the time to discuss with your lab staff and students proper gas handling - students and staff, if you see red flags, don't let up until your PI fixes the issue. It really sucks having something like this happen in your University, let alone your own lab building and community.
William C. Kalb, Retired Research Supv and Chemist (April 21, 2016 12:10 PM)
A terrible tragedy. I agree with all of the comments. I believe the container filling opreation be conducted remotely from outside a closed 4-wall barricade. The barricade should be rated to contain a worst case explosion, which is calculated for the largest permissable container allowed for the operation. A responsible group of knowledgeable persons should be appointed to supervise the design, construction, and all procedures relevant to the operation. This should include regular safety audits of the operation, careful and complete review of any safety incidents, and accountability for seeing that recommended changes are completed prior to restarting the operation. I credit E. I. DuPont, Inc. for all of these ideas.
Thomas Henson (April 21, 2016 8:19 PM)
This was indeed a tragedy not only because there was an incident and the loss of an arm but also because those who should be skilled in the art of reactivity failed to even consider the minimum of safety precautions. Having spent 25 years in an industrial research lab dealing with reactions where a predictive guess can be made the unusual can happen and must be designed into the set ups to help minimize personal exposure. I hope that out of this will come some well formulated procedures to help find and fix possible failures in all lab experiments carried out. This is a very hard and expensive lesson to learn.
John Doe (April 22, 2016 10:29 AM)
I am very sorry for the tragic incident that happened to the researcher.

One can only theorize about the underlying causes that led to the incident - the pressure on the post-doc to conduct research, the general lack of safety culture in many academic labs and the indifference of PIs to maintaining safety standards.

When I hear news like this, I realize how lucky I am to work in industrial R&D. Yes, incidents happen in chemical industry as well. But overall, I feel much more empowered to make my labs safer for my technicians and myself compared with my time in academia.
Phil (April 22, 2016 10:47 AM)
How did Prof. Yu manage to get a PhD and a professor job without knowing that a tank of mixed H2 and O2 is a bomb? I don't just question his commitment to safety; I question his basic competence.
TimC (April 26, 2016 5:38 PM)
I wondered the same thing, Phil. Prof. Yu's PhD is in chemical engineering; he should be fully equipped with the knowledge required to calculate the energetics of the explosive mixture involved. In effect, he allowed his student to build a bomb, set it on the lab bench and work in close proximity to it, hoping that it would not go off. The article's focus is on the pressure gauge as the cause, but given the incredibly poor design and complete lack of appropriate engineering controls, this experiment was a tragedy waiting to happen, regardless of the eventual ignition source.
Pedro Arrechea (April 27, 2016 2:51 PM)
I am in complete agreement with TimC. The regulator though it may have been the immediate cause of the accident is not the major issue here. By mixing oxygen AND hydrogen in a vessel you have built a bomb. There should be every expectation that somehow it will find an ignition source and detonate. Either the process should not have been implemented or the system should have been designed to properly handle an (inevitable) explosion safely.
S Green (April 22, 2016 11:25 AM)
The thing that strikes me looking at the photos is what appear to be unsecured gas cylinders. It isn't clear since you can't see the full length of the cylinders in the photos but any tank with a regulator on it should be secured and the tanks appear to be too close to each other to be secured to the floor and they aren't up against a wall or lab bench they could be secured to.
Jyllian (April 23, 2016 11:42 AM)
We posted only a subset of ~250 photos from the fire department. None shows how all of the tanks were strapped. A couple of partial views show that at least some were strapped, although that group of eight cylinders may share a single strap.
Diane Morris (April 26, 2016 12:37 PM)
Other than the evidence of a very unfortunate situation and huge loss that should not have needed to occur, I too IMMEDIATELY noticed the apparently unsecured gas cylinders. The one picture showed an oxygen tank at an angle. I could not help but think how much worse it might have been had a domino affect occurred and all of them gone down. If they were strapped at all, it must have been rather low so as not to be visible, and with gaps, it would not have been adequate. I am so sorry for the loss of limb and serious injury. I hope many learn from this incident!
Phil Petersen (April 29, 2016 7:20 PM)
The lack of any visible securing of the gas cylinders caught my attention also. Although the complete tanks are not visible, it does essentially no good to secure a tank with straps or chains below its center of gravity. The tilted oxygen cylinder is almost certainly not secured and, as others have said, could have really escalated the damage done had that tank's fittings been broken.
Jyllian Kemsley (July 13, 2016 7:35 PM)
The University of California Center for Laboratory Safety investigation report about the U Hawaii explosion contained more information about gas cylinder storage and use. See:
CB (April 22, 2016 11:33 AM)
I hope someone has set up or secured the oxygen cylinder that is haphazardly hanging there in one of the photos.
FFNY (April 22, 2016 12:37 PM)
Very sad could have been prevent with a gas vault at the very least!

What I also find interesting is that the fire fighters aren’t even using their respirators, exposing their gear and lungs to bacteria and who knows what harmful chemicals are in there also. The blood alone would make me use a disposable suit.
Jyllian (April 23, 2016 11:51 AM)
Reading the fire department report, it appears that there was initial entry into the building/lab to evacuate Ekins-Coward and search for her arm. Those responders exited, and additional entry occurred after responders had spoken with graduate students about what was in the lab and the type of work done there.

The response narratives start on page 39:
Robert Leonetti (April 22, 2016 2:20 PM)
As a school boy many years ago, one of my favorite hangouts was the Franklin Institute. A most impressive display was the automated mixing of hydrogen and oxygen to form droplets of water.The terrific bang that accompanied this micro scale display still remains in my memory.
Bill Doe (April 22, 2016 2:22 PM)
Go visit UH at Manoa, take a walk through the labs and you will understand how and why this accident could have happened and why additional accidents may yet happen. This institution is in urgent need of external oversight.
J.B. (April 28, 2016 1:32 PM)
Honestly, I think you need only walk through many departments to see the lax safety culture that permeates academia, and frankly, it's somewhat amazing that more reported accidents don't happen.
Unfortunate at University (April 22, 2016 3:36 PM)
A totally ridiculous and negligent thing to let happen anywhere, and especially at a University. Chemists at all stages of training widely perceive and believe industrial labs to have better safety cultures than those in academics. At the University level, there is a persistent and unchanging "I'll take care of it myself/I can't be bothered/Everything is fine right now" attitude that is passed from many advisers to their students. I studied at two top universities and now work for a major chemical company. The difference in the perception of safety and the execution of safe lab practices is truly night and day. Students feel un-empowered to report incidents/accidents or to suggest lasting improvements to the safety culture. They are often unaware of how to actually address problems at the correct level, fearful of turning other students against them for pointing out bad/unsafe habits, and fear upsetting or bothering their adviser, who so often claims to be over-worked and too busy for so many others things (actual advising?) already. When will Universities accept that there changes to be made and that the culture has to change from the bottom up, with major input and guidance from PIs?
Khal Spencer (April 22, 2016 7:13 PM)
Where I work, an experiment of this type would never be allowed to become operational until a subject matter expert (or probably a team of them, in this case) fully inspected the design and the operating parameters. Especially if the system was built by a new member of a research team. A full hazard control plan, in writing, would be written up and signed off by anyone touching the experiment. In my world, the subject matter experts are drawn from research scientists familiar with the experimental designs.

Since it was a pressurized system containing an explosive hydrogen gas mixture, I suspect that at minimum, there would be an emphasis on a design that minimized risk including volume limits, an inspection for electrical safety, and likely, some sort of containment system would be incorporated to protect against just this sort of catastrophe. A reviewer would probably ask "is there a safer way to introduce the gas mixture into the reactor?".

These sorts of intensive safety programs add time and cost to the business of doing science (but are ubiquitous in industry and government labs), but the flip side is what we see in these pictures: when things go wrong, they go very, very wrong.

My heart goes out to Thea, and I hope the University of Hawaii and other research campuses take the institutional steps to make sure this scenario never plays out again.
Sanjay Vijayaraghavan (April 22, 2016 11:44 PM)
This is such a preventable tragedy. Makes me feel so sad to read this story. Working with such an easily combustible mixture without following proper standards, ignoring near misses. All these point to a poor culture of safety in labs. In my experience, safety culture in University labs is determined by the Professor (PI) leading the lab. In this lab, the pictures seem to indicate that they do not believe in basic gas cylinder safety. In the fourth photo, there appears to be 8 gas cylinders, most with regulators on not chained to the wall.
Patrick Coyle (April 23, 2016 9:13 AM)
Only one comment about gas cylinders and even that missed the apparent fact that the cylinders were not secured to the structure to prevent them from falling over. Even the most basic safety procedures were not being followed at this lab.
Jyllian (April 23, 2016 11:53 AM)
Copied from above: We posted only a subset of ~250 photos from the fire department. None shows how all of the tanks were strapped. A couple of partial views show that at least some were strapped, although that group of eight cylinders may share a single strap.

Nothing shows whether or how the oxygen cylinders were secured.
Amy (April 27, 2016 3:38 AM)
Another photo I saw suggests the lab doors open inwards which could prevent exit in an emergency, even one in which an explosion didn't jam the doors, not a good idea in a lab with flammable gases. Is that the case?
Jyllian (April 28, 2016 12:46 PM)
@Amy--You are correct--the lab door did open inward.
Phil (April 23, 2016 10:09 AM)
Yes, unsecured gas bottles speaks volumes (no pun intended). Colleagues and regulators, please, please reach out to research faculty at UH to learn more about the conditions under which we are expected to conduct experimental research.
Ronnie Hampton (April 24, 2016 5:57 PM)
Very tragic experiment that could have resulted in loss of life. Thank goodness it did not result in such. A loss of a limb is bad but it could have been much worse. Anytime a scale-up is done more hands and eyes should be part of the review (Haz-Op) to enhance the safety features even more. The massive quantity being mixed in the tank even without oxygen present should entice the research team to perform a diligent assessment to measure the level of hazard and the most reasonable tools and procedure to accomplish the goals safely. An intrinsic gauge is only one tool that would have been beneficial; as mentioned a baracaded tank would have provided optimum safety. This not only could have resulted in the life of the immediate parties but it could have resulted in the loss of life to many others.
Jeffrey Earnest (April 25, 2016 8:39 AM)
The use in this article of the photo of the bloody lab jacket draped over the chair is unnecessary and tasteless. Unless I'm missing something, there isn't anything from that photo that can be taken as a learning tool to prevent future accidents. The other photos show the extent of the damage caused by the accident. The lab jacket photo, however, is not something that, in my opinion, is respectful to Dr. Ekins-Coward.
Jill Hernandez (April 26, 2016 6:55 PM)
Conversely, including a photo of a disembodied arm might go a long way towards making people think twice in the future. This is a pretty mild step in that direction.
Curious Wavefunction (May 2, 2016 11:06 AM)
While hard to view, I don't think it's unnecessary: it's only hard hitting photos like these that can shake up the lax safety culture in so many academic labs.
Sean Alexander (November 15, 2016 11:05 PM)
Perhaps Dr. Ekins-Coward was consulted and agreed to the picture being used? Let's not assume anything.
In any case, a bit of blood might just wake a few people up. It took the death of Sheri Sangji to change the culture at UCLA.
James Lewis (April 25, 2016 2:59 PM)
As a chemist, I extend my condolences after this sad accident. However, I am surprised that neither the author of the article or any of the other comments asked what the pressure in the tank was after filing. That, and the percents reported, is critical to how much energy would have been released in the explosion. Prevention of future injuries depends on solid analysis of past accidents. Are people too busy writing SOPs to think critically about real events?
Jyllian (April 26, 2016 2:45 PM)
The Hawaii fire department report says 117 psi. See page 17:
James Lewis (May 4, 2016 7:33 PM)
Thank you for providing the pressure information.
There is more back story about tragic accidents from pressurizing mixtures of hydrogen and oxygen here:
Death and dismemberment have occurred on at least two other occasions in recent years. Further, CalOSHA was slow to originally act on the intrinsically hazardous nature of this process. Purported existence of an "energized form of water" rather than an exceedingly dangerous mixture of hydrogen and oxygen apparently stumped CalOSHA investigators.
Jyllian (May 6, 2016 12:53 PM)
Thanks for the information! I had thought that the Realm Catalyst incidents were just hydrogen.
Tom Bauer (April 26, 2016 11:04 AM)
Holey Moley, I can't believe what I am seeing. Such a tragic and life altering loss for Ms. Ekins-Coward. That vessel is no way approved for holding a flammable gas mixture. The root cause is apparent from the pictures posted above. NO ONE had a clue about safety practices being followed in this lab. I would also like to thank the poster for including the picture of the bloodied lab coat. It does justice to the extent of this tragedy. Lab safety isn't just a video game where you can just press the reset button and start over. There are real life consequences to slipshod lab safety and it appears our university labs are bearing this out.
Paul Krebaum (April 26, 2016 1:43 PM)
I'll agree with others that this should never have been done. Mixing materials in KNOWN explosive concentrations is just plain stupid and I'm surprised no one thought this through. It took Alfred Nobel a lot of trashed labs to finally learn how to make nitroglycerin and dynamite safely, but the key point is he wasn't around to get damaged ... when industry does "inherently dangerous" reactions it usually does them by remote control, far away from people. Any reaction which is going to result in the transfer of more than one mole of electrons per kilogram of reactants should be reviewed for the potential of a runaway reaction or excessive heat release.
Aloha (April 26, 2016 10:44 PM)
Program managers please reach out to UH Faculty to learn more about the conditions under which experimental research is conducted at this geographically remote location.
Shelagh Mason, Health and Safety Officer, Canterbury, Kent, England (April 27, 2016 3:57 AM)
Is it me, but seeing the picture with all those gas cylinders in the lab. horrified me. Surely in the USA you do what we are all trying to do (and some have achieved) - all gas cylinders are externally caged and are available at lower pressure in each lab. All regulators are replaced every 5 years (hydrogen every 3 due to risk of embrittlement). It's a miracle one or more of them didn't have their regulators knocked off and (as beautifully demonstrated in an episode of Mythbusters) they go off like the torpedoes they are and destroy everything in their path. It shows whoever allowed that number of gas cylinders in a lab. has failed to consider the potential for harm and, accordingly, failed to carry out a "suitable and sufficient" risk assessment. it's not rocket science, is it - except it possibly could be, in this case....
Susanne (April 27, 2016 1:54 PM)
The pictures emphasize that when a researcher puts safety (and common sense) on the back burner, and allows another researcher to give them the "go-ahead" for a plan that already created one (smaller) incident disregarding both the potential for disaster and the evidence of a disaster already extant, a disaster is not just a possibility but a likelihood.

The story warns of "graphic images" but those images should be reviewed by anyone with keys to a lab, and by those planning on continuing a series of experiments already proven to be dangerous... so the researcher realizes that the cost of dropping safety protocols may be higher than one would think.
Allen A. Smith (April 27, 2016 2:10 PM)
The danger is in the quantity. When I was a graduate student at Syracuse University Dr. George Wiley taught me to use explosives in very small quantities. We made diazomethane in batches of ~0.7 g (20 mmoles). We used an IR spectrometer to detect our reaction product (alas, not the one we wanted!). Even at that quantity, we worked with triple-gloved hands around a plexiglass shield to protect our faces and bodies from glass fragments if the diazomethane did explode.
Wally Fu (April 27, 2016 2:12 PM)
Sorry to see someone was injured. I saw more danger than shown. Two photos showed compressed gas cylinders with regulators attached but WERE NOT SECURELY CHAINED. What were these professors/researchers thinking? A broken regulator will launch a cylinder a long distance with severe consequences.
Concerned (April 27, 2016 2:23 PM)
In one of the photos, it looks as if the lab doors open INWARDS. From the photos that you reviewed, Jyllian, is that the case? Even in an accident without an explosion, that could make getting out of the lab impossible. With an explosion, the doors get jammed shut as you noted in your article. Although I'm not an industrial hygiene expert, I would expect that there are requirements for laboratory design depending on amounts of flammable gases present.
Jyllian (April 28, 2016 12:48 PM)
Yes, the lab door opened inward.
Robert Hil (April 27, 2016 2:25 PM)
It is my belief that a root cause of this incident and indeed many incidents is the absence of safety education in undergraduate and graduate chemistry. Safety education is different from safety training. Safety education should seek to explain the "why" of hazards (broadly) so that this knowledge can be carried on to other endeavors such as graduate or post-doctoral research. Safety education serves two purposes: 1)to impart knowledge to students so that they can learn how to "recognize hazards, assess the risks of hazards, minimize the risks of hazards, and prepare for emergencies - RAMP". 2) continuous safety education throughout all the years of student also builds a strong safety ethic that encourages and enables one to always consider safety in their work. I also believe that if universities incorporated safety education into their undergraduate and graduate courses that this would build strong safety cultures as well.
TimC (April 28, 2016 3:43 PM)
I agree, Robert. In this case, I'm sure both the PI and researcher were aware of the risks posed by explosive gas mixtures. But were they familiar with the use of engineering controls to eliminate those risks? Apparently not. It is incredible that universities still turn inexperienced researchers loose in laboratories filled with physical and chemical hazards, without any education in the methods available to control those hazards.
Cyrus A. Lepp, PhD (April 27, 2016 3:00 PM)
just an observation from one of the pictures. The gas cylinders appear to not be properly anchored to the wall by anchor straps or restraints. If the necks of the cylinders broke off as a consequence of the explosion, damage could have been even worse. Toxic CO and pressurized tanks taking off like rockets.
Kevin Yunchen Zhu (April 27, 2016 9:35 PM)
It certainly looks like that the researcher did not take in to account of safety and hazards of the previous explosion before this experiment. Electric pressure gauges that are not sealed properly to prevent gases from entering the electrical part or switch part of the gauge should not have been used in this experiment, especially when 70% hydrogen, 25% oxygen and 5% carbon dioxide gas was used. Hydrogen is extremely reactive with air or oxygen gas, and the exothermic reaction releases a huge amount of energy. When the switch on electrical appliances are turned on or off, the metal contacts in the switch mechanism touch and pull apart, and a spark is transferred between the contacts- this i known as switch-bounce. The small spark carries sufficiently high amount of energy that can cause a huge explosion. As a chemist, I would not have carried out this gas based experiment at all if I checked to find that an electrical garage gauge was used- mechanical pressure gauge may have been an alternative or at the end of the experiment, the gases should have been removed from the gas tank before the electrical gauge is to be turned off. The same reason about the spark caused by switch bounce due to turning on and off of the switch can be used to explain why all flammable gases including carbon monoxide will ignite if the gas is under conditions where a switch is used and the gas is not sealed away from the switch (i.e. a great analogy would be carbon monoxide poisoning where carbon monoxide leaks from the gas pipes and into the room of a house, if the a wall switch to the lights or mains is pressed an explosion results). Although I am an organic chemist, I have worked with flammable gases and flammable chemicals in the past, and I always fill out lab safety forms and get all equipment checked before all experimentation. Looking at the photos, I was shocked to also see that one oxygen cylinder was knocked slightly- has it been knocked further to the ground the explosion could have been stronger and higher in energy killing both the postgraduate researcher and the professor. God saved them that day. If I was the professor, I would have immediately considered alternative options of the use of pressure gauges and what steps needs to be taken if an electronic pressure gauge is used because as a schoolboy decades ago, I studied chemistry, physics and electronics all to an advanced level before studying chemistry at university, and I was always well aware of the use of electronic instruments in flammable gases conditions, even carrying out such experimentation to this day.

In my opinion, both the researcher and professor, and the manufacturers of the electronic pressure gauge are 50:50 to blame for the accident. This is because the PG researcher and professor failed to consider in the safety of usage of highly flammable gases and the explosion from the previous experimentation. The manufacturers are also to blame for failing to manufacture a safe enough instrument to use under flammable gas conditions- manufacturers failed to manufacture an electronic pressure gauge where the circuit board and switch component of the gauge was not sealed tightly so no gases can enter the circuit board and switch component. Both the researcher and her tutor, and the manufacture need to make changes in safety- for the manufacture, they should manufacture instruments that are design safe for gaseous experiments.
Yazeran (May 2, 2016 4:54 AM)
Actually the manufacturer may not be at fault here at all.
We do not know if the gauge was even rated for the use they put it!

My bet (based on the cavalierly manners described) is that they just grabbed the first automatic gauge they could get their hands on and my guess is that it was not (by the manufacturer) rated for flammable/explosive gas mixtures (ATEX approved for us here in the EU).

Also based on the setup described, even had they used ATEX equipment, an explosion could occur anyways as gas flowing through pipes can create enough static electricity to cause sparks......

The golden rule about such things is to keep the volume of explosive mixture as small as ever possible, and in their case that would require 3 independent regulators/valves, one for each pure gas individually, and then only mixing the gasses in the small chamber with the bacteria.....
S. Sutcliffe (April 27, 2016 10:50 PM)
As a volunteer firefighter I have heard propane tanks rupturing at a distance during a massive wildfire; on going back later and seeing the tanks, it was a sobering thing to consider what could have happened. Once it got too intense to defend structures, we pulled back. One of us was unfortunately near enough to a tank when it went to sustain hearing damage for several months; I imagine this is yet another issue Ekins-Coward is having to deal with. I hope that this will be temporary for her too. I agree with the concerns about the lack of apparent constraints on the tanks; while in grad school I was always sure to check for this- and I was just using helium! Unfortunately people can get very cavalier around gas tanks and similar equipment. One day, luck may run out. The initial sparking sensation - never mind the mini-explosion would have been enough for me to stop - despite what my supervisor said. Sometimes the boss is not right.
Ale (April 28, 2016 6:07 AM)
I agree with all the commentators that were "shocked" by seeing such a large amount of inherently unstable gas mixture. The difference between academia vs. industry is most likely the lack of knowledge about "scale-up issues" and we might consider this to be such an issue. (although I wouldn't be happy to be anywhere close to a 1L cylinder with such a mixture).

I am saying this as I transitioned from academia to industry and deal with scale-up and calorimetry on daily basis.
Greg (April 28, 2016 9:40 AM)
Why in the world does the PI need to do this kind of research, and why fund it? Way too dangerous. There are plenty of interesting avenues in science that don't involve making bombs. If you need to make such an experiment to do what you want to do, then perhaps you haven't thought about it hard enough. The current trend is to make things safer and easier. I'm puzzled that a PI thought this project was a good idea.
Ed (April 28, 2016 10:56 PM)
Unsecured gas bottles, laboratory doors that open inwards instead of outwards with latch trip bars, an explosive gas containment vessel designed by the PI and fabricated by the victim, leaks noted and repaired by the campus leak repair shop, prior warning signs that include a "small explosion" and static shocks from said containment vessel,senior university official stating soon after accident "we have been doing it this way for years without any problems"..............HELLO!!!!!!!!!
Danny Yeager (April 28, 2016 11:07 PM)
The lab supervisor and professor in charge should go to jail. This is a tragedy that could have easily been avoided. It should not be tolerated.
Tom C. (April 29, 2016 11:22 AM)
Excellent points Ed.
George Whitmyre (May 2, 2016 8:22 PM)
Commenting as a retired, 41 year veteran lab safety specialist embedded in a Chemical and Biomolecular Engineering Department, we've learned that laboratory safety programs only work when they are top-down, with serious commitments from Regents, Presidents, CEOs, upper management, and even PIs. These leaders must look for and reward good safety behaviors, and expect immediate correction of problems when discovered, taking Soon, Certain, and Positive Action! Mandatory lab hazard reviews, quarterly lab inspections, targeted compressed gases and electrical hazard reviews, personal protective equipment programs, engineering and administrative controls, training and retraining are some of the elements of a working laboratory safety program. By the way in earthquake zones like HI, single restraints will not secure a gas cylinder during the quake. Dual gas cylinder restraints like high and low chains or straps anchored into wall studs are the only way to prevent cylinders vibrating and slipping out during the quake. It's bizarre to see so many cylinders piggy-backed together or not secured at all! Almost as bizarre as management overlooking lab conditions that led to this preventable loss of limb.
Tekla Staley (May 3, 2016 8:18 PM)
It is very unfortunate that another serious accident has happened in a research laboratory. Working in the safety & health industry for 30 years, it boils down to behavior and mindset. Time and time again, we have discussions with post-doc students and PhDs in our industrial research labs, and often receive the same arrogant answer. These individuals are smart, they know they are smart, and they don't believe they need "us" telling them how to do anything. Their funding and time is sometimes limited, and they do not want to spend precious funding and time implementing safety. Quite often researchers get away with deficient hazard controls because the risk is low, but the level of risk is not always recognized or appreciated. It breeds overconfidence, arrogance and complacency--the result is disastrous. It needs to be a team effort from those providing the funding to the researchers, facility management, safety & health support and everyone in between.
David Mertz, P. E. (May 4, 2016 5:42 PM)
If an engineer had designed a vessel for this service and failed to, at a minimum, include a properly-selected burst disc and vent line, and specified an explosion-proof pressure "gauge" or intrinsically safe electric supply for that pressure "gauge" application, they could expect a letter from the Engineer, Architect, Surveyor & Landscape Architect Board of the Hawaii Department of Commerce and Consumer Affairs' Professional and Vocational Licensing Division. That letter would likely request that engineer to appear before the Board and explain why this degree of negligence should NOT result in the revocation of his or her Professional Engineer license. If the Board would decide, as it likely would, to revoke the HI license, any other P. E. licenses from other states would also be automatically revoked as well. The engineer's name and the reason for the revocation would be published in the Board's newsletter periodically sent to all licensees. The now-former engineer would likely looking for work requiring skills like asking "Do you want fries with that?"
Dr. Robert G. Butler (May 5, 2016 10:22 PM)
There will always be an ignition source. One should always calculate the enthalpy of all possible reactions and compare that to TNT. If you have anything close to the enthalpy of decomposition of 0.1 g of TNT, which is 418.4 J, then you should conduct your experiments in a lab designed to mitigate explosions. A fume hood won't do it. Also the burst disc was improperly sized. Considering the amount of damage, the whole end of the tank should have been scored. In such cases people look for a scape goat, but really there is more than enough to go around: The post-doc, her adviser, the tenure committee, the heads of the lab techs and stockroom, the safety officers, the chairman, the dean, OSHA etc. Know the dangers of your chemicals; did you know sugar and flour are explosive? Be afraid and respect your chemicals, they bite.
Howard Lee (May 11, 2016 6:35 PM)
Storing Oxygen near the refrigerator as in the photograph above is risky.
Sanford Kirksey (May 14, 2016 9:50 PM)
Certainly a tragic and preventable event. Typically, there are several factors that contribute to such catastrophic accidents, but one or two root causes. Based on the pictures of the lab, it appears that overcrowding is one of these. This is evidenced by the generally cluttered appearance of the lab benches - very little free space; numerous gas cylinders, some of which appear to be unsecured; chemical storage cabinets in close proximity to the work areas; lab apparatus stacked one atop another. Trying to work safely under such conditions, day in and day out, sets the scene for accidents. Add to this the apparently "Jerry-rigged" pressure vessel apparatus, and perhaps a sense of urgency to get the work done, and you have a "perfect storm" scenario for tragedy.
Most universities have access to specialists for the design and testing of specialized apparatus. Why wasn't this done? In my judgment, any apparatus designed to manipulate pressurized, flammable gases should be built, tested, and certified by such specialists.
David Sweedler (July 6, 2016 3:19 PM)
Hydrogen embrittlement of high strength steels used to construct pressure vessels is a serious problem that may have contributed to the rupture of the secondary storage tank. I did not see this issue raised in any of the reports linked to this article. Hydrogen rapidly diffuses into and through the steel microstructural voids due to adsorption and can cause a very large reduction in the strength of the alloy. Special alloys and coatings are used to make hydrogen pressure vessels and this technology is quite expensive. Engineers in the CPI have a wealth of knowledge and experience with these issues. Any lab working with hydrogen gas at pressure needs to acquire the specilzed equipment and knowledge to safely work with this gas. Hydrogenation equipment used in many chem labs and made by Parr Rearch and others addresses these safety issues explicity.
Jyllian Kemsley (July 11, 2016 2:34 PM)
UPDATE: The University of California Center for Laboratory Safety has completed its investigation of the explosion, and concluded that the immediate cause was not a spark from the pressure gauge but an electrostatic discharge between Ekins-Coward and the gas tank. Going beyond the immediate cause of the explosion, however, “the overall underlying cause of the accident was failure to recognize and control the hazards of an explosive gas mixture of hydrogen and oxygen,” the UCCLS report says.

Story and links to the report are here:
Jyllian Kemsley (July 13, 2016 7:37 PM)
And for all the people who wondered about how the gas cylinders were stored and used:
Gas cylinder storage at the University of Hawaii

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