Continued Development of the
NMSU CHEME Safety Culture
Monthly Safety Meeting
December 13, 2013
Incident at Texas Tech
• On January 7, 2010, a graduate student within
the Chemistry and Biochemistry Department at
Texas Tech University (Texas Tech) lost three
fingers, his hands and face were burned, and one
of his eyes was injured after the chemical he was
working with detonated.
• http://www.csb.gov/videos/experimentingwith-danger/
– 11:11 through 20:30
Investigation at Texas Tech
• The CSB investigated and found systemic
deficiencies within Texas Tech that contributed
to the incident:
– physical hazard risks inherent in the research were
not effectively assessed, planned for, or mitigated;
– lacked safety management, accountability, oversight;
– previous incidents with preventative lessons were
not documented, tracked, and formally
communicated.
Beyond Texas Tech
• While vast references, standards and guidelines
have been developed to describe and promote
different types of hazard evaluation
methodologies in an industrial setting, similar
resources that address the unique cultural and
dynamic nature of an academic laboratory setting
have not been generated.
Beyond Texas Tech
• Universities choosing to use OSHA’s Lab
Standard (29 CFR 1910.1450) as guidance for
developing a plan to mitigate chemical hazards
need to understand that the standard was not
created to address physical hazards of
chemicals, but rather health hazards as a
result of chemical exposures.
§1910.1450 Occupational exposure to hazardous
chemicals in laboratories. (a) Scope and application.
(1) This section shall apply to all employers engaged in the laboratory use
of hazardous chemicals as defined below.
(2) Where this section applies, it shall supersede, for laboratories, the
requirements of all other OSHA health standards in 29 CFR part
1910, subpart Z, except as follows:
(i) For any OSHA health standard, only the requirement to limit
employee exposure to the specific permissible exposure limit shall
apply for laboratories, unless that particular standard states otherwise
or unless the conditions of paragraph (a)(2)(iii) of this section apply.
(iii) Where the action level (or in the absence of an action level, the
permissible exposure limit) is routinely exceeded for an OSHA
regulated substance with exposure monitoring and medical
surveillance requirements, paragraphs (d) and (g)(1)(ii) of this section
shall apply.
1910 Subpart Z - Toxic and Hazardous Substances
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§1910.1000 Air contaminants.
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§1910.1001 Asbestos.
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§1910.1002 Coal tar pitch volatiles; interpretation... •
§1910.1003 13 Carcinogens (4-Nitrobiphenyl, etc.). •
§1910.1004 alpha-Naphthylamine.
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§1910.1006 Methyl chloromethyl ether.
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§1910.1007 3-Dichlorobenzidine (and its salts).
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§1910.1008 bis-Chloromethyl ether.
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§1910.1009 beta-Naphthylamine.
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§1910.1010 Benzidine.
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§1910.1011 4-Aminodiphenyl.
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§1910.1012 Ethyleneimine.
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§1910.1013 beta-Propiolactone.
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§1910.1014 2-Acetylaminofluorene.
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§1910.1015 4-Dimethylaminoazobenzene.
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§1910.1016 N-Nitrosodimethylamine.
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§1910.1017 Vinyl chloride.
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§1910.1018 Inorganic arsenic.
§1910.1020 Access to exposure/medical records.
§1910.1025 Lead.
§1910.1026 Chromium (VI).
§1910.1027 Cadmium.
§1910.1028 Benzene.
§1910.1029 Coke oven emissions.
§1910.1030 Bloodborne pathogens.
§1910.1043 Cotton dust.
§1910.1044 1,2-dibromo-3-chloropropane.
§1910.1045 Acrylonitrile.
§1910.1047 Ethylene oxide.
§1910.1048 Formaldehyde.
§1910.1050 Methylenedianiline.
§1910.1051 1,3-Butadiene.
§1910.1052 Methylene Chloride.
§1910.1096 Ionizing radiation.
§1910.1200 Hazard communication.
§1910.1201 Retention of DOT markings, …, labels.
§1910.1450 Occupational exposure to hazardous
chemicals in laboratories.
CSB Key Lessons from Texas Tech:
1. Academic institutions modeling their laboratory safety
management plan after OSHA’s Lab Standard (29
CFR 1910.1450) should ensure that all safety hazards,
including physical hazards of chemicals, be addressed.
2. Academic institutions should ensure that practices and
procedures are in place to verify that research-specific
hazards are evaluated and mitigated.
CSB Key Lessons from Texas Tech:
3. Comprehensive guidance on managing the hazards
unique to laboratory chemical research in the
academic environment is lacking. Current standards
on hazard evaluations, risk assessments, and hazard
mitigation are geared toward industrial settings and are
not fully transferable to the academic research
laboratory environment.
4. Research-specific written protocols and training
are necessary to manage laboratory research risk.
CSB Key Lessons from Texas Tech:
5. An academic institution’s organizational structure
should ensure that the safety inspector/auditor of
research laboratories directly report to an
identified individual/office with organizational
authority to implement safety improvements.
6. Near-misses and previous incidents provide
opportunities for education and
improvement only if they are documented,
tracked, and communicated to drive safety
change.
Causation
• With any serious event, it is all too common for
attention to be focused on the actions and decisions of
the individuals involved in the immediate activities
preceding the event.
• Modern accident causation theory recognizes that incidents
are not the result of a single malfunctioning piece of
equipment or the erroneous actions of one person, but
instead are the result of a number of failures and
deficiencies at many levels within an organization and
its technical community.
Theory of accident causation:
Swiss cheese model
Within the context of an
academic institution, this
model depicts a series of
safety layers (or system
defenses) capable of
preventing an incident.
The holes represent gaps
within each system where
failure could occur. If a
number of failures align,
an incident results
Causation at Texas Tech
• Through review of evidentiary records, interviews, and
post-incident observations, the CSB concluded that
each layer of safety management within the institution
had deficiencies that contributed to the January 2010
Texas Tech incident.
• The CSB also identified several gaps beyond the
university itself where safety management and practices
of the researchers could have been influenced to aid in
prevention, including the grant funding agency, the
existing laboratory safety regulations, and good practice
guidance.
CSB Causation at Texas Tech
• Physical hazards of the energetic materials research were not
effectively assessed and controlled;
• TT lab safety management program was modeled after 29 CFR
1910.1450; thus did not address physical hazards of chemicals;
• Comprehensive hazard evaluation guidance did not exist;
• Previous TT lab incidents with preventative lessons were not
always documented, tracked, and formally communicated;
• The research-granting agency prescribed no safety provisions
specific to the research work being conducted at TT at the time
of the incident, missing an opportunity for safety influence; and
• Safety accountability and oversight by the principal investigators,
department, and university admin were insufficient.
The Grant Agency’s role
• Department of Homeland Security is one of 19 federal agencies
that collectively provide over $25.3 billion to academic
institutions for scientific research (NSF, 2009), but not all of
these agencies choose to include safety requirements or
stipulations within their grant applications and cooperative
agreements with researchers. DHS did not have safety provisions
specific to the energetic materials research being conducted by
Texas Tech within its cooperative agreement with NEU.
• After the incident, the Office of University Programs in DHS
added a new safety condition to the 2011 cooperative
agreements with all universities funded by any of the DHS
Centers of Excellence. This safety condition, the Research Safety
Plan, has requirements that a contractor include these conditions
in all sub-awards or subcontractors.
Changes to DHS awards:
• Possible research hazards associated with the types of research to
be conducted under the award are identified;
• Research protocols or practices conform to generally accepted
safety principles applicable to the nature of the research;
• Recipient’s processes and procedures
– comply with the applicable protocols and standards;
– prevent unauthorized activities conducted in association with this award;
• Faculty oversees student researchers;
• Research safety education and training to develop a culture of
safety are provided;
• Security access control, where applicable; and
• Independent review by subject matter experts of the safety
protocols and practices is conducted.
CSB Key Lessons from Texas Tech:
5. An academic institution’s organizational structure
should ensure that the safety inspector/auditor of
research laboratories directly report to an
identified individual/office with organizational
authority to implement safety improvements.
Texas Tech Organization Hierarchy
Texas Tech Organization Hierarchy
NMSU Organization Hierarchy
The NMSU CH E Safety Culture
• The development of the department’s safety culture is
dynamic, with changes driven by information gathered
about recent incidents and changes to regulations.
• The current state of our safety awareness is good,
though there is always room for improvement.
• Thank you for your attention to safety in CH E.
Resources to be added to Shires
• Prudent Practices in the Laboratory, Handling and Management
of Chemical Hazards
– THE NATIONAL ACADEMIES PRESS Washington, D.C.
www.nap.edu, Copyright © National Academy of Sciences.
• Identifying and Evaluating Hazards in Research Laboratories
– Guidelines developed by the Hazards Identification and
Evaluation Task Force of the American Chemical Society’s
Committee on Chemical Safety
– Copyright 2013 American Chemical Society
Hydrogen Explosion Incident
http://munews.missouri.edu/news-releases/2010/0709-investigation-of-schweitzer-hall-explosion-complete/
• COLUMBIA, Mo. — Officials from the University of
Missouri have completed an investigation into the cause
of the explosion at Schweitzer Hall that occurred on
Monday, June 28, 2010.
• The explosion occurred in the laboratory of Judy Wall,
professor of biochemistry, during a routine setup of a
microbiological anaerobic growth chamber. Wall and
her team of researchers study anaerobic bacteria, or
bacteria that cannot live in the presence of oxygen. The
bacteria are able to convert toxic metals, such as
uranium and other heavy metals, to less toxic forms.
Investigation of Schweitzer Hall Explosion
• Wall’s team studies the bacteria in chambers that are
roughly 2 cubic meters in volume.
• Standard operating procedures for establishing the
anaerobic environment calls for the use of nitrogen to
fill the chamber. Then, small amounts of hydrogen are
introduced into the chamber to remove any remaining
oxygen by combining to form water. Prior to the
explosion, hydrogen was prematurely introduced into
the chamber and reached an explosive level.
Investigators concluded that the gas was ignited by a
source inside the chamber.
Investigation of Schweitzer Hall Explosion
• Two factors contributed to hydrogen being introduced
prematurely into the chamber:
1. Following a check for leaks in the hydrogen gas lines, the
valve for the hydrogen cylinder was inadvertently left open.
2. The laboratory was using a gas line with a “T-connection”
that normally included a toggle switch used to prevent
nitrogen and hydrogen from being simultaneously
introduced into the chamber. However, a T-connection
without the toggle switch was temporarily being used; thus
both nitrogen and hydrogen entered the chamber
simultaneously.
Investigation of Schweitzer Hall Explosion
• To prevent such accidents in the future, investigators
recommended the following actions:
– Replace the use of pure hydrogen with a 95:5 mixture of nitrogen and
hydrogen.
– Following a check of gas lines for leaks, all gas cylinders should be closed
and only reopened as needed.
– Use of T-connections between gases should be eliminated.
– Investigate use of hydrogen and/or oxygen sensors that could withstand a
corrosive atmospheric environment.
– Give refresher training to all laboratory personnel.
– Review training, guidance materials, and inspection procedures.
– Review compressed gas cylinder storage area to ensure appropriate safety
procedures are in place and look for improvements.
Investigation of Schweitzer Hall Explosion
• Investigators believe several factors helped mitigate damage and
allowed normal building activities to resume quickly, including:
– Wall’s laboratory group was well-organized and clean, minimizing
secondary impacts from the explosion.
– Emergency information about laboratory hazards was posted outside the
door for emergency responders.
– Emergency Action Plan had identified exit routes and building occupants
evacuated in a timely manner.
– Utilities had been reconfigured for the building, allowing maintenance
workers to cut off utility service to the affected laboratories, while
keeping service to the rest of the building.
– Cooperation among the Columbia Fire Department, MU Campus
Facilities, MU Environmental Health and Safety, and the MU Police
Department was excellent. A history of exercises and meetings have
strengthened relationships and cooperation.
Have a
safe holiday!
Don’t work
alone in the labs.