Date: Tue, 28 Jun 2011 14:20:52 +0000
Reply-To: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
Sender: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
From: "Peifer, Patricia" <Patricia.Peifer**At_Symbol_Here**WESTPHARMA.COM>
Subject: Re: Boston College incident follow up
In-Reply-To: <9375A4B942930D458099C4FB6E0874A896D2E0DFA2**At_Symbol_Here**>


About a year ago I decided to conduct some "Safety Drills" in our laborator
y.  Most of these safety drills involved a spill.  My concern was that even
 after sit-down training on how to handle a spill, our scientists would not
 be clear on what to do if something bad actually happened.  (We don't have
 many accidents)

In the first drill (and, yes, I would call it primitive), participants were
 told that they should not dial 911 (the situation didn't call for it anywa
y) and only pretend to pull a safety shower, but otherwise do everything th
ey were trained to do.  I poured 4L of water on myself and told everyone it
 was MIBK.  I then pretended to slip and hurt myself and ended up sitting o
n the floor in the "MIBK".  Everyone just sort of stood there and finally s
omeone asked me what they should do.

This is what I was worried would happen.  Basically, no one knew what to do
.  I am not trying to bust on our scientists, they are excellent at their j
obs.  And I'm not sure, in their place, I would have responded any differen
tly.  I agree wholeheartedly that emergency response needs to be practiced.

After the first run, I told the group how they should have responded and we
 did it again.  I also reviewed the hazards of the particular chemical with
 them.  I think it was a good exercise and also it was an opportunity to se
e if groups outside the lab, like the Medical Response Team, would respond 
as they should have (they did).  I must say it took me out of my comfort zo
ne though, and the participants too.

Pat Peifer
West Pharmaceutical Services
101 Gordon Drive
Lionville, PA  19341

-----Original Message-----
From: DCHAS-L Discussion List [mailto:DCHAS-L**At_Symbol_Here**] On Behalf Of No
rwood, Brad
Sent: Tuesday, June 28, 2011 9:03 AM
To: DCHAS-L**At_Symbol_Here**LIST.UVM.EDU
Subject: Re: [DCHAS-L] Boston College incident follow up


While there is *some* evidence that communication/culture barriers or diffe
rences *might* have played a role here, in my mind the fundamental issue is

Please understand - I am not harping on BC's training in particular, but EV
ERY training program - except one - of which I've ever been a part.

The fundamental truth is that when we get in a panic/emergency situation, i
f this is the first time we've ever really thought about what we would do w
e will almost inevitably do the wrong thing.  This brings me to the ONE tra
ining program that I've been involved in that (IMO) got things very nearly 
totally correct.  Prepare to groan.

The United States Navy (other branches may have similar systems, but after 
20 years active and reserve, the Navy's is the one I'm familiar with).

Emergency training in the Navy is focused on:

1) Simulation of actual events that have happened elsewhere (i.e. "We know 
what they did, but what would you do?")

2) Realistic scenarios of desperate (and, sometimes not so desperate) casua

3) Careful (if primitive) simulation of adverse conditions.  Are you fighti
ng a fire?  Then smoke will obscure your view if it takes too long (and we 
would get green translucent plastic placed over the face shields of our Eme
rgency Air Breather masks, and have to continue fighting the fire until it 
was out and the space was ventilated).

4) Repetition, repetition, repetition.

5) Review and discussion of how the responders handled the situation - what
 they did right, what they did wrong.  In some cases, we turned right aroun
d and repeated the drill if it was determined (in the oh-so-subjective opin
ion of the Executive Officer) that the way the casualty was handled might h
ave led to loss of life or even the entire boat (submarine).

Our saying was, you fight like you train.  This is true in warfare, but the
 focus was getting people "comfortable" with the emergency situation so tha
t in the shock of a real casualty, we would switch into automatic mode and 
do things the way we had been trained.

Ms. Cho was probably so flummoxed and surprised by what happened, that she 
defaulted to "I will go home and get my first aid kit".  In the process of 
doing so, I'm also confident she walked past at least one other convenient 
first aid kit and a couple of phones on which she could have called for hel
p (not to mention the cell phone that was undoubtedly in her pocket).  I ha
d a similar situation occur here at our lab, where *one month* after fire e
xtinguisher training (putting out a real fire with a real fire extinguisher
), we had a minor fire in an instrument.  The technician ran right past the
 CO2 fire extinguisher to get some water to throw on this *electronic* devi
ce, thereby destroying a controller worth about $5K and a lost day of produ

So, to sum up:  Don't look for additional placards or signs by the phone or
 language/cultural training to fix this problem.  The fundamental issue her
e is getting people to automatically think and act the way we need them to 
*in the moment of panic* when an actual accident occurs.  This requires a f
ar more realistic, frequent and site-specific kind of training.  That also 
means that there is no "one size fits all" bureaucratic solution that shoul
d (or can) be imposed from above.  WE are the answer.

Just my $0.02

Dr. Bradley K. Norwood
Arista Laboratories, Inc.
1941 Reymet Road
Richmond, VA  23237
(804) 271-5572

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-----Original Message-----
From: DCHAS-L Discussion List [mailto:DCHAS-L**At_Symbol_Here**] On Behalf Of Se
cretary, ACS Division of Chemical Health and Safety
Sent: Tuesday, June 28, 2011 7:58 AM
To: DCHAS-L**At_Symbol_Here**LIST.UVM.EDU
Subject: [DCHAS-L] Boston College incident follow up

Gail asked me to pass this along to the list as background for some of the 
discussion occurring here. I would also note that there is a lot of specula
tion about the event in the media and blog-world; a summary can be found at

- Ralph

From: Gail Hall 
Date: Jun 27 2011

The Chemistry Department and EHS at Boston College train every graduate stu
dent initially and annually to call Campus Safety in the event of an emerge
ncy. There are signs at every phone. There is even a question on the quiz t
hat they have to take to get their keys.

At the moment we are still collecting information and don't have a cause fo
r the explosion or a reason that the student acted as she did.  We seem to 
have had our share of learning opportunities in the past 18 months, and I w
ill share our hypotheses and/or conclusions on this one when we have been a
ble to fully research the matter.  I hate to think I have enough material f
or an article in JCHAS, but it's beginning to look that way.

In the meantime, if anyone has any ideas about sources of pictograms to hel
p communicate certain things to students for whom English is the second lan
guage, we'd appreciate the information.


Gail Hall
Director, EH&S
Boston College

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