Date: Wed, 29 Jun 2011 09:19:07 -0400
Reply-To: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
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From: "Mary M. Cavanaugh" <cavanaughmm**At_Symbol_Here**APPSTATE.EDU>
Subject: Re: Boston College incident follow up
In-Reply-To: <519A76E7-A9E6-4B68-A09B-7943F5ADFAD1**At_Symbol_Here**>

Rob, we do this at Appalachian for all serious incidents, lab or otherwise.

Case in point:  Sammye Sigmann (our Chemisty Dept’s CHO and an active member on this listserv) did a great lessons learned for a Chemistry Dept lab explosion.

Then, since one root cause of the explosion was inadequate labeling of small lab containers, I used that information to bolster a 3-yr-long attempt to convince management to purchase a chemical inventory system that will make proper labeling of containers easier (and it worked -- the University approved purchase of the system a few months ago and we are in the process of implementing it now).


Mary M. Cavanaugh CIH

Interim Director, Occupational Safety & Health Office

University Industrial Hygienist

Phone 828.262.6838 (Tues-Wed)

Phone 828.262.4008 ext 3# (Mon, Thu, Fri)

Email cavanaughmm**At_Symbol_Here**

From: DCHAS-L Discussion List [mailto:DCHAS-L**At_Symbol_Here**LIST.UVM.EDU] On Behalf Of ILPI
Sent: Tuesday, June 28, 2011 11:25 PM
To: DCHAS-L**At_Symbol_Here**LIST.UVM.EDU
Subject: Re: [DCHAS-L] Boston College incident follow up

Recent events (UCLA, Yale etc.) aside, I have never personally seen serious academic institutional/departmental followup response with Lessons Learned from minor accidents, major incidents, or near misses.   Having a protocol for a formal analysis (What happened?  Facts instead of departmental gossip.  What went wrong? How could this be avoided? What SOP's should change?  etc.), ensuring that the analysis is distributed to all possible stakeholders, and archiving it on an easily accessible web site is a great way of making sure that history does not repeat itself.   I have the impression that this kind of analysis is the norm at places like DuPont, but, sadly, in my own personal experience, academic institutions often fail to do so either out of liability/publicity concerns, leadership inertia/vacuum, or both.     Formal accident followups should be SOP and the importance of these should be stressed in academic safety training courses.

Rob Toreki

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