Date: Wed, 29 Jun 2011 11:20:51 -0400
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: "Koza, Mary Beth (Environment Health & Safety)"

Subject: Re: Boston College incident follow up
In-Reply-To: <519A76E7-A9E6-4B68-A09B-7943F5ADFAD1**At_Symbol_Here**>

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I take exception to suggest ing that  serious academic institutional/departmental follow-up response is not a normal part of the accident review.  Many academic institutio ns have a process, consisting of  root cause analysis and lessons lear ned.  Making such a broad statement is counterproductive to the import ance of safety.

Mary Beth Koza

Director of EHS

University of North Carolina - Ch

From: DCHAS-L Discussion List [mai lto:DCHAS-L**At_Symbol_Here**] 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

I concur that realistic, repetitive training can go a long way to amelior ating panic reactions in emergency situations.  Alas, the resources an d institutional commitment for this sort of thing are lacking in most acade mic situations, and for some folks it just won't ever sink in.

One low-cost method that may be effective is to place a site-s pecific poster-size emergency checklist in the most visible common area of the laboratory/suite.   Focus on the most important response issue (fi re/explosion, for example) only.  Hopefully, the workers in the area w ill better retain their key emergency response skills (or eventually learn them through osmosis) or perhaps they may even turn to the poster in an eme rgency (911 called, fire alarm pulled, evacuation, personnel accounted for etc. etc.).   As a small example of what I mean, see the fire checklis t I have posted at 

I have never personally seen laboratory safety trai ning materials discuss that the trainee or his/her coworkers may freeze, pa nic, or do something completely wrong in an emergency situation.  A co worker's inappropriate reaction can not only be distracting or disorienting , it can compound an already bad situation.   I encourage everyone to include this topic in their training courses.

Recen t events (UCLA, Yale etc.) aside, I have never personally seen serious acad emic institutional/departmental follow-up response with Lessons Learned fro m minor accidents, major incidents, or near misses.   Having a protoco l for a formal analysis (What happened?  Facts instead of departmental gossip.  What went wrong? How could this be avoided? What SOP's shoul d change?  etc.), ensuring that the analysis is distributed to all pos sible 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 DuPon t, but, sadly, in my own personal experience, academic institutions often f ail 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 cou rses.

Finally, those archived incidents make great case studies that should be utilized in laboratory training.  After gi ving the full spiel, take the time to pull out a couple of case studies and ask the trainees what should have been done, what could have been improved etc.  Interactive training forces the trainees to think about the iss ues and the instructor achieves instant feedback on how effective the train ing has been.  This makes training a much more interesting experience for both parties.   If you are fortunate enough not to have any site-s pecific cases to use, a wealth of them are available at HandScommittee/Pages/LaboratorySafetyIncidents.aspx  The unexpecte d dangers reported at also afford additional scenarios.

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Rob Toreki

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On J un 28, 2011, at 8:26 PM, Peter Zavon wrote:

On Tuesday, June 28, 2011 David C. Finster said to the DCHAS-L Discussion
List in pa rt:

I would "second" Brad's comments about the need for training < /o:p>

and education that exposes students to simulated events and

that is heavily based on repet ition.  Truth is:  people panic

when confronted with unexpected events and, in knowing this,

it's almost laughable that one of first "rules" ; we teach in a

panic-inducing situation i s "not to panic." Yeah, right.  So,

I tell students to go ahead and "panic" (for a BRIEF mom ent!)

to get that out of the way and then "go back to your


Since panic is a visceral reaction that prevents reason and logi cal
thinking, it seems to me that telling people "not to panic,&quo t; either in
training or at the time of a frightening event, is one of t he most useless
instructional activities imaginable. Repetitive simulate d practice that
other have endorsed is the way to go. That is likely to prevent panic by
reducing the novelty of the situation.

"Don 't panic" as an instructional step is on a par with "Be more care ful" in
counseling someone whose apparent lack of attention is thou ght to have
caused an "accident." Both phrases make the speake r fell better, but neither
conveys actionable guidance.

Peter Zav on, CIH
Penfield, NY

P ZAVON**At_Symbol_Here**

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