From: Laurence Doemeny <ldoemeny**At_Symbol_Here**COX.NET>
Subject: Re: [DCHAS-L] CCS Statement on the Tornado Incident
Date: Mon, 8 Sep 2014 14:16:49 -0700
Reply-To: DCHAS-L <DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU>
Message-ID: 000101cfcbaa$34169dd0$9c43d970$**At_Symbol_Here**net

Let me offer this for discussion.


One universal solution to this problem could be an institutional policy similar to a hot work permit policy. Any person conducting a demonstration or bringing chemicals into an institutions building should first obtain a permit from building management, the facilities engineer and safety officer. That person should review their qualifications to conduct the procedure or demonstration with those officials and explain potential risks. While this policy is not 100% leak free, it would go a long way toward reducing the risks to spectators and management.


Laurence Doemeny


From: DCHAS-L Discussion List [mailto:dchas-l**At_Symbol_Here**MED.CORNELL.EDU] On Behalf Of Mary Beth Mulcahy
Sent: Monday, September 08, 2014 10:56 AM
Subject: Re: [DCHAS-L] CCS Statement on the Tornado Incident


"How do we educate those who will never see our message? "

Such a great question, and I think there are some more we should sprinkle into the conversation.

How can someone ask a question that they do not know exits?
How do we make sure people get the right knowledge?

How can we start addressing "human error" in these types of experiments/demos?


Each time one of these incidents comes up, I read the inevitable comments that question how a person could have possibly done the demo/experiment. Like someone said, these can be career enders, but my heart goes out to the people that get caught in these accidents because each time I find myself thinking about my own innocently ignorant history.


When I was a 22 year old high school teacher, I did the methane bubbles (chasing bubbles with methane around with a candle at the end of a yard stick), the burning gummy bear, and the woosh bottle demos without any idea that what I was doing could have lead to series incidents. I did not even know enough to ask someone else for help. All I had were books that wrote up demos or the internet (which was just kicking in back when I started teaching), and they did not address safety concerns or come with huge warnings. I was a "fun" teacher, and no one at the schools where I taught questioned what I was doing (nor do I think they had the background to do so).

Fast forward 10 years and I found myself with a PhD back in a high school classroom. I don't remember the exact demo, but one day I had read about one that I thought sounded great and decided to test run it. So I set up the demo and wore my labcoat and googles and even set up a safety shield--I had a lab explosion while I was in grad school and was always concerned about flying shrapnel after it. I ran the demo which turned out to be so exothermic that it caught the hot pad I had put under the reaction on fire and produced a lot of smoke. Needless to say, the fire alarm was triggered and I had to explain to a bunch of firemen and a Hazmat team exactly what I had done. The obvious question that would come out on the list-serve is "how could the person possibly not have used a fumehood?" The answer--there was only 1 for the different classrooms I was teaching in and for some reason it was not easily accessible that day and I simply did not realize how exothermic the reaction I was about to do was. This is where "human error" or "human factors" are not so simple because there are reasons people do what they do and until we addressed why people make the decisions they do, we miss an opportunity to end risky practices. It is possible to make a "bad" decision without actually being thoughtless, it can be the result of being misinformed, not informed, or, unfortunately, externally influenced (like not having an easy to access fumehood).

So much about these demos comes back to individuals because the demonstrators are not part of a systems that had been designed to absorb human  errors or potential problems. So much then comes back to individual people doing the demonstrations, which makes the role human factors play critical. I like this paraphrased quote about addressing human factors--it's about making it easy to do the right thing, and hard to do the wrong thing. So, how can we make it easier to do the right thing?

It would be almost impossible for me to go back to a classroom now and take the same risks I did as either a 22 year old or PhD-chemist-teacher, but that is because of my current job investigating major chemical accidents. I am educated on a daily basis of the consequences of the risks we take when the odds do not play in our favor. I also now have a back pocket full of tools that I would use that are designed to push people to explore risk and seek more knowledge.

How to solve this? I wish I had a great answer. I find myself coming back time and again to undergrad education being a start, but that still leaves a large population of people out there who would still need to be reached. Thank yo for letting me ramble, and I will look forward to the insights the members of this listserve have.


Mary Beth


On Mon, Sep 8, 2014 at 10:37 AM, David Roberts <droberts**At_Symbol_Here**> wrote:

So - I have a general question about this incident (and others like it).

While I understand that many of these incidents are done by what I would term "chemical professionals", meaning people who either teach chemistry at some capacity or are involved in the chemical industry, how many of these incidents are started by people who are not directly in our industry at all?

I ask because I have made some observations here at my facility over the years that have troubled me.  We have a strong outreach presence here at DePauw.  Some of it is sponsored by myself (and I'd like to think we think of safety first), but much of it is sponsored by University clubs, many of which never talk to me before doing something.  Students go in to the community and do a demo of some sort using standard things they can purchase at local stores.  They are supposed to plan months ahead of time, but as is typical with their generation they usually wait until the last minute, then they call up a you-tube video on something they want to show and they go get what they need for it, with little thought or practice before the incident occurs.  Often times they do crazy demos with no thought of safety (it just doesn't cross their mind), and they often get away with it with no casualties.  I'm never in the loop on most of these, I just hear of them second hand from various p!
 eople.  If they do something I don't approve of I do try to get word back to them, but it's always an after the fact sort of thing.

I don't know at all if this incident was like this.  Probably not.  But my point is that regulation of people who aren't going to read the rules is difficult at best.  If they never ask for my help, it's impossible for me to know that they are even doing something.  Even if we instill a University policy, policing that policy is not going to be an easy thing in cases like this.  People who are not receiving these emails often have no idea that there is even a problem doing such a thing.  These demos are all over you tube.

What do we do about that?  How do we educate those who will never see our message?  I'm just asking, not trying to stir up a hornets nest (which I did last week by the way, wow, I know what that means now).

Good luck all.  Stay safe



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