It's highly abnormal to see an accident investigation that doesn't cite a systematic or organizational causal factor. In fact, the causal analysis models I'm familiar with only allow for a few causes that fit outside one of those categories (act of God and mental lapse). I too am going to be very interested in how they define "systemic problem". Hopefully, it was just a poor choice of wording, because the alternative would not be good for anyone.
On Apr 28, 2016, at 4:24 PM, Reinhardt, Peter <peter.reinhardt**At_Symbol_Here**YALE.EDU> wrote:Colleagues,
The following C&E News quote surprised me. I wonder what you think:
"The independent investigation into the March 16, 2016 explosion in a University of Hawai'i at M=C4=81noa laboratory is now expected to be complete in mid to late May-The University of California Center for Laboratory Safety, retained by UH to conduct the investigation-In its preliminary investigation, the UC Center for Laboratory Safety, considered a national leader in laboratory safety, determined that the explosion was an isolated incident and not the result of a systemic problem."
I am not sure how the UC Center for Laboratory Safety defines a "systemic problem," and perhaps I don't know pertinent details of this awful, tragic accident, but I keep pondering the following questions, which allude to systemic safety problems (as I would define them) all too common in academic institutions:
=B7 Was a hazard analysis done prior to the experiments? Does the University of Hawai'i integrate hazard analysis into its research process?=B7 When so many different hazards exist in each research laboratory, how can students and post docs (still in the early phases of their professional development) gain the requisite knowledge and skills to recognize and understand the specific risks associated with their work?=B7 Was there an anonymous, nonpunitive incident and near-miss reporting system? (I realized that, had the person reported the near-miss that preceded the accident, it would have been easy to identify that person.)=B7 What can be done about the dependence of students and postdocs on the principal investigator for their professional advancement, and the way this relationship's power differential affects the willingness of students and post docs to raise safety concerns?
Some of the above wording is verbatim from the National Academies "Safe Science: Promoting a Culture of Safety in Academic Chemical Research" (http://www.nap.edu/read/18706/chapter/7#100). If these systemic problems existed at the University of Hawai'i, I do hope that UC Center for Laboratory Safety shares their findings and recommendations. It would help me and others improve our safety programs.
Peter A. ReinhardtDirector, Office of Environmental Health & SafetyYale University135 College St., Suite 100New Haven, CT 06510-2411(203) 737-2123
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