From: Ralph Stuart <ras2047**At_Symbol_Here**MED.CORNELL.EDU>
Subject: [DCHAS-L] Report on UH lab explosion reveals deep, systemic safety failures
Date: Fri, 8 Jul 2016 10:11:08 -0400
Reply-To: DCHAS-L <DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU>

The 16 March explosion at the University of Hawaii (UH), Manoa, that maimed postdoc Thea Ekins-Coward resulted from a static electricity charge that ignited a tank containing a highly flammable, pressurized mixture of hydrogen, oxygen, and carbon dioxide, finds an investigation by the University of California Center for Laboratory Safety (UCCLS). This conclusion contrasts with that of a previous investigation by the Honolulu Fire Department (HFD), which blamed the tank‰??s ignition on sparking caused by an inappropriate pressure gauge.

Issued late in the afternoon in Honolulu on 1 July, the UCCLS report consists of two parts, a 73-page technical analysis of the incident and a 38-page set of recommendations for changes needed to overcome systemic failures in the lab and university‰??s approach to safety. We will be commenting on the report at greater length soon, but here is the lowdown for now.

The main conclusion is that the tank was not grounded, and the digital pressure gauge ‰??acted as a path to ground for a static charge that ignited the hydrogen/oxygen gas mixture contained within a 13 gallon (50 liter) pressure tank,‰?? the UCCLS technical report states. Ignition most likely happened ‰??when the statically charged researcher touched the metal housing of the gauge and a charge transfer occurred.‰??

The contrasting conclusions of the two investigations indicate differences in their intent and extent rather than any essential disagreement about the factors that led to the explosion. The fire department‰??s investigators aimed to determine the source of the explosion, whether it posed any further danger, and whether it was intentionally caused. The UCCLS investigation, on the other hand, sought to pinpoint the exact cause of the explosion through extensive forensic analysis and laboratory studies of equipment identical to that involved in the explosion.

The UCCLS also looked into the actions and the broader context that led to this sad unfolding of events. Although the postdoc and the principal investigator had both expressed serious interest in safety when the postdoc began work at UH, the explosion ‰??showcases once again the challenges that academic research laboratories face in addressing physical hazards of experimental processes,‰?? especially when experimental procedures are changed, the technical report states. The postdoc had been working on a long-running experiment, but she had modified the method and was using ‰??premixed gas in a portable tank‰?? for the first time, according to the HFD report. Formerly, ‰??each individual gas would have a separate hose line ‰?| eliminating the use of a portable tank.‰?? No risk assessment was done for the new method, however, even after a ‰??near miss‰?? small ignition occurred the day before the explosion, according to the UCCLS technical report.

Fundamental to the lapses that led to the explosion, the recommendations section of the report finds, were ‰??serious deficiencies in the institution‰??s approach to laboratory safety, [especially the] lack of a culture of safety.‰?? The report found that the institution had in place ‰??insufficient training in hazard recognition and risk mitigation, ‰?| a deficient laboratory inspection program, a dated and ineffective chemical hygiene plan, ‰?| inadequate standard operating procedures[,]‰?? and no formal risk assessment protocols for experiments with highly hazardous materials.

Ultimately, the detailed procedures and safety equipment necessary for safely handling so hazardous a material as pressurized flammable gas in a moveable tank were not integrated into daily life in the lab. Absence of appropriate resources can allow researchers, even if concerned about safety, to believe that experiments pose less risk than they actually do and thus not take adequate precautions, notes the recommendations section.

‰??In [academic] research the experimental outcome often becomes the driving force and overrides risk considerations,‰?? the UCCLS technical report goes on. ‰??In this respect, the UH lab explosion is similar to the explosion at Texas Tech University [that maimed graduate student Preston Brown] and the fire at [UC Los Angeles]‰?? that caused the death of lab assistant Sheharbano "Sheri" Sangji and sparked an unprecedented criminal case against UC and chemistry professor Patrick Harran. In these cases, as at UH, institutional safety culture was strikingly inadequate and did not encompass appropriate risk assessment or adherence to well-established safety procedures.

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