From: John Palmer <jgppalmer**At_Symbol_Here**GMAIL.COM>
Subject: Re: [DCHAS-L] University of Hawaii lab explosion/Credibility of Investigation
Date: Sat, 9 Jul 2016 16:39:03 -0700
Reply-To: DCHAS-L <DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU>
Message-ID: 04cb01d1da3b$1413e9b0$3c3bbd10$**At_Symbol_Here**
In-Reply-To <000001d1da17$6f51f480$4df5dd80$**At_Symbol_Here**>

As Chair of the Division of Chemical Health and Safety, I think it might be appropriate that I weigh in on this discussion -- and provide 'my view' of the members of the investigative team from the UC Center for Laboratory Safety. Also, as was pointed out - the appendix to the report provides details/short biographies on the professional expertise of the UC/UCCLS investigative team.

I will also share, up front, that I do know all the UCCLS investigative team members.

I have to say that -- in my opinion -- all 4 individuals on the team were professionally appropriate to this UH accident investigation. Each brought a useful perspective to understanding the associated research and safety considerations, facilities and equipment design issues, and accident root-cause analysis.

1. Eugene Ngai properly states his expertise and professional background! Eugene has been recognized by "OUR" Division for his contributions - he received the 'HOWARD FAWCETT CHEMICAL HEALTH AND SAFETY AWARD' in 2011. He is very familiar with gas-safety accident investigations.
2. Professor Craig Merlic is a very experienced academic chemist, he chair's his department's safety committee (and several UCLA safety committees), is currently director of the UCCLS and has the appropriate background to help judge the safety perceptions and performance of research faculty, staff, and students. I have had many conversations with Professor Merlic and found his safety insight and judgment to be very germane to this type of investigation.
3. Dr. Imke Schroeder has an extremely appropriate microbiology/cell-culture background which afforded the team further insight into the research activities being conducted at the UH lab that had the incident. Additionally, she has helped organize and manage multiple safety workshops which were focused precisely on the failings that lead to accidents in academic research and teaching laboratories. Via those workshops and her familiarity with safety in academic research settings she has gained valuable awareness of the many factors that lead up to systemic failures in risk perception.
4. Ken Smith (CHP, CIH, RRPT) is the EXECUTIVE DIRECTOR, ENVIRONMENT HEALTH & SAFETY for the University of California, Office of the President, and has been involved in research safety in the UC System for decades. He has helped the UC System campuses throughout the "settlement agreement" period that resulted from Sheri Sangji's UCLA laboratory accident and untimely death. In addition to his professional certifications in industrial hygiene and health physics he has a background in chemistry and years of experience helping in laboratory accident investigations.

I might add that when I spoke with University of Hawaii EHS personnel right after the accident - in part, of course, to offer our hopes for Dr. Ekins-Coward's speedy recovery, but also suggest that our division would standby to suggest safety expert names to serve in their post-incident investigation - the thought that the UC System might also be able to provide some expertise was one of my suggestions. I also expressed my hope that the US Chemical Safety Board might be inclined to investigate -- but because of their limited staffing and industry related investigative commitments that, unfortunately, was not a possibility.

My two-cents,

John Palmer, PhD
2016 Chair (ACS-DCHAS)

Sent: Saturday, July 9, 2016 12:24 PM

Subject: Re: [DCHAS-L] University of Hawaii lab explosion/Credibility of Investigation

I remain angry and upset with your comments about our lack of experience. FYI I am not a newbie and I have participated in many ISO and NFPA committees on compressed gases for many years. I am recognized worldwide for compressed gas safety and consult for many major chemical companies.

I had trained the Honolulu Fire Dept HazMat units in March of 2015 on compressed gas safety and emergency response for each squad in 3 days of training, I have been doing this at the New York City Fire Academy since 1998 as well as many other state Fire Academies. HazMat1 responded to this tragic incident a year later. It was interesting for me to debrief them on their response that evening and helped me to piece together what happened.

What exactly is lacking in the report that would have made it better? I find it unprofessional for you to downgrade the authors without apparently reading or even understanding the report

In the last 40 years I have directed almost 10 major investigations on compressed gas incidents. I found this report to be very comprehensive and complete. What would you have done better?

Eugene Ngai
Chemically Speaking LLC

-----Original Message-----
From: DCHAS-L Discussion List [mailto:dchas-l**At_Symbol_Here**] On Behalf Of Eugene Ngai
Sent: Saturday, July 9, 2016 10:05 AM
Subject: Re: [DCHAS-L] University of Hawaii lab explosion/Credibility of Investigation

Biographies are in the appendix by the way. The testing lab has a long history on hydrogen and oxygen compatibility testing. I am still a little confused with your comments

-----Original Message-----
From: DCHAS-L Discussion List [mailto:dchas-l**At_Symbol_Here**] On Behalf Of Eugene Ngai
Sent: Saturday, July 9, 2016 9:55 AM
Subject: Re: [DCHAS-L] University of Hawaii lab explosion/Credibility of Investigation

I take great exception to your comments. I was the outsider that was retained to assist in this investigation. I found the 3 UCCLS investigators to be very professional and knowledgeable. Our reports are extensive and I can tell you that a lot of my personal time has gone into the review of what may have happened. What exactly are you protesting? Have you read the reports? I have investigated some fairly significant incidents over the last 20 years, 160 lb H2Se release, 65 lbs AsH3 release, all with multiple injuries

Eugene Ngai
Chemically Speaking LLC

-----Original Message-----
From: DCHAS-L Discussion List [mailto:dchas-l**At_Symbol_Here**] On Behalf Of Roger McClellan
Sent: Friday, July 8, 2016 12:57 PM
Subject: Re: [DCHAS-L] University of Hawaii lab explosion/Credibility of Investigation

To all:
The credibility of any investigation is rooted in the experience AND credentials of the personnel conducting the investigation. The last time I checked the web site of the University of California Center for Laboratory Safety (UCCLS) I could find NO evidence of the Center having personnel with extensive experience or specific credentials in the safety field. Indeed, one individual listed as staff appeared to have recently arrived at her position by moving through a series of post doctoral appointments at UCLA. All to often safety positions in Universities appear to have been filled in that manner rather than by external searches for experienced and credentialed professionals.
Perhaps, some time in the future the University of California Center for Laboratory Safety will have experienced employees with safety credentials and gained a track record through experience that will warrant its being recognized first locally, then regionally, then nationally and finally internationally has an authoritative organization for conducting safety reviews.
Does the Report prepared by UCCLS on the Hawaii Accident provide biographies on the personnel conducting the investigation? Does it provide a summary of the experience of the personnel or UCCLS in conducting similar investigations? Absent these details the UCCLS Report does not deserve much credibility.
In my opinion, the chemistry community should collectively set higher standards then appear to be manifest in this case. I will admit the sad past experiences of the UCLA accident are still fresh in my mind. I think UCLA needs a decade of solid local experience in the safety arena before marketing its services as an authoritative body investigating accidents at other institutions.
I recognize that UCCLS hired an outside firm to conduct key studies as part of the investigation, that action is to be applauded. However, that is only part of an investigation.
I think the fact that the University of Hawaii engaged the UCCLS to conduct the investigation raises serious questions about leadership in chemical safety at the University of Hawaii.
I think the chemistry community and the scientific community at large should expect more when it comes to investigating serious accidents, what are your views? Is this the kind of safety culture you endorse?
Roger O. McClellan

Roger O. McClellan, DVM, MMS, DSc(Honorary)
Diplomate- ABT and ABVT; Fellow - ATS, AAAR, HPS, SRA, and AAAS Member - National Academy of Medicine Advisor - Toxicology and Human Health Risk Analysis.
Albuquerque, NM

On Fri, 7/8/16, Ralph Stuart wrote:

Subject: [DCHAS-L] University of Hawaii lab explosion likely originated in electrostatic discharge
Date: Friday, July 8, 2016, 7:13 AM

University of Hawaii lab explosion likely originated in electrostatic discharge

The root cause was failure to recognize and control the hazards of explosive gas mixture, investigation report says

By Jyllian Kemsley

The blast caused a postdoc to lose an arm and about $800,000 in lab damage.

An electrostatic discharge between postdoctoral researcher Thea Ekins-Coward and a gas storage tank containing hydrogen, oxygen, and carbon dioxide likely caused an explosion at the University of Hawaii, M€?noa, in which Ekins-Coward lost one of her arms, according to a report by the University of California Center for Laboratory Safety (UCCLS).

UH hired UCCLS to conduct an independent investigation of the March 16 accident and released the report on July 1.
Another investigation by the Honolulu Fire Department, released in April, concluded that the cause was a spark from the pressure gauge. UCCLS dug deeper than the fire department and contracted with an outside laboratory to recreate and test the experimental setup. Those tests ruled out all causes other than a static discharge.

Going beyond the immediate cause of the explosion, however, ‰??the overall underlying cause of the accident was failure to recognize and control the hazards of an explosive gas mixture of hydrogen and oxygen,‰?? the UCCLS report says.

‰??The message to other researchers is that they need to do a better job of educating themselves about the hazards of the materials they‰??re working with‰?? and what could go wrong, says Craig A. Merlic, UCCLS executive director and a chemistry professor at UCLA. And campus safety personnel ‰??need to have conversations with researchers and guide them to the resources that are available‰?? to help conduct experiments safely, he adds.

In the case of the UH explosion, for example, the lab passed a safety inspection in January in part by properly storing
H2 and O2 cylinders 6 meters apart. But no one questioned storing a mixture of the gases in a 49-L steel tank designed for compressed air and not electrically grounded, the UCCLS report says. When the tank exploded, it contained 55% H2, 38% O2, and 7% CO2 at a pressure of 8 atm. UCCLS estimated the energy of the detonation to be equivalent to 70.5 g of TNT.

Ekins-Coward was working for the Hawaii Natural Energy Institute under researcher Jian Yu. The gas mixture was used to feed bacteria to produce biofuels and bioplastics. Yu‰??s lab is still closed, and he and the institute have not yet determined how experiments will be set up going forward, says institute director Richard E. Rocheleau.

The explosion cost about $716,000 in infrastructure damage and $60,000 to $100,000 in equipment losses, and UCCLS was paid $88,000, says UH spokesman Dan Meisenzahl.

UH placed no restrictions on the UCCLS team during its investigation, Merlic says. The Hawaii Occupational Safety & Health Division is also examining the incident.

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