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Prepublication – Subject to Further Editorial Correction SAFE SCIENCE: PROMOTING A CULTURE OF SAFETY IN ACADEMIC CHEMICAL RESEARCH Committee on Establishing and Promoting a Culture of Safety in Academic Laboratory Research Board on Chemical Sciences and Technology Division on Earth and Life Studies Board on Human-Systems Integration Division of Behavioral and Social Sciences and Education The National Academies Press Washington, D.C. www.nap.edu

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Prepublication – Subject to Further Editorial Correction THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This material is based upon work supported by the National Science Foundation under Grant No. CHE-1215772, the U.S. Department of Energy under Award Number DE-SC0007960, the National Institute of Standards and Technology under contract number SB1341-12-CQ-0036/13-100, ExxonMobil Chemical Company, E. I. du Pont de Nemours and Company, and the American Chemical Society. This report was prepared as an account of work sponsored by an agency of the United States Government. Neither the United States Government nor any agency thereof, nor any of their employees, makes any warranty, express or implied, or assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe privately owned rights. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not necessarily constitute or imply its endorsement, recommendation, or favoring by the United States Government or any agency thereof. The views and opinions of authors expressed herein do not necessarily state or reflect those of the United States Government or any agency thereof. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data or International Standard Book Number 0-309-0XXXX-X Library of Congress Catalog Card Number 97-XXXXX Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu/ . Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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Prepublication – Subject to Further Editorial Correction The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Prepublication – Subject to Further Editorial Correction COMMITTEE ON ESTABLISHING AND PROMOTING A CULTURE OF SAFETY IN ACADEMIC LABORATORY RESEARCH Members H. HOLDEN THORP (Chair), Washington University in St. Louis, MO DAVID M. DEJOY (Vice Chair), University of Georgia, Athens JOHN E. BERCAW, NAS, California Institute of Technology, Pasadena, CA ROBERT G. BERGMAN, NAS, University of California, Berkeley JOSEPH M. DEEB, ExxonMobil Corporation, Houston, TX LAWRENCE M. GIBBS,* Stanford University, Stanford, CA THEODORE GOODSON, III, University of Michigan, Ann Arbor ANDREW S. IMADA, A. S. Imada & Associates, Carmichael, CA KIMBERLY BEGLEY JESKIE, Oak Ridge National Laboratory, Oak Ridge, TN BRADLEY L. PENTELUTE, Massachusetts Institute of Technology, Cambridge KARLENE H. ROBERTS, University of California, Berkeley JENNIFER M. SCHOMAKER, University of Wisconsin–Madison ALICE M. YOUNG, Texas Tech University, Lubbock National Research Council Staff DOUGLAS FRIEDMAN, Study Director TOBY WARDEN, Associate Director (through January 3, 2014) ELIZABETH FINKELMAN, Program Coordinator (as of August 12, 2013) CARL-GUSTAV ANDERSON, Research Associate (as of February 3, 2014) AMANDA KHU, Administrative Assistant (through August 9, 2013) NAWINA MATSHONA, Senior Program Assistant (as of October 21, 2013) RACHEL YANCEY, Senior Program Assistant (through June 3, 2013) * Resigned June 10, 2014 v

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Prepublication – Subject to Further Editorial Correction BOARD ON CHEMICAL SCIENCES AND TECHNOLOGY Members TIMOTHY SWAGER, (Co-Chair), NAS, Massachusetts Institute of Technology, Cambridge DAVID WALT, (Co-Chair), NAE, Tufts University, Medford, Massachusetts HÉCTOR D. ABRUÑA, Cornell University, Ithaca, New York JOEL C. BARRISH, Bristol-Myers Squibb, Princeton, New Jersey MARK A. BARTEAU, NAE, University of Michigan, Ann Arbor DAVID BEM, The Dow Chemical Company, Philadelphia, PA ROBERT G. BERGMAN, NAS, University of California, Berkeley JOAN BRENNECKE, NAE, University of Notre Dame, Indiana HENRY E. BRYNDZA, E. I. du Pont de Nemours & Company, Wilmington, Delaware MICHELLE V. BUCHANAN, Oak Ridge National Laboratory, Oak Ridge, Tennessee DAVID W. CHRISTIANSON, University of Pennsylvania, Philadelphia RICHARD EISENBERG, NAS, University of Rochester, New York JILL HRUBY, Sandia National Laboratories, Albuquerque, New Mexico FRANCES S. LIGLER, NAE, North Carolina State University, Raleigh SANDER G. MILLS, Merck Research Laboratories (Ret.), Scotch Plains, New Jersey JOSEPH B. POWELL, Shell, Houston, Texas ROBERT E. ROBERTS, Institute for Defense Analyses, Alexandria, Virginia PETER J. ROSSKY, NAS, The University of Texas at Austin DARLENE SOLOMON, Agilent Technologies, Santa Clara, California National Research Council Staff TERESA FRYBERGER, Director DOUGLAS FRIEDMAN, Senior Program Officer KATHRYN HUGHES, Senior Program Officer CARL-GUSTAV ANDERSON, Research Associate ELIZABETH FINKELMAN, Program Coordinator NAWINA MATSHONA, Senior Program Assistant vi

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Prepublication – Subject to Further Editorial Correction BOARD ON HUMAN-SYSTEMS INTEGRATION Members NANCY J. COOKE (Chair), College of Technology and Innovation and Department of Biomedical Informatics, Arizona State University, Phoenix ELLEN BASS, College of Information Science and Technology and College of Nursing and Health Professions, Drexel University, Philadelphia, PA PASCALE CARAYON, Department of Industrial and Systems Engineering and Center for Quality and Productivity Improvement, University of Wisconsin–Madison SARA J. CZAJA, Department of Psychiatry and Behavioral Sciences and Industrial Engineering, University of Miami, Coral Gables, FL FRANCIS (FRANK) T. DURSO, School of Psychology, Georgia Institute of Technology, Atlanta ANDREW S. IMADA, A. S. Imada and Associates, Carmichael, CA KARL S. PISTER, NAE, University of California, Berkeley (Emeritus) DAVID REMPEL, Department of Medicine, University of California, San Francisco MATTHEW RIZZO, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE BARBARA SILVERSTEIN, Washington State Department of Labor and Industries, Olympia DAVID H. WEGMAN, Department of Work Environment, University of Massachusetts at Lowell (Emeritus) National Research Council Staff BARBARA A. WANCHISEN, Director JATRYCE JACKSON, Program Associate MICKELLE RODRIGUEZ, Program Coordinator vii

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Prepublication – Subject to Further Editorial Correction Preface While the hazards of academic chemical research have long been recognized, recent incidents prompted the National Research Council to ask whether there was another way to look at instilling stronger safety practices in chemical research. In particular, could the ideas and methodologies of safety culture from the industrial sector, including non-laboratory settings such as the airline industry, healthcare, and manufacturing, be brought in a more intentioned way to produce recommendations for making laboratory science safer? As such, a panel was formed consisting of university academic leadership and safety and health administrators, highly distinguished chemistry faculty members, and experts in the field of safety culture and human– systems integration. The committee brought expertise and outlooks that had never been assembled similarly before. One member is a university provost who has been a dean, chemistry department chair, and chancellor during a time when numerous new regulations were being imposed on higher education, and thus understands the difficulty of achieving compliance and shifting culture. We had environmental health and safety officials from academia, industry, and the national labs who have years of experience in implementing safety regulations and encouraging safe science. We had senior, highly distinguished faculty members, who have led labs handling chemical hazards for decades and have seen the evolution in safety attitudes. We had young faculty just setting up their labs for the first time. And we had experts in safety culture and the behavioral sciences, who had been involved in numerous industries and had dealt with changes in practices that followed high-profile incidents of many different kinds. The process of building a common language among this group of disparate perspectives was challenging, but worthwhile. Initially, it was not obvious to the group that social-behavioral heuristics and rubrics of safety culture could be applied to chemical research. Conversely, the specific practices of laboratory behavior and extraordinary autonomy afforded to chemical researchers when it comes to safety were new to the safety culture experts. We persevered in these conversations, came to common understandings, and achieved results that we believe are unusual and important. The committee engaged a similarly wide group, ranging from young graduate students just beginning to work with chemical hazards to seasoned laboratory veterans. We talked to individuals from both highly resourced schools with large research budgets and operations as well as regional public universities and private liberal arts colleges that had only one person working in environmental health and safety. We talked to faculty members whose expertise varied from ultrafast laser spectroscopy to an anthropologist, who studies power dynamics in academic laboratories. For decades, laboratory incidents have resulted in new regulations. The committee upholds that compliance is important and that there is always room for better adherence to regulations, which make research safer. However, in writing our recommendations, we strove not to simply produce a list of new regulations. Rather, we hoped that our report would move chemical ix

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Prepublication – Subject to Further Editorial Correction research beyond simple compliance to the adoption of a culture of safety in academic laboratories that transcends inspections, standard operating procedures, and chemical safety plans. A true safety culture represents a total commitment to achieving safety even in the absence of specific rules or other regulatory guidance. It means making safety an ongoing operational priority. Our recommendations challenge many longstanding ideas about chemical research. Working long hours and late into the night are still seen as rites of passage in the development of scientists. Student desks for data analysis, writing, and eating still persist inside the laboratories. Principal investigators and visitors to the laboratory often feel that they do not need personal protective equipment if they are not handling any hazardous materials. From our work, we believe there is eagerness among young scientists and veterans alike to challenge these assumptions. H. Holden Thorp, Chair David M. DeJoy, Vice Chair Douglas Friedman, Study Director Committee on Establishing and Promoting a Culture of Safety in Academic Research Laboratories. x

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Prepublication – Subject to Further Editorial Correction Acknowledgment of Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Donna Blackmond, NAE, The Scripps Research Institute Dominick J. Casadonte, Jr., Texas Tech University Sharon Clarke, University of Manchester Kenneth Fivizzani, Nalco Company (ret.) David A. Hofmann, University of North Carolina, Chapel Hill Robin Izzo, Princeton University Brian M. Kleiner, Virginia Polytechnic Institute and State University David Korn, IOM, Massachusetts General Hospital and Harvard Medical School Stephen R. Leone, NAS, University of California, Berkeley William Tolman, University of Minnesota Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Julia M. Phillips, NAE, Sandia National Laboratories, and Jeffrey J. Siirola, NAE, Eastman Chemical Company (ret.). Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. xi

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Prepublication – Subject to Further Editorial Correction Contents SUMMARY ......................................................................................................................................................... 1 SAFETY CULTURE IN CHEMICAL RESEARCH ...........................................................................................................................2 RECOMMENDATIONS ......................................................................................................................................................3 Institution-Wide Dynamics and Resources............................................................................................................3 Research Group Dynamics ....................................................................................................................................3 Data, Hazard Identification, and Analysis .............................................................................................................4 Training and Learning ...........................................................................................................................................4 ACTIONS FOR KEY STAKEHOLDERS......................................................................................................................................5 1: INTRODUCTION .............................................................................................................................................. 7 MOTIVATION AND BACKGROUND ......................................................................................................................................8 Dartmouth Incident...............................................................................................................................................8 UCLA Incident ........................................................................................................................................................9 Texas Tech Incident .............................................................................................................................................10 Motivation ..........................................................................................................................................................11 Interest in Safety Culture ....................................................................................................................................12 RECENT WORK ............................................................................................................................................................13 ACS Report and Prudent Practices Discuss Safety Culture in Labs ......................................................................13 ORGANIZATION OF THE REPORT ......................................................................................................................................14 2: SAFETY SYSTEMS AND CULTURES ..................................................................................................................17 INTRODUCTION ............................................................................................................................................................17 The First Epoch: The Technology Period..............................................................................................................17 The Second Epoch: The Systems Perspective ......................................................................................................18 The Third Epoch: Safety Culture ..........................................................................................................................19 Mindfulness and Situational Awareness .............................................................................................................21 INVOLVEMENT, GROUPS, AND TEAMS .............................................................................................................................. 22 KNOWLEDGE FROM OTHER SAFETY SYSTEMS .....................................................................................................................24 Aviation ...............................................................................................................................................................24 Health Care .........................................................................................................................................................26 Industrial Research Facilities ...............................................................................................................................28 Nuclear Industry ..................................................................................................................................................30 HOW DO INSTITUTIONS CHANGE? ...................................................................................................................................32 SAFETY SYSTEMS AND CULTURES .....................................................................................................................................34 3: LABORATORY SAFETY IN CHEMICAL RESEARCH IN ACADEMIC SETTINGS ........................................................35 INTRODUCTION ............................................................................................................................................................35 LABORATORY RESEARCH SAFETY ......................................................................................................................................36 What Is Laboratory Safety? ................................................................................................................................36 CHARACTERISTICS OF UNIVERSITY-BASED RESEARCH ORGANIZATIONS.....................................................................................37 Facility Characteristics ........................................................................................................................................38 Organizational and Operational Structure..........................................................................................................39 Populations .........................................................................................................................................................39 xiii

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Prepublication – Subject to Further Editorial Correction ROLES, RESPONSIBILITIES, AUTHORITIES, AND ACCOUNTABILITY FOR THE CONDUCT OF SAFE SCIENCE IN ACADEMIC RESEARCH INSTITUTIONS ..............................................................................................................................................................42 Senior University Administration ........................................................................................................................42 Provosts and College and School Deans..............................................................................................................43 Research Administration .....................................................................................................................................44 Environmental Health and Safety .......................................................................................................................44 Department Chairs ..............................................................................................................................................46 Principal Investigators.........................................................................................................................................47 Lab Researchers ..................................................................................................................................................48 EXTERNAL AND INTERNAL OVERSIGHT .............................................................................................................................. 50 External ...............................................................................................................................................................50 Internal................................................................................................................................................................52 CHALLENGES FOR EXISTING ACADEMIC LABORATORY RESEARCH SAFETY .................................................................................52 New Research Facility Design .............................................................................................................................52 Multidisciplinary and Interdepartmental Research ............................................................................................53 SAFETY CULTURE KNOWLEDGE GAPS WITHIN ACADEMIC RESEARCH LABORATORIES.....................................................................53 Hierarchical System Within Academia ................................................................................................................53 Research Laboratory Interface ............................................................................................................................54 4: LABORATORY SAFETY DYNAMICS TO IMPROVE SAFETY CULTURE ..................................................................55 PRACTICES FROM NATIONAL LABORATORIES ......................................................................................................................55 INFLUENCES FROM THE TOP DOWN ..................................................................................................................................56 Academic Units ...................................................................................................................................................56 Productivity as a Cultural Imperative ..................................................................................................................56 YOUNGER PEOPLE AT WORK AND RISKY BEHAVIOR .............................................................................................................57 Type of Work .......................................................................................................................................................58 Risk Assessment ..................................................................................................................................................58 COMMUNICATION ABOUT LAB SAFETY ............................................................................................................................. 59 Communication Content .....................................................................................................................................59 Implementation ..................................................................................................................................................60 LEADERSHIP SHOULD INCLUDE SAFETY AS A VALUE AT ALL LEVELS ............................................................................................61 INFLUENCES FROM THE OUTSIDE IN .................................................................................................................................62 Incorporating Safety into Performance and Evaluation Measures for Faculty ...................................................62 Journals Should Include Safety and Health Information .....................................................................................63 LABORATORY PROCESSES ...............................................................................................................................................64 Hazard Analysis ...................................................................................................................................................64 Laboratories ........................................................................................................................................................64 Engineering Controls ...........................................................................................................................................66 Distribution of Costs ............................................................................................................................................66 Important Characteristics in the Laboratory .......................................................................................................66 INFLUENCES FROM THE BOTTOM-UP................................................................................................................................67 Recalcitrant Group Leaders and/or Co-workers..................................................................................................68 IDEAS TO ADDRESS SAFETY DYNAMICS.............................................................................................................................. 68 Advantages for Recruiting and Laboratory Funding ...........................................................................................68 Safety in Departmental Rankings .......................................................................................................................69 Role of the Principal Investigator ........................................................................................................................69 xiv

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Prepublication – Subject to Further Editorial Correction SKILLS AND TOOLS FOR PRINCIPAL INVESTIGATORS ..............................................................................................................69 5: FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS ...................................................................................73 BEYOND ACADEMIC CHEMISTRY LABORATORIES .................................................................................................................73 FOCUS ON CHEMICAL RESEARCH: FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS .............................................................73 Institution-Wide Dynamics and Resources..........................................................................................................74 Research Group Dynamics ..................................................................................................................................75 Data, Hazard Identification, and Analysis ...........................................................................................................76 Training and Learning .........................................................................................................................................77 APPENDIX A: BIOGRAPHIES OF COMMITTEE MEMBERS AND STAFF ...................................................................79 xv

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