The publicity surrounding recent incidents in university research laboratories continues to draw attention to the importance of promoting safety within academic laboratory settings. In addition to drawing significant attention to laboratory safety, these incidents have evoked a broad range of institutional responses. At the request of the study sponsors,1 the National Research Council appointed a committee of experts to examine laboratory safety in academic and non-industrial chemical research settings and to provide recommendations, grounded in insights from behavioral science, on how to improve the overall safety performance of such laboratories (Box 1-1).
Serious and sometimes fatal accidents in chemistry research laboratories at universities have driven government agencies and professional societies to engage in renewed efforts to examine safety in university labs. Investigations from recent, highly publicized incidents, including those occurring at UCLA in 2008 and Texas Tech in 2010, identified issues of preparedness, proper training, and adherence to laboratory safety protocols as precursors to the incidents that transpired. Sometimes, though,
1 This study was supported by the National Science Foundation, the U.S. Department of Energy, ExxonMobil Chemical Company, E.I. du Pont de Nemours and Company, the American Chemical Society, and the National Institute of Standards and Technology.
Statement of Task
The National Research Council, through its Board on Chemical Science and Technology and Board on Human Systems Integration, will examine laboratory safety in chemical research in non-industrial settings. It will compare practices and attitudes in these settings with knowledge about promoting safe practices from the behavioral science literature. It will make recommendations for systems and practices that would improve the safety of chemistry research laboratories specifically and other non-industrial research laboratories more generally. It will
- Describe the current hierarchy of actors responsible for laboratory safety in U.S. education and in national laboratories. Identify the strengths and shortcomings of these hierarchies and how they impact the development of a culture of safety in academic research laboratories.
- Examine knowledge from the behavioral sciences and experience with safety systems from other sectors (such as industrial research facilities, nuclear energy, aviation, and medical) for key attributes of successful safety systems and cultures. Use this to draw lessons that could be applied in non-industrial laboratory research.
- Provide guidance on systems (such as training and reporting) that might be established, maintained, and utilized to raise the overall safety performance of U.S. chemistry research laboratories.
- Determine key actors required to achieve broad implementation of improved safety performance in research laboratories, especially in the U.S. higher educational system, and provide guidance on their roles and how they might be effectively engaged in improving safe laboratory practice.
The resulting findings and conclusions will be disseminated broadly to key actors in non-industrial laboratory safety.
even when carried out by researchers with extensive training and prudent behavior, standard safety precautions can fail, as tragically exemplified by the 1997 death of Karen Wetterhahn, a respected chemistry professor from Dartmouth College.
Karen Wetterhahn, a specialist in metal toxicology, was a professor of chemistry at Dartmouth College and founding director of the university’s Toxic Metals Research Program. In August 1996, while transferring dimethylmercury between containers, Wetterhahn dropped one to several
drops of the compound onto her left, gloved hand.2 During the transfer, Wetterhahn observed the standard safety protocol at the time, conducting the transfer in a fume hood, wearing eye goggles, and disposable latex gloves. Wetterhahn thought nothing of the minor spill. When she was done, she cleaned her equipment, removed her gloves, and washed her hands. Roughly five months later, Wetterhahn began experiencing difficulty seeing, speaking, hearing, and walking. Upon medical examination, Wetterhahn was diagnosed with acute mercury toxicity due to exposure to dimethylmercury. Despite aggressive chelation therapy, her condition continued to deteriorate, and in February 1997, Wetterhahn went into a coma. She died on June 8, 1997, only ten months after the initial exposure.3
The unsettling characteristic of this incident is that Wetterhahn carried out the dimethylmercury transfer appropriately and safely to the best of anyone’s knowledge at the time. Notably, the Material Safety Data Sheets (MSDS) for dimethylmercury recommended the use of rubber, neoprene, or otherwise “chemically impervious gloves” when handling the compound. The MSDS offered no additional detail on the subject. Following Wetterhahn’s death, permeation testing of disposable latex gloves revealed that dimethylmercury permeates latex, PVC, and neoprene almost immediately upon contact.4 Acknowledging the great risk associated with handling dimethylmercury as well as its lethal properties, OSHA amended its safety guidelines for the compound, discouraging its further use, unless absolutely necessary. In OSHA’s memorandum issued after Wetterhahn’s death, the agency noted the critical need for research laboratories to produce a “protective chemical hygiene plan, which includes adequate guidance on the appropriate selection of personal protective equipment and engineering controls.”5 The memorandum stressed that even “highly placed or very well qualified researchers” do not always possess the most accurate or adequate health and safety information. The memorandum goes on to underscore the need for collaborative relationships between university researchers and health and safety professionals in creating safe and effective laboratory environments.
2 U.S. Department of Labor, Occupational Safety and Health Administration. Dimethyl Mercury: Hazard Information Bulletin. Accessed June 30, 2014. http://www.osha.gov/dts/hib/hib_data/hib19980309.html.
3 Dartmouth Undergraduate Journal of Science. Remembering Karen Wetterhahn. May 16, 2008. http://dujs.dartmouth.edu/spring-2008-10th-anniversary-edition/rememberingkaren-wetterhahn.
4 U.S. Department of Labor, Occupational Safety and Health Administration. Dimethyl Mercury: Hazard Information Bulletin. Accessed June 30, 2014. http://www.osha.gov/dts/hib/hib_data/hib19980309.html.
Sheharbano (Sheri) Sangji, a staff research assistant at the University of California, Los Angeles (UCLA) working in the lab of Professor Patrick Harran, was attempting to transfer a tert-butyllithium solution in hexanes from a reagent bottle to a reaction flask when the plunger of the syringe she was using separated from the barrel, spraying her hands with the pyrophoric compound. Both the tert-butyllithium and the hexane ignited, also igniting some additional hexane that had spilled in the commotion and, in the absence of a lab coat, Sangji’s highly flammable synthetic sweater caught fire. She initially ran in the opposite direction from the lab safety shower until a co-worker reached her and attempted to extinguish the flames with his lab coat. Another co-worker used water from a nearby sink to finally extinguish the flames. Sangji was rushed to the hospital, but died from her injuries weeks later.
Following Sheri Sangji’s death, the State of California’s Division of Occupational Safety and Health (Cal/OSHA) undertook an investigation of the accident and the circumstances that led to it. In its report,6 Cal/OSHA found that Sangji was not following proper safety procedures for handling pyrophoric reagents and had never received adequate training for working with hazardous chemicals required by California code. The report also found that the appropriate personal protective equipment (PPE), specifically lab coats, were not required to be worn. In fact, the report notes that the absence of PPE for researchers was considered “part of the culture”7 by environmental health and safety (EHS) officials at UCLA.
UCLA took two major steps in response to the Cal/OSHA report. The first was an increase in laboratory safety activities by the EHS office. The EHS office enacted more stringent policies with respect to particularly dangerous chemicals and began inspecting labs more frequently. Laboratory training classes were made mandatory for all laboratory personnel and made available both online and in person on a weekly basis, rather than quarterly as before.8
In addition to increasing the role of EHS in laboratory safety, the University of California system created a Center for Laboratory Safety (CLS). The missions of the center, as described on the center’s website, are to “sponsor and support research in laboratory safety,” “develop and trans-
6 Baudendistel, B. UCLA Investigation Report; S 1110-003-09; 2009.
7 Id., p. 17.
8Kemsley, J. N. Learning from UCLA. Chemical and Engineering News 2009; 87(31): 29-31, 33-34. http://cen.acs.org/articles/87/i31/Learning-UCLA.html.
fer research into applied best practices,” and to “facilitate implementation and optimization of laboratory safety practices.”9
Nearly two years after Sangji’s death, the Los Angeles district attorney’s office filed felony criminal charges against both the University of California Regents and Professor Harran for willfully violating occupational health and safety standards. The case against Professor Harran was being heard during the drafting of this report. On June 20, 2014, Harran reached a deferred prosecution agreement with the prosecution, after acknowledging responsibility for the conditions of the laboratory in which the incident occurred. Based on the terms of the agreement, the four criminal counts against Harran will be dropped in five years, if he pays the requested $10,000 fine, fulfills 800 hours of community service at UCLA’s hospital, and conducts a summer chemistry course for inner-city high school graduates.10
In 2012, the court accepted a plea agreement between the District Attorney and the Regents under which the University of California agreed to strict safety compliance requirements to be enforced by Cal/OSHA. Also, as part of the plea agreement, University of California chemistry departments must compile and maintain standard operating procedures (SOPs) detailing the safety precautions to be taken when using a number of hazardous compounds that are listed in the plea agreement. These SOPs are to be written by senior laboratory staff and then reviewed by “qualified personnel.” In addition, the agreement specifies a campus-wide SOP for using pyrophoric materials at UCLA. All SOPs must be made easily available to laboratory personnel, either electronically or in print.
The agreement also prescribes that PPE, including fire-resistant lab coats, must be made available to laboratory researchers. Principal investigators are responsible for reporting any recordable injury11 or illness to Cal/OSHA and are required to preserve the scenes of any such incidents for subsequent investigation. The University Regents agreed to allow up
10 Whitcomb, D. “UCLA professor ordered to perform community service in fatal lab fire.” Reuters, June 20, 2014. Accessed June 25, 2014. http://www.reuters.com/article/2014/06/20/us-usa-laboratory-fire-idUSKBN0EV2KW20140620.
11 According to OSHA, an injury or illness is recordable, if it results in any of the following: death, days away from work, restricted work or transfer to another job, medical treatment beyond first aid, or loss of consciousness. An incident is recordable if it involves a significant injury or illness diagnosed by a physician or other licensed health care professional, even if it does not result in death, days away from work, restricted work or job transfer, medical treatment beyond first aid, or loss of consciousness (Occupational Safety & Health Administration [OSHA]. 2014. Regulations (Standards-29 CFR). Accessed July 1, 2014, https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9638).
to three unannounced laboratory inspections by Cal/OSHA per year for 4 years, until 2016.
Another serious incident, this time involving the shock-sensitive, explosive compound nickel hydrazine perchlorate (NHP), occurred at Texas Tech University in 2010. This incident became the subject of the first investigation of an academic research lab by the U.S. Chemical Safety and Hazard Investigation Board (CSB).12 The CSB is a nonregulatory government organization that investigates the root cause of chemical accidents, historically focusing on industrial incidents. According to the CSB report,13 a graduate student attempted to scale up the NHP synthesis, making more than 10 times the amount that had been informally considered an upper limit by his research group. The resulting product, NHP, was clumpy, so the graduate student set out to homogenize the sample by crushing it with a mortar and pestle on an open lab bench. The student removed his safety glasses and subsequently began to crush the NHP “one more time.”14 As the student finished breaking up the clumps, the NHP detonated. The student suffered serious injury to his face, an eye, and his hands, ultimately losing three fingers.
The CSB’s analysis in this case was based on the “Swiss-cheese” model of accident causation, where multiple failures align, resulting in an incident. Through this model, the report examined not only the individual mistakes made by the researcher, but the shortcomings across all levels of the organization.
The CSB identified three major flaws in the safety practices at Texas Tech. The first shortcoming, most directly related to the specifics of the accident, was a lack of training and documentation of the physical hazards (e.g., risk of explosion) associated with laboratory research. The second issue identified was a lack of a mechanism for reporting and keeping records of laboratory accidents and “near misses.” The CSB argued that without such a mechanism, it is exceedingly difficult to learn from past mistakes. Finally, the CSB found that safety management and oversight were insufficient. The report examined the role of the principal investigator, EHS organization, university leadership, and funding agencies in promoting safety in the laboratory.
12 U.S. Chemical Safety and Hazard Investigation Board. Texas Tech University Laboratory Explosion: Case Study. Case No. 2010-05-I-TX. Washington, DC, October 19, 2011.
14 Id., p. 15.
The incidents at Dartmouth, UCLA, and Texas Tech are notable because of the responses they have garnered, but they by no means represent the totality of reported incidents in U.S. chemistry research labs over the years. In December 2010, a researcher at Northwestern University was injured when an unexpected explosive byproduct was formed in his reaction vessel and detonated.15 At Yale University in 2011, an undergraduate was killed when her hair was caught in a lathe while she worked alone in a chemistry department machine shop.16 A less serious accident from the last few years includes the explosion of a glass vial at the University of Colorado at Boulder that caused minor injuries.17
Serious accidents in research labs are not limited to academia. In 2008, a researcher at the National Institute of Standards and Technology (NIST) laboratory in Boulder, Colorado, was working with a bottle of radioactive plutonium sulfate tetrahydrate when the bottle broke. The plutonium sulfate got on the researcher’s hands and he attempted to wash his hands in the sink before, apparently, realizing the severity of the spill and evacuating. The accident resulted in plutonium being introduced to the Boulder sewer system and the hallway surrounding the lab where the accident happened.18
In considering the responsibilities set forth in the statement of task (Box 1-1), understanding the response of oversight organizations to the high-profile accidents at Dartmouth, UCLA, and Texas Tech is critical. Both the Cal/OSHA report on the UCLA incident and the CSB report on the Texas Tech incident point to a deficient safety culture as a primary cause. The three themes from the CSB report are also addressed in the plea agreement between the UC Regents and the State of California. In these cases, the creation of reporting mechanisms, comprehensive SOPs for hazardous compounds, and more comprehensive organizational oversight are emphasized. These incidents have served as new precedents for
15 Hupp, T., and S. Nguyen. Chemical safety: Synthesis procedure. Chemical and Engineering News 2011; 89(2): 2.
16 Henderson, D., E. Rosenfeld, and D. Serna. Michele Dufault ‘11 dies in Sterling Chemistry Laboratory accident. Yale News, April 13, 2011. Available at http://yaledailynews.com/blog/2011/04/13/michele-dufault-11-dies-in-sterling-chemistry-laboratory-accident/. Accessed September 17, 2012.
17 University of Colorado Boulder. Glass vial explosion causes evacuation of south wing of CU Engineering Center. News Release, November 30, 2010. Available at http://www.colorado.edu/news/releases/2010/11/30/glass-vial-explosion-causes-evacuation-southwing-cu-engineering-center. Accessed September 17, 2012.
18 National Institute of Standards and Technology. Final Report of the NIST Blue Ribbon Commission on Management and Safety. U.S. Department of Commerce, Washington, DC, November 2008. Available at http://www.nist.gov/director/blueribbon/upload/final1108.pdf.
the involvement of government agencies and all levels of an organization hierarchy in laboratory safety.
The recent serious incidents in academic laboratories have generated significant interest among researchers and safety professionals, demonstrated by frequent editorial articles and blog posts. Numerous editorials in Chemical and Engineering News (the news magazine of the American Chemical Society), Nature, Scientific American, and other publications have focused on the UCLA accident and the implications of California’s response. Blogs maintained by chemists, such as ChemJobber19 and ChemBark,20 have also devoted a great deal of effort to discussing both the scientific details of the incidents and ways to improve safety culture to avoid future occurrences.
Some of the discussion of the UCLA and Texas Tech incidents is motivated by the response of regulatory agencies to those accidents. The criminal charges against Professor Harran have sparked intense debate about who bears the ultimate responsibility for laboratory safety. The CSB report on the Texas Tech incident has generated interest not only because it is the first CSB investigation of an academic laboratory or institution, but also because it recommends that funding agencies use safety record as one qualifier for awarding funding. These more controversial topics are rooted in the basic problem of determining how best to promote positive safety culture in academic research labs.
As the details of these incidents continue to be discussed, attention has centered on what could have been done differently in each case. At the same time, a broader discussion of how to prevent serious incidents from occurring in the future and how to give laboratory researchers and emergency personnel the resources to respond appropriately when emergencies do occur is growing.
In light of the recent serious safety incidents described above, the American Chemical Society and the National Research Council commissioned or revised reports to emphasize safety in research laboratories.
Below is a brief overview of the ACS report on Creating Safety Cultures in Academic Institutions and the NRC Prudent Practices in the Laboratory.
The American Chemical Society Report
In 2012, ACS assembled a task force to report on Creating Safety Cultures in Academic Institutions,21 which focuses largely on undergraduate teaching laboratories and touches on research labs. It defines safety culture as “a reflection of the actions, attitudes, and behaviors of its members toward safety” and suggests seven characteristics of a strong safety culture: (1) strong leadership and management for safety; (2) continuous learning about safety; (3) strong safety attitudes, awareness, and ethics; (4) learning from incidents; (5) collaborative efforts to build safety culture; (6) promoting and communicating safety; (7) institutional support for funding safety.
With these seven characteristics in mind, the report makes 17 recommendations for academic institutions attempting to improve safety culture. Each recommendation aims to help institutions more strongly demonstrate the seven characteristics of safety culture that the report identifies.
The ACS report focuses on and emphasizes the importance of safety education in undergraduate teaching laboratories. The authors of the report expect that strong safety education during undergraduate studies will translate to graduate students, who form the bulk of the research personnel in academia, with stronger safety ethics and will lead to stronger safety culture in academic labs. In analogy to the responses to the ULCA and Texas Tech incidents, the ACS report emphasizes the need for reporting systems, investigation systems, and a database of safety incidents. The authors suggest that such incident reporting supports continuous learning about safety. In addition to its broader recommendations about strengthening safety culture, the ACS report offers suggestions for the duties that the entire hierarchy of academic laboratories, from university presidents, to principal investigators and faculty, to laboratory staff, might undertake to promote safety.
21 American Chemical Society Committee on Chemical Safety. Creating Safety Cultures in Academic Institutions. American Chemical Society, Washington, DC, 2012: 34.
Prudent Practices in the Laboratory
In 2011, the National Research Council’s report, Prudent Practices in the Laboratory: Handling and Management of Chemical Hazards (Prudent Practices), was updated and included a brief discussion of the role of safety culture in chemical research labs.22 This report describes safety culture as a “culture of habitual risk assessment, experiment planning, and consideration of worst-case possibilities.”23Prudent Practices notes that researchers leaving academic research labs for industry or government labs are often surprised by the stronger safety culture in industry and government facilities. The report asserts that, “The industrial or government laboratory environment provides strong corporate structure and discipline for maintaining a well-organized safety program where the culture of safety is thoroughly understood, respected, and enforced from the highest level of management down.”24
In contrast to institutional practices that support a safety culture in industry, academic research laboratories often are embedded in institutions in which safety is rarely discussed outside of targeted training sessions to satisfy regulatory requirements. The turnover in research workers is high; the range of materials and procedures performed by these workers varies considerably across any given institution; and aside from the aforementioned, limited training, many research workers in academic laboratories may have primarily received their safety training from laboratory coursework in chemistry. As a result, safety culture in academic labs faces the difficulty that
[u]nlike laboratory course work, where training comes primarily from repeating well-established procedures, research often involves making new materials by new methods, which may pose unknown hazards. As a result, workers in academic research laboratories do not always operate from a deep experience base.25
This creates challenges for principal investigators and their institutions, particularly in areas of resources and leadership needed to create and sustain safety analyses and practices. As Prudent Practices suggests, “[w]hen each principal investigator offers leadership that demonstrates a deep concern for safety, fewer people get hurt.”26 This concern about leadership is a key aspect of safety culture.
22 National Research Council. Prudent Practices in the Laboratory: Handling and Management of Chemical Hazards, Updated Version. The National Academies Press, Washington, DC, 2011.
23 Id., p. 2.
24 Id., p. 5.
25 Id., p. 4.
This report is geared to provide guidance to academic research communities on how to strengthen their safety cultures.
Chapter 2 examines safety systems and culture, primarily in the context of sectors outside of academic chemical research. It identifies key themes, principles, and methods that are relevant to laboratory safety and expands on knowledge and experiences in those areas. The chapter culminates by identifying the key attributes of successful safety systems and cultures from the other sectors that are relevant to academic research labs. It cites exemplary approaches and methods utilized in the airline, health care services, and nuclear industries.
Chapter 3 addresses the current state of laboratory safety in chemical research in academic settings. The chapter looks at current practices and attitudes in the context of the current hierarchy of actors involved in laboratory safety, examining current systems that have been utilized and how they work to hinder or raise the safety performance in laboratory research.
Chapter 4 then focuses on understanding laboratory safety dynamics. This final chapter examines the interdependencies that characterize the structure of safety overall, in the context of the current hierarchy of actors involved. After identifying the strengths and weaknesses of the actors, the chapter identifies systems that may be established to raise the overall safety performance of academic research labs.
Chapter 5 presents a series of findings, conclusions, and recommendations that, if followed, can assist institutions in establishing and promoting a culture of safety in academic chemistry research. In keeping with the task at hand, the conclusions and recommendations are focused on chemistry research, but in many cases may be more widely applicable. Chemical hazards can be found in many academic environments, including in the biological sciences, medical schools, many engineering disciplines, and art studios.