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Category → Chemical Safety & Hazard Investigation Board

The principles of “inherently safer” processes or experiments

The U.S. Chemical Safety & Hazard Investigation Board released a video a couple of weeks ago on “Inherently Safer: The Future of Risk Reduction.” Although the video stems from CSB and National Research Council investigations into the BayerCropScience explosion in 2008, the principles of inherently safer processes can also be applied to research-scale experiments.

As outlined in the video, those principles are:

  • Minimize – reduce the amount of hazardous material in the process
  • Substitute – replace one material with another that is less hazardous
  • Moderate – use less hazardous process conditions, such as lower pressure or temperature
  • Simplify – design processes to be less complicated and therefore less prone to failure

“It’s not a specific technology or a set of tools and activities, but it’s really an approach to design and it’s a way of thinking,” said Dennis Hendershot, a consultant with the American Institute of Chemical Engineers Center for Chemical Process Safety, at a 2009 CSB meeting. “The safety features are built right into the process, not added on. Hazards are eliminated or significantly reduced rather than controlled or managed.”

The video goes on to say that the goal of inherently safer process design is not only to prevent an accident but to reduce the consequences of an accident should one occur. A research lab experiment gone wrong, of course, is unlikely to affect the surrounding community in the way that a manufacturing incident might. But research lab incidents have cost millions of dollars and caused personal injuries in the form of lost eyes, hands, and fingers; burns and other unspecified injuries; and deaths of several researchers (for more, see the Laboratory Safety Institute’s Memorial Wall).

CSB video on Texas Tech incident released

The Chemical Safety & Hazard Investigation Board yesterday released its report into last year’s explosion at Texas Tech University; today it released the video to go with that report.

Yes, that Dr. Kemsley is indeed yours truly.

I also wanted to highlight these passages from the report itself. It’s not often that one sees the first two paragraphs spelled out in a public document:

In academia, the PI generally has significant authority over his/her research. At Texas Tech,
the issue of academic “fiefdoms” was evident; in the fiefdom system, a department is broken
into smaller units that have individuals in charge (in this context, “fiefs”), where these
individuals “are nominally subordinate to a person or persons above them, but in practice
do pretty much whatever they want so long as they do not stray too far into some other
fief’s territory.” As such, “each fief has an intellectual or administrative territory over which
he or she reigns.” (McCroskey, 1990, p. 474)

At academic research institutions, PIs may view laboratory inspections by an outside entity
as infringing upon their academic freedom. This was the case at Texas Tech, where EH&S
laboratory safety checks were not viewed as a means to understand how a PIs’ laboratory
practiced safety in their absence. Instead, some PIs saw the notification of safety violations
to the Chair as “building a case” against them, felt that the safety inspections inhibited their
research, and considered recommended safety changes outside their control because they
could not “babysit” their students.

To combat cultural issues (such as fiefdoms) and bring a focus to safety within any given organization,
it is important to ensure that the reporting structure allows for communication
of safety information to those within the organizational hierarchy that have the authority
and resources to implement safety change. Often, the Department Chair is considered the
responsible person for ensuring safety; however, in practice, the Chair holds this managerial
role while at the same time maintaining his/her role as a principal investigator for research;
thus, a potential conflict exists due to the duality of the position. Authority and oversight
of safety at a level above the Chair is a critical component of safety management within an
academic structure.

CSB report on Texas Tech includes recommendation for ACS action

The U.S. Chemical Hazard & Safety Investigation Board today released its report on its investigation into the explosion at Texas Tech University nearly two years ago. While the nature of the problems at Texas Tech have been well documented previously, today’s CSB webinar enabled the attendee to get an overall picture from several perspectives. As the Texas Tech Director of Communications noted, it was a “disturbing, poignant presentation” that essentially pointed out that the organizational structure prevented any chance of effectively protecting students.

Overall, I thought the webinar was well organized, and while I’ve heard some disappointment that no new material was presented, one thing that was clearly new was the recommendations made to Texas Tech, the Occupational Safety & Health Administration (OSHA), and the American Chemical Society. While I am not completely versed on previous CSB reports, I was struck by the directive to ACS to create hazard guidance and evaluation tools. Specifically, the report recommended that ACS “Develop good practice guidance that identifies and describes methodologies to assess and control hazards that can be used successfully in a research laboratory.”

So how should ACS proceed? And is there enough consistency in how research institutions address safety to suggest that one size fits all? How do university environmental health and safety (EH&S) offices and staff fit in? As several institutions have noted, there is great variance in the organizational structure of university safety programs, and many EH&S offices have better working relationships (authority, resources, sufficient staff) with research groups than others where safety is not taken as seriously.

 

Friday chemical safety round-up

Chemical health and safety news from the past week:

  • The U.S. Chemical Safety board will hold a webinar (pdf) next week to discuss its investigation into the explosion last year at Texas Tech University: Wednesday, Oct. 19, 12:30 Eastern. To register, e-mail webinar@csb.gov by Tuesday at 2 p.m. Eastern.
  • The Occupational Safety & Health Administration released “new educational materials on protecting workers from hazards found in laboratories“–mostly it seems to be a collection of preexisting materials, but there is a new booklet on Laboratory Safety Guidance (pdf)
  • Chemjobber flagged Apple’s corporate innovation? The ‘directly responsible individual’–necessary for good management of lab safety, too?
  • CJ also wrote about using metal hydride reagents in sealed bags at process scale
  • Experts recommend electronic health records contain information about patients’ work history, reported the Pump Handle–I thought I remembered that my doctor had noted general chemical exposure in my record, but I don’t see it there now
  • Also at the Pump Handle: Congressman tells OSHA chief not to use “buzz” words like cancer
  • Everyday Scientist sam listed his three most important safety rules, plus an addendum
  • The Chemical Plant Safety Blog discussed the hazards of cobalt powder production
  • Eckart America agreed to pay a $668,000 fine to settle air quality violations at a Kentucky pigment-manufacturing plant
  • Breaking the “no meth labs” rule: Hats off to the Tulsa, Okla., hazmat crew who had to clean up one in a storm drain

Fires and explosions:

  • A Texas Instruments worker, Roy Aguilar, was killed when a water purifier exploded at a chip fabrication unit
  • A hydrogen leak sparked a fire at a ConocoPhillips refinery in California
  • Two workers in India tried to dispose of chemical waste from marble polishing into a storm drain, causing some sort of explosion
  • Connecticut state police got to blow up an old bottle of tetrahydrofuran after a woman brought it to a hazardous waste collection event; she said that it was from her husband’s home lab (no word on what else he had)
  • A University of Florida student received minor cuts when he was weighing out benzotriazol-1-yl sulfonyl azide (“a new crystalline, stable, and easily available diazotransfer reagent”) and the sample exploded
  • A fire in an Illinois high school chemistry lab started with a chemical reaction in one beaker and spread to another. “The classroom was evacuated and the fire was doused with a fire extinguisher. No other classes were evacuated and [the principal] said the biggest mess was from the fire extinguisher.” The teacher suffered burns on her hands.

Leaks, spills, and other exposures:

  • Capsaicin, in a Salt Lake City hotel when “a housekeeper inadvertently discharged a canister of bear repellent spray in a hallway”
  • Hydrofluoric acid at a patroleum refinery in Kentucky
  • Some sort of acid at a plating business in Arizona; two workers were sent to a local hospital
  • Some sort of weak acid at Quantum Corp. in Colorado; “employees who were cleaning and processing a piece of equipment developed a skin rash”
  • Boron trichloride at Physical Sciences in New Hampshire
  • Chlorine at Hygenic in Ohio; one worker was injured
  • “A foul-smelling sulphur compound”, about 1-2 L, at an Exxon Mobil refinery in Australia; residents got a shelter in place order and “hundreds” of workers were evacuated
  • (Natural?) gas leaked in a lab at Georgia Tech; four students were treated at the scene and released
  • Battery acid at the University of Virginia’s Fontaine Research Park
  • Mercury, from a 6-year-old bottle in the basement of a Massachusetts house
  • Radioactive cesium-137 leaked at Brookhaven National Laboratory; although the amount was small, the lab has shut down all radiological operations while it investigates
  • Medical waste with low-level radiation in a dumpster also caused a furor at the Walter Reed Bethesda, Md., campus

Not covered: meth labs; ammonia leaks; incidents involving floor sealants, cleaning solutions, or pool chemicals; and fires from oil, natural gas, or other fuels

Friday round-up

The big news today is the release of the results of the Chemical Safety & Hazard Investigation Board‘s investigation into the fatal Bayer CropScience explosion in 2008. From Jeff Johnson’s story, Bayer accused of skirting safety:

Workers at the Bayer plant were under pressure to resume production of the pesticides methomyl and Larvin after a lengthy maintenance shutdown, according to the CSB investigation. As a result, they failed to evaluate new computer programs, inspect safety equipment, and conduct safety process checks.

Most critical, the report says, was the intentional overriding of an interlock system that was designed to prevent a runaway reaction inside a residue treater pressure vessel.

CSB also released an animation of the events that led to the explosion, which killed two workers and required 40,000 nearby residents to shelter in place:

Other chemical health and safety news from the past week:

  • President Obama issued an executive order directing agencies “to weed out or update obsolete regulations and ensure that federal rules’ benefits justify their costs”; industry groups praised the move and some progressives decried it, although others said that maybe it’s an improvement
  • Chemical Equipment Labs charged with violating Clean Water Act in Pennsylvania; employees “routinely rinsed plastic containers that had previously held chemicals, then discharged the wastewater into a drain in a bathroom that led to the sewer system”

Fires and explosions:

  • Indian biotechnology lecturer dies of burns sustained in lab accident: “Nilamma was re-arranging chemicals used in the experiment back into the cupboard when the accident took place. A bottle of highly combustible chemical slipped out of her hand to fall on the burner lit by her to boil chemicals used in the experiment. Fire spread and Nilamma’s saree caught fire before causing severe burn injuries.”
  • A leak lead to a fire in an aromatics complex at Equate Petrochemical complex in Kuwait
  • An explosion involving ferrotitanium injured three at an Odermath USA plant in South Carolina; the company makes specialty wires
  • A flash fire from methyl acetate vapors burned one worker at Milprint Flexible Packaging in Pennsylvania
  • Small explosion causes hole in roof at Markland Industries, a manufacturing and plating company in California; some sort of chemical reaction reportedly caused an explosion in the (air?) filtration system; four employees were taken to a hospital for observation
  • A reaction between household chemicals stored under a sink reportedly caused an explosion and fire at an apartment in New Jersey, blowing out the windows and burning one man, but “We’re still trying to put the pieces of the puzzle together. Some of the things just don’t add up,” says the fire department chief
  • A truck with a load of polyurethane caught fire at a construction site in California

Leaks, spills, and other exposures:

  • Fumes from sulfuric and muriatic acid, used to clean tanks at a nickel-processing plant in Brazil, led to the deaths of four workers; “A worker cleaning the tank fainted and fell inside, and two co-workers who went to help him also died, plant employees said.”
  • Fumes from something led to the death of one and hospitalization of two Baxter Healthcare workers in California; the one who died tried to help two colleagues who were overcome by fumes when they were cleaning a blood storage tank with some sort of detergent
  • An explosion at PetroChina’s Fushun refining complex started a fire at a heavy-oil catalytic cracking unit; 30 people were injured
  • A drum of waste nitric acid ruptured under pressure at Spectrum Microwave in Massachusetts; about a gallon of the acid was sprayed around a lab; 19 people were treaded at local hospitals and released
  • Liquid nitrogen at Tandem Labs in Utah after a 6,000-gal tank sprung a leak
  • Hydrochloric acid, no volume given, at a Las Vegas casino ice skating rink (anyone know the role HCl plays in ice production?)
  • Tetrahydrothiophene, no volume given, at Hamilton College in New York
  • Fumes from mixing chemicals sent a farm worker to a hospital in the U.K.; “The man had been mixing chemicals to carry out work on the farm. He’d used the chemicals before but had mixed them in a steel bucket. On this occasion he used larger quantities than normal and mixed them in a plastic bucket. There was a chemical reaction which resulted in the bucket melting and chlorine gas being produced.”
  • For the “make sure you know which cap goes to the gas tank” files: Gas pump error becomes hazmat incident when “a boater pumped 71 gallons of gas into the rod holder [of a boat] rather than the gas tank,” filling the hull of the boat.
  • On roads and railways: sodium hydrosulfide; wood sealant, embalming fluid, and refrigerant; trimethylolpropane poloxypropylene triamine; some sort of corrosive liquid

Promoting lessons learned

A guest post by Arnab Chakrabarty, a chemical engineer at Baker Engineering & Risk Consultants.

Accidents happen in both academia and industry. To help prevent recurrence of similar events, it’s important to learn what we can from those incidents. Mark Kaszniak, an investigator with US Chemical Safety and Hazard Investigation Board (CSB), summarized in a recent Process Safety Progress

article lessons learned from 21 CSB investigations (DOI: 10.1002/prs.10373). Kaszniak points out that, of the cases studied, no process hazard analysis was conducted prior to 43% of the incidents. In 38% of the cases, process hazard analyses were done but did not include lessons learned from previous incidents. Incomplete implementation of recommendations from hazard analyses, no facility siting studies, and inadequate evaluation of safeguards and layers of protection are among the other issues that Kaszniak links to undetected or underappreciated process hazards.

In another article in the Journal of Loss Prevention in the Process Industries, Miloš Ferjenčik and Zdeněk Jalový of the Institute of Energetic Materials at the Czech Republic’s University of Pardubice go over lessons learned from incidents in chemistry laboratories at their school (DOI: 10.1016/j.jlp.2010.06.009). Ferjenčik and Jalový propose that a systematic root cause analysis of incidents be done with students to identify errors—including errors committed by teachers—and come up with corrective measures. “The best way to show students how to learn from their own errors is for teachers to demonstrate how they have learned from their own experiences,” the authors write. They add that setting up such a system not only teaches students cause analysis but promotes a cultural behavior pattern of learning from mistakes.

Texas Tech correction

I had to correct the Texas Tech story last week. The correction illustrates an important point in academic laboratory health and safety: There may be no one overseeing a public university’s health and safety program.

The original paragraphs in Texas Tech Lessons:

The internal TTU investigation identified multiple violations of the university’s chemical hygiene plan (CHP). A CHP is required by the federal Occupational Safety & Health Administration for laboratories that use hazardous chemicals. OSHA sets requirements for what must be covered in a CHP, but it is up to the organization to decide how those requirements are addressed, says Russell W. Phifer, a safety consultant and past-chair of ACS’s Division of Chemical Health & Safety. The organization then must comply with the policies and procedures it establishes. In TTU’s investigation, the university found a lack of training and standard operating procedures, among other deficiencies.

So far, OSHA itself has not investigated the incident. OSHA typically does not get directly involved unless there is a fatality or multiple injuries requiring hospitalization or unless an institution or company has an accident rate that is much higher than comparable establishments, Phifer says. If an employee complains to OSHA, the agency sends a letter to the employer asking for a response to the charges and will investigate if the response is deemed inadequate, Phifer says.

The correction:

The federal Occupational Safety & Health Administration does not oversee laboratory safety at Texas Tech University because OSHA does not have jurisdiction over public employees. Texas Tech is required by a Texas governor’s executive order to develop and implement a risk management and safety program for its employees and the citizens it serves.

Texas does have a state Office of Risk Management, but spokesman Paul Harris says that the office does not cover the University of Texas, Texas A&M University, or Texas Tech University.

The error highlights a regulatory gap that affects a lot of people: In U.S. states and territories that have not developed their own occupational safety and health programs and continue to rely on federal OSHA coverage, public workers are not protected. Here’s the breakdown:

  • States and territories with OSHA-approved plans that cover all workers, public and private: Alaska, Arizona, California, Hawaii, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, Nevada, New Mexico, North Carolina, Oregon, Puerto Rico, South Carolina, Tennesssee, Utah, Vermont, Virginia, Washington, Wyoming
  • States and territories with plans that cover only public workers (private workers fall under federal OSHA): Connecticut, Illinois, New Jersey, New York, Virgin Islands
  • States and territories that fall fully under federal OSHA: Alabama, American Samoa, Arkansas, Colorado, Delaware, District of Columbia, Florida, Georgia, Guam, Idaho, Kansas, Louisiana, Maine, Massachusetts, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Northern Marianas Islands, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Texas, West Virginia, Wisconsin

Last week, OSHA released a report on its evaluation of the state plans.

Some people would probably argue that liability concerns are effective at keeping universities and other public workplaces on their toes and that we don’t need more bureaucracy. Others clearly disagree. The Chemical Safety & Hazard Investigation Board has been lobbying for OSHA coverage of public workers  since at least 2007, after it investigated a 2006 incident at a Florida wastewater treatment plant in which two municipal workers were killed after cutting torches ignited methanol vapor. “It is simply inequitable to afford public employees with lesser workplace protections than workers in private industry,” said then-CSB chairman Carolyn W. Merritt in 2007 congressional testimony.

CSB chairman speaks at ACS meeting

U.S. Chemical Safety & Hazard Investigation Board (CSB) Chairman Rafael Moure-Eraso spoke at the ACS National Meeting in Boston this afternoon, in the Presidential Event on Laboratory Safety. C&EN Senior Correspondent Cheryl Hogue attended the talk and tweeted from it. We weren’t organized enough to get the live-tweeting thing set up a la The Haystack, so I’ve manually copied the tweets here for your reading pleasure:

  • #Chemical explosions due to active (equipment or human) & latent (like lack of training) errors says #Chemsafety Board Chairman
  • #Chemsafety Board Chairman recorded 1 academic lab fatality, 96 injuries, 97 evacuations since 2001
  • Injured grad student #TexasTech lab explosion wore no goggles, lab coat, blast/face shield says #Chemsafety Board chairman
  • Latent errors, such as lack of training “pretty glaring” at US academic #chemistry labs says #Chemsafety board Chairman
  • Universities in developing countries struggle to institute #chemsafety. US has problems too: #Chemsafety Board chairman
  • OSHA needs to revisit decision to exempt student lab researchers from safety regulations: #Chemsafety Board chairman

Did anyone attend the talk on the update to Prudent Practices in the Laboratory?