Addressing the deeper cause of safety incidents

Some months back, we reported on the innovative effort to improve safety culture in the chemistry labs at the University of Minnesota, Twin Cities. But even the best of intentions, it turns out, don’t make people immune to mishaps. On 17 June, graduate student Walter Partlo suffered second-degree burns and damage to an eardrum and needed surgery to remove glass fragments from his arm when a reaction he was running exploded.

To date, investigators have not pinned down the incident’s exact cause, reports Jyllian Kemsley at The Safety Zone (ablog), who also provides a detailed description of the chemistry involved. Perhaps more importantly, however, department chair William Tolman, one of the driving forces behind the overall safety effort, believes that he has identified the “deeper root cause of the incident: insufficient recognition of the reaction’s hazards,” Kemsley writes. “Warnings included with literature protocols were ‘pretty lame,’ he says. He also thinks that the lab group became … complacent after doing the reaction several times without incident. ‘While they were aware of the hazards, concern about them became less up front,’ he says.”

An important lesson, adds Partlo, as quoted by Kemsley, is “that researchers need to be sure that they are properly heeding the warnings that they do have, and properly recognizing the risk of everything that could go wrong in a particular synthesis, even if those risks seem unlikely. … When planning a reaction, these things should be considered and the equipment and scale of the reaction should be adjusted accordingly to ensure proper management of potential risks.”

Recognizing these weaknesses inspired Tolman to call a meeting of the entire department and to mandate a range of improvements, including requiring each lab to review and, if necessary, revise its standard operating procedures by mid-August and to discuss safety at monthly meetings. By 2 September, each lab must also develop safe operation cards, which provide the details of the reactions running in each hood and their potential hazards.

“I think our safety culture has improved a lot,” Tolman says, in the article. “But like any culture, there’s variable adhesion to it, so you have people who are strong players and leaders who are ahead of the game, and people just going along for the ride. … We have to look out for each other and help each other.”

Though energetic dedication to building a strong safety culture does not guarantee safety, it does appear to turn untoward incidents into opportunities to learn how to strengthen the culture even further, and make the procedures, analyses, and knowledge it entails even more focused and useful.

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