Role of Hazard Analysis in Academic Research Anna Sitek Research Safety Specialist

Goal: Conservation of Life 2 Look for similarities  Do you work with reactive materials?  Do you visit labs where reactive materials are stored? Relate lessons to your work  Hazard Analysis process

CEMS special safety seminar Incidents in academia UMN Case Study  Review what happened  Identify how the incident could have been prevented  Apply Lessons Learned 3

Incidents in Academia UCLA Texas Tech Dartmouth Yale 4

Incidents in Academia 5 Dartmouth 1997 Toxic heavy metal Inappropriate glove Death

Incidents in Academia UCLA 2009 Pyrophoric, flammable Poor technique, no ppe, improper response Death lawsuit 6

Incidents in Academia 7 Texas Tech 2010 Explosive Scale, technique Injury, damage to lab

Incidents in Academia 8 Yale 2011 Machine Work alone, E-stop not accessible Death

Incidents in Academia 9 UMN 2014 Explosive Scale, technique Injury, damage to lab

Incidents in Academia 10 Yale 2011 Machine Loose hair, E-stop not accessible death DartmouthUCLATX TechYaleUMN HazardToxicPyrophoricExplosiveHigh speed parts Explosive ErrorHazard Analysis PPE Hazard Analysis Technique PPE Hazard Analysis Scale Technique Hazard Analysis Equipment Work alone Hazard Analysis Scale Technique PPE ResultDeath Injury, Damage to lab Death Injury, Damage to lab

UMN Case Study

Likely causes (official cause unknown): 1.NaN 3 + PEG 300 (moisture?) to yield hydrazoic acid 2.Overheating of NaN 3 colorless, volatile, toxic and explosive liquid Contributing factors: Moisture, contaminants in the reagents, stirring, scale Explosive decomposition: What Happened? – Direct Cause

What Happened? – Root Cause Flawed Hazard Analysis:  Scale overwhelmed available controls  Unequal mixing indication of safety issue  Purity and choice of reagents used new but not purified solvent substitution not vetted on large scale

What Happened? – Hazard Analysis Risk of Hazard = severity x probability  Severity (scale, inherent properties material)  Probability (experiment conditions) Reaction conditions (T, P, atmosphere, light, solubility, purity of solvents and reagents, mixing, incompatibilities) Operator conditions ( experience, attention, current health etc)

Identify how the incident could have been prevented 16 Hazard Analysis Hazard Communication Safety Culture

Hazard Analysis- When, How? Scientific Method 1. Theory 2. Prediction 3. Experiment 4. Observation Plan Experiment 1. Propose Conditions 2. Identify Hazards 3. Hazard Analysis 4. Select Controls 17 Evaluate Hazards 1. Limits- Can I? 2. Best Practices- How do others? 3. Prepare for problems- What if? 1. Communicate Hazards 2. Standardize Process 3. Check plan and implementation Document Safety Information

Limits ex. DOW SOC

Hazard Evaluation Resources 19

Hazard Analysis- When, How? Scientific Method 1. Theory 2. Prediction 3. Experiment 4. Observation Plan Experiment 1. Propose Conditions 2. Identify Hazards 3. Hazard Analysis 4. Select Controls 20 Evaluate Hazards 1. Limits- Can I? 2. Best Practices- How do others? 3. Prepare for problems- What if? 1. Communicate Hazards 2. Standardize Process 3. Check plan and implementation Document Safety Information

Controls reflect Hazard Analysis Hierarchy of Controls Elimination: Remove the hazard  Eliminate the procedure  Change your setup Substitution: Replace the hazard  Use a non-hazardous or less hazardous reagent  Use a milder route or process

Controls reflect Hazard Analysis Engineering: Change the process or equipment to reduce the hazard  Fume hood  Blast shield  Steel vessel Warning: Post signs warning of the danger  Sign in your area with details and contact information  External sign (room door, fridge door)

Controls reflect Hazard Analysis Administrative: Establish policies to reduce risk or limit exposure  Draft Standard Operating Procedures (SOPs) to detail correct procedures Personal Protective Equipment: Last line of defense (“seatbelt”)  safety goggles/glasses  lab coat  gloves

Hazard Analysis- When, How? Scientific Method 1. Theory 2. Prediction 3. Experiment 4. Observation Plan Experiment 1. Propose Conditions 2. Identify Hazards 3. Hazard Analysis 4. Select Controls 24 Evaluate Hazards 1. Limits- Can I? 2. Best Practices- How do others? 3. Prepare for problems- What if? 1. Communicate Hazards 2. Standardize Process 3. Check plan and implementation Document Safety Information

Communicate Hazards- Safe Operation Cards

Standardize Process Review Standard Operating Procedures

Apply Lessons Learned 27 Hazard Analysis  Limits synthesis  Add physical hazards  Training Hazard Communication  Warning relevant journals & organizations  Policy on group meetings  SOPs  SOCs Safety Culture  Spread Awareness

How can you apply lessons? 28 PIs, Managers, Committees –set upper limits –Train on factors affecting probability & severity Experiment Planners –Design around primary reaction vessel –Discuss warning signs with researchers Experiment Performers –Follow group policies –Communicate with others, signage –Be Mindful

Life-Long Learning Always search for new/more resources  Literature updates  New safety standards, literature and equipment  New materials and techniques Never assume you know all the answers  Avoid being “overly comfortable”  “That will never happen to me”

Communicate and Ask Questions Good Resources:  Advisor/PI  Faculty  Postdocs, lab techs, graduate students  Safety professionals Research Safety Officer DEHS Don’t be satisfied with an unsafe method or conditions!

Apply Lessons Learned What is CEMS doing?  Safety committee  JST  Share resources?  Seminar  Questions, Suggestions? 31

Thank you! Anna Sitek Research Safety Specialist (612) Investigation contributors: CHEM Safety Committee: Bill Tolman, Chuck Tomlinson, Ian Tonks, Valerie Pierre DEHS: Jodi Ogilvie, Joe Klancher, Mike Austin

Questions How did you hear about the incident? What was your initial reaction? Suggestions for identifying limits? How many people think SOCs are a good idea? Going to review your group policies? 33