CSB Case Studies

Thursday, 19 January 2023 2:11 AM

Three Laboratory Accidents

1.) 2008 Fatality a UCLA : Sheri Sangji
- University of California, Los Angeles
- Sherry, Laboratory Research Assistant at UCLA (23)
- On December 29, 2008, she was transferring a highly reactive chemical when some of it
sprayed to her hands and synthetic sweater and spontaneously ignited
- Had third degree burns for over 40% of her body, died from her injuries 18 days after the
accident
- Solution of tert-butyllithium that ignites fire when exposed to air
- Neglect in having proper protective equipment (esp. fire-resistant laboratory gown)

STEPS UCLA TOOK TO IMPROVE CHEMICAL SAFETY

• Improve safety accountability and oversight
• Improve training
• Provide proper protective equipment
• Conduct unannounced safety inspections
• Improve laboratory safety culture

2.) Death by Accidental Poisoning at Dartmouth in 1997 : Dr. Karen Wetternhahn

- August 1996, research on biological impacts of heavy metals
- Working with highly toxic compound called dimethyl mercury
- Wearing latex rubber gloves, one or two drops landed on her left gloved hand
- No one in the department knew that dimethyl mercury could seep into the gloves the
researcher had worn
- Five months later, in January 1997, showed serious neurologic symptoms (balance, gait, and
speech deteriorated rapidly)
- Died in June 1997 despite treatments for heavy metal poisoning, 10 months after the accident

3.) 2010 Explosion at Texas Tech University : Preston Brown

- January 2010, research on energetic or explosive compounds
- Working on a derivative of nickel hydrazine perchlorate
- Loss of three fingers, perforation to his eye, and cuts and burns to other parts of his body
- Researcher did not receive any formal training when working with potentially explosive
compounds

DEFICIENCIES IN SAFETY MANAGEMENT OF THE INSTITUTION

• Insufficient safety accountability and oversight by the principal investigators, the chemistry
department, and the university's administration
• Use of personal protective equipment within the university's laboratory was not consistently
enforced

RECOMMENDED FOR THE AMERICAN CHEMICAL SOCIETY

• Develop a methodology for evaluating and controlling hazards in academic research
laboratories

RECOMMENDED FOR THE TEXAS TECH UNIVERSITY

• Revise and expand its chemical hygiene plan to ensure that the physical hazards of chemicals
are controlled
• Develop and implement an incident and near-miss reporting system

KEY LESSONS
 Laboratory Safety Institute, apply high standards for laboratory safety programs and
environmental safety programs

ENGCHEM Page 1
 environmental safety programs
 Ensure that research-specific hazards are evaluated and then controlled by developing specific
written protocols and training
 Expand existing laboratory safety plans to address physical hazards
 Ensure that safety personnel report directly to a university official who has the authority to
oversee research laboratories and implement safety improvements
 Document and communicate all laboratory near-misses and incidents

ENGCHEM Page 2