Friday, February 27, 2009

What happened to Sheri Sangji?

This post has been a long, long time in coming, but I wanted to wait a respectful amount of time.

Now that Ms. Sangji's passing has been noted in C&EN (2/16/09 issue, pg. 59), I feel that now is the appropriate time for this post. In addition, the LA Times published an article on Sunday that has quite a bit of detail on the matter. However, the article goes off the rails towards the end, but I don't really blame Ms. Christensen -- she(?) is a reporter and cannot be held completely responsible for missed details that a chemist would recognize.

I write this post not as a list of recriminations against the Harran lab or UCLA; however, I think this incident touches on a number of sensitive issues in chemistry. I feel that, even after the LA Times article, there are still a number of questions left unanswered:

1. How much, if at all, did 1) the holiday, 2) lack of safety training or 3) language or communications issues on the part of her coworkers contribute to her injuries?
2. Did her work fall under "critical research needs", as laid out by UCLA department policy?
3. If the LA Times is correct and the coroner's report reveals that she succumbed to "respiratory failure, infection and other complications", are we to include death as a potential consequence of mishandling t-butyllithium? Perhaps I am naive about burn injuries, but I find Ms. Sangji's death to be surprising. Is this a consequence of the unique details of this case or will there be a more general impact? Is this simply an issue with tBuLi or all alkyllithium reagents?
4. How much did her sweater contribute to her injuries? Is Dr. Langerman's characterization of her synthetic sweater as "solid gasoline" an accurate statement or reporter-bait hyperbole? How much did her nitrile gloves contribute to her injuries? What is the best PPE combination for tBuLi?

Again, I write this post not as idle gossip, but for three reasons:

1. I think it is in the interest of bench chemists and the overall chemistry community that we learn as much as possible from this tragedy.
2. Again, I am stunned at the unfortunate outcome -- I have reconsidered my personal assessment of the dangers of tBuLi.
3. I want to get some of my thoughts on the incident in writing, as the data trickles in.

14 comments:

  1. Thank you for putting this topic up.

    I think this incident can fall broadly into the mishandling of pyrophoric alkyllithium reagents category. Any reasonable observer will conclude that she was not adequately trained to handle this reagent by herself. It is too easy to blame Harran for this, but in the end the person who is most responsible for your safety is yourself.

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  2. When I was an undergrad chemistry student, I used to use LITERS of t-BuLi with never any problem. However, I was trained to work safely...gloves, lab coat, goggles, hood sash down...we all knew where the safety shower, eyewash, fire extinguisher were...we had MANDATORY safety training BEFORE we were even allowed to set foot in the lab. This was back in the mid to late 1990s...it was the same throughout my PhD and postdoc, so the fact that the professor (Harran)'s lab was so lax is inexcusable.

    I'm a synthetic chemist but the safety regulations and crackdowns from the campus EH&S inspections (I went to Univ. of New Hampshire and then Clemson) were severe, so we always stayed on top of it. From the articles it seems either UCLA and/or the professor did not heed any warnings from their previous violations, which may have indirectly led to this tragedy.

    From C&E News and the LA Times article it is clear she didn't really know what she was doing, but the actions of the other people in the lab were atrocious! Trying to smother the flames with a labcoat? Where was the fire blanket (every lab in our departments had one). Throwing water on her from the sink? They should have yanked on the safety shower and shoved her under it. Very poor all around. And the most tragic thing had someone in the lab (or Harran) taken the time to train her properly in both technique and safety protocol (something obviously the entire lab needed, as well), she would most likely be alive today...

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  3. This comment has been removed by a blog administrator.

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  4. I didn't mean to imply Harran doesn't deserve to get a slice of the blame pie. Rereading what I wrote I see how I did not convey what I wanted.

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  5. Anonymous 12:51,

    Unless you e-mail the address above (or leave another comment) and state that you saw the incident with your own eyes, I am deleting your comment or at least the portion that references Harran.

    While I agree with Mitch that Professor Harran gets a slice, I don't think I can let a comment that is potentially libelous sit unremarked upon. - Chemjobber

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  6. Although I don't really know anything about product safety regulations, it seems unlikely to me that companies would be allowed to sell sweaters that were "like solid gasoline," as claimed by the LA Times article.

    Regarding Mitch's comment that "Any reasonable observer will conclude that she was not adequately trained to handle this reagent by herself," perhaps I'm not a "reasonable" observer, but it isn't clear to me that she wasn't properly trained. Using a syringe to transfer tBuLi is a pretty common technique that's used by many experined synthetic chemists. Her running away from the shower might have been the result of panic, rather than of not knowing where it was.

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  7. Sorry, A12:51, but unfounded allegations don't belong here.

    The original comment, now redacted was:

    "Mitch- you wouldn't be saying this if:
    1. You hadn't been trained to work with dangerous chemicals and sustained 43% burn injuries as a result.
    2. [THIS PORTION REMOVED BY CHEMJOBBER.]

    "Any reasonable observer will conclude that she was not adequately trained to handle this reagent by herself."

    Who is responsible for training new workers to handle dangerous reagents, if not the PI? It is not "too easy" to blame Patrick Harran- it is appropriate."

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  8. Does anyone know the exact details of the reaction she was setting up? I'm assuming that she should have used a cannula under inert atmosphere to transfer the t-butyl lithium? monitoring the reaction by tlc and watching it go to completion? i've used a syringe and needle (tightly wrapped with teflon tape) to withdraw small (mL) ammounts of t-butyl lithium (1M in pentane) under positive pressure of argon. I absolutely hated it because the needle immediately started to corrode, and the sure seal started to catch onto it, creating a tremendous amount of friction. My biggest fear was the needle popping off, and I was furious at the end of the transfer (maybe I could have used a fresher needle). In a separate incident again using small amounts of tBuLi I remember the very tip of the syringe catching fire briefly as it was exposed to air after my transfer. I must say though that I felt safe at all times because I was repeating the procedure as I had seen an experienced postdoc trained in total synthesis. my technique and experience level seems to share some similarities with Sangji's, and I can't help but wonder if really it did have more to do with the (flammable) "protective" equipment and the people's response. was her sash closed sufficiently? how deep in the hood was she working?

    I hate drawing fluid into 60 mL syringes because of the pressure required to fill it at a reasonable rate (had many pop open and douse my hands). I would never fill one with tBuLi, but that's just me ...

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  9. Hi, splinewave:

    It appears that Ms. Sangji was not cannulating, but using a similar technique. The relevant details have not been released.

    The far safer "airlock" technique is mentioned here: http://pipeline.corante.com/archives/2007/03/01/how_not_to_do_it_tertiary_butyllithium.php#193956

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  10. As I read your post and the subsequent comments, I remembered a Boston Globe article today in which a former employee of 14 years at CVS said of a report of CVS unlawfully overpricing items, “ . . . it is costlier for CVS to follow the pricing laws than to pay the fines.” Maybe this is an analogy.
    I view the UCLA incident in the comprehensive sphere of priorities, in which safety is not the highest priority. A somewhat related issue is data falsification which has received considerable attention in Science magazine for at least the past 15-25 years. In both cases, achievement of the objective (say, a publication “First”) supercedes that of the means to attain that objective (safety or unaltered data). Achievement of the objective is frequently the result of a desire for prestige, but there can be other motives, such as truly desiring to find a cure to a disease.
    In this framework, a “culture change” is in order, but how to make it happen is an extremely difficult question. When a fatality such as that at UCLA occurs, it may help to push the needle toward the desired culture change, but by how much is difficult to quantify. The improvements in safety which subsequently are implemented are limited frequently to the site of the original tragedy and a few other sites that recognize both the benefit of being safety-proactive and the efforts needed to muster the necessary resources.
    Arguments about blame and trying to quantify who is more responsible may be justified but should be secondary to trying to find ways to move the safety issue into higher priority than say, the prestige issue. The latter is a formidable endeavor.
    The institution which does not implement 100% of needed safety attitudes and procedures, is 100% guaranteed not to have a 100% safe or risk-free environment.

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  11. Harran had many violations of fire regulations and safety rules at his previous university. Shouldn't this also be considered?

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  12. A8:43:

    You get 48 hours to come up with a shred of proof of that statement or I'm deleting your comment. As I said above, unfounded allegations do not belong here.

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  13. I heard about this incident while I was working for Furman University as a post doc. When it comes to undergraduate researchers or green bench lab workers, it pays to plan your reaction out determining the steps one should perform. Most importantly I feel if a "dry run" had been performed the student would have been able to experience first hand how pressure in the vessel would have popped out the plunger of the syringe. While the incident was tragic, I feel we as research chemists can learn from the incident. Colleges and Universities can use the incident to provide better awareness for supervising graduate students.

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