Monday, April 11, 2016

The Institution speaks for itself and investigates itself

Via Beryl Benderly, I see that the University of Hawaii has hired UCLA's Center for Laboratory Safety to investigate the recent explosion that resulted in serious injury of Dr. Thea Ekins-Coward, including the loss of her arm. From the official press release:
The University of Hawaiʻi at Mānoa has retained the University of California (UC) Center for Laboratory Safety to conduct an independent investigation to determine the cause of the explosion in a Hawaiʻi Natural Energy Institute biofuels research laboratory in the UH Mānoa Pacific Ocean Science and Technology building on March 16, 2016. A visiting researcher seriously injured in the accident has been released from the hospital. 
“The entire Mānoa community is keeping her in our thoughts and prayers for a speedy recovery,” said UH Mānoa Chancellor Robert Bley-Vroman in a message released to UH Mānoa community on April 4, 2016. 
The UC Center for Laboratory Safety is considered a national leader in laboratory safety in developing evidence-based best practices and facilitating implementation and optimization of laboratory safety practices. The UC Laboratory Safety Team was on the Mānoa campus the week of March 28 and the investigation is expected to be complete by the end of April. 
“All preliminary indications are that the accident was an isolated incident and not the result of a systemic problem at Mānoa or intentional wrongdoing,” said Bley-Vroman.
As I said on Twitter, analogies are terrible, but this is like a college football team hiring NFL investigators to tell them how to avoid concussions. 

[Perhaps my problem with CLS is their origin. From my jaded perspective, to serve as a true "lessons learned" organization, they should perhaps focus on and publish the lessons they should learn from the Sheri Sangji incident. But I am a skeptic, and I await the University of Hawaii publishing CLS' work product.]

It also frustrates me how often organizations (all organizations) will get out in front of these incidents by swearing up and down that it was an "isolated incident", and that it's most certainly not systemic. (Don't forget "tragic accident.") In these situations, I think "it happened, we are sorry, and we are investigating" is all I want to hear until there is a full report to be given. 

36 comments:

  1. I'm surprised that you don't give UH Manoa at least a little credit for voluntarily calling in an outside organization rather than conducting a purely internal investigation, which is what we often complain about in academia. As a product of the UC system myself, I appreciate some of the shortcomings of CLS but I think I am also not completely cynical about their ability to properly assess a safety incident.

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    1. Hard to say. I guess I will know when we know the identity of the CLS investigators. Something tells me that they will not be people that have higher-than-median laboratory accident investigation experience, but I could be wrong.

      I agree that it's better than an internal investigation, but not by much. We shall see - you may be correct, and my skepticism will be unwarranted.

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  2. It IS ironic, however, that they'd pick the university where a girl died from legitimately poor lab safety practices and a series of unfortunate events, rather than any of the other prestigious universities with excellent safety practices.

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  3. @Anon, 8:43 AM,
    I'm sure there are some "prestigious universities with excellent safety practices", but my experience tells me the "excellent safety practice" is based somewhat on luck. Meaning someone just hasn't gotten hurt yet, not because of what they are doing. Industry, in general, has much better safety practices and maybe they should have gone with one of them. I've worked both in industry and currently work in academia and there really is no comparison between the two as far as safety goes.

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    1. I didn't realize you were the only one with such experience. Thank you for the correction.

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

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  4. "Isolated incident" = "Nobody's lost an arm in our labs for at least two weeks. A couple of people might have lost feet or eyes, but those are totally different incidents."

    I don't know if UCLA is good at safety but they're probably good at spin control, based on history. That wouldn't make me optimistic for the safety of people at Manoa. (They might have tried to get people at one of the big companies, but they're too busy merging.)

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  5. I would think an institution who has been recently forced to take stock of its safety measures and deal with the fall out of a major event publicly is probably the best, and currently most aware party to get help from.

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    1. Yes, best practices in media CYA will surely be covered well.

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    2. I think it would be better to get help from institutions that didn't know but cared and learned. Trying to avoid blame and the need to change (as UCLA did for a while) makes it unlikely that an institution will have learned any safety lessons well enough to help someone else because it likely hasn't internalized the need for them. On the other hand, if not getting caught and looking good if you do get caught in accidents is important, then they'd be a good source.

      You would also be better getting best practices from places that have practiced them more thoroughly and taught them to others previously. Having recent experience (even with change in heart) with safety principles and techniques doesn't necessarily mean that you can teach them to others.

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    3. Maybe it'll work out better than I think, and I'm being too cynical and angry at UCLA and Manoa. I don't know. I will read the thesis when I can.

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  6. Do Universities have to report TRIF numbers or equivalent (total recordable incident frequency)? It's one of the key measures for safety in the oil & gas industry, to the point that having a high TRIF can disqualify a company from bidding for work with some clients. I'd like to see some kind of metric in place for academic labs and have that prominently pointed out in university recruitment material. At least give potential students/employees some information on what kind of safety culture they're walking into before they sign up.

    My previous (tangential) experience with workplace fatalities was immediate public sympathy and providing aid to everyone involved (victims/families), followed by quiet but extensive firings when the incident investigation was complete. Being in upper management was no protection; management has to answer for the actions of their reports, so systemic safety failures very quickly rolled uphill.

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    1. Report TRIF numbers to whom?

      OSHA reporting depends on the school. My understanding is that private schools are subject to OSHA reporting rules for employees. For state schools, government employees may be covered *if* there is a state plan in place to do so (yes in California and Hawaii, no in Florida and Texas). Undergrads are never considered to be employees. Whether graduate students and postdocs are considered to be employees depends on unclear criteria and may vary by state.

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    2. Looks like it's TRIR (total reportable incident rate) in the US, reported to OSHA but not consistently. I'm still learning the ropes about OSHA guidelines as a recent ex-pat. You're right that the conveniently vague employment status of students/postdocs is a barrier to incident reporting, and one I forgot about. I guess I had a brief moment of optimism and hoped that universities would want to track outcomes and provide a safer environment for their communities...ha! Back to cynicism for me!

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    3. Whether grad students are employees or students varies depending on what's convenient for the university at the moment.

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  7. If I were looking for someone in academia to evaluate the safety of biofuel research, I think that I would look for some chemical engineering safety specialists, like the process safety group at Texas A&M. (http://process-safety.tamu.edu/)

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  8. Having worked for 6 yrs at a lab in the UC system I can confidently say the only reason there aren't many more serious incidents like Sheri Sangji's is simple dumb luck. Most PI's prefer not to know ('I'm sure the postdocs are helping/monitoring the grad students'), while others simply don't care.

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    1. Having likewise worked for 6 yrs at a lab in the UC system, I can confidently say that Eka-silicon is exaggerating. It depends quite strongly on the safety culture of the campus, department, and individual lab.

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  9. From a comment in the last link, a procedure they may have used in that lab:

    "The jars were flushed with a gas (H2:O2:CO2 = 7:2:1), sealed and incubated at 30 °C. The gas was prepared from cylinders of H2, O2 and CO2 through a gas proportioner (T3215-56, Cole-Parmer, Vernon Hills, IL)

    If this was used, I guess some kind of spark would have been enough to ignite the mixture. Its eye-opening to think that a wanton spark from friction could have caused this

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    1. I had a microbiology professor who was using a similar mixture in the lab. The lab had absolutely no protective systems at all! I told him that I thought it was an unsafe practice and that I wouldn't work anywhere near it. (I was a chem/micro double major at the time)

      He filled a big trash bag with it (it must have been a 55 gallon bag) out in front of the building and put a match to to it.

      The University Police across the street must have thought that the Students for Democratic Society had blown up the ROTC building. :-)

      He woke up in the ambulance on the way to the county hospital. Thankfully, he just lost some hair and eyebrows.

      :-)

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    2. I had a similar demonstration in high school actually. The chemistry teacher filled up a balloon with one part oxygen and two parts hydrogen and then exploded it over a front row desk. It was pretty loud and two of the students' books got wet.

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  10. I think the U. S. Chemical Safety Board should become involved.

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  11. CJ, when you criticize the UC system for not "publishing the lessons they should learn from the Sheri Sangji incident," it is worth keeping in mind that the entire UC system is still subject to the requirements of the settlement between UCOP and the Los Angeles DA. That settlement is an ongoing thing, and if for any reason the courts think any part of UC is in violation of the settlement, UC could still be liable. Anything that any single department (or any UC safety professional, or UCOP) publishes can potentially have very serious legal ramifications in terms of what constitutes official safety policies. And rumor has it that Cal/OSHA has been known to take things that individual departments intended to be frank discussions of acceptable practices vs best practices, and instead treat them as across-the-board required practices, and thus citable and fineable when the "best" practices weren't followed. This has the unfortunate effect of making people feel as if it is unsafe to speak when (ironically) they only want to have open discussions about safety within the UC system. (Thanks, Cal/OSHA!)

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    1. Hello, Anon5:24:

      Thank you for your informed comment. Perhaps you are correct, and James Gibson and Patrick Harran sat down and wrote up a "Lessons Learned from the Sangji Death" report that wasn't "There are some graphs and charts that show that we're compliant now!", and that report is sadly trapped on a shelf somewhere. I hope that's true, and the second (sometime in 2019? I forget) when the Settlement Agreement is complete, that report will be on its way to the Journal of Chemical Health and Safety.

      I'm not holding my breath.

      Cheers, CJ

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    2. I should note one more thing: I'm actually not criticizing the whole UC system. I have a problem with CLS. - CJ

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    3. I'm not holding my breath either.

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    4. I was not referring to--nor defending--Patrick Harran or any other individual. I was referring to people who really do care about the safety of our colleagues and our students.

      My point was simply this: there are a lot of legal landmines that influence and limit what people who care about safety in the UC system are able to accomplish--at least for the time being. And this is especially true so long as everyone on every single one of the 10 campuses feels threatened by Cal/OSHA, even in cases when we are clearly trying to improve the safety culture around us.

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    5. This (that Cal/OSHA is making people nerous) is an interesting point that, to my knowledge, hasn't been made elsewhere. Thank you, Anon.

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    6. Although the particular charges relating to Sangji's death will be off the table if the settlement agreements are completed successfully, Cal/OSHA won't cease to exist. UC representatives will still have to work with the agency.

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    7. OK, I think that what I am failing to understand here is the perception of Cal/OSHA amongst UC representatives.

      It is my impression that Cal/OSHA's enforcement arms were not particularly active (I mean, I don't think the first citation was all that?), and that Brian Baudendistel's very condemnatory* report was basically an outlier. Of course, their attitude may have changed over the intervening 7 years, and up to this point, they have probably not had the leverage that they had before, i.e. they've never had an active Settlement Agreement to use as a pressure point.

      But I'm a guy who doesn't read media reports about Cal/OSHA very often, or understand how much of a regulatory/enforcement role they're playing in the UC Settlement Agreement.

      So sincerely, thanks for explaining that, Anon.

      *The English language is failing me today.

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    8. CJ - Here is a "lesson learned" from an explosion at Texas Tech a month ago: http://www.depts.ttu.edu/vpr/integrity/lessons-learned/march-2016.php. What do you and others think about this report? Personally, I find that the lack of details renders it pretty much useless.

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    9. I agree that the lack of details makes it not very helpful.

      I would hope that a "lessons learned" report from an incident that resulted in a fatality would be far more thorough.

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  12. News updates. Chilling to read about the earlier small explosion, foreshadowing the bigger one....

    http://khon2.com/2016/04/18/hfd-releases-investigation-report-on-uh-manoa-lab-explosion/

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    1. "Ekins-Coward said the tank’s assembly was designed by laboratory professor Jian Yu, Ph.D. In his statement, however, he said:

      The tank that failed was Ms. Ekins-Coward’s design. She bought the equipment (tank, digital gauge, pressure relieve valve, and fittings) between November 2015 and January 2016."

      Am I the only one tempted to buy a plane ticket just so I can punch this guy in the face?

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  13. Due to the tragic consequences of the incident at U of H-Manoa, and current investigation, we would all do well to resist speculation as to the root cause. Our intentions would be best served thinking about the welfare of the injured researcher, Ms. Ekins-Coward. Upon completion of the investigation by CLS, we can then argue for or against the findings, the investigating body and so on. The lessons learned should be quite clear at that point. My thoughts and prayers lie only with Ms Ekins-Coward. May she find the strength and desire to move forward from this horrific injury. Amen.

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