Role of Hazard Analysis in Academic Research

Anna Sitek

Research Safety Specialist

Goal: Conservation of Life

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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

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CEMS special safety seminar Incidents in academia

UMN Case Study Review what happened Identify how the incident could have been

prevented Apply Lessons Learned

Incidents in Academia

UCLA Texas Tech Dartmouth Yale

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Incidents in Academia

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Dartmouth 1997 Toxic heavy metal Inappropriate glove Death

Incidents in Academia

UCLA 2009 Pyrophoric,

flammable Poor technique, no

ppe, improper response

Death lawsuit

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Incidents in Academia

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Texas Tech 2010 Explosive Scale, technique Injury, damage to

lab

Incidents in Academia

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Yale 2011 Machine Work alone, E-stop

not accessible Death

Incidents in Academia

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UMN 2014 Explosive Scale, technique Injury, damage to lab

Incidents in Academia

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Yale 2011 Machine Loose hair, E-stop

not accessible death

Dartmouth UCLA TX Tech Yale UMN

Hazard Toxic Pyrophoric Explosive High speed parts

Explosive

Error Hazard Analysis

PPE

Hazard Analysis

Technique

PPE

Hazard Analysis

Scale

Technique

Hazard Analysis

Equipment

Work alone

Hazard Analysis

Scale

Technique

PPE

Result Death DeathInjury, Damage to lab

DeathInjury, Damage to lab

UMN Case Study

UMN Case Study

Likely causes (official cause unknown):

1. NaN3 + PEG 300 (moisture?) to yield hydrazoic acid

2. Overheating of NaN3colorless, volatile, toxic

and explosive liquid

Contributing factors:Moisture, contaminants in the reagents, stirring, scale

Explosive decomposition:

2 H2 + 3N2HN3

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)

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

Hazard Analysis- When, How?Scientific Method1. Theory

2. Prediction

3. Experiment

4. Observation

Plan Experiment

1. Propose Conditions

2. Identify Hazards

3. Hazard Analysis4. Select Controls

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Evaluate Hazards1. 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

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Hazard Analysis- When, How?Scientific Method1. Theory

2. Prediction

3. Experiment

4. Observation

Plan Experiment

1. Propose Conditions

2. Identify Hazards

3. Hazard Analysis

4. Select Controls

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Evaluate Hazards1. 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 Method1. Theory

2. Prediction

3. Experiment

4. Observation

Plan Experiment

1. Propose Conditions

2. Identify Hazards

3. Hazard Analysis

4. Select Controls

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Evaluate Hazards1. 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

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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?

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• 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!

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Apply Lessons Learned 

What is CEMS doing? Safety committee JST Share resources? Seminar Questions, Suggestions?

Thank you!Anna Sitek

Research Safety Specialist

 (612) 625-8925 

engl0131@umn.edu

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?

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