Report on UH lab explosion reveals deep, systemic safety failures

by Beryl Lieff Benderly, ScienceMag.org, July 7, 2016 (excerpt)

The 16 March explosion at the University of Hawaii (UH), Manoa, that maimed postdoc Thea Ekins-Coward resulted from a static electricity charge that ignited a tank containing a highly flammable, pressurized mixture of hydrogen, oxygen, and carbon dioxide, finds an investigation by the University of California Center for Laboratory Safety (UCCLS). This conclusion contrasts with that of a previous investigation by the Honolulu Fire Department (HFD), which blamed the tank’s ignition on sparking caused by an inappropriate pressure gauge.

Issued late in the afternoon in Honolulu on 1 July, the UCCLS report consists of two parts, a 73-page technical analysis of the incident and a 38-page set of recommendations for changes needed to overcome systemic failures in the lab and university’s approach to safety. We will be commenting on the report at greater length soon, but here is the lowdown for now.

The main conclusion is that the tank was not grounded, and the digital pressure gauge “acted as a path to ground for a static charge that ignited the hydrogen/oxygen gas mixture contained within a 13 gallon (50 liter) pressure tank,” the UCCLS technical report states. Ignition most likely happened “when the statically charged researcher touched the metal housing of the gauge and a charge transfer occurred.”

The contrasting conclusions of the two investigations indicate differences in their intent and extent rather than any essential disagreement about the factors that led to the explosion. The fire department’s investigators aimed to determine the source of the explosion, whether it posed any further danger, and whether it was intentionally caused. The UCCLS investigation, on the other hand, sought to pinpoint the exact cause of the explosion through extensive forensic analysis and laboratory studies of equipment identical to that involved in the explosion….

Fundamental to the lapses that led to the explosion, the recommendations section of the report finds, were “serious deficiencies in the institution’s approach to laboratory safety, [especially the] lack of a culture of safety.” The report found that the institution had in place “insufficient training in hazard recognition and risk mitigation, … a deficient laboratory inspection program, a dated and ineffective chemical hygiene plan, … inadequate standard operating procedures[,]” and no formal risk assessment protocols for experiments with highly hazardous materials….

read … Systemic Safety Failures