Rethinking

safety Laboratory Safety

learnings for Chemistry
Students
from
incidents
Rethinking safety learnings from incidents
• This section describes how you can learn lessons from a critical
analysis of an incident using the “five whys”.
HAIR ON FIRE

• Armand had long hair.

• The instructor told all students to be sure that any long hair was tied up so they could
safely work at their laboratory bench.
• The girls in the class followed the instructions.
• But some of the boys with long hair did not follow these instructions and the male
instructor did not strongly enforce the rule for boys.
• While using a Bunsen burner, Armand leaned too close to the burner and his hair caught
fire.
• He was able to quickly extinguish the flames by beating them out with his hand.
• A fellow student also helped by pouring water on Armand’s hair.
• Armand received slight burns to his hand, face, and ear.
 • You can review any incidents through the filter
of RAMP
• With an incident in mind, think about the
What following questions:
• In what way did someone not recognize a
lessons can hazard?
be learned • In what way did someone not assess the risk
posed by that hazard?
from this • In what way did someone not minimize the risk
incident? properly, which allowed something bad to
happen?
• Was everyone prepared for the emergency
when it happened?
‫‪Review any incidents through the filter of‬‬
‫‪RAMP‬‬
‫ن‬ ‫ن‬ ‫ن خ‬
‫کس طرح سے کسی ے طرہ ہی ں پ ہچ ا ا؟‬
‫ن ن‬ ‫خ‬ ‫خ‬ ‫ن‬
‫کس طرح سے کسی ے اس طرے سے الحق طرے کا ا دازہ ہی ں لگای ا؟‬
‫ن‬ ‫ن‬ ‫ن‬ ‫ق‬ ‫ن خ‬
‫ے سے کم ہی ں ک ی ا‪ ،‬جس ے چک ھ ب را ہ وے‬ ‫طر‬ ‫ح‬ ‫ص‬
‫کس طرح سے کسی ے طرے کو یح‬
‫ی‬
‫دی ا؟‬
‫ت ت‬ ‫ئ‬ ‫ق‬ ‫ن‬
‫ک ی ا ای مرج سی کے و ت ہ ر کو ی ی ار ھا؟‬
 • You can use the four RAMP concepts in
analyzing “what went wrong” for any
incident
• This is one way to think about the incident
What went that can easily reveal mistakes.
wrong • Often, however, there is more than one
mistake that leads to an incident.
• Additionally, as you think about incidents
you will learn that there are underlying or
root causes of incidents.
 • In this section we will introduce another
method of incident analysis that can reveal
more about causes of incidents and how to
prevent them.
Another • Incidents are unplanned, unexpected, and
undesirable events that have adverse
method of impacts (injury, death, and damage) and
incident consequences on health, property, materials,
or the environment.
analysis • Accidents carry with them the perception
that they were chance happenings, being
unavoidable and without specific
preventable causes.
 • For that reason many safety professionals don’t
like to use the term accident because every
incident always has one or more preventable
Safety causes – some of which are obvious while other
preventable causes are indirect and often
professionals unrecognized without an in-depth or careful
don’t like to review of the facts of the incident.
• Near misses are unplanned events (also
use the term sometimes called “close calls” or “near hits”),
accident which did not have severe adverse impacts on
health or the environment, but just narrowly
missed causing severe injury or damage.
 • Recognizing near misses is important
because they could be signs to future serious
incidents.
Recognizing
• Using the information from an analysis of
near misses the near miss can help develop “lessons
learned”, a term that describes how we can
derive actions to prevent future incidents.
 • In examining incidents, there are a few
important considerations to keep in mind.
Learning • It is important NOT to fix “the blame” on any
individual for an incident, but rather to focus
Lessons for on determining factors that caused the
Prevention, incident and how these factors can be
avoided to prevent future incidents.
Not • Many thorough investigations have shown
Blaming that the root cause of incidents in a place of
work is frequently due to a lack of proper
Someone management and is rarely due to
intentional, irresponsible, or deliberately
dangerous individual acts.
• In these situations, it is the absence of a positive safety culture that allows
at-risk behavior to occur.
• Incidents are often the result of at-risk behavior and this is due to either a
lack of knowledge about the danger of the behavior or knowing about the
danger but ignoring it.
• In either case, better education about the behavior can address the
problem.
• In some cases, incidents occur due to a combination of several small
actions that when examined individually might not have caused an incident
but when taken together under the circumstances of time and place
resulted in an unexpected and adverse event.
Laboratory bench at Texas Tech University after an explosion. Two
student were seriously injured.
 • The extent of any investigation depends on the
seriousness and impact of a given incident.
• For a minor incident there is not likely to be formal
investigation but rather a “lessons learned”
scenario, a described below.
Types of • In cases of serious injury or major laboratory or
equipment damage, a more formal investigation by
Investigatio safety professionals will likely be conducted.
ns • In any case, we can usually learn a lot from
examination of incidents, and it is not unusual to
find that a similar incident has occurred in some
laboratory somewhere.
• Collections of incidents reveal that we continue to
make the same mistakes over and over again!
HOT GLASS Incident
• During a first-year laboratory session, students were asked to learn to
bend a glass tubing to form a 90◦ bend using a Bunsen burner.
• A student performed the operation and took the glass tubing to the
instructor
• She handed the tubing to her instructor, who promptly dropped the
glass tubing after burning her hand because the tubing was still hot
from being held in the burner.
• The tubing broke when it hit the floor.
 • What happened?
• A hot piece of glass tubing was placed in the hand of the instructor,
causing a burn and causing the glass tubing to be damaged when it
dropped to the floor.
• There were two adverse outcomes – a burn and a broken glass tube.
• How did it happen?
• The tubing was heated to red hot, bent, and then removed from the
Analysis of flame.
• Once the glass was removed from the flame, it began to cool;
incident however, as most cooks know, glass retains heat well and the glass
tubing was still very hot.
• The student must have walked quickly to the instructor with the glass
tubing, holding it at the ends.
• Not being aware that the glass was still hot, it was handed to him to
examine to determine if it was a good bend.
• Thus, the student did not recognize the hazard. Furthermore, the
instructor did not recognize (the hazard) that the glass was hot or
could have been hot, and grabbed the hot glass in his hand.
 • Why?[#1] The student did not recognize the
hazard.
• Why? [#2] The instructor did not alert the
student to the potential hazard (hot glass) that
resulted from the heating.
Why did it • Why? [#3] The instructor failed to recognize the
potential hazard of hot glass, as indicated by his
happen? acceptance of the hot glass.
• Why? [#4] The instructor had not taken time to
consider (assess) the potential hazards of the
experiment prior to the start of the experiment.
• Why? [#5] The instructor had not been taught
about the hazards of this experiment.
Why did it happen?
• Why? [#1] The instructor did not recognize the hazard.
• Why? [#2] Hot glass looks like cold glass and the instructor did not
think a student would hand a hot object to another person.
• Why? [#3] The instructor did not have enough safety education or
experience in working with students.
• Why? [#4] The safety education the instructor received did not
address this topic.
• Why? [#5] The organization (college) failed to adequately educate
instructors about the specific and general risks in chemistry labs.
• These two analyses they both end up at the same root cause:
inadequate instructor education in safety.
How Might We Prevent This Incident
From Happening Again?
1. Instructors should be educated about assessing, recognizing, and
managing the hazards of experiments.
2. Instructors should communicate the hazards to the students before
the experiments begin.
3. For this specific experiment, instructors should not hold out their
hands to receive tubing that may be hot; instructors should keep their
hands in their pockets or behind their backs.
4. The instructor should pass on this lesson learned to other instructors
so they are also aware of this hazard and will not make the same
mistake.
 • A student needed to use trifluoroacetic acid (TFA) in a procedure.
• She had done this procedure many times before and was comfortable in doing it.
• As a result she did not consider the risk of what she was doing.
• While she was wearing safety glasses and working in a hood, she did not wear a lab
STUDENT coat.
• She was using a large plastic syringe from which she had pulled the plunger.
SERIOUSLY • She poured the TFA into the syringe but when she tried to put in the plunger, it
BURNED BY slipped and the TFA splashed onto to her arm.
•
TRIFLUOROAC Lab mates near to her immediately got her to the sink where she washed her arm
for 30 minutes.

ETIC ACID • She noted, however, that her arm had gone numb almost immediately and she
knew something was very wrong.
• A doctor told her that she may need skin grafts and that greatly worried her.
• In the end they scraped away the dead skin and worked to get new skin to grow
back.
• It took many months to recover.
• Now apply the “Why” strategy to this incident.