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Oct 19, 2011

CSB Releases Investigation into 2010 Texas Tech Laboratory Accident; Case Study Identifies Systemic Deficiencies in University Safety Management Practices

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Denver, CO, October 19, 2011 – The U.S. Chemical Safety Board (CSB) today released its final report into a January 7, 2010, chemistry laboratory explosion at Texas Tech University in Lubbock, Texas, recommending that the American Chemical Society develop new hazard evaluation guidelines for laboratories and calling on the Occupational Safety and Health Administration to issue a Safety Bulletin on the importance of controlling the physical hazards of chemicals in academic laboratories.

The accident occurred during the handling of explosive compounds and resulted in serious injuries to a graduate student. The case study – released today via webinar in Denver, Colorado, identifies systemic deficiencies in safety accountability and oversight by the principal investigators, the chemistry department, and the university administration at Texas Tech.  Furthermore, according to investigators there were also important gaps beyond the university itself, gaps which are addressed in the CSB’s safety recommendations.

CSB Chairman Rafael Moure-Eraso said, “Research conducted at university laboratories is often on the forefront of technology and innovation.  It is important that this research continues and thrives. But it must be done within a strong safety culture based upon effective safety management systems where preventing hazards is an important value.”

In January 2010, two graduate students at Texas Tech University were conducting research funded by the U.S. Department of Homeland Security on energetic or explosive compounds; at the time of the accident a senior graduate student had been working on the project for about a year and was helping train a first-year graduate student.  The students were tasked with synthesizing and performing tests on a new compound, a derivative of nickel hydrazine perchlorate (NHP).

The two principal investigators for the research believed they had verbally established a 100 milligram limit on the production of energetic materials, but the CSB investigation found there was no formal system for communicating this limit or verifying compliance. Few of the graduate students interviewed during the investigation believed that a strict 100 mg limit existed.  

The CSB found that initially, the compound was made in small batches of less than 300 milligrams, but the two students were concerned about potential variability among different small batches of the compound which could affect later test results. They decided to scale up the synthesis to make a single batch of approximately 10 grams, enough for all of their testing. The graduate students believed that keeping the compound wet with a solvent would prevent it from exploding.  After producing the larger batch, the more senior graduate student observed that it contained clumps that he believed needed to be broken using a mortar and pestle up prior to testing. As the pestle pressed against the compound, it detonated.  The graduate student was seriously injured: his left hand severely damaged by the force of the explosion, causing the loss of three fingers, perforation of his eye, and cuts and burns to other parts of his body.

The CSB’s investigation determined there had been two previous near-misses within the laboratories of the same principal investigators since 2007.  While no one was injured, CSB investigators concluded there were similarities in the causes of these previous incidents to the January 2010 explosion.  But these key lessons were missed at the time of the earlier incidents.

           CSB Investigator Mary Beth Mulcahy said, “The CSB would like to see Texas Tech and really all universities create a tracking system to document the accidents that are happening within the university so that they can facilitate learning not just in the laboratory where the accident happened but in all laboratories.”

As a result of the investigation, the CSB recommended that Texas Tech revise and expand its Chemical Hygiene Plan to ensure the physical hazards of chemicals are identified and controlled. In addition, the CSB recommended that Texas Tech develop and implement an incident and near miss reporting system which should document and communicate lessons learned from all laboratory near misses and incidents.

             “The CSB is concerned with laboratory safety because when compared to industry it’s an area that is unregulated and lacks good practice guidance,” said Investigator Cheryl MacKenzie. “There is an OSHA laboratory standard requiring universities to create Chemical Hygiene Plans, but its focus is on exposure hazards and health hazards of the research work being conducted. We found that there is no comprehensive guidance for conducting hazard evaluations within the dynamic environment of academic research laboratories.”

In an effort to improve guidance in laboratories across the country the CSB issued a recommendation to the Occupational Safety and Health Administration to develop a bulletin on the importance of controlling physical hazards of chemicals in academic laboratories. The Chemical Safety Board also recommended that the American Chemical Society develop a methodology for evaluating and controlling hazards in academic research laboratories.

Investigator MacKenzie said, “Comprehensive guidance would help researchers determine the most effective way to evaluate the hazards of their work. The CSB’s investigation concluded that the American Chemical Society is uniquely positioned to create guidance appropriate for an academic laboratory setting.”

In addition, the CSB’s case study identifies several key lessons meant to improve safety practices at all academic laboratories.  “The CSB’s case study is a call to academia to examine internal safety policies and procedures for research labs,” Dr. Moure-Eraso said.  “It’s also an opportunity for research funding agencies to require universities to ensure that effective safety systems are in place before awarding grants for scientific studies.”

The CSB investigation identified six key lessons for universities and others, including calling on universities to: 

- Ensure that research-specific hazards are evaluated and then controlled by developing specific written protocols and training.

- Expand existing laboratory safety plans to address the physical hazards of chemicals

- Ensure that safety personnel report directly to a university official who has the authority to oversee research laboratories and implement safety improvements

- Document and communicate all laboratory near-misses and incidents to educate individuals and track safety at the university.

The CSB will be releasing a safety video discussing the Texas Tech accident and several other laboratory incidents tomorrow, Thursday, October 20 at 10 am EDT.  The video will be available to view and download at www.csb.gov.

The CSB is an independent federal agency charged with investigating serious chemical accidents.  The agency’s board members are appointed by the president and confirmed by the Senate.  CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in safety management systems. The Board does not issue citations or fines but does make safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.  Please visit our website, www.CSB.gov. 

Contact:  For more information, contact Communications Manager Hillary Cohen at 202.446.8094 or via email at Hillary.Cohen@csb.gov or Sandy Gilmour at 202.251-5496 or via email at Sandy.Gilmour@csb.gov.

 

 

 

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