Chemistry's Cautionary Chronicles: August 2024

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Newsletter in printable and sharable format

 

Zebras or Horses II? MORE ZEBRAS LESS HORSES, THE TEXAS TECH LABORATORY EXPLOSION

by Vicky Wang

Continuing our Zebras or Horses journey on how a false sense of security can lead to lab accidents (see Part I in the Mar 2024 issue), keep in mind that it's easy to judge others’ actions in hindsight. This series aims to help us improve our lab safety preparedness. Our research often exposes us to both expected (horses) and unexpected (zebras) risks. Consequently, it is vital that we establish and properly use safety barriers—policies, operating procedures, supervision, and equipment—to mitigate these risks. The following describes an incident where such barriers were not in place.

In Jan. 2010, a Texas Tech University (TTU) chemistry lab experienced a catastrophic incident that would become a hallmark example of poor safety protocols, inadequate lab management, and severely lacking communication. Operating under the “Awareness and Localization of Explosive Related Threats” (ALERT) program funded by the U.S. Department of Homeland Security (DHS), the TTU lab was researching a novel, potentially shock sensitive nickel hydrazine perchlorate (NHP) derivative. Initially, 5th-year graduate student, Preston Brown, was preparing batches of 50-300 mg. But to avoid batch inconsistencies during testing, he decided to scale up the synthesis to 10 g. Aiming to eliminate chunks in the reaction product, Brown placed 5 g of the NHP derivative in a mortar with hexane and stirred with a pestle. Leaving and returning some minutes later without his safety goggles, Brown gave the sample one last stir. The sample detonated unexpectedly, causing Brown to lose three fingers and suffer an eye injury and burns to his face and hands.

Brown’s previous research had not been on energetic materials. thus, to him, this work was a zebra. However, one’s zebra might be another’s horse—you should always seek out knowledgeable sources throughout your work. For Brown, his principal investigators (PIs) should have been those invaluable sources. Yet, they failed to provide him with adequate training, even with the entirely new lab techniques. Instead, Brown was simply instructed to complete an independent literature review of the energetic materials.

In addition, Brown’s lab:

• Did not perform hazard assessments before synthesizing new compounds or performing new lab techniques;
• Had no documented policies that required researchers to consult with a PI before changing experimental parameters;
• Had no written operating procedures or rules for working with energetic materials. The PIs relied on verbal communications with the senior graduate students, who in turn were expected to share the information with other group members.
• Lab activities were poorly documented in lab notebooks (e.g., the amounts of reactants used for each synthesis were not always recorded and entries were not dated);
• Wearing PPE was made a personal choice based on how dangerous researchers perceived an activity to be.

And this list goes on. As evidenced by the above, the lack of safety awareness in the lab was not limited to the researchers directly involved in this incident. An overrelaxed attitude toward safety extended throughout the lab, pointing to safety oversights that encompassed the administrative levels of the lab, department, and university. The ALERT program also did not require pre-approval of experimental procedures, intending to provide researchers with maximum scientific freedom. Tragically, their lack of supervision was detrimental to the TTU researchers’ safety.

This event prompted major changes in how many institutions handle laboratory safety. Strict safety policies have since been implemented, and most now include protocols for establishing accountability in response to safety defects. By engaging in self-reflection and taking corrective actions, we grow in our ability to prevent our zebras from becoming lab accidents.

So, are there things that you, your lab, and your institution could be doing better to prevent your zebras from becoming the next major laboratory incident? For the U.S. Chemical Safety and Hazard Investigation Board’s full incident report, its consequences and a 10 years later retrospective, and a summary of TTU’s institutional changes, refer to the cited sources.

Safety Officer Spotlight: Dani Rodriques

by Natalie Clay

WOrd Scramble

Unscramble the letters to form a meaningful safety or chemistry related word.

Self-reported Mistakes from Not Voodoo 

 

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Events and More

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Special thanks to Mirna A., Natalie C., Annie M., Luis N., and Vicky W. for your contributions to this issue!