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APPLYING LESSONS OF NOD TO CHEMICAL LABORATORY SAFETY

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ROBERT H. HILL, JR., CAPT, U.S. PUBLIC HEALTH SERVICE (RETIRED)

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DIANE VAUGHN’S �THE CHALLENGER LAUNCH DECISION: �RISKY TECHNOLOGY, CULTURE, AND DEVIANCE AT NASA

  • PROFESSOR, SOCIOLOGIST, COLUMBIA UNIVERSITY
  • STUDIED NASA’S CHALLENGER, COLUMBIA DISASTERS
  • FOUND CLEARLY UNSAFE PRACTICES ACCEPTED AS NORMAL; WARNING SIGNS OF DANGERS ARE IGNORED, MISSED
  • TERMED “NORMALIZATION OF DEVIANCE” OR NOD�

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NORMALIZATION OF DEVIANCE�IN CHEMISTRY EDUCATION

  • SAFETY EDUCATION MISSING FROM CHEMISTRY CURRICULA
  • CHEMISTRY DEPARTMENTS DECIDED:
    • TEACHING SAFETY NOT IMPORTANT
    • OTHER CHEMISTRIES PRIORITIZED OVER CHEMICAL SAFETY EDUCATION
    • SUBSTITUTED GENERAL SAFETY TRAINING FOR SAFETY EDUCATION

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  • ADVERSE CONSEQUENCES FOR GRADUATES, & EMPLOYERS
    • DON’T KNOW THEY DON’T KNOW
    • LACK OF SAFETY KNOWLEDGE
    • LACK OF SAFETY ETHICS
    • SUSCEPTIBLE TO INCIDENTS INVOLVING HIGH HAZARD CHEMICALS

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Normalization of Deviance (NOD) at work

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R Hill, Undergraduates Need A Safety Education, J Chem Ed, 93, 1495 (2016)

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FACTORS LEADING TO SAFETY ERRORS�IN LABORATORY RESEARCH

  • RESEARCHERS (PRINCIPAL INVESTIGATORS, GRADATE STUDENTS, POST-GRADUATE) SEEK:
    • DEGREES, PUBLICATIONS, RECOGNITION, FUNDING, PROMOTIONS
  • SAFETY MAY BE OVERLOOKED IN RESULT-DRIVEN RESEARCH
  • WEAK OR MISSING SAFETY CULTURES
  • UNRECOGNIZED APPEARANCE OF NOD

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UNIVERSITY OF HAWAII RESEARCHER LOSES ARM IN EXPLOSION - 2016

  • RESEARCH GROWING BACTERIA TO PRODUCE BIOFUELS, BIOPLASTICS WITH H2, O2, CO2 (OPEN GAS SYSTEM)
  • RESEARCHER TO DEVELOP CLOSED GAS SYSTEM
  • ACTIVATED GAUGE ON 13-GAL GAS TANK – EXPLOSION
  • RESEARCHER LOST LOWER RIGHT ARM, SEVERE BURNS, TEMPORARY HEARING LOSS

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INVESTIGATIONS OF INCIDENT AT UH� BY HONOLULU FIRE DEPARTMENT

  • HFD INVESTIGATOR FINDING
    • SPARK FROM PRESSURE GAUGE (NOT INTRINSICALLY SAFE) IGNITED FLAMMABLE GAS MIXTURE

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INVESTIGATION OF INCIDENT AT UH�UCCLS (INDEPENDENT)

  • UNIVERSITY OF CALIFORNIA,

CENTER FOR LABORATORY SAFETY (UCCLS); HTTP://CLS.UCLA.EDU

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  • DIRECT CAUSE:
    • ELECTROSTATIC DISCHARGE BETWEEN RESEARCHER & GAS TANK

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  • UNDERLYING CAUSES:
    • SERIOUS DEFICIENCIES IN UH APPROACH TO LAB SAFETY
    • LACK OF SAFETY CULTURE
    • FAILURE TO RECOGNIZE, CONTROL HAZARDS OF EXPLOSIVE GAS MIXTURE

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UCCLS INVESTIGATION AT UH�– RESEARCH SAFETY ISSUES

  • NO RISK ASSESSMENT
  • SAFETY CONCERNS UNANSWERED
  • EARLY WARNINGS MISSED
    • SHOCKED TOUCHING GAS TANKS, PRESSURE VESSEL
    • NEAR MISS

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  • HIGH HAZARD SPECIFIC TRAINING LACKING
  • H2/O2 MIXTURES IN EXPLOSIVE RANGE ARE DANGEROUS – MUST AVOID IGNITION SOURCES

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This Photo by Unknown Author is licensed under CC BY-SA

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UCCLS INVESTIGATION AT UH�– RESEARCH SAFETY ISSUES

  • NEAR MISS (WARNING) 1 DAY BEFORE INCIDENT:
    • ACTIVATED GAUGE ON 1-GAL TANK, HEARD “CRACKING” SOUND
    • EVIDENCE OF COMBUSTION: BURNED, CRACKED, DISCOLORED PETRI DISHES
    • RESEARCHER CONCERNED. CAUSE UNDETERMINED
    • PI DON’T USE TANK
    • PI DID NOT STOP WORK OR STAND-DOWN

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UCCLS INVESTIGATION UH�– RESEARCH SAFETY ISSUES

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UCCLS INVESTIGATION AT UH�– SYSTEMIC ISSUES

  • OVERSIGHT OF RESEARCH SAFETY – LACKING, INEFFECTIVE
  • TRAINING LACKING IN HAZARD RECOGNITION, RISK MINIMIZATION
  • NO RISK ASSESSMENTS FOR HIGH HAZARD CHEMICALS
  • INADEQUATE STANDARD OPERATING PROCEDURES (SOPS)
  • OUTDATED, INEFFECTIVE CHEMICAL HYGIENE PLAN
  • DEFICIENT LAB INSPECTION PROGRAM
  • EHSO STAFF SKILLED RESEARCH SAFETY - LACKING
  • CYLINDER SAFETY - LACKING

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NORMALIZATION OF DEVIANCE�IN UH INCIDENT

  • DANGER OF H2 + O2 (HAZARD) NOT RECOGNIZED OR UNDERSTOOD
  • WORK W/HIGH HAZARD GASES, RELAXED, MORE ROUTINE
  • LACK OF FOCUS ON SAFETY
  • NO RESEARCH SAFETY PROGRAM; SAFETY RESPONSIBILITIES MISSING
  • NEAR MISSES, WARNINGS UNRECOGNIZED, LESSONS MISSED
  • SPECIFIC HIGH-HAZARD TRAINING - LACKING
  • NO SPECIFIC RISK ASSESSMENT
  • NO MANAGEMENT OF CHANGE
  • PPE NOT USED OR NOT WORN; NO BARRIERS
  • EQUIPMENT NOT DESIGNED FOR USE

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NORMALIZATION OF DEVIANCE (NOD)

  • ACCEPTING UNSAFE PRACTICES, PROCEDURES AS NORMAL
    • IS OFTEN COMMON
    • CAN BE VERY RISKY – EVEN DANGEROUS
    • OFTEN INDICATION OF A POOR OR WEAK SAFETY CULTURE
  • CAREFUL STUDY OF INCIDENTS (INVESTIGATIONS) CAN UNCOVER NOD AND OTHER SAFETY ISSUES

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RESEARCH IS AN IMPORTANT, CRITICAL PART OF CHEMISTRY, AND IT CAN BE DONE SAFELY IF RISKS ARE MINIMIZED!

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SAFETY REQUIRES YOU: RECOGNIZE HAZARDS, ASSESS RISKS OF HAZARDS, MINIMIZE RISKS OF HAZARDS, PREPARE FOR EMERGENCY (RAMP) AND BE PROACTIVE FOR YOUR OWN SAFETY!

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SAFETY EDUCATION BUILDS SAFETY KNOWLEDGE, ETHICS – IT IS THE KEY TO PREVENTION!

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