Lessons Learned

Lessons Learned Vol. 3

General Categories

Eye Splashes/Exposures

Eye splashes/exposures and near-misses involving the eyes are some of the most common yet easily avoidable safety incidents in research labs. There are numerous lab activities which pose a significant risk to eyes, including: (a) using a syringe (especially with a syringe filter), (b) dispensing of liquids, (c) carrying chemicals or trays of gels, (d) working with dry ice or liquid nitrogen, and (e) working with glass apparatus, e.g., Schlenk lines. Various forms of eye protection should be worn depending on the hazard. Below are summaries of selected incidents at USC that have occurred and the lessons taken from them.

Safety Management Takeaway

Notable facts from past eye splash incident investigations:

  • Zero (0) people wearing splash goggles have suffered eye splash injuries.
  • 25% of those splashed were wearing safety glasses (not splash goggles).
  • 75% were not wearing any eye protection.

Remember: When working in a laboratory, consistently wearing the appropriate eye protection for the hazards is one of the simplest actions with the biggest benefit to personal safety that you can take!

A Chemical Splash: The Eyes Have It

A researcher was pushing a snapping cap back onto a small chemical bottle when a few droplets of the solution ejected from the side of the snapping cap into both of their eyes. The researcher used the eyewash station to flush their eyes for at least 15 minutes and then called their PI and DPS to report the exposure. EH&S was notified and responded on scene shortly after. At the time of the incident, the researcher was wearing a lab coat and nitrile gloves but no eye protection.

Contributing Factors & Root Causes

  • Researcher was not wearing proper eye protection for the task

Satisfactory Action(s)

  • Researcher utilized the safety eyewash station.
  • Researcher notified the correct parties in the event of an incident.

Corrective Action(s)

  • PI to reiterate the use of proper eye protection (see Eye Protection) when working with splash hazards.
TFA in The Face

A researcher was withdrawing a small volume of trifluoroacetic acid (TFA) from a 15 ml vial using a syringe in a fume hood at chin level, working behind the glass sash. The vial slipped from their hand and struck the fume hood work surface. The vial did not break but drops of liquid splashed upwards onto the researcher’s face. The PI and another colleague were in the lab and assisted in getting the researcher to the eyewash station. The lab called EH&S and took the researcher to the Student Health Center to be evaluated. DPS was not notified.

At the time of incident, the researcher was wearing a lab coat, thick nitrile gloves, and safety glasses.

The researcher sustained burns to multiple areas of the face.

Contributing Factors & Root Causes

  • Researcher was not wearing proper eye protection for the task. Safety goggles are required to be used when the risk of liquid splashes is present.
    • Safety glasses do not reliably protect against liquid splashes, especially when splashes come from below or from the sides; therefore, it was only by luck that eye damage (potentially permanent) was avoided in this case.

Satisfactory Action(s)

  • PI and other researchers who were present gave the splashed student immediate assistance in getting to the eyewash station and decontaminating.
  • Eyewash station was used to decontaminate face.
    • Although they were burned, the burns were superficial likely as a result of the rapid decontamination; they fully healed without scarring.
  • Lab notified EH&S.

Corrective Action(s)

  • PI to reiterate the use of proper eye protection when working with splash hazards.
Unwanted THF Splash to The Face

After a researcher dispensed THF from a solvent purification system into a small open flask, a nitrogen purge was completed. A few drops of THF splashed out of the flask onto the researcher’s face. The researcher notified the lab safety officer and washed their face at the sink-mounted eyewash/drench hose. There was no injury to the researcher though they sought medical attention as a precaution. At the time of the incident, the researcher and lab personnel followed proper emergency response procedures. The researcher was wearing goggles, lab coat, and nitrile gloves. The appropriate parties were notified, and the designated emergency equipment was used.

Contributing Factors & Root Causes

  • N/A

Satisfactory Action(s)

  • Researcher utilized the eyewash station.
  • Researcher was wearing proper eye protection.
  • Personnel reported the incident in a timely manner.

Corrective Action(s)

  • PI to review operation of solvent purification system with lab members
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Hazard Awareness

Effective hazard communication in research laboratories is essential for ensuring the safety of personnel and preventing incidents. In an environment where chemicals, biological agents, and specialized equipment are frequently used, clear communication of hazards is vital. Even commercial reagent kits, which are designed to simplify procedures and reduce direct handling of hazardous substances, still carry inherent dangers. These kits, which are ubiquitous across biomedical-type labs, often contain chemicals or materials that can cause harm if mishandled, emphasizing the need for proper labeling, reading of safety data sheets, and training to ensure that all users are aware of the potential risks and required safety protocols.

Below are summaries of selected incidents that have occurred at USC and the lessons taken from them. These incidents illustrate the dangers of researchers not being aware of the hazards they are working with.

A Researcher’s Close Call

A researcher eluted a small amount of a guanidinium thiocyanate-containing reagent off a DNA column; the reagent was one component of a kit. The researcher treated the liquid waste as biohazardous and added it to a waste bottle containing bleach. The mixture produced a yellow color, started bubbling, and generated a noticeable odor. The researcher immediately capped the waste bottle, transferred it to a fume hood, and evacuated the lab. The researcher called DPS and EH&S.

At the time of the incident, the researcher was wearing a lab coat and nitrile gloves but no eye protection.

Contributing Factors & Root Causes

  • The investigation revealed that the researcher was entirely unaware of the hazards and proper handling procedures for the material being used.
    • No review of SDS and contents of reagent kits was completed before starting work.
    • Guanidinium thiocyanate is marginally toxic and slightly corrosive to the skin; however, it is a GHS Category 1 corrosive to eyes. Eye protection should have been worn.
    • Guanidinium thiocyanate is known to react with bleach (sodium hypochlorite) to produce a complicated mixture of noxious gases which may include HCl, HCN, NO, NO2, and CO.
  • Incorrect waste segregation — hazardous chemicals are always disposed of as chemical waste, not biowaste.

Satisfactory Action(s)

  • Researcher immediately sealed the bottle following the chemical reaction keeping others from being exposed to the potential gases.
    • NOTE: It would likely be safer to have left the bottle uncapped in the fume hood then immediately evacuate and call DPS.
  • Researcher moved the bottle to the hood and closed the sash.
  • Lab was evacuated.
  • Personnel remained on scene to speak with emergency personnel.

Corrective Action(s)

  • PI to reiterate the use of proper eye protection.
  • PI to re-educate lab on:
    • Waste segregation
    • SDS review
  • Personnel are directed to review the Guanidinium Thiocyanate Guide Sheet for additional information on guanidinium thiocyanate.
Dilute Sulfuric Acid Solution to The Eye

A researcher was disposing of an ELISA kit into a biohazardous waste container when a row from the 96-well plate slipped out of their hand and landed on the work bench. Liquid containing diluted sulfuric acid flew into their right eye. The researcher went to the restroom to flush their eye and later used the eyewash station. The lab manager called DPS.

At the time of incident, the researcher was wearing a fluid resistant lab coat and nitrile gloves but no eye protection.

The researcher sustained redness and swelling to the eye but no lasting effects.

Contributing Factors & Root Causes

  • The researcher did not review the SDS for this specific ELISA kit prior to beginning work.
  • Lab did not utilize the designated emergency eyewash in the initial response.

Satisfactory Action(s)

  • The Lab Manager called DPS.
  • The PI had the researcher use the eyewash station for an appropriate amount of time to flush the affected area.

Corrective Action(s)

  • PI to reiterate the following:
    • Policies when reviewing SDS prior to start of work.
    • Use of proper eye protection.
    • Importance of using the safety eyewash/shower station. Restroom sink use is not an appropriate response.
  • Review appropriate waste segregation
Another Eye-Felt Moment

While performing a DNA extraction, a researcher following a Qiagen protocol filled a microfuge tube with Buffer QG. Buffer QG is composed of 50-70% guanidinium thiocyanate. While closing the lid, a small amount of liquid splashed into their eye. They rinsed their eye in the lab sink before moving to the eye wash station. The researcher had performed DNA extractions in the past with different kits and buffers but had never worked with this protocol.

At the time of incident, the researcher was wearing a flame resistant-treated cotton lab coat and nitrile gloves but no eye protection.

Contributing Factors and Root Causes

  • No eye protection was worn.
  • Researcher was not trained on this specific protocol.
  • SDS was not reviewed.
  • Lab personnel did not utilize the designated eyewash station in initial response to the exposure.

Satisfactory Action(s)

  • Eyewash station was used for the proper amount of time.

Corrective Action(s)

  • PI to reiterate the following:
    • Policies when reviewing SDS prior to start of work.
    • Use of proper eye protection.
    • Importance of using the safety eyewash/shower station. Restroom sink use is not an appropriate response.
In Summary…

There are a few common contributing factors seen in these incidents:

  • The reagent kits had corrosive materials in them.
  • No review of SDS took place prior to work.
  • Appropriate PPE was not worn (see PPE Selection).
  • Designated emergency equipment was not utilized.
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Safety Management Failures and Major Incidents

The USC Research Personnel Protection Policy (RPPP) explicitly states the responsibilities that PIs must adhere to. They do not necessarily have to perform all day-to-day safety management themselves as they have the authority to delegate these responsibilities; however, they retain ultimate responsibility for quality of the delegated safety work. Therefore, it is incumbent upon PIs to exert effective management and leadership. These incidents demonstrate the absence of basic safety management in the lab. While workers must follow the lab rules and safety practices, their supervisors are ultimately responsible for ensuring their personnel follow these policies and perform safe work practices.

The following incidents prompted serious response from USC EH&S, the Schools and Departments, and, when necessary, the Los Angeles Fire Department (LAFD).

Safety Management Takeaway

Safety management of research labs can be improved dramatically by the following:

  • Review internal policies and SOPs with research staff regularly (beyond the Annual Refresher).
  • Reacquaint everyone with the CHP especially waste management and disposal.
  • Stipulate review of SDSs prior to work.
  • Ensure everyone is aware of:
Errors in Flow Control Led to Hydrogen Explosion

Combustion research was taking place using a small flow of dilute flammable gases and/or vapors into a combustor. The flow control system was lab-built and contained four flow controllers and four gas inputs. Two were connected to nitrogen and the other two were connected to hydrogen. The flow control system was covered by a close fitting but not airtight clear acrylic box-shaped cover.

At the time of incident, a researcher was attempting to generate a 0.3% hydrogen in nitrogen mixture to perform specific tests. They turned on the flow control system and computer and went to the instrument for the test. They found that there was a small amount of gas flowing into the instrument even though the flow was supposed to be off at that time. When they returned to the flow control system two flow controllers were displaying warning lights. The hydrogen supply was 60 psi. The controller was showing a “big flow” but the flow at the instrument was small, so the researcher thought it was some kind of error. The researcher then went to turn off the hydrogen supply at the station, but not the nitrogen. The researcher looked through the acrylic cover to read the LCD display on the hydrogen flow controller and there was an explosion. The researcher was struck by the acrylic cover and fell. Another researcher in the lab responded to the incident and all personnel evacuated the lab. The PI called DPS who then notified USC HazMat and LAFD.

At the time of incident, the researcher was wearing safety glasses. 

The researcher sustained abrasions and bruises to their face and substantial temporary hearing loss.

Contributing Factors and Root Causes

  • Equipment using flammable gases should not be enclosed.
  • No flammable gas detector inside the flow control system to alert of potential leaks.
  • Buildup of hydrogen gas in enclosed spaces can create an explosive environment.
  • There was unsuitable tubing in the flow control system (soft polymer tubing) which is inappropriate for pressurized hydrogen.
  • Swagelok compression fitting designed for metal tubing was used on the plastic tubing which will not form a gastight seal and may deform over time.
  • Excessive hydrogen pressure (60psi).

Satisfactory Action(s)

  • The researcher put their safety glasses on just before approaching the flow control system.
  • Other lab members helped the injured researcher before evacuating.
  • The lab did not attempt to shut off the audibly leaking gas after the explosion. This was later determined to be nitrogen.
  • DPS was immediately notified once the lab was evacuated – prioritizing the health and safety of those at most immediate risk and then warning others.

Corrective Action(s)

  • PI should audit the experimental design to ensure appropriate equipment is used and codify in an SOP, what is and isn’t appropriate for specific hazardous applications.
  • Tubing should be clearly labeled to indicate what gas is flowing.
  • Regulators should be suitably scaled for the necessary pressures.
  • Periodic leak testing should be performed.
  • Gas alarms should be regularly maintained and tested.
Two-Person Phenol Splash

Two researchers were completing an RNA extraction in a fume hood using an old bottle of Phenol:Chloroform:Isoamyl Alcohol. The reaction wasn’t working properly, so the lab personnel went to the Senior Researcher (SR) for assistance. Researcher #1 (R1) tilted the presumed sealed bottle above eye level to see if there was any precipitate. Some liquid leaked out of the bottle and, startled, R1 dropped it. The contents splashed onto the two researchers’ hands, face, and lab coat. The researchers were directed to use the safety eyewash/shower station outside the lab and the SR stayed to clean the spill. The two researchers went first to a safety shower and used that but found the eyewash station to be non-functional. R1 was then directed to a functional eyewash station by Facilities while R2 went to a restroom sink to rinse their eyes and face. The floor and subsequent floors below were flooded in the process. FPM then called DPS.

At the time of incident, the researchers were wearing lab coats and gloves. The two researchers were transported to the hospital.

Contributing Factors and Root Causes

  • Lab workers did not review SDS.
  • New personnel did not review SOPs.
  • Inappropriate emergency response and incident investigation from lab management.
    • Senior researcher left the scene after injured personnel were transported via EMS.
    • Lab did not immediately report the incident to DPS at time of occurrence; incident response was prompted after discovery by another party.
    • Incorrect chemical reported to emergency responders.
    • Lack of communication between lab personnel and supervisor at the time of the incident.
  • Emergency contact numbers on the door sign were incorrect.
  • Trizol was used as a substitute for Phenol:Chloroform:Isoamyl alcohol, which is similar but they are NOT the same chemical.
  • No eye protection worn.

Satisfactory Action(s)

  • Ensuring well-being of students

Corrective Action(s)

  • PI to:
    • Make safety a focal point when discussing lab protocols.
    • Re-train all lab personnel on spill response, including the tracking of spill paths in their entirety and barricading them, where appropriate.
    • Ensure senior members of the lab understand the roles and responsibilities outlined in the RPPP.
    • Update emergency contact information.
    • Educate lab personnel on proper emergency response, including timeliness of notifications and response to follow-up investigations.
  • Use safety eyewash/shower stations instead of facilities with drains (e.g., restroom sinks).
Acetic Anhydride Spill

Researcher #1 from Lab A was lifting a 4-L bottle of acetic anhydride from a flammable cabinet. The bottle slipped out of their hands and broke on the floor. The chemical spill went out into the hallway and went unnoticed by Lab A. Researcher #1 donned a half-face respirator and goggles and attempted to neutralize the spill. PI of Lab A was notified by lab personnel. The PI evacuated the adjacent room and called DPS and EH&S.

Researcher #2 from Lab B was walking down the hall and slipped and fell in the liquid, making contact with their right arm and right leg. Researcher #2 began experiencing a burning throat, eyes, and uncontrollable tearing. They were unable to get an immediate response from their PI. Researcher #1 and another researcher, Researcher #3, from Lab A took Researcher #2 from Lab B to a lower floor to wash off in a restroom.

Researcher #2 did not have PPE on as it is not required in hallways.

The PI from Lab A pulled the fire alarm and evacuated the building on instructions from DPS. USC HazMat responded to the scene.

Contributing Factors and Root Causes

  • The lab had an excessive chemical inventory.
  • The lab did not follow proper spill response procedures.
    • The spill was not barricaded immediately.
    • Lab personnel attempted to clean the spill without appropriate spill response training.
    • Inappropriate neutralization of acetic anhydride.
  • Respirators should only be used for the functions workers have been trained to use them for.
  • Lab did not track the path of the entire spill. Incorrect chemical was reported to emergency responders – it was acetic anhydride not acetic acid.
  • Designated safety shower was not used in the building – restroom was used instead.

Satisfactory Action(s)

  • The PI immediately notified DPS and followed the instructions.

Corrective Action(s)

  • PI to:
    • Ensure lab personnel understand where safety equipment is located.
    • Change work practices – personnel to work in fume hoods.
    • Reduce working quantities. Handling an oversize bottle both increased the probability of an accident and increased the severity of the accident when it occurred.
    • Emergency showers should be used instead of facilities with drains.
    • Re-training on spill response.
      • Spill paths should be tracked in their entirety and barricaded where appropriate.
  • Use safety eyewash/shower stations instead of facilities with drains (e.g., restroom sinks).
Graphene Experiment Gone Awry

A researcher used a silica tube substrate to grow graphene. This process requires passing a flow of hydrogen and methane through a silica tube. The gas runs from high pressure gas cylinders (at 30-40 psi) through plastic tubing connected to two flow controllers to the tube furnace and out to a vacuum pump with a pressure gauge. It then runs to an outlet in the fume hood. The hydrogen runs from the beginning of the experiment and the methane gets turned on once the furnace is at temperature. While the experiment was running the researcher heard a loud hissing noise, went to investigate and saw flames. They evacuated the lab and pulled the fire alarm. The fire sprinklers activated and LAFD responded.

Contributing Factors and Root Causes

  • Integrity of the tubing was compromised.
  • The line going into the flow controller (high pressure) was too long. The flow controllers should have been closer to the cylinders while the low-pressure line should have been the longer line.
  • General housekeeping issues.

Satisfactory Action(s)

  • The lab evacuated and did not attempt to close the gas cylinder valve.

Corrective Action(s)

  • PI should review design of experiment prior to start.
  • General housekeeping should always be maintained.
Hazardous Waste Leak

An unknown brown liquid with a fishy smell leaked from a waste container in a shared lab. The waste container was unlabeled, corroded, and not in secondary containment. DPS was called by a researcher who then notified LAFD, LA County HazMat, EH&S On-Call, and EH&S HazMat.

The lab was evacuated and LAFD secured the area. There was no external door sign so the first responders could not contact a responsible party. EH&S HazMat was able to transfer the waste to another container and decontaminate the floor.

No one was injured or suspected to be exposed.

Contributing Factors and Root Causes

  • The waste was not in a required secondary container.
  • The waste was incompatible with the container material (presumed acid in a steel drum).
  • The waste was unlabeled.
  • The leak was reported after 3 days.

Satisfactory Action(s)

  • The researcher eventually notified DPS of the leak.

Corrective Action(s)

  • PI to:
    • Ensure lab maintains general housekeeping.
    • Ensure proper procedures for waste handling, including secondary containment, labeling, and understanding incompatible materials are followed.
    • Reiterate the proper use of PPE.
    • Ensure that the chemical inventory is up-to-date.
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