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Subject: Re: Boston College incident follow up
Date: Wed, 29 Jun 2011 11:20:51 -0400
Author: "Koza, Mary Beth (Environment Health & Safety)" 		Next by Date:
Subject: Re: Boston College incident follow up
Date: Wed, 29 Jun 2011 12:12:05 -0400
Author: Margaret Rakas


Date: Wed, 29 Jun 2011 12:10:49 -0400
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From: ILPI <info**At_Symbol_Here**ILPI.COM>
Subject: Re: Boston College incident follow up
In-Reply-To: <1677852553957F45BA7188EE44766EB34C8C710A86**At_Symbol_Here**AUXSEXCHCCR.aux-services.unc.edu>

I did not make a broad statement.  I very specifically said in my own personal experience which involves four major academic institutions. 

And in that personal experience, whatever formal policies existed at the time either were not enforced or insufficient.  For example, after serious laboratory explosions involving injuries there may have been internal reports etc. of which I was unaware, but clearly there was little or no effort made to *communicate* the information or lessons learned to the stakeholders.  Whether I was an undergrad, grad student, postdoc or professor I never **once** received **any** report or followup on **any** incident, including very serious ones in **which I was directly involved**.  None of these academic institutions implemented a formal process for continuous safety improvement for near misses or minor accidents/fires (they might have had them, I suppose, but we never saw them or used them).   Sure, buried somewhere in the Chemical Hygiene Plan there might be some form to fill out, but clearly these were never used.  Not once.

And again, I never once saw a specific case study mentioned in the safety training that I received at these major academic institutions.  Of course, I was always sure to used ample examples when training workers in my laboratories.  I am quite pleased that others on the list have reported that such activities do occur, and hopefully they have, or will become, the norm nowadays.

Finally, I see nothing counterproductive about my comments.  In fact, I believe they give some folks a rare glimpse of life on the "other side" of what is sometimes unfortunately construed as an adversarial relationship rather than the cooperative partnership it should be.  I am not pointing fingers at EHS or anyone else.  The decentralized nature of academic research and professional priorities of PI's makes implementation and maintenance of safety culture an extremely difficult task, one that can only be accomplished if we approach the issue from as many viewpoints as possible.

Rob Toreki

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On Jun 29, 2011, at 11:20 AM, Koza, Mary Beth (Environment Health & Safety) wrote:

Group,
I take exception to suggesting that  serious academic institutional/departmental follow-up response is not a normal part of the accident review.  Many academic institutions have a process, consisting of  root cause analysis and lessons learned.  Making such a broad statement is counterproductive to the importance of safety.
Mary Beth Koza
Director of EHS
University of North Carolina - Ch
From: DCHAS-L Discussion List [mailto:DCHAS-L**At_Symbol_Here**list.uvm.edu] On Behalf Of ILPI
Sent: Tuesday, June 28, 2011 11:25 PM
To: DCHAS-L**At_Symbol_Here**LIST.UVM.EDU
Subject: Re: [DCHAS-L] Boston College incident follow up
I concur that realistic, repetitive training can go a long way to ameliorating panic reactions in emergency situations.  Alas, the resources and institutional commitment for this sort of thing are lacking in most academic situations, and for some folks it just won't ever sink in.
One low-cost method that may be effective is to place a site-specific poster-size emergency checklist in the most visible common area of the laboratory/suite.   Focus on the most important response issue (fire/explosion, for example) only.  Hopefully, the workers in the area will better retain their key emergency response skills (or eventually learn them through osmosis) or perhaps they may even turn to the poster in an emergency (911 called, fire alarm pulled, evacuation, personnel accounted for etc. etc.).   As a small example of what I mean, see the fire checklist I have posted at http://www.ilpi.com/safety/extinguishers.html#Using 
I have never personally seen laboratory safety training materials discuss that the trainee or his/her coworkers may freeze, panic, or do something completely wrong in an emergency situation.  A coworker's inappropriate reaction can not only be distracting or disorienting, it can compound an already bad situation.   I encourage everyone to include this topic in their training courses.
Recent events (UCLA, Yale etc.) aside, I have never personally seen serious academic institutional/departmental follow-up response with Lessons Learned from minor accidents, major incidents, or near misses.   Having a protocol for a formal analysis (What happened?  Facts instead of departmental gossip.  What went wrong? How could this be avoided? What SOP's should change?  etc.), ensuring that the analysis is distributed to all possible stakeholders, and archiving it on an easily accessible web site is a great way of making sure that history does not repeat itself.   I have the impression that this kind of analysis is the norm at places like DuPont, but, sadly, in my own personal experience, academic institutions often fail to do so either out of liability/publicity concerns, leadership inertia/vacuum, or both.     Formal accident followups should be SOP and the importance of these should be stressed in academic safety training courses.
Finally, those archived incidents make great case studies that should be utilized in laboratory training.  After giving the full spiel, take the time to pull out a couple of case studies and ask the trainees what should have been done, what could have been improved etc.  Interactive training forces the trainees to think about the issues and the instructor achieves instant feedback on how effective the training has been.  This makes training a much more interesting experience for both parties.   If you are fortunate enough not to have any site-specific cases to use, a wealth of them are available at http://www.aiha.org/insideaiha/volunteergroups/labHandScommittee/Pages/L aboratorySafetyIncidents.aspx  The unexpected dangers reported at http://pubs.acs.org/cen/safety/index.html also afford additional scenarios.
Rob Toreki
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Fax: (856) 553-6154, PO Box 1003, Blackwood, NJ 08012


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