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Date: Wed, 29 Jun 2011 14:12:39 -0400
Reply-To: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
Sender: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
From: Ken Kretchman <ken_kretchman**At_Symbol_Here**NCSU.EDU>
Subject: Re: Boston College incident follow up
In-Reply-To: <4E0B1695020000BA0002E911**At_Symbol_Here**gwsmtp1.smith.edu>
Well said Margaret. The intent of the AIHA database is to encourage
sharing lesson learned without any fear of the sad but real obstacles that
would make this sharing less likely if institutions or persons were named.
Adding identifying information lends little to the lessons learned
anyway. Identifying information about an institution would be scrubbed
out before posting to the AIHA site.
Kenneth Kretchman, CSP, CIH
Director, Environmental Health and Safety
NC State University
Raleigh, NC 27695-8007
919-515-6860 (p)
919-515-6307 (f)
ken_kretchman**At_Symbol_Here**ncsu.edu
>>> Margaret Rakas 6/29/2011 12:12 PM >>>
Frank Demer's database and that of the AIHA are terrific. Frank's stands
out to me because of the institutional support, while the AIHA database is
'anonymous'--you don't know where the incidents occurred.
While I don't doubt many institutions do have a 'what happened/how to
prevent it' review, that knowledge often appears to be kept within the
institution. Whether this is for legal reasons, or the PR folks don't
like to have this information available, or another reason, I don't know.
And of course, from time to time C&E News will print letters from
researchers about an experiment that should have been standard, but
wasn't. What is particularly helpful about a database collated by EH&S is
that you can see accidents that occurred in biology, biochem, neuroscience
labs, etc. These are important chemical-use research areas where the
researchers are not focused on the chemical aspects and might be reluctant
to go to a "Accidents in Chemistry Labs" blog or even know about C&E News.
The "we don't talk about it to outsiders" response has happened to me
personally as I tried to follow up with a college in New England regarding
a chemical fire that was reported via the news. It hit home because a
year or so earlier, they had contacted me about an accident here. I
shared my details with them and other colleges in our New England Small
Colleges Association, precisely so a repeat incident could be avoided
elsewhere. Unfortunately their institution did not permit reciprocation.
And I think if you look at a number of these incidents, many which don't
involve employees (and bring in OSHA) or which occur at private institution
s (so no FOIA requirements) are not shared with the community beyond what
is first reported in the news (and we know how helpful THAT is at getting
to the root cause!) And they should be, at least in a database that
shields the institution, if desired.
My personal opinion only, not legal or business advice, and may not be the
opinion of my employer or any group to which I belong.
Margaret Rakas
>>> "Koza, Mary Beth (Environment Health & Safety)" 6/29/2011 11:20 AM >>>
Group,
I take exception to suggesting that serious academic institutional/departm
ental 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 counterprod
uctive 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/explos
ion, 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#Us
ing
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 institutio
ns 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/labHan
dScommittee/Pages/LaboratorySafetyIncidents.aspx The unexpected dangers
reported at http://pubs.acs.org/cen/safety/index.html also afford
additional scenarios.
Rob Toreki
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On Jun 28, 2011, at 8:26 PM, Peter Zavon wrote:
On Tuesday, June 28, 2011 David C. Finster said to the DCHAS-L Discussion
List in part:
I would "second" Brad's comments about the need for training
and education that exposes students to simulated events and
that is heavily based on repetition. Truth is: people panic
when confronted with unexpected events and, in knowing this,
it's almost laughable that one of first "rules" we teach in a
panic-inducing situation is "not to panic." Yeah, right. So,
I tell students to go ahead and "panic" (for a BRIEF moment!)
to get that out of the way and then "go back to your
training".
Since panic is a visceral reaction that prevents reason and logical
thinking, it seems to me that telling people "not to panic," either in
training or at the time of a frightening event, is one of the most useless
instructional activities imaginable. Repetitive simulated practice that
other have endorsed is the way to go. That is likely to prevent panic by
reducing the novelty of the situation.
"Don't panic" as an instructional step is on a par with "Be more careful"
in
counseling someone whose apparent lack of attention is thought to have
caused an "accident." Both phrases make the speaker fell better, but
neither
conveys actionable guidance.
Peter Zavon, CIH
Penfield, NY
PZAVON**At_Symbol_Here**Rochester.rr.com
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