We’re pretty open a bout lessons learned. We share incident information with our research ers and maintain a website of lessons learned from incidents at our institution. We use them as case studies during lab safety training and talk not just about the causes, but the choices made and behaviors exhi bited in each incident.
Robin M. Izzo, M.S.< /span>
Associate Director, EHS
609-258-6259 (office )
How many legs does a d og have if you call the tail a leg? Four. Calling it a tail a l eg doesn't make it a leg.
~ Abraham Lincoln
The DOE has an excellent "lessons le
arned" program. There reports used to be available to the public, but
I think most now require a password/account to get to.
Remember to wash your hands!
Lab Safety Specialist
Stony Brook University
EH&S Web site:
Remember to wash your hands!
argaret Rakas <mrakas**At_Symbol_Here**SMITH.EDU>
To: D CHAS-L**At_Symbol_Here**LIST.UVM.EDU
Date: 0 6/29/2011 12:22 PM
Subject: Re: [DCHAS-L] Boston College incident follow up
Sent by: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
Frank Demer's database and that of the AIHA are terrific. Frank's stands ou t to me because of the institutional support, while the AIHA database is 'a nonymous'--you don't know where the incidents occurred.
While I don't doubt many institutions do have a 'what happened/how to preve nt it' review, that knowledge often appears to be kept within the instituti on. 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 be en standard, but wasn't. What is particularly helpful about a databas e 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 focuse d 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 t o me personally as I tried to follow up with a college in New England regar ding a chemical fire that was reported via the news. It hit home beca use a year or so earlier, they had contacted me about an accident here. I shared my details with them and other coll eges in our New England Small Colleges Association, precisely so a repeat i ncident could be avoided elsewhere. Unfortunately their institution d id not permit reciprocation. And I think if you look at a number of these incidents, many which don't involve emplo yees (and bring in OSHA) or which occur at private institutions (so no FOIA requirements) are not shared with the community beyond what is first repor ted in the news (and we know how helpful THAT is at getting to the root cause!) And they should be, a t 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.
>>> "Koza, Mary Beth (Environment Health & Safety)"
011 11:20 AM >>>
I take exception to suggesting that serious academic institutional/departmental follow-u p 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 counterproduct ive 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.uv m.edu] On Behalf Of ILPI
Sent: Tuesday, June 28, 2011 11:25 PM
Subject: Re: [DCHAS-L] Boston College incident follow up
I concur that realistic, repetitive training can go a long way to ameliorat ing panic reactions in emergency situations. Alas, the resources and institutional commitment for this sort of thing are lacking in most academi c 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 poste r-size emergency checklist in the most visible common area of the laborator y/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 eve ntually learn them through osmosis) or perhaps they may even turn to the po ster 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 t hat the trainee or his/her coworkers may freeze, panic, or do something com pletely wrong in an emergency situation. A coworker's inappropriate r eaction 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 Learne d from minor accidents, major incidents, or near misses. Having a pr otocol for a formal analysis (What happened? Facts instead of departmental gossip. What went wrong? How cou ld this be avoided? What SOP's should change? etc.), ensuring that th e 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 impress ion that this kind of analysis is the norm at places like DuPont, but, sadl y, 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 followup s 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 ut ilized 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 abou t the issues and the instructor achieves instant feedback on how effective the training has been. This makes training a much more interesting ex perience for both parties. If you are fortunate enough not to have any site-specific cases to use, a wealth of them are av ailable at http://www.aiha.org/insideaiha/volunteergroups/labHandScommittee/Pages/Labo ratorySafetyIncidents.aspx The unexpected dangers reported at http://pubs.acs.org/c en/safety/index.html also afford additional scenarios.
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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
Since panic is a visceral reaction that prevents reason and logical
thinking, it seems to me that telling people "not to panic," eith er in
training or at the time of a frightening event, is one of the most useless< br> 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
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