UCLA has received the findings of an investigation by the California Division of Occupational Safety and Health (Cal/OSHA) into a UCLA laboratory accident that led to the death of a staff research assistant on Jan. 16.
Sheharbano (Sheri) Sangji, 23, died from burns sustained in a chemical fire in UCLA's Molecular Sciences Building on Dec. 29, 2008. She was working with t-butyl lithium, a highly flammable compound that spontaneously burns upon exposure to air. Cal/OSHA said the plunger on the syringe she was using became dislodged, and the compound ignited and engulfed her clothing. Cal/OSHA said the lack of a lab coat was the single most significant factor in the severity of the burns that led to Sangji's death.
While concluding there were no willful violations, Cal/OSHA issued findings critical of UCLA's lab safety inspection follow-up, training and record-keeping programs and its failure to ensure the use of personal protective equipment and fined the campus $31,875. UCLA said it will not contest the findings or appeal the fine.
"In the wake of Sheri's tragic accident, I communicated to the UCLA community plans for a comprehensive review of our laboratory inspection programs and implementation of revised procedures to ensure the safety of our researchers. Although substantial progress has already been made, we will continue to thoroughly monitor and assess our lab training and safety protocols as an integral component of our daily operations. The Cal/OSHA report will provide critical assistance with these ongoing efforts," Chancellor Gene Block said. "As we continue to mourn Sheri's death and grieve for her family, we are determined to rededicate ourselves to ensuring the safety of each and every member of our entire Bruin family."
Among the substantial changes made so far:
- Flame-resistant lab coats have been purchased and are being distributed to laboratory personnel in the department of chemistry and biochemistry who work with flammable materials. Other labs will be required to make coats available whenever high-risk activities are performed.
- The UCLA Office of Environment, Health and Safety (EH&S) now requires each laboratory to quantify chemical, biological and other hazards; assess potential risks based on lab activities; and specify applicable protective equipment. As part of the assessment, labs also are required to train all personnel in the use of protective equipment specific to the lab activities and to provide written documentation to EH&S. While this work continues, assessments have so far been completed for more than 500 laboratories, and training has been provided to nearly 1,400 lab personnel. Plans call for labs to be categorized based on potential risk and for those with the greatest risk to receive more rigorous follow-up.
- EH&S now lists a greater number of potential hazards on inspection forms and reports, specifically notes critical violations, and, for those violations, requires corrective action and reinspection within 48 hours, substantially shortening follow-up time.
- EH&S also provides inspection reports to lab directors within one business day of inspections, reducing the previous typical timeline of up to two weeks.
- The campus has updated standard operating procedures for the handling of pyrophorics such as the t-butyl lithium that ignited in the Dec. 29 accident. Now called "safe operating procedures," they include added safety precautions that significantly exceed industry standards. In addition, the campus is in the process of developing updated operating procedures for other high-risk chemicals and materials.
Improvements are ongoing, and additional changes are expected in coming months as the lab safety committee continues its work. For example, EH&S is developing an automated reporting system — planned before the accident — that will make the inspection process more timely and efficient.
Campus officials emphasized several points related to the investigation:
- While corrective actions were taken after an inspection noted deficiencies in the lab where Sangji worked, they were not properly documented because a reinspection was delayed until the lab was relocated.
- While Sangji was trained in general lab safety as well as the specific procedure she was performing when the accident took place, the training was not documented.
- Protective equipment is a fundamental rule of safety among chemists with extensive lab experience such as Sangji, and the two postdoctoral researchers in the lab with her on that day were wearing lab coats. The chancellor emphasized that everyone on campus needs to do a better job of instilling a culture of shared responsibility that compels us to remind those around us of important safety precautions.
- The findings include points everyone must learn from, and, as Chancellor Block emphasized when establishing the campuswide lab safety committee, we all have a responsibility to ensure safety — from professors and their staff and student researchers, to the Office of Environment, Health and Safety, as well as research administrators and campus leaders.