Thursday, July 7, 2016

A laboratory explosion at the University of Hawaii that resulted in a researcher losing her arm was likely caused by static electricity and not by a pressure gauge





Hawaii lab explosion caused by static discharge
6 July 2016

Agata Blaszczak-Boxe






The explosion at the lab seriously injured a postdoc working there © University of Hawai'i ManoaAn explosion at a University of Hawaii Mānoa laboratory that took the arm of a visiting postdoctoral researcher was likely caused by static discharge, according to the results of an independent investigation.

The University of California Center for Laboratory Safety has released two reports outlining its findings and providing recommendations on how the university and other research institutions can improve laboratory safety.

Investigators also noted that certain safety failings might have played a role in the incident. 'While it could be argued that the experimental circumstances in the POST 30 lab were unique, the Investigative Team concludes that serious deficiencies in the institution’s approach to laboratory safety contributed to a lapse in proper risk assessment and lack of a culture of safety that ultimately led to the accident,' they say in one of the reports.

The explosion occurred in March at the Hawaii Natural Energy Institute biofuels research laboratory, when visiting research fellow, Thea Ekins-Coward, was transferring hydrogen, oxygen and carbon dioxide into a low-pressure gas tank to make a growth medium for cells.

A previous, preliminary analysis conducted by the Honolulu Fire Department suggested that an inappropriate pressure gauge, which was not designed for use with flammable gases, might have been to blame for the explosion. However, the team in charge of the new investigation has concluded that static electricity released into the tank was most likely the cause, Michael Bruno, vice chancellor for research at the University of Hawaii at Manoa, said in a press conference on Friday.

'Their assessment is that it did not require a significant discharge of electricity to ignite the mixture, and that was the likely cause,' Bruno said. 'By all accounts and from everything that we know so far, there were many, many efforts to make this process as safe as possible, and in fact the exact same experiment essentially had been conducted 10 or perhaps 11 times prior to this accident occurring.’

All the labs at the university that work with flammable or pressurized gases have been shut down since the day of the accident, and they are expected to start opening this week, Bruno said. Following the accident, the university also established a Chemical and Physical Hazards Committee, in accordance with one of the recommendations by the UC Lab Safety Team.
Warning signs

In their reports, the investigators pointed out that there had been other, 'near miss' incidents prior to the explosion that had not been sufficiently addressed. For example, one day before the incident, Ekins-Coward reported a cracking sound during another experiment, which involved a smaller pressure vessel, to her principal investigator (PI), who advised her not to use the same vessel again. Still, that event 'should have triggered a shutdown of operations and initiated a thorough investigation of all procedures’, said the investigators. 'But the significance of this near miss event went unrecognized and nothing happened.'

Weeks before the accident, Ekins-Coward had also told the PI about receiving static shocks when touching the pressure vessel and the gas storage tank during prior experiments, but he told her not to worry about it.

'I think there is no question that the PI was negligent in his behavior,' says Paul Bracher, a chemist at Saint Louis University, US, who was not involved in the reports. 'It is one thing to not foresee a problem. But when someone brings an obvious problem or a potential problem to your attention, and then you still don't fix it or ignore it, that's a whole new level of negligence.' He adds that Ekins-Coward was 'way better than the average person' when it came to dealing with safety, based on information in the reports. And, as the investigators noted, she had come to UH from a research environment in the UK, where the culture of safety is more rigorous than in the US. 'The system and her advisor failed her,' Bracher says, ‘and she paid the price.'

At the same time, he noted that insufficient resources and increasing workloads that PIs commonly face likely contribute to such safety issues. 'PIs have schools counting on them to do a ridiculous amount of stuff for one person,' Bracher says. 'You are running classes, you are designing classes … you are expected to run a research lab, where you are being productive, you are bringing in money, and somewhere in that list is making sure that everything that is going on in your lab is safe.' He thinks one of the most important recommendations made in the reports is that researchers should not ignore ‘near miss’ events that may come up during experiments. 'If you have something that happens and it seems serious, it probably is,’ he says. ‘And you need to take the time and stop and evaluate what went wrong to lead to that near miss before you just go ahead and start new experiments.'





============================================


Hawaii Lab Explosion Likely Caused by Static Electricity
By CATHY BUSSEWITZ | July 5, 2016

A laboratory explosion at the University of Hawaii that resulted in a researcher losing her arm was likely caused by static electricity, according to an independent investigation.

The University of California Center for Laboratory Safety, which handled the investigation, released its results Friday.


The explosion that occurred in March was initially thought to have been caused by a faulty pressure gauge, but the investigators said static electricity released into a tank most likely caused the explosion, said Michael Bruno, vice chancellor for research at the University of Hawaii at Manoa.

“By all accounts and from everything that we know so far, there were many, many efforts to make this process as safe as possible, and in fact the exact same experiment essentially had been conducted 10 or perhaps 11 times prior to this accident occurring,” Bruno said.

The researcher had told fire department investigators she would get shocked on occasion when touching the tank. She reported that to the professor who hired her to conduct research into bioplastics and biofuels, but he told her not to worry about it.

The day before the explosion, the researcher reported hearing a cracking sound while conducting an experiment. She was advised to use different equipment, advice Bruno referred to as “what looks like a tragic decision.”

“In hindsight, that was not the right interpretation of what had happened,” Bruno said.

Investigators said it was challenging to determine the cause of the detonation because they weren’t able to inspect the accident scene until 13 days later. It was important to first clean up the blood and damage to the lab and to ensure that the building was structurally sound, Bruno said.

The investigators also weren’t able to interview the researcher so they had to rely on a report from fire department officials who interviewed her.

“She went through a tragic and traumatic experience that I don’t think any of us can even imagine,” Bruno said. “She was conscious throughout, and she elected not to have contact while she was in the hospital. Soon after she left the hospital, she went back to her native United Kingdom, and so we have not to this day been able to speak to the researcher.”

Investigators said a digital pressure gauge was the origin of the electrical current that caused the detonation. The researcher and some equipment in the lab were not properly grounded, they said.

The laboratory is part of the Hawaii Natural Energy Institute on the school’s flagship Manoa campus. Every laboratory at the university that’s involved with the use of flammable or pressured gases has been shut down since the day of the accident, and the university is enacting many of the recommendations listed in the report, Bruno said. After the accident, the university established a safety committee to review experiments involving highly hazardous substances.

Bruno expects that some labs may be ready to re-open this week.





=====================================






Spark from pressure gauge caused University of Hawaii explosion, fire department says
Postdoc Thea Ekins-Coward, who lost an arm in the incident, was using a gauge not specified for work with flammable gases
By Jyllian Kemsley

[+]Enlarge




Debris littered a lab bench after the explosion.
Credit: Honolulu Fire Department


An explosion last month that caused a University of Hawaii, Manoa, postdoctoral researcher to lose an arm was caused by a spark from a digital pressure gauge that was not designed for use with flammable gases, says a Honolulu Fire Department investigation report.


Thea Ekins-Coward was combining hydrogen, carbon dioxide, and oxygen gases from high-pressure cylinders into a lower pressure tank when the incident occurred. She has not given the university permission to release information about her condition, said spokesman Daniel Meisenzahl at an April 18 press conference.


The gas mixture was “food” for bacteria being used to produce biofuels and bioplastics. Ekins-Coward was working for the Hawaii Natural Energy Institute under researcher Jian Yu. A 2013 paper by Yu indicates a set-up in which gases are plumbed through a mixing device called a gas proportioner directly into the bioreactor (Int. J. Hydrogen Energy 2013, DOI: 10.1016/j.ijhydene.2013.04.153). The gas gauge identified in the paper is an “intrinsically safe” model designed to prevent ignition.


But after Ekins-Coward started in the lab last fall, she purchased a 49-L steel gas tank, a different gauge not rated as intrinsically safe, a pressure-relief valve, and fittings, and she put them together, Yu and Ekins-Coward told fire department investigators, according to the report. Ekins-Coward would add the gases to the portable tank, which would then be connected to the bioreactor. She was using a mixture of 70% hydrogen, 25% oxygen, and 5% carbon dioxide for her experiments, the report says.


In the week before the incident, a similar set-up with a 3.8-L tank resulted in a “small internal explosion” when Ekins-Coward pressed the off button on the gauge, the fire department report says. She also occasionally experienced static shocks when touching the tank, which was not grounded. She reported the shocks and possibly the small explosion to Yu, who told her not to worry about it, the report says.


On the day of the incident, the 49-L tank exploded when Ekins-Coward pressed the off button on the gauge. “She did not lose consciousness or hit her head; she was aware that she lost her arm in the explosion,” the report says. “She couldn’t open the door to the lab, the door was stuck closed.” Security officers and a graduate student kicked in the door to help Ekins-Coward get out. Her right arm was severed just above the elbow, the report says.


The University of Hawaii hired the University of California Center for Laboratory Safety to independently investigate the incident. That report is expected to be completed by the end of this month. The Hawaii Occupational Safety & Health Division is also investigating the incident.
Disaster Scene

These photos, released by the Honolulu Fire Department,
llustrate the force of the March 16 explosion and its consequences.
(warning: some images are graphic)
[+]Enlarge




The steel tank that ruptured in the March 16 explosion.
Credit: Jian Yu/U Hawaii
[+]Enlarge




The explosion caused damage in the hallway outside of the lab.
Credit: Honolulu Fire Department
[+]Enlarge




The hallway outside the lab door after the explosion.
Credit: Honolulu Fire Department
[+]Enlarge




Compressed gases in the lab included hydrogen, carbon dioxide, helium, and carbon monoxide.
Credit: Honolulu Fire Department
[+]Enlarge




This steel tank ruptured during the explosion, which severed a researcher’s arm.
Credit: Honolulu Fire Department
[+]Enlarge




Chemical bottles fell and glass broke in the northeast corner of the lab, next to the bioreactor for growing bacteria.
Credit: Honolulu Fire Department
[+]Enlarge




The explosion knocked down ceiling panels, broke light fixtures, and scattered debris throughout the lab.
Credit: Honolulu Fire Department
[+]Enlarge




The remains of the steel tank sit at the site of the explosion, near the south wall of the lab.
Credit: Honolulu Fire Department
[+]Enlarge




The explosion also shattered fume hood sash windows and knocked over equipment in the northwest corner of the lab.
Credit: Honolulu Fire Department
[+]Enlarge




An oxygen cylinder was nearly knocked over in the southwest corner of the lab, something that could have added to the damage.
Credit: Honolulu Fire Department
[+]Enlarge




Possible circuit board from the pressure gauge that caused the explosion.
Credit: Honolulu Fire Department
[+]Enlarge




Photo of a circuit board on top of debris.
Credit: Honolulu Fire Department
[+]Enlarge




Postdoctoral researcher Thea Ekins-Coward lost an arm in the explosion.
Credit: Honolulu Fire Department