Key Instruction Points
A graduate student was injured by flash fire due to a reaction product hat contained about 1 liter of ether. The ether was to be filtered through a cup shaped device containing the desiccant sodium sulfate. The filter apparatus was placed in a two-liter round bottom flask and connected to house vacuum. The round bottom flask was attached to a ring stand.
The 2-liter Erlenmeyer flask that containing the diethyl ether and reaction product broke and spilled into the hood and onto the floor in front of the hood. The whole assembly was situated at the front of the fume hood on the sill adjacent to the fume hood airfoil so when the container broke the flammable mixture was not contained in the hood. In addition, the sash on the hood was fully open.
Seconds later, a fire rising from the floor in front of the fume hood engulfed the student. The source of ignition was most likely a drying oven that was situated under the hood. Unfortunately the student was wearing shorts and sandals. The student moved away from the fume hood and rolled on the floor to extinguish the flames. A nearby safety shower was blocked by equipment.
The student was able to leave the building with help from colleagues where he waited for emergency response. After initial treatment by fire department technicians, an ambulance arrived and transported him to a regional burn treatment center.
There was no written standard operating procedure and apparently this was an elementary procedure that the student had performed thousands of times. The lab manager had performed and reviewed the procedure with the student but the procedure was not documented in the students notebook or in the Laboratory Safety Plan. The student had recently attended a general department training program.
During the two years prior to the fire, the lab had undergone three safety inspections. The inspection reports documented many deficiencies in procedure and had noted the extremely crowded laboratory conditions.
The PI had not responded to the reports.
Several steps could have been taken to prevent or mitigate incidents:
Check glassware before using it for cracks or scratches. Replace damaged glassware.
Use plastic coated glassware for transporting or holding solvents. When glassware is replaced, order some of the break resistant glassware.
Allow more space for workers. There were at times as many as 14 people in the lab
Work at least 6 inches inside the chemical hood. This is critical for containment of vapors. In addition, the work top on the chemical hood is dished and will contain a spill.
Work with the chemical hood sash pulled down to shoulder height. The sash can protect the workers face and breathing zone from a deflagration and can greatly reduce exposure to gases and vapors in the hood. With the sash at this height, a hood may contain a fire.
Do not block safety equipment such as the safety shower.
Do not house drying ovens under chemical hoods.
Require lab personnel to wear long pants and shoes in the laboratory. Prohibit shorts and sandals. In addition, goggles and lab coats should be required for procedures involving large quantities of hazardous liquids.
Training must be documented for new workers and annually thereafter. Require training for all personnel working in the laboratory. Ensure that laboratory workers document safe procedures in their notebooks, send students to the fall departmental training sessions and hold periodic meetings with staff. At lab meetings, include a safety related agenda and file the agenda.