By Joe Damiano, Mike Miller, and Charlyn Reihman
Did you know that the AIHA Laboratory Health and Safety Committee (LHSC) maintains an open-access website containing lessons-learned summary reports that describe incidents that have occurred in laboratories? AIHA members and others can use these reports as educational tools to reinforce health and safety practices in laboratory operations and to address similar hazards within their own organizations.
The reports are prepared by AIHA LHSC members, and are based on experience in their organizations or incidents that are brought to their attention by colleagues in other laboratories. Each report is a concise summary that includes key learnings, the effects of the incident (for example, injury or explosion), a description of the incident, causation, and corrective actions. Many of the reports feature photos of damaged equipment or other images to help convey an understanding of what occurred. The reports are anonymous and do not contain information identifying the organization, location, or personnel associated with the incident.
The AIHA LHSC website currently features more than 90 reports that fall into fourteen categories:
- Autoclave incidents
- Biological agent incidents
- Centrifuge incidents
- Chemical incidents – airborne exposure
- Chemical incidents – skin or eye exposure
- Chemical reactivity incidents
- Chemical waste incidents
- Compressed gas incidents
- Cryogen and dry ice incidents
- Electrical incidents
- Fire incidents
- Ionizing radiation incidents
- Non-ionizing radiation incidents
- Pressure hazard incidents
Users are encouraged to browse the lessons-learned incident report titles listed under each category or to use the website word search function to locate reports of interest.
Access all laboratory lessons-learned incident reports via the committee’s website.
Example Lessons-Learned Incident Report
What does a lessons-learned incident report look like? A good example that appears on the committee’s website is the August 2011 incident in which a bench scale lab chemical reaction resulted in an explosion. This incident illustrates the importance of careful planning and verification of reagent and solvent mixtures when scaling chemical reactions. To learn more about this incident, including its cause and the corrective actions taken to prevent reoccurrence, view the lessons-learned report on the LHSC website.
An In-Depth Look at Incident Investigations
Incident investigations are a fundamental element of an effective health and safety program. Incidents are investigated for the purpose of understanding what happened, how it happened, why it happened, and what should be done to prevent similar incidents from reoccurring.
First, information is gathered through interviews, an examination of evidence, a review of relevant documents, and possibly the evaluation or testing of materials and conditions. Next, the facts of the incident are analyzed by personnel with relevant experience and expertise (often including industrial hygienists in labs) who inferentially determine the cause of the incident. Normally this analysis begins with establishing the direct cause. Further analysis determines causation one-step removed, often referred to as the indirect cause.
The analysis continues with the identification of underlying causes until the investigation uncovers one or more "root causes." A root cause is generally viewed as a management system failure. Examples of a root-cause include a gap or error in a health and safety program or weak enforcement of required health and safety practices. The "five-why" process is an often-used technique for identifying the root cause. Generally the identification and mitigation of the root cause is necessary in order to prevent similar incidents from reoccurring within an organization.1
1. “Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigations – Third Edition.” D.K. Lorenzo and W.E. Hanson: Rothstein Associated Publisher (2008).
Other Lesson-Learned Websites
Many universities also maintain websites that collect laboratory lessons-learned incident reports. The AIHA LHSC lists the following links that may be of interest:
Submit Your Own Reports
All AIHA members are encouraged to submit lessons-learned reports to the Lab Health and Safety Committee for posting on the website. The process for submitting reports is simple. To learn more about the committee’s process for creating and posting lessons-learned incident reports, visit the “submit an incident” page.
Joe Damiano, MS, CIH, CSP, is an industrial hygienist at the URS Inc. DOE National Energy Technology Lab in Pittsburgh, Pa. Damiano is an AIHA Fellow and past chair of the AIHA Exposure Assessment Management Committee and the AIHA Management Committee. He is co-editor of the AIHA publication A Strategy for Assessing and Managing Occupational Exposures, 2nd edition. He can be reached via e-mail.
Mike Miller, MHS, CIH, is an industrial hygiene and safety manager at the Federal Bureau of Investigation, Laboratory Division in Quantico, Va. Miller is an AIHA Fellow and past chair of the AIHA Laboratory Health and Safety Committee. He is co-editor of the AIHA publication A Strategy for Assessing and Managing Occupational Exposures, 4th edition, chapter 20, “Exposure Assessment in the Laboratory Environment.”
Charlyn M. Reihman, MPH, CIH, is a senior manager of safety, health and industrial hygiene for IES Engineers in Blue Bell, Pa. Charlyn has over 25 years of experience in occupational safety and health, primarily in the pharmaceutical industry and in research laboratories. She is a past chair of the AIHA Laboratory Health and Safety Committee and past secretary of the AIHA Biosafety and Microbiology Committee.