As the hideous revelations from Pennsylvania State University reverberate across the country, another scandal involving willful inattention and bureaucratic power continues to endanger vulnerable young people on campuses nationwide. This second scandal lacks a sickening sexual component, but the resulting deaths and injuries are every bit as real. And many of those deaths and injuries were every bit as preventable had university officials fulfilled their responsibility to those entrusted to their care.
A groundbreaking document from the U.S. Chemical Safety and Hazard Investigation Board (CSB) has removed the excuse that academic officials do not know about the risks that students, postdocs, and others face when working in academic laboratories or how institutions can protect them better. Issued in October, a CSB report entitled Texas Tech University: Laboratory Explosion lays out in 23 pages of straightforward, nontechnical language what went wrong in a near-fatal 2010 incident on the Lubbock campus and what needs to be done to prevent anything like it from happening again.
The report goes far beyond the usual accident investigation’s list of technical mishaps. It views the maiming of Texas Tech University (TTU) graduate student Preston Brown not as an isolated series of individual errors but as the predictable outcome of a culture, set of values, and system of organization prevalent not only at TTU but also at many other campuses. Having collected at least “preliminary information” on 120 other such incidents, CSB declares itself “greatly concerned about the frequency of academic laboratory incidents in the United States.”
The study focuses on chemistry because of CSB’s charter and expertise. But as the recent death of Yale University physics student Michele Dufault makes clear, the issues it uncovers apply to other disciplines as well. The findings and recommendations thus concern administrators, deans, department chairs, lab chiefs, learned societies, and funding agencies across the sciences.
To spread the word, CSB has posted a video that underlines its message with two other examples: the deaths of University of California, Los Angeles, technician Sheri Sangji in 2009 and Dartmouth College professor Karen Wetterhahn in 1997. CSB is distributing both the video and the report to every chemistry chair in the nation, and investigator Mary Beth Mulcahy “will be speaking around the country to some significant audiences,” the agency’s director, Daniel Horowitz, tells Science Careers in an e-mail.
Aligning the holes
The report’s message is simple: “Incidents are not the result of a single malfunctioning piece of equipment or the erroneous actions of one person.” Behind any “serious event” lie “a number of failures and deficiencies at many levels within an organization." Focusing on the details of a particular event “misses the underlying organizational factors that influence and contribute to an accident.”
The report uses the widely accepted "Swiss cheese" model of accident causation, developed by the aptly named James Reason, to show that safety incidents happen when “holes” in the various layers of an organization’s safety system align. Brown, for example, was working with an unsafe amount of the potentially explosive material nickel hydrazine perchlorate (NHP) while not wearing safety goggles, which indicates a series of institutional deficiencies.
At the level closest to the action, the report says, the holes included multiple failures by Brown’s supervising professor, Louisa Hope-Weeks. She did not effectively communicate and enforce a limit on the quantity of NHP that students should use, train students to handle this dangerous substance properly, or require them to use complete safety gear at all times.
Further from the scene, pertinent holes included failure by the university authorities to do an overall assessment of the dangers posed by potentially explosive materials; to require that principal investigators (PIs) report, discuss, and learn from previous near-misses, including some in Hope-Weeks’s own lab; and to establish and enforce real accountability for safety conditions and procedures. Beyond the TTU campus, professional societies and safety regulators failed to develop procedures and standards that meet the needs of academic research labs and mitigate the physical dangers of chemicals. Yet another hole was the failure of the funding agency, in this case the Department of Homeland Security (DHS), to stipulate safety standards.
Taming the fiefs
Underlying all these failures, the report continues, is an organizing principle common in academic science that it calls the “fiefdom” system. Like the feudal domains that the word originally denoted, this arrangement gives PIs “an intellectual or administrative territory" in which they can “do pretty much whatever they want so long as they do not stray too far into some other fief’s territory,” the report says.
As the report states, and this column has previously reported, such independence allows PIs to regard safety officials “as infringing on their academic freedom” -- quoting the report -- rather than as offering information useful for lessening risks. TTU’s environmental health and safety (EH&S) officials, like those at many other institutions, worked in a “consultant” capacity and reported up a chain of command that culminated in the facilities office, which lacks any authority to affect PI decisions. PIs, meanwhile, worked under the aegis of department heads, deans, the university’s provost, and ultimately the vice president for research, who has “direct authority over research policies (including compliance policies) and internal research funds” and can therefore exercise “influence over the faculty.” This arrangement gave safety officials “no direct communication link [with] an authority who could enforce … recommendations with the PIs,” the report says.
Closing safety holes requires that “the safety inspector/auditor of research laboratories directly report to an identified individual/office with organizational authority to implement safety improvements,” the report concludes. TTU has since reorganized the lines of authority so that EH&S now reports directly to the vice president for research. Funding agencies can also “play a critical role in influencing immediate safety change,” it adds; DHS has since tightened its safety policies.
Beyond this, the report recommends that the Occupational Safety and Health Administration “broadly and explicitly” deal with universities’ need for adequate standards to control the physical hazards of chemicals. It asks the American Chemical Society to provide specific guidance for assessing and controlling chemical hazards in academic labs. CSB will “follow up with [them] and TTU on the implementation of the safety recommendations,” Horowitz notes in his e-mail.
More knowledge and action needed
As the CSB video reveals, controlling dangers requires ongoing efforts to advance safety knowledge. Wetterhahn, a widely respected senior researcher, meticulously followed every known safety precaution as she worked with highly toxic dimethyl mercury. She wore latex rubber gloves as advised by the chemical supplier. Unbeknownst to her, and to many others at the time, the compound can penetrate latex. Two small drops fell on her hand and apparently caused the heavy metal poisoning that took her life 10 months later. This “unimaginably shocking” loss, says John Winn, then Dartmouth’s chemistry chair, in the video, shows that we must learn all we can about each potential safety hazard and "the protections that can be taken to handle it safely.”
Clearly, the “identified safety gaps and other issues deserve further examination and research in a larger, more comprehensive study,” the report concurs. Exactly when CSB will have resources to undertake such a study is unclear, Horowitz says. The agency already has discussed with the National Academy of Sciences “a follow-up study they are hoping to fund and conduct on lab safety culture.”
The nation has already waited far too long and seen far too many lives destroyed for the academic community to continue allowing, even inadvertently, bureaucratic prerogatives and inaction to threaten the safety of students, postdocs, and other lab workers. CSB has outlined steps that universities, regulators, scholarly societies, and funders can take immediately. The time for action is now.