Near Miss/Incident Reports act as an educational tool to increase awareness and help create a safe, productive research environment. If you are aware of a near miss or incident, please provide information on the situation so we can all learn from it. These reports do not include any identifying information and are meant to be completely anonymous.
University-wide reports can be viewed on the EHS website.
Please use the Near Miss / Incident form to alert us to safety incidents or "near misses". These reports are not used to penalize or lay blame, but are used to help us illustrate real-world safety incidents as they arise so that we may all learn from the experience.
Your submission may be submitted anonymously, but we request you enter your email address so that we may follow-up with any questions. Your submission will be reviewed by our safety officers and may be discussed with the MSAO so that we may continue to improve out safety protocol.
Example Reports
Unlabeled Beaker in Hood
Incident Overview:
A large (1000 mL) beaker of mixed chemicals was left in a hood without any labeling of chemical ID or contact information for the user.
Root Cause:
A lack of the proper disposal container (of correct type and size) caused the lab user to leave the chemicals in the hood instead of disposing of them. A note had originally been left with the chemicals, however, it disappeared while the unlabeled waste remained.
Preventative Actions:
The best action would have been prior to mixing the chemicals, a waste container should have been located and been available to ensure proper disposal of the waste directly after it was used. However, at a minimum, a chemical sticky note label should have been filled out with the beaker contents identified and contact information for the lab user, and placed directly on the beaker until a proper waste container was obtained.
Gas Cylinder Regulator Malfunction
Incident Overview:
Tubing popped in hood due to high pressure from the gas tank.
Root Cause:
When opening a gas valve on a gas cylinder the second gauge on the gas tank regulator did not accurately display the correct pressure. It was already acting “funny”. The gauge was not moving even though it was being turned on. The gauge then instantaneously jumped to a very high pressure. The flow meter connected to experiment was on lower. The build up of pressure caused the tubing to burst with a loud “pop”. We believe that the pressure gauge is not working probably. When another regulator was placed on the tank. There was a hissing noise from the tank, but we could not determine where it was coming from and stopped using the tank. We capped the tank.
Preventative Actions:
I kept opening the valve thinking “why isn’t this gauge moving?”. I should have known that something was wrong and stopped turning the valve. Also, once the regulator was removed to get it out of service, it was brought to my attention that Teflon tape was being used on the connection between the gas cylinder and the regulator. This connection does not need Teflon and it could very well have formed debris that affected the regulator.
Nitric Acid Burn
Incident Overview:
The researcher was closing a concentrated nitric acid bottle in the fume hood, when a small drop of nitric acid flew from the lid of the bottle to the student's arm. The acid was in contact with the skin for less than 15 seconds, which caused a small chemical burn on the forearm that was about 1 cm by 0.5 cm in size. The wound was immediately irrigated with tap water for 10 minutes and the researcher proceeded to Mt Nittany Medical Center ER to have the wound inspected. The wound was characterized as a first/second degree burn and the ER professionals dressed the burn with neosporin and a band-aid.
Root Cause:
The researcher was not wearing a lab coat to protect arms and torso, even though the researcher was wearing goggles and gloves and was working with the hood sash down.
Preventative Actions:
All researchers in the (Research group's) lab are required to wear lab coats, goggles, and face shields when working with concentrated acids, concentrated bases, caustic chemicals, and organic solvents. A zero tolerance policy will be implemented in our labs such that any personnel caught without PPE will be permanently banned from working in our (Research group's) labs.
The individual will be banned from laboratory activity if caught without PPE in the future. Within the month, one of the group meetings will be devoted to discussing the use of PPE at all times in the lab.
With the dissolution of the group in three different locations remote from one another, we will need to pay particular attention to ensure that students handling inherently dangerous compounds will only do so during regular working hours.
The lack of proper air conditioning and air handling in the Steidle laboratories creates a catalyst for noncompliance in the wearing of PPE, particularly in the height of summer but also in the interim from early spring until May 15 when the university permits air conditioning to be turned on. Nonetheless, a zero tolerance policy will be implemented (within the Research group) toward those individuals who neglect to wear PPE.
Spilled DMF
Incident Overview:
On Jun 8th night, when I finished the testing of mass uptake of membranes in DMF(Dimethyl Formamide), I locked the door to the lab. There was a lab notebook in my left hand, and a secondary container with five 20mL Vials on my right hand. When I used my key to lock the door, one of the 20mL Vials fell out from the secondary container and broke. I cleaned the spill immediately with the paper towel. Then, I washed the floor with ethanol several times until there was no DMF left. Lastly, I dried the floor with paper towel completely. It should be fine, there was no harmful chemicals left on the floor. Unfortunately, the solubility of the DMF is so good that it might dissolve the surface of the floor.
Root Cause:
It was the late night of weekend, so I was tired, preventing me from concentrating on it. Also, when I locked the door, I should have freed both of my hands firstly, rather than locking it with both of my hands occupied.
Preventative Actions:
A good relaxation is essential for working in chemistry lab. When I worked in the chemistry lab, I should let my mind be highly alert because a chemistry incident might happen at any time. I should slow down my speed in the lab in the future. This accident could have been prevented if the lay down all the stuff in my hands first, and locked the door.
Persulfate Pressurization Leading to Burst Bottle
Incident Overview:
On October 14th at approximately 4:30pm a student who was working in N37 heard a loud sound, like a glass bottle being dropped to the floor from N40. However there was no one at that time at N40, so after opening the chemical storage cabinets, he found that a bottle had burst in the Acid storage cabinet (yellow) in N40. The bottle that had burst had an orange waste tag clearly mentioning sodium persulfate (Na2S2O8). The bottle could not be opened and was bubbling inside. Also to be noted, there was a distinctive smell of acetic acid (C2H5COOH) in the cabinet. (Note that sodium persulfate is odorless.)
Sarah took the broken glass pieces and dumped them into the broken glass waste disposal container. At that moment I saw that we had one more Na2S2O8 container, which was almost completely full. We then decided to phone EH&S. EH&S came in at 5:30 and tried, but also could not open the other persulfate container. It was kept in a bucket in the fume hood (large), and was removed the next morning.
Root Cause:
Pressurization caused the bottle to burst, however we do not know how long the pressure had been building. Also persulfate is an oxidizer, and is not very stable in an aqueous solution. Over time it degrades to form sulfate radicals and hydrogen peroxide. The hydrogen peroxide itself degrades to form oxygen and water.
Thus the pressurization could have happened from three sources:
- Oxygen built up due to persulfate decomposition
- CO2 build up due to mixing of organic stuff like acetone/IPA with persulfate solution
- H2 and CO2 build up due to degradation of acetic acid with persulfate (Note: I mentioned there was a vinegar smell when the cabinet was opened so acetic acid and persulfate may well have been mixed)
This would have not happened if we had used vented caps. I did not know about vented caps, which are always used in Prof. Redwing’s labs. I will be using them from now on.
Preventative Actions:
- Use of vented caps
- Bi-weekly disposal of persulfate waste
- Only pour persulfate waste in the bottle as marked! (This applies to all waste!)
