Texas Tech University

Failure to Follow Spill Procedures Leads to Acute Chemical Exposure and Hospitalization

What happened?

On March 27, 2018, a four-liter glass bottle secondary container of dichloromethane (DCM) broke during a chemical transfer. A laboratory worker was refilling the secondary container of from a 20-liter metal drum primary container. After the secondary container was full, the primary drum was put back in storage. While picking up the secondary container, the container slipped and fell approximately three feet to the floor breaking and releasing its entire contents onto the floor and the lower legs and feet of the worker. No emergency services were called, nor was Environmental Health and Safety (EH&S) or the Departmental Safety Officer (DSO) notified immediately after the incident. Approximately two hours after the incident, the student started to demonstrate symptoms of DCM exposure (dizziness, drowsiness, headache and nausea ) and was hospitalized for treatment.

 

socks on desk

The red circle shows a pair of socks that were left on a desk area that appeared to be the socks worn by the student during the time of the incident.

dcm spill

The red circle indicates where the DCM spill occurred. The blue arrow shows where the student was standing while the DCM evaporated. The yellow arrows show the black marks made by the student's boots that dissolved from DCM contact.

What was the cause?

This incident was an accident. Proper personal protective equipment was worn, and the process used to transfer the DCM was appropriate. The worker simply lost their grip on the bottle. The seriousness of the incident was aggravated by the lack of appropriate chemical spill response. This inappropriate spill response was linked to incomplete training covering hazard awareness and proper spill response protocols within the lab. A review of records showed the worker had taken Texas Tech University Health Science Center lab safety training, but no specific training on how to handle a spill or the hazards of the chemicals that they were working with was provided by the laboratory supervisor. Additionally, the laboratory safety plan did not have any direction on how to handle a spill or emergency procedures in the event of a spill.

After the worker dropped the bottle and it broke, they did not immediately exit the laboratory or use the safety shower located in the laboratory. The worker stood in the corner next to the spill for approximately 15 minutes until the spill area had evaporated enough for them to get around it without stepping directly in the DCM. During this time the worker received an acute inhalation exposure to DCM fumes. The worker then went to the public bathroom and rinsed off their feet in the sink and changed into a different pair of shoes. The worker then opened the laboratory doors to increase ventilation and allow the DCM to evaporate completely. Once the DCM evaporated the worker went to class leaving the broken glass for other laboratory workers to clean up. While in class the worker started to feel ill and contacted their primary care physician who told them to call 911 after they were informed of the exposure. The worker was treated and then released after an observation period.

The severity of this incident was caused by a failure of the supervisor to supply proper training regarding laboratory-specific hazards and laboratory-specific emergency response procedure. The supervisor also failed to provide proper documentation for these items resulting in that the student did not have a means to self-teach.

What corrective actions were taken?

EH&S was notified of the incident from the TTU Fire Marshalls who had been contacted by the University Medical Center after the student had been admitted. When EH&S arrived at the laboratory where the incident had occurred there were no dangers present in the laboratory due to the DCM spill. A survey and report where conducted in the laboratory and given to the supervisor and department to address issues that were found in the laboratory.

  • The following are the corrective measures recommended to prevent similar events:
  • Laboratory workers need to receive specific training from the PI on how to handle chemical spills, including who and how to notify the appropriate responders (i.e., DSO, CHO, EH&S, etc.)
  • Laboratory workers need to receive specific training from the PI on what to do for chemical exposures and how to use emergency equipment such as eyewashes and safety showers.
  • The Work Area Safety Plan also referred to as the Laboratory Specific Safety Plan needs to be kept current with requirements of the Laboratory Safety Manual (LSM) section A11 and A12 requiring Standard Operating Procedures.
  • Use of smaller containers instead of 4L bottles would limit the amount of a potential spill and be physically easier to handle.
  • The use of non-glass chemical-compatible bottles could help prevent breakage in the event a container is dropped.
  • Use of plastic-coated bottles could also be used to prevent breakage in the event a container is dropped.

How can we prevent incidents like this?

  • Review Work Area Safety Plans on a regular basis (at least annually) and when procedures change. This is to ensure that they cover the most current operations that are being conducted in the laboratory. All potential hazards (chemical, biological, physical, etc.) must be addressed.
  • Supervisors need to ensure personnel in their work areas have adequate training and immediate access to work area-specific information on the procedures and hazards present.
  • Proper spill kits for the types and quantity of chemicals present should be located in the laboratory. All laboratory personnel should be trained on how to use the spill kits.

flow chart. see word document for accessible version

Download the Spill Response Decision Tree

Resources

  1. TTU Laboratory Safety Manual Sections A5.5, A11, A12 and Appendix AC.
  2. Spill Response Decision Tree

 

 

Environmental Health & Safety