Lessons Learned

Reports on incidents that involve injury, exposure (real or potential), or significant damage property. Lessons Learned detail what happened and how similar incidents can be avoided in the future.

Fact Sheets

Fact Sheets

EH&S Fact Sheets serve as campus-wide Standard Operating Procedures (SOP).

Chemical Explosion Causes Eye Injury

May 31, 2015

ANSI-approved safety glasses—and other personal protective equipment specified in the Standard Operating Procedures (SOPs)—are essential whenever working with hazardous materials. SOPs also indicate other precautions that must be followed to ensure safety, such as performing work with energetic or explosive materials behind a fume hood sash or blast shield.

What happened?

A graduate student researcher was working at a laboratory bench synthesizing approximately one gram of diazonium perchlorate crystals. The student was transferring synthesized perchlorate using a metal spatula...

Eye Exposure to Specular and Diffuse Reflections

October 17, 2016
What happened?

A student conducting a physics experiment was briefly exposed to specular and diffuse reflections from a continuous wave 975 nm invisible laser beam while not wearing laser eye protection. The student was applying oil to an objective lens with a glass stick when it was noted that the laser was still on. The student was immediately referred to the optometry clinic and was promptly examined. No eye damage was found.

What went right?

The student immediately stopped work and alerted their professor as soon as...

Nitric Acid Waste Over-pressurization Event

July 3, 2018
What happened?

A graduate student researcher was consolidating aqueous nitric acid solutions into a 4-L bottle marked as hazardous waste. The bottle was stored inside a fume hood along with other waste bottles, organic reagent bottles, a hotplate and an oil bath. The fume hood sash was left open when all researchers left at the end of the day.

Several hours later, a custodian entered the lab and saw broken glass and brown liquid on the floor. It appears that the nitric acid waste was stored in a bottle that contained residual organic compounds, the combination of which generated...

Fall from Fixed Ladder with Grab Bars Results in Injury and Fine

October 24, 2018
What happened?

A campus employee was holding onto the grab bars at the top of a fixed vertical ladder and was beginning to descend when one of the grab bars broke off, causing the employee to fall about 13 feet. The employee sustained significant injuries to several toes. The incident occurred on a roof mounted cooling tower.

What went right? Two employees were working together and a third was nearby and able to help, Emergency medical providers and UCPD were called and responded immediately. What should have been done differently? The ladder system should have been built to withstand...

Vacuum Chamber Over-pressurization

October 22, 2019
What happened?

A vacuum chamber over-pressurized while a researcher was returning the vacuum to atmosphere by venting with nitrogen from a gas cylinder. The chamber was left to fill while the researcher worked on other tasks. By the time the researcher returned, the chamber had over-pressurized and the view window shattered.

The researcher sustained multiple cuts to the face, three of which required stitches on their forehead. Their injuries could have been worse if it weren't for an aluminum panel that deflected pieces of glass. Visible dents in the panel were noted after the...

Dry Scraping Causes Chemical Explosion

November 13, 2015
What Happened?

A postdoctoral researcher was synthesizing potentially explosive material in a fume hood, following a well-established procedure published in a peer-reviewed journal. The researcher was transferring a residual amount of the synthesized material using a plastic spatula when the material exploded in his hands. The shattered glassware caused some minor cuts to the researcher’s hands.

Other group members helped the injured researcher wash the injuries and called campus police. He was taken to the hospital where he got treatment for the injuries, and he was released from...

Glass Reactor Over-pressurization Causes Serious Injury to Grad Student Researcher

October 31, 2011
What Happened?

A recent lab accident caused serious injury to a UCB graduate student due to an over-pressurization that caused a glass reactor to fail. Glass was sprayed at the researcher who received cuts to his lip, chin, chest, and serious cuts to his hands. 911 was called and the researcher was taken by ambulance to the hospital. The cuts to the hand were serious enough to require stitches and surgery on the palm.

The chemical research involved a toxic/flammable gas that was liquefied and used with a pyrophoric reagent. The reaction was done inside a fume hood, so no one else...

Forklift Rollover

December 31, 2006
What Happened?

A veteran forklift operator with 20 years of experience started his day just as he had often done, then soon realized just how fast things can change. Due to an oversized load, the operator was transporting a dumpster bin on the forks of his forklift while he was traveling in reverse. While in reverse, he hit a curb, causing the forklift to roll over onto its side.

The stunned operator was transported by ambulance to the hospital emergency room, where he was treated for a fractured leg.

The operator understood the importance of wearing a seat belt and holding-...