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.

Biological Safety

Providing support, in the form of risk assessment, review, consultation and training, for research at UC Berkeley that involves the use of recombinant DNA, biohazardous materials and biological toxins.

Biosafety How Do I: collapse all...

Laser Eye Exposure from a Specular Reflection

June 17, 2024
What happened?

A researcher walking towards an optical table was exposed to a laser beam that reflected off a hex ball driver tool. Another researcher at a nearby bench was installing an optical component on a breadboard when the hex ball driver he was using inadvertently moved into an active beam path. The hex ball tool had a reflective surface.

Resources and Guides

Job Safety Analysis (JSA)

A JSA describes job tasks in step-by-step fashion, identifies associated hazards at each step, and outlines proper hazard controls that minimize the risk of injury or illness to the individual(s) performing that task.

JSAs Listed by Topic: Body Mechanics ...

Lessons Learned: Fume Hood Vessel Overpressurization and Skin Burns from Heating Glass

October 2, 2023

The following lessons learned reports detail what went wrong and what corrective actions have been taken or will take place to address the incidents.

Skin Burns from Heating Glass Vessel

September 25, 2023
What happened?

A researcher was heating a small volume (<30mL) of hexanes/ethyl acetate containing approximately one gram of an organic azide. The solution was placed in a capped, 40mL pyrex media storage bottle. Holding the bottle of the azide solution in their left hand, the researcher was heating it with a heat gun with their right hand behind a horizontal fume hood sash protecting their face and torso.

Fume Hood Sash Cracks due to Reaction Vessel Overpressurization

September 25, 2023
What happened?

Using dry Dimethyl Sulfoxide (DMSO) as solvent, a reaction between an organic macrocycle and bromoethane was placed in a round bottom pressure vessel. The reaction was heated using armor aluminum beads in a stainless steel bowl sitting atop a hotplate. The setup was briefly left unattended inside a fume hood with the sash closed.

Without a means for temperature control, the hotplate generated excess heat, which in turn produced excess pressure. Overpressurization caused the round bottom vessel to shatter. Glass shards along with the aluminum heating beads...

Workplace Safety

California state regulations require every employer to establish, implement and maintain an effective Injury & Illness Prevention Program (IIPP). In August 2017, the University adopted a campuswide Workplace Safety Program that serves as the University’s central IIPP for creating a safe and healthful work environment. Having one program for the whole University helps to improve access, consistency, and usability across all departments. EH&S is the responsible department for overseeing the campuswide Workplace Safety Program. The campus Workplace Safety Program is based on the Injury...

Laser Eye Exposure from a 1 Watt Class 4 Laser Beam

January 5, 2022
What happened?

A researcher was exposed to a 1 watt continuous wave beam from a Ti-Sapphire (852 nm) laser while visually inspecting a non-linear crystal on the optical table with a dielectric mirror. The researcher was unaware that the beam was present and it was directed into their right eye. The researcher was not wearing laser eye protection because they thought the laser was off.

Shortly after finishing the visual inspection, the researcher noticed a spot in their field of vision and realized that they had been exposed to the 852 nm laser beam. The researcher was seen at the...

Improper Labeling Causes Injury from Acid Spray

September 30, 2004
What Happened?

A UC Berkeley researcher was preparing a sample for microscopy. After he had cleaned the sample with isopropanol, he poured the extra isopropanol into a container for unwanted chemicals labeled “isopropanol.” There was an immediate chemical reaction that caused the plastic container to rupture and spray the mixture around the area. He was later surprised to learn that the container actually held concentrated nitric acid in the form of spent copper etchant.

The researcher was startled and called for help. Other researchers promptly came to his assistance and called 911...

Employee's Toes Crushed by Falling Compressed Gas Cylinder

March 31, 2007
What Happened?

In February 2007, a University of California, Berkeley (UC Berkeley) researcher was loading a gas cylinder on a two-cylinder cart when the previously loaded cylinder fell and crushed his toes.

What was the cause of the accident? What were the contributing factors?

The most likely cause of this accident is the fact that this two-cylinder cart had no means to secure both cylinders independently. Therefore, when positioning the second cylinder on the cart, there was no way to secure the first cylinder. Loading the second cylinder puts the...