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.

Improper Labeling Causes Injury from Acid Spray

September 30, 2004
Office of Environment, Health, and Safety
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
Office of Environment, Health, and Safety
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...

Job Safety Analysis (JSA) Library

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.

Fact Sheets

Fact Sheets

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

Nitric Acid Waste Over-pressurization Event

July 3, 2018
Office of Environment, Health, and Safety
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...

Vacuum Chamber Over-pressurization

October 22, 2019
Office of Environment, Health, and Safety
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...

Lessons Learned at UC Berkeley

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

October 31, 2011
Office of Environment, Health, and Safety
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
Office of Environment, Health, and Safety
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-...

Paper Cutter Guards

November 30, 2000
Office of Environment, Health, and Safety

Don't lose your thumb! Paper cutters such as the one here are not safe or legal. Cal/OSHA has cited campus departments for allowing unguarded paper cutters in the workplace in prior years.

a hand on a paper cutter with no finger guard

Lessons Learned

Please be sure all paper cutters in your department have a guard like the one seen here.