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.

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-...

Paper Cutter Guards

November 30, 2000

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.

Improper Hazardous Material Disposal

September 30, 2002
What Happened?

A can of epoxy hardener was included in a salvage cart (see photo) and spilled at some point in the process of moving the salvage cart. An employee came in contact with the spilled material and was instructed to immediately wash with soap and water. EH&S then cleaned up the spill (see photos).

Lessons Learned

Please remind your staff of proper disposal methods for hazardous materials.

Bolt and Brace Your Shop Equipment

October 31, 2002
What Happened?

Someone was using the vice pictured below to hold an item in the process of a normal workday. In the process of performing a task, the vice toppled off the surface onto the person's foot causing a serious injury. The person was not wearing steel-toed boots.

Lessons Learned

Always wear your steel-toed boots when working around heavy machinery and shop equipment. All shop equipment that is designed to be braced to a work surface or floor must be braced. Do not use equipment that could fall or otherwise cause injury if it is not braced according to...