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.

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...

Employee Receives Electrical Shock

March 31, 2004
What Happened?

A university employee was changing ballasts above a drop ceiling in a department reception area. The employee received an electrical shock from a 277volt circuit and was knocked off a step stool that she had placed on top of the reception desk. She fell from a height of 46.5 inches, but received only minor injuries and returned to work the following day.

What was the cause? The power source was not locked and tagged out. Instead, the light switch was turned off. The ladder to be used was too large to work from behind the reception desk, so a...

Laser Safety in Research Laboratories

July 31, 2003

In April 2003, the Non-Ionizing Radiation Safety Committee (NIRSC) informed the laser research community that a serious laser eye injury had occurred on the UC Berkeley campus. The campus Laboratory Safety Officer (LSO) performed an investigation of the incident. The following information and lessons learned are based on the LSO’s investigation of the incident.

What Happened?

The incident involved a short pulse, Class 4, invisible (1064 nm), Nd:YAG laser in a multi-user laser laboratory. During alignment of the laser's Nd:YAG beam, a graduate student was struck in the...

Needlestick from Regular Trash

July 31, 2005
What Happened?

An employee in Campus Recycling & Refuse Services was stuck by a needle while emptying trash bags from a dumpster behind Wellman Hall. The incident happened early in the morning, and the employee sought immediate off-site medical care. A physician dispensed antiretrovirals for a possible Human Immunodeficiency Virus (HIV) exposure, and the employee was very concerned that he might have been infected with a life-threatening disease.

The employee’s supervisor had saved the trash bag, and employees from the Office of Environment, Health & Safety (EH...

Injury Caused by High Voltage Capacitor Discharge

May 31, 2005
What Happened?

A campus employee working in an electronics shop was repairing a power supply unit. The cooling fan had not been working properly, causing the unit to overheat. The employee replaced the defective cooling fan and then reached into the open top of the power supply unit to check the airflow from the replacement fan. The employee either made contact with a charged capacitor or was close enough (within 1/4") to allow electricity to arc to his hand causing an electric shock that entered his left hand and exited through his right hand.

Immediately after the...

Fire Hazard with Immersion Water Heaters

September 30, 2005
What Happened?

It is believed that a Cole Parmer Polystat 12002 immersion heater in a University of California, Santa Cruz (UCSC) microbiology laboratory did not shut off as the water level in the plastic bath dropped, allowing the temperature to rise to the point that the bath material ignited. The fire caused extensive damage to the building and shut down research for several months.

What was the cause?

Immersion water heaters/circulators used in plastic tubs (baths) have been associated with laboratory fires at several universities in recent years. When...

Peroxide Explosion Injures Campus Researcher

November 30, 2006
What Happened?

An undergraduate student researcher was working at the laboratory bench when the apparatus she was using exploded, sending glass fragments into her face and upper torso. The researcher was using a rotary evaporator (rotovap) to remove organic solvents from an azobenzene precipitate. She adjusted the bottom flask which then exploded sending glass towards her face, hitting her safety goggles and forehead. Lab personnel helped her to the safety shower and called 911. She was taken by ambulance to the hospital where she received stitches above her eyes and other treatment...

Missing Guard on Incubator Fan Injures Post Doc

July 31, 2007
What Happened?

A postdoctoral researcher was reaching into a New Brunswick Scientific Model G-25R Shaker Table Incubator to clean up a spill when her right hand got caught in the spinning exhaust fan blade. She lacerated her middle finger and lost part of the fingernail. She was treated in a local hospital emergency room.

 New Brunswick Scientific Model G-25R Shaker Table Incubator...

Researcher Smells Toxic Fluorine Gas When Changing Out Gas Cylinder

April 30, 2007
What Happened?

Two researchers were changing out a gas cylinder containing a low concentration of fluorine used in an excimer laser. After reconnecting the regulator, researchers opened the cylinder valve, heard a hissing sound, and smelled a pungent odor. They quickly turned off the cylinder valve and reported the incident to their department safety coordinator (DSC). Fluorine is a very toxic and reactive gas, but fortunately, the concentration was dilute, less than 0.1% fluorine. The DSC contacted EH&S and was advised that researchers involved should be medically evaluated because of...

Acetone Fire

July 31, 2008
What happened?

A student worker in a Berkeley campus laboratory was refilling squirt bottles with acetone from a larger dispensing container when he spilled approximately one cup of acetone liquid onto the floor. Due to lack of training, and/or an error in judgment, the student lit the acetone with a match to burn it off instead of following proper spill clean-up procedures. While doing so, the student accidentally knocked over another uncapped squirt bottle on the benchtop that was filled with acetone. This additional acetone ignited and set-off the fire sprinklers in the room,...