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.

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,...

Oleylamine Chemical Burn

December 31, 2008
What happened? A laboratory researcher suffered a delayed chemical burn after only a few drops of a highly corrosive organic chemical splattered on his unprotected left forearm. The burns first appeared hours after exposure, got worse overnight, and eventually required treatment at a hospital.

forearm with spotted chemical burns

The researcher's forearm


Pressurized Dewar Cap is Blown Off and Causes Minor Injury

February 28, 2009
What happened?

In July 2008, a guest scientist at the Lawrence Berkeley National Laboratory sustained a minor injury when the cap of a 50-Liter liquid nitrogen Dewar burst off and hit his forehead. The scientist needed to fill the Dewar - which hadn't been used for several months - and assumed it was depressurized because of its lack of use.

Without wearing safety goggles or a face shield, the scientist attempted to verify the Dewar was depressurized by pulling a pressure relief plug. The relief plug was not designed to be manually operated (it did not have a pull ring), and it is...

Ladder Fall Results in $19,125 Fine and Serious Injury

August 31, 2009

In 2008 and 2009 UC Berkeley experienced two serious injuries resulting from falls from ladders.

2009 Incident

During the summer a campus employee was disassembling equipment attached to a wall. He was using a wooden step ladder that had been left on-site by a contractor. He did not open the ladder and the ladder was lacking anti-skid material on its feet. The height of his stance on the ladder was approximately three to four feet from the concrete floor. The ladder, which was leaning against the wall, slipped and he fell to the floor and sustained a serious injury to his right arm/...

Ethanol Fire Burns Researcher

July 31, 2011
What Happened?

A researcher was plating bacteria onto a petri dish using ethanol and a Bunsen burner as part of a standard sterile transfer on a lab bench. The metal spreader was dipped in a jar of ethanol and burned off in the burner. Somehow, the jar of ethanol spilled on the lab bench and onto the researcher's bare arms and t-shirt, and caught fire. The flames were reported to be up to two feet high. The researcher immediately went to the safety shower, pulled the handle which activated the emergency shower and got in. The shower water quickly put out the fire and cooled...

Lab Fire Caused By Hotplate Heating Oil Bath That Injured Researcher

March 31, 2013
What Happened?

A chemistry researcher was using an older model hot plate to heat an oil bath to 120-150°F. He borrowed the hotplate from someone else and was not familiar with the temperature controls. On this particular hot plate the temperature dial could go around from “LO” to “OFF” and back to “HI” heat. The researcher thought he had turned the hotplate “OFF” but it was still in the “ON” position and 30 minutes later the mineral oil bath ignited.

Fortunately, the oil bath was in a fume hood which kept the flames and fire inside the hood, it was reasonably clean and no other...

Severe Finger Injury from Wedding Ring

July 31, 2013
What happened?

An employee was working in the bed of a large pickup truck. The truck was equipped with a Tommy Gate lift and hinged gate doors that opened outward. The employee was attempting to get down from the truck, so he placed his left hand on the door hinge and jumped down. His wedding ring caught on the grease fitting and caused an avulsion* injury of the finger, also referred to as “degloving.”

*Avulsion means the removal of the skin and soft tissue, usually leaving the underlying bone and tendons, however fractured or damaged. Avulsions require significant...

Accidental Mixing of Bleach and Acid

October 31, 2009
What Happened?

A researcher working in a laboratory glassware washing area thought she should refresh the bleach solution for soaking lab glassware. In an "inattentive moment" she added fresh bleach to what she thought was the bleach soaking tub; unfortunately the tub did not contain bleach but contained 5% hydrochloric acid. The acid solution (with bleach) immediately turned from clear to yellow. She quickly realized that bleach and acid should never be mixed because toxic chlorine gas can be created. She immediately had everyone leave the room; she considered calling 911, but since...