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.

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...

Eye Exposure to Specular Reflection

July 31, 2015
What happened?

A researcher was diagnosing a power loss from a Spectra Physics 3900 Ti-Sapphire (oscillator) that is pumped by a Spectra Physics Millennia eV DPSS laser. During this procedure, they noticed some leakage in the form of a slight green diffuse light being emitted from the end of the metal tube connecting the DPSS pump laser to the Ti-Sapphire laser. The researcher attempted to re-adjust the beam tube to eliminate the leakage to improve the beam tube alignment. As he touched the beam tube, it became dislodged from its mounting, striking the 532 nm laser beam as it fell, causing...

Corrosive Waste Spill

August 31, 2015
What Happened?

A UC Berkeley researcher was working in a lab with a highly corrosive sulfuric acid and hydrogen peroxide (piranha) solution to clean the surface of a glass sample in a fume hood.

After completing the work, the researcher found the existing waste container to be greater than 75 percent full. Rather than add the recently used piranha solution to the already overfilled waste container, the researcher found an additional empty waste container and attempted to pour off some of the overfilled waste into the empty bottle.

During this attempt, some of the corrosive...

Exploding Cylinder in Garbage

July 31, 2007
What Happened?

On April 11, 2007, an employee of Campus Recycling and Refuse Services was alarmed when a suspected compressed gas cylinder ruptured in the rear hopper of a garbage truck. The employee was standing at the rear of the truck and had activated the blade that sweeps the garbage from the hopper into the body of the truck for further compaction. The pressurized gas cylinder was believed to be concealed inside a plastic trash bag. The sweeping action of the blade ruptured the cylinder and the residual contents sprayed into the employee’s face.

A cylinder in a garbage truck...

Discovery of an Old Container of Potentially Explosive Chemical

June 30, 2008
What Happened?

While working in a UC Berkeley laboratory, a graduate student discovered the presence of an old experimental set-up, which was labeled as containing a small amount of hydrazoic acid, in a shared cold room with no responsible contact person. This material is a potentially explosive chemical under certain circumstances, so the student referred the set-up to the Department Safety Coordinator (DSC). The DSC requested the assistance of EH&S who recommended that the set-up be disposed of by an explosives material contractor because very little was known about the source...