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.

Severe Finger Injury from Wedding Ring

July 31, 2013
Office of Environment, Health, and Safety
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...

Ethanol Fire Burns Researcher

July 31, 2011
Office of Environment, Health, and Safety
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...

Exploding Cylinder in Garbage

July 31, 2007
Office of Environment, Health, and Safety
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...

Improperly Vented Experiment Causes Explosion and Burns

June 30, 2008
Office of Environment, Health, and Safety
What Happened?

A graduate student working in a UC Berkeley laboratory was performing a series of evaporation procedures outside of a fume hood using a general-purpose electric pump and a roto-evaporator that had no exhaust equipment. In an effort to make the solvent recovery more efficient, the student applied a vacuum to the condenser tower but quickly turned the pump off because the vacuum was too strong. By that time, the pump exhaust had already formed an explosive mixture of the acetone and ether vapors which ignited when the power shut-off switch was activated, resulting in...

Superconducting Magnet Explosion

July 31, 2008
Office of Environment, Health, and Safety
What Happened?

A 9.4 Tesla superconducting magnet, used for mass spectroscopy in a campus laboratory recently suffered a catastrophic failure. The incident was apparently caused by over-pressurization and failure of the liquid helium (LHe) chamber. Although there were no injuries because the incident occurred during off-hours, the potential for significant injury due to the venting of LHe into the facility was present. There was also significant damage to equipment associated with the magnet.

A magnet achieves superconductivity (zero resistance to electrical current) when it is...

Fall from Fixed Ladder with Grab Bars Results in Injury and Fine (October 2018)

Lessons Learned

In addition to the lessons described in the What Should Have Been Done Differently section, major takeaways are to guard against complacency and to always consider the Integrated Safety Management (ISM) process, even for routine tasks.

For additional assistance, contact EH&S at ehs@berkeley.edu or (510) 642-3073, Lessons Learned date: 7.2018