INTRODUCTION TO LAB

SAFETY
A part of 30hrs Lab Safety Training

Learning Objectives
Recognize standards, legal requirements and ADNOC COPs relevant to lab safety
Outline the causes for accidents
List and describe the classes/types of laboratories
Explain the importance of reporting near misses and hazardous conditions
Discuss the need for conducting a risk assessment of laboratory work
Learn from accidents reviewed at other & PI laboratories

PI-HSE
75HSE or 75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout

Slide 1

___________________________________
The Petroleum Institute

___________________________________
___________________________________
30-hr Lab Safety Training
Topic 1: Introduction to Lab Safety

___________________________________
___________________________________
___________________________________
___________________________________

Slide 2

Learning Objective

___________________________________

Attendees will be able to:

Recognize standards, legal requirements and ADNOC COPs
relevant to lab safety

___________________________________

Outline the causes for accidents

List and describe the classes/types of laboratories
Explain the importance of reporting near misses and hazardous
conditions

___________________________________

Discuss the need for conducting a risk assessment of laboratory

work
Learn from accidents reviewed at other & PI laboratories

___________________________________
___________________________________
___________________________________
___________________________________
Slide 3

Causes of Lab Incidents

___________________________________

Lack of understanding of hazards

Improper or unintended use of equipment or reagents
Inexperienced / Over experienced Staff

___________________________________

Distractions, lack/loss of attention to task

Broken, damaged/improperly maintained equipment
Inadequate training and indoctrination

___________________________________

Lack of accountability

None or inadequate risk assessment

___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 4

___________________________________

Accident Ratio Study

Serious Incident

1
10

Includes recordable and disabling Injuries

___________________________________

Minor Injuries
Any reported injury less than a recordable

60
600

Property Damage & Incidents

All Types, including environmental releases

Incidents with no visible

Injury or Damage

(Critical Incidents - Near Misses)

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 5

Encourage Reporting of Near Miss Incidents by

Ensuring all employees are told to report near miss
incidents.
Positively reinforcing each other when reporting near
miss incidents.

___________________________________
___________________________________

Reminding ourselves of its importance.

Sharing successes--improved work environment across
the entire university.

___________________________________

Using the incident investigation form (see PI website).

Make employees aware of the reporting process.

___________________________________
___________________________________
___________________________________
___________________________________

Slide 6

Learning from Incidents

___________________________________

Learning from Incidents requires:

Know what happened - register facts for communication and
cause analysis

___________________________________

Know why it happened - carry out cause analysis

Know why the consequences were what they were evaluate post event actions
Know what to do - so it won't happen again

___________________________________

Carry out remedial actions - make sure they will be done well
and on time; assign responsibilities
Let others know - communicate and report so they will learn
as well

___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 7

Codes and Standards

29 CFR 1910.1450: OSHAOccupational Exposures to Hazardous

Chemicals in Laboratories http://www.osha.gov/

ANSI/ISEA Z358.1Emergency Eyewash and Shower Equipment

http://ansi.org/

ANSI/AIHAAmerican National Standard Z9.5 for Laboratory

Ventilation http://ansi.org/

National Institutes of Health (NIH)Guidelines for the Laboratory use

of Chemical Carcinogens, Pub. No. 81-2385 http://www.nih.gov/

National Fire Protection Association (NFPA) 30Flammable and

Combustible Liquids Code www.nfpa.org

NFPA 45Fire Protection for Laboratories using Chemical www.nfpa.org

US Environmental Protection Agency (EPA)-40 CFR Part 262

Subpart K- Standards for managing hazardous waste in academic
laboratories www.epa.gov
Compressed Gas Association CGA - safety standards and safe
practices in the industrial gas cylinder industry http://www.cganet.com/

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 8

The Occupational Safety and Healths (OSHAs)

Requirements
Because you work with chemicals in a laboratory, OSHA
requires that you be familiar with:

___________________________________
___________________________________

The contents of the Chemical Hygiene Plan (CHP)

The location and use of MSDS for all chemicals in your

work area
The management and proper disposal of hazardous
wastes that you generate

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 9

Federal & Abu Dhabi Emirate Legal Requirements

___________________________________

Environmental Legislations
Federal Law No. 24 of 1999

Protection & Development of the Environment for

UAE

Local Law No. 16,2005

Concerning the Re-organization of the

Environment Agency-Abu Dhabi & Requirements
to assess environmental impacts of sewage,
hazardous waste management.

Local law No.21,2005

Waste Management in the emirate of Abu Dhabi

Federal law No.1,2002

Regulation and Control of the Use of Radioactive

Sources and Protection against its Hazards

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 10

Federal & Abu Dhabi Emirate Legal Requirements

Health & Safety Legislations
Federal Law No.8 of 1980
(Chapter5)

Occupational Safety, Preventive Health & Social

care

Federal Law No. 1,2002

Regulation and control of the use of Radioactive

Sources & Protection against its Hazards (Article9)

Ministerial Order No. 32

,1982

Determination of Preventive Methods & Measures

for the Protection of Workers from the Risk of Work
(Issued by
MOL)

Ministerial Decrees 55/2004

Basic Regulation for Protection against Ionizing

Radiation

Ministerial Decrees 57/2004

Regarding Regulation for Radioactive Waste

Management

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 11

___________________________________

ADNOC COPs
COP Ref. NO

Document Title

ADNOC-COPV5-03

ADNOC-COPV5-06

Risk Assessment & Quantitative Risk

Assessment (QRA)

ADNOC-COPV1-11

ADNOC HSE Audit Programme

ADNOC-COPV1-02

HSEIA Requirements

ADNOC-COPV1-09

___________________________________

HSE Risk Management

ADNOC HSE Management System

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 12

Laboratory Classifications
According to National Institute of Building Sciences
(NIBS),U.S .,
The amount and type of chemicals will determine the building
classification.

The following are the four laboratory classes, with the special practices
associated with each:
1. Low Risk
2. Moderate Risk
3. Substantial Risk
4. High Risk
www.wbdg.org/resources/secure_safelab.php

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 13

Laboratory Classifications

___________________________________

Low Risk
There are no special practices associated
with a low-risk laboratory.

___________________________________

Moderate Risk
Work with materials with safety and health
ratings of 3 or greater in any category must
be performed in a fume hood.

Work with substantial amounts of materials

with hazard ratings of 1 or 2 must be
performed in a hood or in an assembly
designed to be safe in the event of a failure.
Appropriate personal protective equipment,
such as goggles, must be worn in the work

area.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 14

Laboratory Classifications
Substantial and High Risk
Specific policies, depending on the nature of the hazard, must be made
part of the laboratory industrial and hygiene plan as well as the safety
plan.
All work that can be completed separately from the laboratory
operations should be completed in a separate area of the lab or in a
room adjacent to the lab. All paperwork should be performed outside
the lab.

___________________________________
___________________________________
___________________________________

No safety feature should be altered in any way without written approval.

Personal safety equipment must be worn.

A laboratory safety committee should review each new experiment
planned to determine whether it can be carried out safely (risk
assessment)

___________________________________
___________________________________
___________________________________
___________________________________

Slide 15

Learning From Accidents

Accidents - "errors", "mistakes", "omissions",
"oversights", etc. - are opportunities to learn
from and to take steps to make sure that the
same or similar will not happen again.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 16

Bhopal India gas leak 1984

___________________________________

Courtesy: http://www.filtersfast.com/Worst-Man-Made-Environmental-Disasters.asp

___________________________________
___________________________________
This has been called the world's worst catastrophe. On
December 2-3, 1984, methyl isocyanite gas leaked from
a pesticide plant in Bhopal, near Madhya Pradesh in
India, resulting in the exposure of over 500,000 people.
Twenty-thousand deaths since the leak can be
attributed to the accident, which killed 3,000 people in a
few days and is linked to hundreds of thousands of
illnesses since.

___________________________________
___________________________________
___________________________________
___________________________________

Slide 17

BP Texas City refinery explosion, 2005

___________________________________

Courtesy: http://www.telegraph.co.uk/finance/newsbysector/energy/oilandgas/7941750/BP-caves-inover-record-50m-fine-for-Texas-safety-failings.html
http://www.youtube.com/watch?v=VCcN4SQkb9A

___________________________________
___________________________________

On March 23, 2005, a fire and explosion occurred at BP's Texas City Refinery in Texas City, Texas, killing 15 workers and injuring more than
170 others. BP was charged with criminal violations of federal environmental laws, and has been subject to lawsuits from the victim's families.
The Occupational Safety and Health Administration slapped BP with a then-record fine for hundreds of safety violations, and subsequently
imposed an even larger fine after claiming that BP had failed to implement safety improvements following the disaster.

___________________________________
___________________________________
___________________________________
___________________________________

Slide 18

BP again Deepwater Horizon 2010

The explosion killed 11 men working on the platform and injured 17 others. On
July 15, 2010, the leak was stopped by capping the gushing wellhead, after it
had released about 4.9 million barrels (780,000 m 3) of crude oil.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 19

___________________________________
___________________________________
Blowout Aftermath

___________________________________
___________________________________
Slide Courtesy: Dr. John Williams

___________________________________
___________________________________
___________________________________
Slide 20

Learning From Accidents

___________________________________

(Other Universities)

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 21

Lab Accident Statistics

There were nearly 10,000 accidents in research
laboratories in 2005 injuring nearly 2 out of
every 100 researchers, according to U.S
government statistics. These accidents were
OSHA Recordable & nearly one-half of the
accidents resulted in days away from work or
restricted work duties
The rate of lab accidents at schools and
colleges is up to 100 times that in the chemical
industry. It's 100 to 500 times greater than in
places like Dow and DuPont, (James Kaufman, President,

___________________________________
___________________________________
___________________________________
___________________________________

Laboratory Safety Institute)

___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 22

Lab Accident Statistics (2009)-Iowa State University

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 23

Lab Accident Statistics (2009) Iowa State University

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 24

Research Lab Explosion Injures Four People University of Missouri

June 29,2010 : One person is in the hospital
after a hydrogen gas blast destroyed a
University of Missouri Biochemistry lab

During an experiment with bacteria in

hydrogen-rich environments, lab personnel
turned on the hydrogen supply to an anaerobic
hood and left the gas on. Once the gas
reached an ignition source, it exploded
according to Fire Dept.
The explosion "is believed to have been
caused by a spontaneous combustion of
gases including hydrogen and nitrogen that
were being used in a research experiment,
according to university officials

The injured researchers included one graduate

student, two postdoctoral researchers, and a
staff research scientist

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 25

Fire in Science Building Southern Illinois University

June 2,2010
An undergraduate student working in chemistry lab had
been using hexane to clean oil from vacuum pumps. When
the student returned from lunch, he found that some of the
solvent had leaked onto a counter top. Before he could
clean it up, an ignition source ignited the solvent vapor.

University estimates the building repairs at $750,000 and

the cost to repair or replace equipmentincluding lasers
and a nuclear magnetic resonance spectrometerat
$500,000, and complete repairs could take until the end of
the year.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 26

Explosion and Fire in Chemistry Lab Ohio State University

___________________________________

April 8,2005

___________________________________

Students were helping to unload a shipment

of hexane into a solvent storage cabinet
"I loaded 12 bottles, and as I put the 12th
bottle up, the shelf collapsed.
"This has happened before," he continues,
"and it's not something where you get too
alarmed. I was more concerned about
breathing the vapors, and I noticed I had a
small cut on my arm. Within five minutes,
the explosion occurred.

Destroyed lab after the explosion and

fire

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 27

Explosion and Fire in Chemistry Lab Ohio State University (contd.)

The explosion could have been triggered by any
number of ignition sources including static
electricity or a spark from a motor or switch.

___________________________________

One preventive solution, might be to outfit the labs

with an emergency power-off switch so that all
electricity can be killed in a lab whenever there is a
solvent or other flammable liquids spill.

___________________________________

The solvent storage cabinet although properly

vented, it was close to a freezer and probably
should not have been.
With routine inspections somebody might have
spotted the unstable shelves

___________________________________

A collapsed shelf in a
solvent storage cabinet is
implicated in the fire
incident.

___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 28

Texas Tech University (TTU) Explosion

___________________________________

Jan 7, 2010

___________________________________

Graduate student Preston Brown was

working with another graduate student to
synthesize and characterize an energetic
material, most likely nickel hydrazine
perchlorate.

___________________________________

Despite being told by their chemistry

professor not to make more than 100 mg
of the material, the students synthesized
10 g.

REPERCUSSION: The blast that

injured Brown also damaged the lab

___________________________________
___________________________________
___________________________________
___________________________________

Slide 29

Texas Tech University (TTU) Explosion (contd.)

Because the product was lumpy,
Brown believed that the compound
was safe when wet, so he added
some hexane & used a pestle to try
to break up the chunks
When Brown thought he was done,
he set down the mortar and took off
his goggles. Then he decided to give
the compound one last stir. The
mortar exploded in Browns hands.

___________________________________
___________________________________
___________________________________

EXPLOSIVE :The purple compound made

by the students was likely nickel
hydrazine perchlorate

___________________________________
___________________________________
___________________________________
___________________________________
Slide 30

Radiation Exposure Incident(2005) Wright State University

___________________________________

Prof. Jaworowski used a 2 MeV Van de Graff

generator in a particle accelerator in the physics
laboratory.

When the generator was moved to a new location,

various safety features were disabled during packing,
and were not enabled at the destination.

Jaworowski continued to use the generator at its new

location, although he knew that not only were the
safety features disabled, but also the radiation safety
committee at the university had not authorized the
use of the generator at its new location.

___________________________________

Jaworowski accidentally placed his hand in the

particle beam, and received a massive dose of
radiation that required a partial amputation of his
hand

___________________________________

___________________________________

___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
0

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 31

___________________________________

Glimpse of Past Lab Accidents

Name

Year

University

Dr. Nanaj
Bhamare

2011

Edgewood
Killed from an explosion
laboratory Aberdeen
Proving Ground

Reason

2011

Yale University,
Chemistry Dept

Nilamma

2011

Mysore, India.

Alcohol fire

Sheri Sangji

2009

University of
California, Los
Angles.

Wasn't wearing the required

flame-resistant lab coat and died
from burns after a chemical(Tbutyllithium pyrophoric) fire ignited
her sweater.

Jason Siddell

2008

New Jersey

___________________________________

Working alone, she was strangled

when her hair caught in a lathe.

Michelle
Dufault

24-year-old chemist died after

being exposed to
trimethylsilydiazomethane

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 32

Glimpse of Past Lab Accidents (contd.)

Name

Year

University

Reason

Richard Folaron

2009

DuPont facility,
Tonawanda, NY

Killed in explosion

Roland Daigle

2008

Windsor, Nova
Scotia, Sepracor
Pharmaceutical,

Poisoning,
Trimethylsilydiazomethane. D
aigle is the second chemist to
die in a 12-month period after
exposure to the chemical

Parish Ashley,
Charles Bolchoz
Robert Gallagher
& Karey Henry

2007

T2 ,Laboratories
in Jacksonville,
Florida

___________________________________
___________________________________
___________________________________

Explosion

___________________________________
___________________________________
___________________________________
___________________________________
Slide 33

Glimpse of Past Lab Accidents (contd.)

Name

Year

Dominique
Burget

2006

University

Reason

France, National
Inst. of Higher
Learning in
Chemistry,

Ethane explosion

Electrocution

Tarun K. Mal

2005

Cleveland State
University,

Scott Spjut

2003,

Rochester, NY,

Industrial lab explosion

Wroclaw, Poland,

Professor killed in explosion

Scotland,

Nitrogen suffocation

Edmonton,
Canada, Agat
Laboratories

Toluene inhalation death

Unknown
2001
Unknown

1999,

Unknown

1999,

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
1

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 34

___________________________________
INCIDENT INVESTIGATION REPORT

___________________________________

Autoclave Explosion Incident at PI

Location
Building
Date of the incident
Time of the incident

: Lab 8230, Arzanah

___________________________________

: 12th April, 2012

: 14:10 Hrs.

___________________________________
___________________________________
___________________________________
___________________________________
Slide 35

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 36

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
2

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 37

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 38

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 39

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
3

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 40

Summary
Thursday, April 12th, 2012, at around 14:10 Hrs.
Autoclave exploded while conducting experiment - Autoclave Assisted Thermal
Decomposition of Ammonium Tetrathiomolybdate and Carbon Nano Tube (CNT)
Impregnation.

___________________________________
___________________________________

Laboratory 8230 @ Arzanah Building at PI.

___________________________________

No injuries.
Significant damage to autoclave, fume hood and furnace.
Potential to cause catastrophic injuries.
Detailed investigation initiated by PI HSE.

___________________________________
___________________________________
___________________________________
___________________________________

Slide 41

Sequence of Events

___________________________________

Experiment started by Lab Engineer -

Two Teflon-lined reaction autoclaves (125 ml capacity each) were used in the

experiment.

12:00
noon

Reactants in the first autoclave: 33 mg of Ammonium Tetrathiomolybdate (ATM),

100 mg of Carbon Nano Tube (CNT) and 65 cm3 of water.

Reactants in the second autoclave: 33 mg of ATM, 100 mg of CNT and 65 cm3 of

___________________________________

Dimethyl Sulphoxide (DMSO).

Both autoclaves were placed in, and heated, in a bench top furnace.
Rate of increase in temperature of the furnace was set at 5 0C per minute, to attain a

final steady state of 3000 C. The experiment was to run for 72 hrs.

13:00
Hrs

observed the temperature in the furnace reached 3000C.

14:00
Hrs

Fellow researcher ( ) working on a separate experiment in the vicinity of this

experimental setup, left the lab (8-230) to help another researcher in the adjacent
lab.

14:10
Hrs

Explosion occurred. Upon hearing the explosion, (who was outside the lab at
the time) responded to the incident and cut off power supply to the lab via the
emergency power shut off switch located at the entrance to the lab.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 42

Sequence of Events (continued.)

14:15
Hrs

HSE was notified by .

14:20
Hrs

HSE reached the lab to evaluate the situation.

As an initial measure all gas cylinder were shut off and all experiments that were in
progress were shut down.
Fume hood involved in the incident was allowed to run to vent any toxic or
flammable chemicals that may have still been present.
Lab (8-230) was secured to restrict any further work in the lab until further notice
and approval from HSE.

14:30
Hrs

Dr. Saeed Alhassan, Assistant professor, Chemical Engineering joined the research
group for preliminary investigation.

16:45
Hrs

Lab was re-visited by HSE as part of the data collection phase of the investigation.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
4

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 43

___________________________________
Observations and Analysis
Based on the following categories:

___________________________________

Equipment Factor

Personal Factor

___________________________________

Chemical Chemistry Factor

Job factor

___________________________________
___________________________________
___________________________________
___________________________________

Slide 44

Equipment Factor
The autoclave (Model No 4750 pressure
vessel: capacity 125 ml; Maximum Pressure
- 3000 psi (200 bars); Max temp: 3500 C )
used in the experiment is from Parr
Instrument Company, which was supplied by
Business Communications LLC to PI (PI
Purchase order dated: 28 Nov-2010).

The autoclave was used brand new after

purchase.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 45

Equipment Factor -1
The manufacturers (Parr Instruments) operating instructions
manual (#230 M) titled: Safety in the operation of laboratory
reactors and pressure vessels carries the following note: All
standard Parr pressure vessels are provided with either a suitable
relief device or a means to attach one (typically in the form of a
plugged opening). When a pressure vessel is delivered without a
pressure venting device, it is the customers responsibility to
provide pressure relief in order to protect the operator & the
equipment from destructive high pressure (page-3).

As per the PI purchase order# 100250, the autoclave was purchased

without a pressure relief device and was used in the experiment without a

pressure relief device.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
5

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 46

___________________________________
Equipment Factor - 2
Parr Instruments document #230 M, mentions the following:
Certain explosive reactions proceed with such speed that the
shock wave created by the explosion may damage the vessel
before the rupture disc can dump the excess pressure. The best
protection against the hazard is to operate the reactor behind a
suitable barricade or in a pressure test cubicle or cell .

This experiment was carried out in a general purpose fume hood without
any barricades to protect against explosion.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 47

___________________________________
Equipment Factor - 3
Parr Instruments literature on polymer liners (document #314)
states the following: TFE polymer liners will significantly alter the
heat transfer characteristics of a reactor and may necessitate the
use of other temperature measurement and control methods to
protect the liner and the reactor from overheating. The
recommended maximum operating temperature for these TFE
liners in 2500 C.

This experiment was set for operation at 3000 C.

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 48

Chemical/Chemistry Factor
Parr Instruments document #230 M mentions: Since safety in bench
scale pressure reactions is so closely related to the chemistry involved
in the process, there are several basic questions that the operator must
always consider before starting to use the pressure equipment:

___________________________________
___________________________________

Is the reaction exothermic?

What By-products will be produced & what will be their behavior?
What maximum temperature & pressure limits will be observed?

___________________________________

Under what circumstances (temperature, pressure & catalyzing

agents) might the reaction run out of control?
By considering these and any other related safety questions before
starting a pressure operation, the user should be able to anticipate any
violent chemical behavior & take steps to prevent it

___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
6

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 49

Chemical/Chemistry Factor
Dimethyl Sulfoxide (DMSO) solvent
Flash point 870 C;
Boiling point-1890 C &
Auto ignition temperature 2150 C
Thermally unstable, especially in the presence of other materials.
Quantity used exceeded the normal amounts used in autoclaves of
such size.
Heating above its decomposition temperature in the presence of an
ammonia generating compound caused the violent reaction that
lead to a surge in temperature/pressure.
MSDS (material safety data sheets) of the chemicals

___________________________________
___________________________________
___________________________________
___________________________________

(AMT, DMSO, MoS2 etc.) were not referred to.

___________________________________
___________________________________
___________________________________
Slide 50

___________________________________
Job Factor
PIs HSE Policy and Procedure # PIP 10012 on Risk

Assessment was not followed.

___________________________________

Approved SOP and risk assessment were not available.

Experiment was not conducted in accordance with the

departments internal procedure (notifying and seeking

approval from the departments HSE committee).

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 51

___________________________________
Other Observations
It was fortunate that no one was present in the lab at the time of
explosion. Or else, serious injuries could have occurred.

___________________________________

Manufacturers literature mentions that Ear protection is also recommended

since the loud report produced by bursting rupture disc may damage the hearing of anyone
standing near the reactor. Neither nor who was working in vicinity

of the experiment was wearing hearing protection. It was

fortunate however, as mentioned above, that none of them were
present in the lab at the time of the incident.

___________________________________

Experiment was carried out in a fume hood that was not

approved for the purpose, BUT this reduced the impact of the
explosion on other equipment in the lab.

___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
7

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 52

___________________________________
Accident Causation

Immediate Cause

Additional / Intermediate causes

Dimethyl Sulfoxide (DMSO) solvent (flash point 870oC; boiling point-1890C & auto-ignition
temperature 2150C), used in the experiment is thermally unstable, especially in the presence
of other materials.
The amount used admittedly exceeded the normal amounts used in autoclaves of such sizes,
and when compounded by heating above its decomposition temperature in the presence of
an ammonia generating compound, caused the violent reaction and subsequent explosion to
occur.

Pressure relief device was not installed for the autoclave

Manufacturers recommendations were not followed when using Teflon lined autoclaves
(250oC maximum operating temperature).

___________________________________
___________________________________

Root Cause

Risk assessment, as required by PI policy, for the research experiment was not carried out.
MSDS of the chemicals involved in the experiment were not referred to.
Lack of awareness of the hazards involved with experiments using Dimethyl Sulfoxide
(DMSO) as solvent.

___________________________________
___________________________________
___________________________________
___________________________________

Slide 53

___________________________________
Recommendations
S. No

Recommendations

Action By

Target date

Each experiment must have a written approval (sign-off) from the

researcher-in-charge, before commencing.

Research In-Charge

Immediate

Each experiment must have documented risk assessment that

has been reviewed and approved by PI HSE, before start-up.

Research In-Charge / PI
HSE

Immediate

The existing procedure of having all new experiments and

procedures reviewed and approved by the departmental HSE
committee must be enforced.

Departmental HSE
committee

Immediate

The research-in-charge must make sure that his/her reports

receive adequate training.

Research In-Charge

Immediate

The researcher-in-charge must establish an accountability

system which focuses on violations of rules/procedures/best
practices, whether it results in an accident or not.

Research In-Charge

Immediate

This incident must be included in HSE briefings to all members of

the department to avoid re-occurrence of such events.

Safety Alert and lessons learned shall be sent to ALL PI

All researchers and lab personnel must have at least the 30-Hr.
Lab HSE Passport (offered by PI HSE), before commencing any
lab activities.

Departmental HSE
Committee
PI-HSE

All lab personal

___________________________________
___________________________________

NOW

NOW

___________________________________

Next round of lab safety

training

___________________________________
___________________________________
___________________________________
Slide 54

SAMPLE

___________________________________

Photographs

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
8

THE PETROLEUM INSTITUTE, HSE DEPARTMENT

30 Hrs LAB SAFETY TRAINING
INTRODUCTION TO LAB SAFETY - Handout
Slide 55

___________________________________

Summary
Before you do an experiment, demonstration
or activity...
KNOW the hazards.
KNOW the worst credible thing that could happen.
KNOW what to do and how to do it if they should
happen.
KNOW and use the prudent practices, protective
facilities, and protective equipment needed to
minimize the risks.
In other words, conduct a risk assessment of your work
PI Policy

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 56

___________________________________
___________________________________
___________________________________
Presentation by:
Team HSE
The Petroleum Institute

___________________________________
___________________________________
___________________________________
___________________________________

PI-HSE
75473

1
9