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Texas Tech University Chemistry Lab Explosion

Overview

On January 7, 2010, a graduate student in the Chemistry and Biochemistry Department at Texas Tech University was severely injured when a nickel hydrazine perchlorate (NHP) derivative detonated during energetic materials synthesis work. The CSB found systemic deficiencies in hazard evaluation, training, communication, and safety oversight within Texas Tech's research environment.

Incident Snapshot

Field Value
Facility / Company Texas Tech University
Location Lubbock, TX
Incident Date 01/07/2010
Investigation Status The CSB's investigation was released via webinar on October 19, 2011.
Accident Type Reactive Incident
Final Report Release Date 10/19/2011

What Happened

  • In October 2008, Texas Tech entered into a subcontract agreement with Northeastern University to participate in the ALERT program.
  • The injured Texas Tech student began working on the ALERT project about a year prior to the incident.
  • The graduate student did not receive any formal training for working with energetic compounds.
  • Safety restrictions, such as a 100 milligram limit, were verbally communicated by the two Principal Investigators to some students.
  • Beginning about a month prior to the January 7 incident, the fifth-year graduate student and a first-year graduate student he was mentoring began synthesizing a nickel hydrazine perchlorate (NHP) derivative.
  • The amounts of NHP synthesized were on the order of 50-300 milligrams.
  • The students decided to scale-up the synthesis of NHP to make approximately 10 grams.
  • The PIs of the research were not consulted on the decision to scale up.
  • No formal hazard evaluation was conducted to analyze the effectiveness of using either water or hexane to mitigate the potential explosive hazards associated with the quantity of NHP synthesized the day of the incident.
  • The more senior student transferred about half of the synthesized NHP into a mortar, added hexane, and then used a pestle to gently break up the clumps.
  • The graduate student removed his goggles and walked away from the mortar after he finished breaking the clumps.
  • The more senior student returned to the mortar but did not replace his goggles while he stirred the NHP "one more time."
  • At this point, the compound detonated.
  • After the incident, all of the universities who were partners in the ALERT program implemented a voluntary stop-work order in the laboratories working with energetic materials.

Facility and Process Context

  • Texas Tech University Chemistry and Biochemistry Department research laboratory
  • Research on energetic materials under the ALERT program funded by the U.S. Department of Homeland Security (DHS)
  • Synthesis of nickel hydrazine perchlorate (NHP) derivative
  • Academic laboratory research involving high-energy materials

Consequences

  • Fatalities: 0
  • Injuries: A graduate student lost three fingers, his hands and face were burned, and one of his eyes was injured.
  • Environmental Release:
  • Facility Damage:
  • Operational Impact: After the incident, all of the universities who were partners in the ALERT program implemented a voluntary stop-work order in the laboratories working with energetic materials. The stop-work order at Texas Tech lasted approximately 4 months and up to 10 months at the other universities.

Key Findings

Immediate Causes

  • The compound detonated while the more senior student was stirring the NHP in a mortar.
  • The students assumed the hazards of larger quantities of NHP would be controlled in a similar manner to smaller amounts wet with water or hexane.

Contributing Factors

  • The physical hazard risks inherent in the research were not effectively assessed, planned for, or mitigated.
  • No formal hazard evaluation was conducted.
  • The students had no research-specific training for working with energetic compounds.
  • The students were not aware of a strict 100 milligram limit.
  • No written policies or procedures existed at the laboratory, departmental, or university levels which would have required the students to consult with the PIs before making the decision to scale up.
  • The laboratory had no written protocols or SOPs for synthesizing NHP or other energetic materials.
  • The laboratory had no written restrictions concerning the amount of compound to be synthesized.
  • The laboratory had no written mandatory safety requirements pertaining to the synthetic work.
  • Students were allowed to determine their PPE needs on an individual and situational basis.
  • Several individuals reported that they used their ordinary prescription glasses for eye protection.
  • Weekly group meetings focused primarily on experimental results, not actual research activities and the safety implications of the work.
  • Lab notebooks were not consistently reviewed by PIs and varied greatly among students.
  • Previous incidents and near-misses were not reported outside the research groups.

Organizational and Systemic Factors

  • The university lacked safety management accountability and oversight.
  • Safety accountability and oversight by the principal investigators, the department, and university administration at Texas Tech were insufficient.
  • No single person or entity within the university was accountable for ensuring that the CHP was up-to-date, enforced, and applicable to the laboratories it was meant to regulate.
  • EH&S had no authority to shut down a laboratory.
  • EH&S saw itself as a "consultant" advising the department about how to improve and maintain safety.
  • EH&S had no direct communication link within the organizational hierarchy to an authority who could enforce EH&S’s safety inspection recommendations with the PIs.
  • The organizational structure inhibited opportunities for safety issues to be raised to those within the university with the necessary authority to ensure safety improvements were implemented.
  • The research-granting agency, DHS, prescribed no safety provisions specific to the research work being conducted at Texas Tech at the time of the incident.
  • The grant funding body’s role in safety was a missed opportunity to influence positive safety management and behavior.
  • Previous Texas Tech laboratory incidents with preventative lessons were not always documented, tracked, and formally communicated at the university.
  • The Chemistry Department students were not required to attend the general laboratory safety training.
  • The department had not documented attendance of the training since 2002.
  • Texas Tech's laboratory safety management program was modeled after OSHA's Occupational Exposure to Hazardous Chemicals in Laboratories Standard (29 CFR 1910.1450), which was not designed to address physical hazards of chemicals.
  • Comprehensive hazard evaluation guidance for research laboratories does not exist.

Failed Safeguards or Barrier Breakdowns

  • The physical hazards of the energetic materials research work were not effectively assessed and controlled at Texas Tech.
  • Texas Tech’s laboratory safety management program was modeled after OSHA’s Occupational Exposure to Hazardous Chemicals in Laboratories Standard (29 CFR 1910.1450), yet the Standard was created not to address physical hazards of chemicals, but rather health hazards as a result of chemical exposures.
  • Comprehensive hazard evaluation guidance for research laboratories does not exist.
  • Previous Texas Tech laboratory incidents with preventative lessons were not always documented, tracked, and formally communicated at the university.
  • The research-granting agency, DHS, prescribed no safety provisions specific to the research work being conducted at Texas Tech at the time of the incident, missing an opportunity for safety influence.
  • Safety accountability and oversight by the principal investigators, the department, and university administration at Texas Tech were insufficient.
  • No formal documentation system was in place to ensure that safety restrictions were effectively communicated to students and/or that students understood the information.
  • No formal hazard evaluation was conducted to analyze the effectiveness of using either water or hexane to mitigate the potential explosive hazards associated with the quantity of NHP synthesized the day of the incident.
  • The students were not required to obtain permission or seek approval from their PIs prior to changing research experiment variables.
  • The laboratory had no written protocols or SOPs for synthesizing NHP or other energetic materials.
  • The laboratory had no written restrictions concerning the amount of compound to be synthesized.
  • The laboratory had no written mandatory safety requirements pertaining to the synthetic work.

Recommendations

  1. 2010-5-I-TX-R1 | Recipient: Occupational Safety and Health Administration | Status: Closed- Acceptable Action | Summary: Broadly and explicitly communicate to the target audience of research laboratories the findings and recommendations of the CSB Texas Tech report focusing on the message that while the intent of 29 CFR 1910.1450 (Occupational Exposure to Hazardous Chemicals in Laboratories Standard) is to comprehensively address health hazards of chemicals, organizations also need to effectively implement programs and procedures to control physical hazards of chemicals (as defined in 1910.1450(b)). At a minimum: a. Develop a Safety and Health Information Bulletin (SHIB) pertaining to the need to control physical hazards of chemicals; and b. Disseminate the SHIB (and any related products) on the OSHA Safety and Health Topics website pertaining to Laboratories (http://www.osha.gov/SLTC/laboratories/index.html)

  2. 2010-5-I-TX-R2 | Recipient: American Chemical Society (ACS) | Status: Closed – Exceeds Recommended Action | Summary: Develop good practice guidance that identifies and describes methodologies to assess and control hazards that can be used successfully in a research laboratory.

  3. 2010-5-I-TX-R3 | Recipient: Texas Tech University | Status: Closed – Acceptable Action | Summary: Revise and expand the university chemical hygiene plan (CHP) to ensure that physical safety hazards are addressed and controlled, and develop a verification program that ensures that the safety provisions of the CHP are communicated, followed, and enforced at all levels within the university.

  4. 2010-5-I-TX-R4 | Recipient: Texas Tech University | Status: Closed – Acceptable Action | Summary: Develop and implement an incident and near-miss reporting system that can be used as an educational resource for researchers, a basis for continuous safety system improvement, and a metric for the university to assess its safety progress. Ensure that the reporting system has a single point of authority with the responsibility of ensuring that remedial actions are implemented in a timely manner.

Key Engineering Lessons

  • Research involving energetic materials requires a formal hazard evaluation before scale-up or procedural changes are made.
  • Controls used successfully for small quantities cannot be assumed to remain effective when quantities are increased.
  • Written protocols, written quantity limits, and mandatory safety requirements are needed for energetic materials work.
  • Physical hazards must be addressed explicitly in laboratory safety management programs, not only health hazards from chemical exposure.
  • Safety-critical communication should be documented and verified, not left to informal verbal communication.
  • Incident and near-miss reporting systems should feed continuous improvement and have a clear authority for corrective action.

Source Notes

  • Primary incident facts, causal findings, and recommendations were taken from the final report (source_priority 1) and override lower-priority summaries where conflicts existed.
  • Recommendation status updates from later CSB status summaries were used for final recommendation statuses.
  • No external facts were added beyond the provided source extracts.

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