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Fallout From a Lab Tragedy
Sheharbano “Sheri” Sangji, a 23-year-old University of California at Los Angeles staff research assistant, died three years ago after suffering massive second- and third-degree burns when a chemical she was handling caught fire. After her death, UCLA beefed up its policies on compound handling and training for laboratory work. UCLA itself issued several new requirements to rectify some of the lapses in safety that resulted in a state agency fining the university nearly $32,000.
Now, a new development in the case is likely to reinvigorate the training and safety discussion not just at UCLA, but at any college or university where chemical work is performed: prosecutors last week filed felony charges against the UC regents and the chemistry professor who oversaw the lab, Patrick Harran, marking what researchers believe is the first criminal indictment stemming from an accident in the history of American academe.
The charges, filed by the Los Angeles District Attorney’s Office days before the statute of limitations was set to expire, allege that the regents and Harran violated state codes mandating employee training on handling hazardous chemicals and minimizing risk of exposure, as well as requirements for proper staff safeguards and clothing. Sangji was wearing a synthetic sweater, not a protective lab coat, which caught fire and melted when the syringe she was using to transfer t-butyl lithium -- a chemical that ignites when exposed to air -- fell apart. Harran faces up to 4 1/2 years in prison, and UCLA could be fined up to $1.5 million for each of the three counts, all of which target both the professor and the regents.
“This particular researcher was working with an extremely hazardous substance, she was basically working alone, had very little experience with this procedure … and she was making three times as much of the material as she had the only previous time she had done it,” said Russ Phifer, executive director of the National Registry of Certified Chemists. “Any one of about five or six things would have saved this woman’s life, and they’re all safety-related.”
UCLA, however, has denounced the “outrageous” criminal charges, noting that, unlike the DA’s office, the previous investigation by the California Division of Occupational Safety and Health found no “willful violations.” That report cited similar violations of state law, though, determining that Sangji was not properly trained and finding nonexistent record-keeping of the inadequate training she had received. The office also fined UCLA for not addressing safety issues identified in an annual inspection two months prior, including a lack of safety gear and too many chemical liquids.
“Following a meeting with the district attorney in October 2010, UCLA had not been contacted by the district attorney or received any requests for documents or interviews until being notified about pending charges two days before Christmas. The district attorney’s decision to file charges today is truly baffling and directly contradicts the findings of the state agency responsible for evaluating workplace safety,” the university said in a Dec. 27 statement. “The facts provide absolutely no basis for the appalling allegation of criminal conduct, and UCLA is confident an impartial jury would agree."
The university declined to comment further, as did the DA’s office. The professor's lawyer also declined comment.
While Sangji was a staff member, the reactive chemicals she handled are also “fairly common” in work for the many graduate students who work in university labs, said Harry Elston, editor of the Journal of Chemical Health and Safety. In those cases, new graduate students are trained by their more senior peers – but a lack of prioritized and substantial safety training has been a key issue for decades, he said, making for a dangerous setting if nobody learns the proper skills in the first place. “You’re never going to live in a zero-risk environment,” Elston said, but “the risk decreases as the training increases.”
The three fundamental lab safety controls all fell short in this instance, Phifer said: administrative (rules and policies), engineering equipment (providing the right tools), and personal protective equipment (ensuring the individual knows how to respond if and when something goes wrong). The case emphasizes “the importance of developing not just a good training program, but a culture where people actually pay attention to safety – not just, ‘Yeah, I got my annual training and I’m done,’ and that’s it,” Phifer said, noting that the real issue at UCLA was a lack of job-specific training, not general lab safety training. (Most colleges have fairly comprehensive general chemical safety training, he said. And although “there’s no such thing as going overboard” in this area, Princeton University’s expansive Laboratory Safety Program is one of a few that are headed in that direction, Phifer said.) “It’s good to get basic safety training, but I think it really has to be much more hands-on and much more closely supervised than it has been.”
The charges will likely pressure principal investigators and frontline supervisors to pay more attention to training, get into the lab and work closely with university safety departments, Elston said. But he also hopes that awareness rises up through the ranks: if a chancellor cares deeply about lab safety, the department chairs will, too, and that ripple effect will extend all the way down, he said.
"There is a problem with holding supervisors accountable in the academy. Their industrial counterparts have safety and safe work practices ingrained into them as a condition of employment. Supervisors are held accountable -- their compensation depends on the safety of the individuals who work for them," Elston said. “I think that until we move into a model that will hold individuals in the academy accountable for the safety of the people that work for them, we're not going to see a lot of change."
James Kaufman, president and CEO of the Laboratory Safety Institute, a nonprofit group that trains educators and professionals in lab safety, said the UCLA case could be “a game-changer.”
“In some cases this is very difficult for [Harran], being the first one to be charged this way, because there is a system that has existed for so long, that has tolerated behaviors that might otherwise have been viewed differently. And I think as society changes, behaviors get viewed differently, and we’re on the cusp of a potentially significant change in how we view the responsibilities of the professors of the university and the board of directors of the university,” Kaufman said. “We’re in new territory now.”
(Among LSI’s guidelines for lab safety: forbid working alone in any laboratory, and provide adequate supplies of personal protective equipment, such as lab coats.)
Yet, based on Kaufman’s experience, it’s not shocking that training was a factor in Sangji’s death. Only six states require that secondary school teachers be skilled in lab safety. It’s generally not emphasized much at the undergraduate level, he said, and in graduate school there’s “little to no emphasis.” And fewer than 5 percent of 70,000 scientists and educators have answered in the affirmative when Kaufman asked them whether, when interviewing with a potential employer, they were asked about lab safety. “There’s a certain amount of inbreeding in this.”
To break the cycle, universities will have to start providing incentives for practicing good safety, not just have policies mandating it or punishments to dole out when something goes wrong, Kaufman said. For example, grant money or research space could serve as a reward for the safest labs.
“My feeling is that you always will need a balance of carrots and sticks. You need rewards, and you need discipline, and you need punishment,” Kaufman said. “But how do we learn, and how do we improve our safety programs? We need more ways to say ‘thank you’ for doing a good job.”