CSB s Texas Tech University Case Study 1

Case Study

U.S. Chemical Safety and Hazard Investigation Board

Texas Tech University

Laboratory Explosion 

No. 2010-05-I-TX

 ISSUES

s Laboratory safety management for physical hazards

s Hazard evaluation of experimental work in research laboratories 

s Organizational accountability and oversight of safety
CSB s Texas Tech University Case Study 2

1.0 INTRODUCTION

On January 7, 2010, a graduate student within 

the Chemistry and Biochemistry Department at 

Texas Tech University (Texas Tech) lost three 

fi ngers, his hands and face were burned, and one 

of his eyes was injured after the chemical he was 

working with detonated. The Chemical Safety 

Board (CSB) investigated and found systemic 

defi ciencies within Texas Tech that contributed 

to the incident: the physical hazard risks inherent in the research were not effectively assessed, 

planned for, or mitigated; the university lacked 

safety management accountability and oversight; 

and previous incidents with preventative lessons 

were not documented, tracked, and formally 

communicated. The lessons learned from the 

incident provide all academic institutions with 

an important opportunity to compare their own 

policies and practices to that which existed at 

Texas Tech leading up to the incident. 

Looking beyond Texas Tech, the CSB identifi ed 

a lack of good practice guidance recognized by 

the academic community; limitations in using 

the Occupational Safety and Health Administration’s (OSHA) Occupational Exposure to 

Hazardous Chemicals in Laboratories Standard (29 CFR 1910.1450) as guidance for mitigating physical hazards in the laboratory; and a missed opportunity for a granting agency 

to infl uence safety practices. While a vast number of references, standards and guidelines 

have been developed to describe and promote different types of hazard evaluation methodologies in an industrial setting, similar resources that address the unique cultural and 

dynamic nature of an academic laboratory setting have not been generated. Good-practice 

guidelines would provide universities a metric to evaluate their current hazard evaluation 

procedures against, or for schools with none in place, would enable a more rapid process 

for their development. If universities choose to use OSHA’s Laboratory Standard as guidance for developing a plan to mitigate chemical hazards, they need to understand that the 

standard was not created to address physical hazards of chemicals, but rather health hazards as a result of chemical exposures. Physical hazards though, as evidenced in the Texas 

Tech incident and the 2008 laboratory fi re that resulted in the death of a staff research 

associate at University of California, Los Angeles (UCLA), are deserving of similar attention 

to that given to health hazards. Finally, the granting agency, which provides funding for the 

research and thus maintains a level of control and authority over the researchers, did not 

prescribe any safety provisions specifi c to the research work being conducted at Texas Tech 

until after the incident occurred. 

TABLE OF CONTENTS

 1.0 Introduction 2

 2.0 Background 3

 3.0 Pre-incident Events 3

w 5.0 Incident Analysis 5

 6.0 Physical Hazards in the 7 

Laboratory Not Managed

 7.0 Lessons Not Learned 13

From Previous Incidents 

and Near Misses

 8.0 Lack of Organizational 14 

Accountability and 

Oversight for Safety

 9.0 Key Lessons 18

 10.0 Recommendations 18

 11.0 References 19
CSB s Texas Tech University Case Study 3

1

Carnegie Foundation Classification, http://classifications.carnegiefoundation.org/lookup_listings/institution.php, accessed 8/4/11, and Texas Tech University Institutional Fact Summary, http://www.ors.ttu.edu/Newors/newhome/Proposal_preparation/Boilerplate.pdf, accessed 8/4/11.

2

ALERT’s stated mission is to “conduct transformational research, technology and educational development for effective characterization, detection, mitigation and response to the explosives-related threats facing the country and the world.” http://www.northeastern.edu/alert/mission/, accessed 8/4/11.

3

As defined by Rock Blasting and Explosives Engineering (1994), “energetic material is mostly used to comprise all materials that can undergo exothermal 

chemical reaction releasing a considerable amount of thermal energy (emphasis in original).” An explosive energetic material is one that creates a high 

pressure shock wave when the products rapidly expand in volume. 

4

http://www.northeastern.edu/alert/, accessed on 9/1/2011

2.0 BACKGROUND

Texas Tech includes 11 colleges, a School of Law, and more than 160 Master’s and doctoral 

degree programs. It has a student population of over 31,500 and maintains a Carnegie 

Foundation Classification as a doctoral research-extensive university.1

 Within the Department 

of Chemistry and Biochemistry (Chemistry Department), there are approximately 140 graduate and postdoctoral researchers, 225 undergraduate students, 26 faculty, and 19 staffers. 

At the time of the incident, the campus included 368 laboratories; 118 were part of the 

Chemistry Department.

3.0 PRE-INCIDENT EVENTS

In October 2008, Texas Tech entered into a subcontract agreement with Northeastern 

University (NEU) to participate in a program titled “Awareness and Localization of ExplosiveRelated Threats” (ALERT), which was (and continues to be) funded by the U.S. Department of 

Homeland Security (DHS).2

 Texas Tech’s research focus is the detection of energetic materials 

that could represent a future security threat and includes synthesizing and characterizing new 

potentially energetic materials.3

 NEU and University of Rhode Island lead the ALERT program, which includes Texas Tech and several other academic partners.4

The terms of the subcontract agreement between NEU and Texas Tech were intended to 

provide maximum scientific freedom to Texas Tech while remaining consistent with the overall 

objectives of the ALERT program and DHS regulations. Both the cooperative agreement 

between DHS and NEU and the subcontractor agreement between NEU and Texas Tech 
CSB s Texas Tech University Case Study 4

stipulated a number of research practices that required pre-approval of research protocols by 

various committees before work could begin.5

 However, pre-approval of experimental protocols for the energetic work being conducted at Texas Tech was not required. 

The injured Texas Tech student, in his fifth year of graduate study at the time of the incident, 

began working on the ALERT project about a year prior to the incident. None of the graduate 

student’s previous work had been with energetics, thus when he began the project, he had to 

learn new techniques and methods. The graduate student did not receive any formal training 

for working with energetic compounds, but he stated to the CSB that he independently completed a literature review prior to beginning work to familiarize himself with similar energetic 

compounds. Safety restrictions, such as a 100 milligram limit on the amount of compound 

permitted to be synthesized, were verbally communicated by the two Principal Investigators 

(PIs)6

 of the research to some students. It was assumed senior graduate students would transmit 

the information to newer group members; however, no formal documentation system was in 

place to ensure that such information was effectively communicated to students and/or that 

students understood the information. Consequently, none of the students the CSB interviewed 

as part of its investigation, including those directly involved in the incident, stated they were 

aware of a strict 100 milligram limit. Instead, students indicated to the CSB they believed they 

should work with “very small amounts,” on the order of 200 to 300 milligrams.

4.0 INCIDENT DESCRIPTION

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.7

 The amounts of NHP synthesized were on the order of 

50-300 milligrams. Typical analytical techniques used in the laboratory to characterize the 

energetic properties of new compounds included differential scanning calorimetry (DSC),8

drop hammer tests,9

 and thermal gravimetric analysis (TGA).10 Due to the amounts of compound needed to run each analytical test,11 the students synthesizing the NHP decided they 

would need to make several batches of the compound to fully characterize it; additionally, 

they had concerns of reproducibility between batches. They wanted to synthesize a single 

batch of NHP that would provide enough compound to complete all the necessary characterizations; thus, they decided to scale-up the synthesis of NHP to make approximately 10 

grams.12 The PIs of the research were not consulted on the decision to scale up. No written 

policies or procedures existed at the laboratory, departmental, or university levels which 

5

The research practices requiring pre-approval of protocols included protection of human subjects, care and treatment of laboratory animals, and 

recombinant DNA and refer to the National Institute of Health’s (NIH) Institutional Biosafety Committee (IBC). NIH states that as part of a PI’s general 

responsibility, the PI (i.e. professor in charge of the research) should provide laboratory research staff with protocols describing potential biohazards and 

necessary precautions (http://oba.od.nih.gov/rdna_ibc/ibc.html, accessed on 8/4/2011)

6

The PI is responsible for the conduct of scientific or educational research and the publication of its results. At a university, the PI is typically a professor in 

charge of the research, students, postdoctoral researchers, and technicians working in the laboratory.

7 The events leading up to the January 7 incident were documented mainly with interviews conducted by the CSB because little written documentation 

was available. Laboratory notebooks were not dated and did not always indicate amounts of reactants used during synthesis. 

8

A technique that detects the absorption or release of heat of a sample as it is heated at a constant rate.

9

Drop hammer tests can be used as a qualitative means to determine if a material can be safely handled with reasonable care by comparing relative 

impact sensitivities to those of known explosive materials. 

10TGA is a technique detects the change in weight of a sample as a function of temperature or time.

11The laboratory protocols for DSC and TGA recommend 2 and 10 milligrams, respectively, although interviews indicated that closer to 20 milligrams were 

used for the TGA tests. The drop hammer tests require more sample, between 15 and 20 milligrams per drop, and several tests at various hammer 

heights to obtain meaningful data.

12The actual amount synthesized on the day of the incident is unknown since the product was never weighed.
CSB s Texas Tech University Case Study 5

would have required the students to consult with the PIs before making this decision. Based 

on experience, the two students had discovered that smaller amounts of the compound 

would not ignite or explode on impact when wet with water or hexane, and they assumed 

the hazards of larger quantities of NHP would be controlled in a similar manner.

After the scale-up, the more senior student observed clumps in the product, and believed 

uniform particle size of the sample was important. As a result, he transferred about half of 

the synthesized NHP into a mortar, added hexane, and then used a pestle to gently break 

up the clumps. No formal hazard evaluation13 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. At this point, the graduate student 

working on the clumps was wearing goggles, but removed them and walked away from the 

mortar after he finished breaking the clumps. Several individuals from the lab indicated that 

the decision to wear goggles was a personal choice which they based on how dangerous an 

activity was perceived to be. 

The more senior student working with NHP 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. 

This stop-work was maintained until safety changes could be implemented and an independent review board made up of energetic materials experts could audit the laboratories’ 

written standard operating procedures and safety protocols. The stop-work order at Texas 

Tech lasted approximately 4 months and up to 10 months at the other universities.

5.0 INCIDENT ANALYSIS

With any serious event, it is all too common for attention to be focused on the actions and 

decisions of the individuals involved in the immediate activities preceding the event. Yet 

modern accident causation theory recognizes that incidents are not the result of a single 

malfunctioning piece of equipment or the erroneous actions of one person, but instead are 

the result of a number of failures and deficiencies at many levels within an organization 

and its technical community (CCPS, 2003, p.89-90). Focusing safety improvements at the 

immediate level of accident causation has limited reach and impact because doing so misses 

the underlying organizational factors that influence and contribute to an incident; examining higher-level system deficiencies within an organization and making safety changes at 

those levels have a much greater preventative impact.14

This theory of accident causation can be illustrated using James Reason’s aptly named 

“Swiss cheese model” within the context of an academic institution (Figure 1).15 Reason 

uses his model to depict a series of safety layers (or system defenses) capable of preventing 

an incident. The holes represent gaps within each system where failure could occur. If a 

number of failures align, an incident results (Reason, 2000, p.769).

Thus, when the CSB investigates an incident, it not only examines the immediate events 

leading up to that incident, but it also looks beyond those events to the larger organization 

13A hazard evaluation is an organized effort to identify and analyze the significance of hazardous situations associated with a process or activity (CCPS, 

2008, p. 15).

14The Center for Chemical Process Safety (CCPS) states that identifying the underlying or root causes of an incident has a greater preventative impact 

by addressing safety system deficiencies and averting the occurrence of numerous other similar incidents; conversely, addressing the immediate cause 

prevents only the identical incident from recurring (CCPS, 2003, p. 179). 

15Reason’s “Swiss cheese model” illustrates the complexity and organizational layers that influence incident causation. Not addressed here are important 

issues that relate to the relative significance of the gaps or “holes” and the reliability or availability of the safety layers. 
CSB s Texas Tech University Case Study 6

or company involved. It identifies the regulatory framework that existed at the time of the 

incident for the work being conducted, and the safety influence of technical associations 

and professional societies. Appendix A provides a more detailed visual representation of the 

CSB’s investigative analysis; the agency used a modified technique of the AcciMap accident 

analysis tool, which aims to identify various decision-makers that have a potential for 

improving safety (Rasmussen, 2000, p. 20). 

Through a review of evidentiary records, interviews, and post-incident observations, the CSB 

concluded that each layer of safety management within the institution had deficiencies that 

contributed to the January 2010 Texas Tech incident. Additionally, the CSB identified several 

gaps beyond the university itself where safety management and practices of the researchers 

could have been influenced to aid in prevention, including the grant funding agency, the existing laboratory safety regulations, and good practice guidance. Specifically, the CSB found: 

UÊThe physical hazards of the energetic materials research work were not effectively assessed 

and controlled at Texas Tech;

UÊTexas 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;

UÊComprehensive hazard evaluation guidance for research laboratories does not exist;

UÊPrevious Texas Tech laboratory incidents with preventative lessons were not always documented, tracked, and formally communicated at the university;

UÊThe 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; and

UÊSafety accountability and oversight by the principal investigators, the department, and 

university administration at Texas Tech were insufficient.

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FIGURE 1

Examining a laboratory 

incident using James 

Reason’s Swiss Cheese 

Model of Accident 

Causation as the 

framework for analysis
CSB s Texas Tech University Case Study 7

6.0 PHYSICAL HAZARDS IN THE LABORATORY 

NOT MANAGED

6.1 TEXAS TECH LABORATORY MANAGEMENT POLICIES

In 1997 Texas Tech created a Chemical Hygiene Plan (CHP) intended to establish policies, 

procedures, and work practices to inform employees of hazards associated with chemicals in laboratories.16 The CHP was developed in accordance with OSHA’s Occupational 

Exposure to Hazardous Chemicals in Laboratories Standard (29 CFR 1910.1450). 

Developing the CHP was voluntary, as Texas is regulated by federal OSHA, and the State of 

Texas has not adopted state laws that would extend workplace safety regulations to public 

employees, including those of publicly funded universities, such as Texas Tech. The practice 

of a publicly funded university using the Laboratory Standard as guidance for creating 

its own Chemical Hygiene Plan is not uncommon. The CSB has observed other publicly 

funded universities in federal OSHA states also citing the Laboratory Standard as guidance.

As Texas Tech and various other academic institutions use OSHA’s Laboratory Standard as 

guidance, exploring the impetus for and creation of the standard is useful. Before the standard 

was established, OSHA controlled exposure to hazardous chemicals though substance-specific 

standards or, if specific standards did not exist, through permissible exposure limits (PELs) 

listed in 29 CFR 1910, subpart Z. The substance-specific standards and PELs worked well 

for industrial settings where workers were exposed to large quantities of hazardous chemicals 

in standardized, continuous, or repetitive processes (51 FR 26663). OSHA acknowledged 

that in laboratories, however, workers typically use a larger variety of hazardous chemicals, 

but in smaller amounts than in an industrial workplace, and that chemicals and procedures 

can change frequently (Hanson, 1986, p.16-17; 51 FR 26684). In response, in 1990 OSHA 

created the performance-oriented Laboratory Standard that was intended to allow employers flexibility to create work practices and procedures specific to their laboratory operations 

(Hanson, 1986, p.16-17). According to the standard, the practices and procedures created by 

the workplace itself would be included in a written chemical hygiene plan. 

Also included in the Laboratory Standard are two non-mandatory appendices intended to 

provide guidance to employers developing CHPs. Appendix A summarizes the first edition 

of the National Research Council’s (NRC) Prudent Practices for Handling Hazardous 

Chemicals in the Laboratories (Prudent Practices) (1981). Since the standard was created, 

the NRC published three updated editions of Prudent Practices: one in 1983, one in 1995, 

and one in 2011. The motivation for the 1983 and 1985 versions was “to provide an 

authoritative reference on the handling and disposal of chemicals at the laboratory level” 

(NRC, 2011, p. vii-viii). The 1995 edition evolved to address laboratory culture as it related 

to safety, health, and environmental protection (NRC, 2011, p. vii-viii). The latest edition 

expands upon the “safety culture” concept with a much stronger emphasis on management 

practices needed to ensure that organizations do not neglect safety culture (NRC, 2011, p. 

vii-viii). However, Appendix A of the OSHA standard has not been revised to reference this 

newest edition of Prudent Practices.

The Laboratory Standard addresses hazardous chemicals, which are defined as chemicals 

that have been found through statistically significant evidence to cause possible acute or 

chronic health effects. The standard has a clear focus on health hazards resulting from carcinogens, toxins, irritants, corrosives, and other “exposure” type hazards. Chemicals with 

physical hazards, such as combustible liquids, compressed gases, explosives, or flammables, 

among others, are addressed by the standard only under the employer’s training program 

16www.depts.ttu.edu/ehs/Web/Docs/Chem_Hygiene_Plan.pdf, accessed August 2011.
CSB s Texas Tech University Case Study 8

(1910.1450(f)(4)(i)(B)). The standard lacks a hazard evaluation requirement to identify or 

mitigate physical hazards.

OSHA’s initiative for a laboratory standard was to focus on hazardous chemicals. Ultimately, 

OSHA recognized that the CHP requirements of the standard did not address all laboratory 

hazards, but believed that the requirement to train employees on chemicals with physical 

hazards and other safety regulations would effectively provide protection (55 FR 3314).

Texas Tech’s CHP paralleled the OSHA Laboratory Standard, focusing on exposure hazards 

of hazardous chemicals. Table 1 lists many of the safety elements found in Texas Tech’s 

Chemical Hygiene Plan and identifies whether physical hazards were addressed within 

each. As indicated in the table, there is a requirement for written procedures, but the CHP 

explicitly states that the procedures are required for the use of carcinogens, mutagens,17 or 

teratogens,18 not physical hazards. Additionally, the CHP has requirements for hazard determinations, communication of hazards, and pre-approval of procedures, but again according 

to the CHP, these requirements do not extend to the physical hazards of chemicals.

In addition to the Chemical Hygiene Plan, Texas Tech also had several standard operating 

procedures (SOPs) that were applicable to laboratories on campus, including one titled 

“Handling and Storing Explosives.”19 The stated purpose of this SOP was to “ensure the 

protection of all employees required to handle and store explosives while performing their 

duties and experiments.” As noted in Table 1, this SOP did address training on handling 

explosive materials, but it did not address any of the other safety elements listed in the CHP 

for chemical health hazards. 

SAFETY ELEMENT POLICY DOCUMENT PHYSICAL HAZARDS OF 

CHEMICALS ADDRESSED

Perform hazard determination CHP

Reduce employee exposure CHP

Protective apparel CHP

Training on hazards of 

chemicals CHP 

Training on handling of material 

through approved facility University SOP 

Written procedures CHP

Standard operating procedures CHP

Communication of hazards CHP

Pre- approval of procedures CHP

Document material usage University SOP 

The lack of policies in the laboratory, Chemistry Department, and university to help both 

manage work and set minimum expectations will be addressed throughout the case study. 

17OSHA defines a mutagen as a substance or agent capable of altering the genetic material in a living cell (mutation), 

http://www.osha.gov/dsg/hazcom/ghd053107.html, accessed 9/22/2011. 

18OSHA defines a teratogen as a substance that can cause malformations or alterations in the appearance or function of a developing embryo, 

http://www.osha.gov/dsg/hazcom/ghd053107.html, accessed 9/22/2011.

19http://www.depts.ttu.edu/opmanual/OP60.20.pdf, accessed 9/22/2011.

TABLE 1.

Safety elements 

addressed by Texas 

Tech’s CHP and its SOP, 

“Handling and Storing 

Explosives” 
CSB s Texas Tech University Case Study 9

6.2 HAZARD DETERMINATION

The university CHP stated that PIs were responsible for determining the hazards of chemicals generated within a laboratory, but neither Texas Tech nor its Chemistry Department 

trained researchers to determine hazards, described what an appropriate determination 

includes, or verified that any evaluations had been completed prior to experimental work 

commencing. Prudent Practices recognizes that “the ability to accurately identify and 

address hazards in the laboratory is not a skill that comes naturally, and it must be taught 

and encouraged through training and ongoing organizational support” (NRC, 2011, 

p.7). Although the CHP did not identify graduate students as responsible for determining 

hazards, it seems prudent that they too should receive similar training since they may be 

working in laboratories for extended periods without PI supervision. 

While not all standards and practices used in the chemical process industry can be directly 

applied to an academic laboratory environment, drawing applicable parallels to harness the 

field’s experience and knowledge of hazardous activities involving chemicals can be useful. 

In the industrial sector, hazard determinations can be considered a three-part exercise that 

encompasses: (1) hazard evaluations and (2) risk assessments, both of which lead to (3) 

implementation of appropriate hazard mitigation strategies. 

Hazard evaluations are “organized effort[s] to identify and analyze the significance of 

hazardous situations associated with a process or activity” and have been used in the 

chemical process industry for more than 30 years (CCPS, 2008, p. 15-16). The Center for 

Chemical Process Safety (CCPS) suggests that while hazard evaluations typically analyze 

equipment failure or human error, they can also identify deficiencies within an organization’s safety management system (p. 17). In his paper titled “Improving engineering 

research laboratory safety by addressing the human aspects of research management,” 

Zakzeski (2009) offers one model of how an academic laboratory borrowed concepts from 

the industrial and business worlds to promote safety, which included formal evaluations by 

the researchers working in the laboratory. These researchers learned to conduct Hazard and 

Operability (HAZOP) analyses, a common and well-accepted tool in the chemical industry 

to analyze the ways a process can fail and result in an accident (Crowl and Louvar, 1990). 

Additionally, the researchers self-audited and used external audits to enhance risk analyses 

in the laboratory. Because a university’s Environmental, Health and Safety (EH&S) staff 

will likely not have a complete and in-depth understanding of the unique research-specific 

hazards of every laboratory, audits by those involved in the research and others with similar 

backgrounds can potentially identify hazards that may otherwise go unnoticed and provide 

an opportunity for the PI to interact and mentor graduate students on hazard identification. 

Risk assessment allows an organization to analyze the frequency and expected outcomes 

from potential incidents. It can be performed simultaneously with a hazard evaluation or 

separately once the evaluation is complete. Using a risk assessment, the organization can 

determine if it is appropriately emphasizing the most significant risks and/or how it might 

mitigate them.20 Prior to the incident at Texas Tech, there was no ALERT-wide policy that 

limited the quantity of energetic compound that could be synthesized. Post-incident, the 

ALERT Safety Review Board, which was convened to review policies and procedures of 

all laboratories participating in the ALERT program, recommended a maximum limit of 

500 milligrams. The Safety Review Board chose this limit because it follows guidelines 

set by the Navy, which determined that 500 milligrams can cause bodily injury, but that 

the injury will not be permanent. The Texas Tech PIs working with the ALERT program 

decided not to tolerate this level of risk, and so restricted the limit to just 50 milligrams in 

20The NRC provides detailed lists of data resources concerning the properties of various physical and chemical hazards and outlines that summarize steps 

used to assess risks in handling toxic chemicals and physical hazards (NRC 2011, p. 48-79)
CSB s Texas Tech University Case Study 10

their laboratories. This decision was documented by Texas Tech’s Institutional Biosafety 

and Hazardous Material Committee (IBC).21 Post-incident, the university began to include 

explosive materials in the scope of IBC reviewed research.22 

Hazard mitigation is the process of eliminating or reducing the frequency of a risk, the potential consequences of a risk, or both. A common method to mitigate hazards is the use of 

personal protective equipment (PPE). In any workplace with hazards, an organization should 

examine the reliability of the controls used to mitigate or remove the hazards (ANSI/AIHA 

Z10-2005, p. 11). Some controls are more reliable; those controls that require an individual 

to act are less reliable, and thus, less desirable to mitigate hazards. PPE usage is on the lowest 

level of the hierarchy of control because it requires the individual to take action (i.e., determine 

appropriate PPE and then use that PPE each time) for the PPE to work as a control measure. 

This was evidenced in the Texas Tech lab where the incident happened – students were allowed 

to determine their PPE needs on an individual and situational basis. For example, several 

individuals reported that they used their ordinary prescription glasses for eye protection.23 PIs 

in these laboratories made similar decisions concerning PPE, thus modeling the behavior. 

Another type of control is a procedural or administrative one, which uses safe work practices 

and procedures to reduce risk, such as a documented procedure for how to safely use a piece 

of laboratory equipment. (CCPS, 2009, p.13). Post-incident, DHS, the granting agency, 

immediately initiated several administrative safety controls, including a requirement that 

all universities involved in the ALERT program generate written SOPs and protocols to be 

reviewed by an external board of experts. Additional post-incident administrative controls 

included a Safety Awareness Education Program to provide an “Explosive Safety Protocols 

and Procedures” course every six months24 and a Safety Compliance Assurance Program.25

6.2.1 LACK OF HAZARD EVALUATION GUIDANCE IN RESEARCH LABORATORIES

The 2011 version of Prudent Practices includes a “Quick Guide” for physical, flammable, 

explosive, and reactive hazards (NRC, 2011, p. 66). The Quick Guide summarizes steps researchers might use when assessing hazards in their laboratories and includes questions that 

could lead researchers to consider potential hazards associated with their work. Prudent 

Practices does not include recommended hazard evaluation techniques labs might use to 

assure that all necessary risk information has been gathered, or any recommended practices 

for how a researcher might determine when an activity is particularly hazardous and may 

warrant input from someone with more experience. 

In industry, companies use a variety of methodologies to assess hazards, and both guidelines 

and worked examples of the different techniques have been developed and published. For 

example, CCPS’s Guidelines for Hazard Evaluation Procedures is a 550-page book that 

presents 12 different hazard evaluation methodologies, provides worked examples to demonstrate what an effective evaluation encompasses, and identifies limitations of the various 

21Texas Tech’s IBC is made up of faculty, administration, and two community members that are not affiliated with TTU, in accordance with NIH guidelines. 

The TTU IBC provides guidance “regarding proper acquisition, handling, transfer, and disposal of potentially hazardous or regulated hazardous materials,” http://www.depts.ttu.edu/ehs/Web/BioISafety.aspx#CM, accessed 9/15/2011.

22Texas Tech’s IBC defines “explosive” as “[a]ny substance or article, including a device, which is designed to function by explosion (i.e. an extremely rapid 

release of gas and heat) or which, by chemical reaction within itself, is able to function in a similar manner even if not designed to function by explosion. 

The term includes a pyrotechnic substance or article” (http://www.depts.ttu.edu/ehs/Web/Docs/HazardousChemicalProtocolForm7.12.10.doc, 

accessed 9/22/2011).

23According to Prudent Practices, “Ordinary prescription glasses do not provide adequate protection against injury because they lack side shields and are 

not resistant to impact” (NRC, 2011, p.109).

24Individuals in the ALERT program are required to attend the course within six months of joining the program and then at least every other year thereafter.

25The program includes yearly visits by the Safety Review Board to audit the safety program. Programs found to be deficient will have the opportunity to 

improve weaknesses. Failure to do so will result in a stop-work order.
CSB s Texas Tech University Case Study 11

techniques (CCPS, 2008, p.180). Figure 2, an abbreviated chart from Guidelines for Hazard 

Evaluation Procedures, identifies a number of work activities that may be performed in an 

industrial setting and indicates which of the 7 different methodologies listed would be most 

appropriate to assess the hazards of each.

At academic institutions, the research of individual PIs can differ significantly;26 consequently, 

the hazards of research can vary widely among different laboratories. Even within the same 

laboratory under a single PI, students commonly work on different projects that can pose 

diverse safety hazards. This indicates a need for guidance on various hazard evaluation methodologies and instruction on how and when each should be used within an academic laboratory 

research work environment. Detailed examples for multiple methodologies would help researchers determine the most effective way to evaluate the hazards of their work, whether they are due 

to routine procedures, modifications to current research, or entirely new endeavors.

When OSHA’s Laboratory Standard was being created, OSHA identified the American 

Chemical Society (ACS) as being instrumental in establishing that practices in laboratories 

are different enough from those in industry to warrant different rules (Hanson, 1986, p.17). 

The ACS is a nonprofit organization, chartered by Congress, with more than 163,000 

members, whose stated mission is “to advance the broader chemistry enterprise and its 

practitioners for the benefit of Earth and its people.”27 Just as laboratories warrant different 

rules, the CSB recognizes that industrial guidelines may not lend themselves to be directly 

applied to the dynamic environment of an academic laboratory without modification. An 

organization such as the ACS could create guidance appropriate for the academic laboratory setting. The ACS already has various committees (to which members are elected), 

divisions (groups of voluntary members), and task forces (formed by various committee 

and division members for a specific purpose or goal) that are focused on health and safety 

as it relates to chemistry. These include the Committee on Chemical Safety, the Division of 

FIGURE 2

Abbreviated chart from 

CCPS’s Guidelines 

for Hazard Evaluation 

Procedures listing 

hazard evaluation 

methodologies and the 

appropriateness of each 

for a variety of industrial 

activities. Research & Development ! ! " " " ! !

Pilot Plant Operation ! " ! " " " "

Construction/Start-up " " ! ! " " !

Routine Operation " " ! ! " " "

Modification " " " " " " "

Incident Investigation ! ! ! ! " ! "

Decommissioning " " ! ! " " !

SAFETY REVIEW

CHECKLIST

RELATIVE RANKING

PRELIMINARY

 HAZARD ANALYSIS

WHAT-IF

WHAT-IF/CHECKLIST

HAZOP

! Not Recommended

" Recommended

26The significance of this is amplified when contrasting the academic laboratory work environment to that of industrial chemical and refining facilities that 

often produce a limited number of products and function within well defined operating parameters.

27http://portal.acs.org/portal/acs/corg/content?_nfpb=true&_pageLabel=PP_TRANSITIONMAIN&node_id=225&use_sec=false&sec_url_var=region1&__

uuid=85cbc45b-0637-4f67-85f2-7068559c284c, accessed 9/2/2011
CSB s Texas Tech University Case Study 12

Chemical Health and Safety, and the Safety Culture Task Force. The ACS is not a standard 

setting body, but it has published several examples of safety guidance that are widely accessed, including Safety in the Academic Chemistry Laboratory (2003).

6.2.2. NO TRAINING FOR RESEARCH-SPECIFIC SAFETY RISKS 

Beyond completing a literature review, the students synthesizing the NHP had no researchspecific training, nor were the students’ understanding of the risks formally assessed before they 

started the energetic materials research. At the time of the incident, most chemistry graduate 

students, including the one injured, had not taken the university-offered general laboratory 

safety training class, which was available both online and in person by EH&S staff. In fact, 

Chemistry Department students were not required to attend this general laboratory safety 

training, and the department had not documented attendance of the training since 2002. While 

general safety training would likely not have prevented the January 7 incident, the lack of 

training is an indication of deficiencies in the safety management program at the university. The 

only safety instruction most Chemistry Department graduate students received was the general 

safety training provided when they were teaching assistants (TAs), which consisted of watching 

a 1991 ACS safety video.28 This video was intended for undergraduates and demonstrated basic 

lab safety principles. However, the safety training needs of undergraduates, who often perform 

“cookbook” laboratory work with well-understood and defined risks, differ greatly from those 

of students performing research (NRC, 2011, p.4). The ACS video does not address the need for 

hazard evaluations prior to commencing laboratory research.

6.2.3 LACK OF FORMAL DOCUMENTATION AND COMMUNICATION

To increase the likelihood that all parties are knowledgeable and aware of the risks, safetycritical information should be provided in writing and additional steps should be taken 

to verify that the recipients understand the material. The laboratory where the January 7 

incident occurred had no written protocols or SOPs for synthesizing NHP or other energetic 

materials, no written restrictions concerning the amount of compound to be synthesized, 

and no written mandatory safety requirements pertaining to the synthetic work. As such, at 

the time of the incident, there was no documented communication telling the students how 

to minimize the potential safety risks inherent in this research activity.

Formalizing policies and accepted work conduct does not necessarily prohibit a researcher 

from deviating from the laboratory standards, but the acceptable process for deviating 

should also be defined and the change documented. For example, the Department of Energy’s 

DOE Explosives Safety Manual29 describes how contractors and subcontractors are required 

to submit a written request for an exemption from a mandatory safety requirement (DOE, 

2006, p. 5). The manual states that an experienced engineer reviews the request and that an 

approved request must include plans to mitigate any safety risks the change will introduce; in 

the chemical process industry, this is called management of change. 

Prudent Practices acknowledges that “[t]he concept of change of management in the laboratory environment varies markedly from methods typically prescribed, for example in manufacturing operations. By its very nature, the business of conducting experiments is constantly 

changing. Therefore, it is part of everyday activities to evaluate modification and/or technological developments in experimental and scale-up processes” (NRC, 2011, p.13). Although 

Prudent Practices cites relevant resources of safety critical information, the CSB has found 

no guidelines or best practices on how laboratory environments might manage such changes, 

despite the inherent variable nature of the work that takes place within them. 

28The ACS video is no longer published but can be found here (http://vimeo.com/6170550), accessed 9/15/2011.

29http://www.hss.doe.gov/enforce/docs/manuals/DOE_Manual_440_1_1A_Explosives_Safety_Manual.pdf, accessed August 2011
CSB s Texas Tech University Case Study 13

Not managing these changes particularly places new graduate students at risk if their only 

training has been as undergraduates. Hill and Finster acknowledge that “[b]ecause new [undergraduate] students don’t have to design experiments, they also don’t have to think about 

designing good safety procedures into laboratory experiments because that has already been 

done by the author of the procedure. Unfortunately, in a sense, students get trained not to 

think as much about safety...” (2010, p. 6). Students in the energetic labs were not required 

to obtain permission or seek approval from their PIs prior to changing research experiment 

variables, including subjectively determined “small” increases of material synthesized and 

temperature variations. Supervisory involvement at Texas Tech with the daily laboratory 

research activities depended heavily on the students’ efforts to seek out the PI for advice 

or input. This system relied upon students correctly assessing when the PI, who possessed 

more experience and knowledge, should be sought out for consultation. There was no 

Texas Tech policy in place either at the laboratory, department, or university level that 

might provide guidance as to when it would be prudent to seek approval or input.

Two additional communication tools that could have been, but were not, used to their full 

potential at the Texas Tech lab to share daily laboratory activity information were group 

meetings and laboratory notebooks. Prior to the incident, weekly group meetings between 

students and PIs were held, but the focus was primarily on experimental results, not actual 

research activities and the safety implications of the work. Lab notebooks, often seen as a 

primary means of documenting research plans and activities, were not consistently reviewed 

by PIs and varied greatly among students; some students kept notes only on new discoveries 

while others also included daily work activities. 

7.0 LESSONS NOT LEARNED FROM PREVIOUS 

INCIDENTS AND NEAR-MISSES

“Good organizations learn lessons from incidents and take actions to strengthen their safety 

processes and programs and foster a strong safety culture” (Hill and Finster, 2010, p. 31). Yet 

reporting and learning from incidents does not always occur. Prudent Practices states, “The 

‘culture of chemistry’ is still at odds with that of safety. Some of us may have witnessed unsafe 

behavior or minor accidents, and yet, rather than viewing these incidents with concern and as 

opportunities to modify practices and behavior, we often have failed to act upon these ‘teachable 

moments.’” (NRC, 2011, p. viii) 

Approximately three years prior to the January 2010 detonation, two previous incidents had occurred within the same research groups; however, some students within these groups indicated 

that they were unaware of the incidents until after the 2010 event. While no one was injured in 

the previous incidents, they presented the PIs, and the entire Chemistry Department, an opportunity to recognize gaps in safety-critical knowledge and hazard awareness.

The first incident occurred when a reaction was being completed by a student. The reaction 

began to emit nitrogen, causing loud bangs. After another student recommended removing 

the reaction from the ice bath it was in, the banging increased. This frightened the student 

and caused her to flee. The lesson learned, as reported to the CSB investigators, was that a 

student should not leave the scene because responders may need information to be able to 

mitigate the situation. While it is important that researchers are available to consult with 

emergency responders, the CSB concludes that other safety issues could also have been 

identified. Similarities between this incident and the 2010 detonation include:

UÊNo formal hazard evaluation and risk assessment had been completed to characterize the 

potential danger of the research activity and to plan for the worst-case scenario;

UÊStudent sought peer advice;
CSB s Texas Tech University Case Study 14

UÊNo policy was in place at the laboratory, department, or university level to prompt a student to seek PI advice or evaluation of experimental activities.

Had remedial actions been taken after this 2007 incident, they could have played a preventative 

role in the 2010 event. 

The second previous incident involved a scale-up situation within the same research groups; 

a student unintentionally used the wrong units of measure and created an excess of a 

known energetic material. While reporting the synthesis at a group meeting, the PI asked 

how much compound the student had made, at which point the student reported 30 grams; 

the PI immediately separated the 30 grams of explosive material into smaller, less hazardous 

quantities. The graduate student injured in the 2010 incident was a researcher in the laboratory at the time of this near-miss and witnessed the interaction between the PI and the 

student, but the near-miss was not reported to anyone outside of the research groups. Had 

the dangers of scale-up been formally communicated through written SOPs and reinforced 

as new students joined the research group, the likelihood of the occurrence of the 2010 

incident may have been lessened.

Entities looking to improve safety should encourage the reporting of such incidents, even 

when injuries or damage do not result, as accidents and near-miss reports indicate critical 

areas where safety controls may be needed. The collection of reports from an entire department could be used as a safety metric to help determine how a department as a whole is 

doing and/or improving. 

In addition, incident and near-miss reports could become a resource for future researchers as those individuals assess and mitigate the potential hazards of their work. Zakzeski 

(2008, p. 8) suggests storing near-miss reports in an online database accessible to researchers beginning work with new chemicals or processes.30

8.0 LACK OF ORGANIZATIONAL ACCOUNTABILITY AND 

OVERSIGHT FOR SAFETY

Prudent Practices acknowledges that “the ultimate responsibility for creating a safe environment and for encouraging a culture of safety rests with the head of the organization 

and its operating units....Even a well-conceived safety program will be treated casually by 

workers if it is neglected by top management.” (NRC, 2011, p.2) The CSB determined that 

research laboratory safety was not being adequately managed at Texas Tech.

Pre-incident, both the Texas Tech Chemistry Department Safety Advisor and the EH&S 

Laboratory Safety Inspector conducted safety audits and inspections of the 118 chemistry 

laboratories on campus; they frequently found general laboratory safety violations and 

reported their findings to the PI and the Department Chair. However, remedial actions were 

often not taken. Many university safety policies either did not exist or were not enforced 

(see Section 6.0 of this case study). 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. As such, the PIs involved in the energetic materials’ 

research were aware of the university CHP, but had not read the entire document. And 

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. 

30For an example of an online near-miss database, view Department of Energy’s (DOE) Hydrogen Program website, which facilitates the sharing of lessons 

learned while working with hydrogen: http://www.h2incidents.org/. 
CSB s Texas Tech University Case Study 15

8.1 DEFICIENT SAFETY MANAGEMENT ACCOUNTABILITY AND OVERSIGHT

In order for safety to be properly managed, it should play a prominent role within the 

layers of the organizational hierarchy and with those that are involved in the work being 

conducted but may be outside the organization itself.

8.1.1 THE ROLE OF THE PRINCIPAL INVESTIGATOR

In academia, the PI generally has significant authority over his/her research. At Texas Tech, 

the issue of academic “fiefdoms” was evident; in the fiefdom system, a department is broken into smaller units that have individuals in charge (in this context, “fiefs”), where these 

individuals “are nominally subordinate to a person or persons above them, but in practice 

do pretty much whatever they want so long as they do not stray too far into some other 

fief’s territory.” As such, “each fief has an intellectual or administrative territory over which 

he or she reigns.” (McCroskey, 1990, p. 474) 

At academic research institutions, PIs may view laboratory inspections by an outside entity 

as infringing upon their academic freedom. This was the case at Texas Tech, where EH&S 

laboratory safety checks were not viewed as a means to understand how a PIs’ laboratory 

practiced safety in their absence. Instead, some PIs saw the notification of safety violations 

to the Chair as “building a case” against them, felt that the safety inspections inhibited their 

research, and considered recommended safety changes outside their control because they 

could not “babysit” their students. 

To combat cultural issues (such as fiefdoms) and bring a focus to safety within any given organization, it is important to ensure that the reporting structure allows for communication 

of safety information to those within the organizational hierarchy that have the authority 

and resources to implement safety change. Often, the Department Chair is considered the 

responsible person for ensuring safety; however, in practice, the Chair holds this managerial 

role while at the same time maintaining his/her role as a principal investigator for research; 

thus, a potential conflict exists due to the duality of the position. Authority and oversight 

of safety at a level above the Chair is a critical component of safety management within an 

academic structure. 

8.1.2 THE ROLE OF ENVIRONMENTAL HEALTH AND SAFETY

Texas Tech’s CHP stipulated that the Chemical Hygiene Specialist function as the University 

Chemical Hygiene Officer (UCHO) and be responsible for overseeing all aspects of the 

CHP. The EH&S Inspector identified himself as the Chemical Hygiene Specialist, and 

EH&S was the group responsible for conducting laboratory safety inspections. Even so, 

EH&S had no authority to shut down a laboratory; rather, EH&S saw itself as a “consultant” advising the department about how to improve and maintain safety. 

The organizational structure of Texas Tech supported this consultant role of EH&S, and 

no other group or person was appointed with an empowered oversight role. Faculty members, including the PIs, report to their Department Chair, Dean, and the Provost, who have 

direct authority over faculty and, as a result, can affect their behavior. The Vice President 

for Research has direct authority over research policies (including compliance policies) and 

internal research funds, both of which also allow for influence over faculty. At the time of 

the 2010 incident, EH&S was not under the authority of the Vice President for Research, 

but was part of the facilities office and reported to the Vice President for Administration 

and Finance (Figure 3). 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. EH&S was not required, nor expected, to report its laboratory safety inspection reports and findings to either the Vice President for Research or the Provost. 
CSB s Texas Tech University Case Study 16

FIGURE 3.

Simplified pre-incident 

organizational structure. 

Some positions are not 

included.

University

President

Vice.President.for

ĚŵŝŶŝƐƚƌĂƟŽŶĂŶĚ&ŝŶĂŶĐĞ

Provost

Chemistry.and

Biochemistry.Department

Chair

WƌŝŶĐŝƉĂů/ŶǀĞƐƟŐĂƚŽƌƐ

EH&S.Director

EH&S.Associate.Director

ZĂĚŝĂƟŽŶͬ>ĂƐĞƌͬ>Ăď^ĂĨĞƚLJ

DĂŶĂŐĞƌ

>ĂďŽƌĂƚŽƌLJ^ĂĨĞƚLJ

Specialist

;,Θ^>Ăď/ŶƐƉĞĐƚŽƌͿ

Vice.President.for

Research

ĞĂŶŽĨƚŚĞŽůůĞŐĞŽĨ

Arts.&.Sciences

Vice.President.for

KƉĞƌĂƟŽŶƐ

Post-incident, Texas Tech recognized these challenges and modified its organizational structure so that the EH&S Director reports directly to the Vice President for Research (Figure 4). 

FIGURE 4. 

Simplified post-incident 

organizational structure.. 

Some positions are 

not included. Note that 

EH&S reports to the 

Vice President who, 

through responsibilities 

of internal research 

funding and research 

policy enforcement, has 

influence over the faculty 

(indicated by dashed 

line).

University

President

Vice.President.for

ĚŵŝŶŝƐƚƌĂƟŽŶĂŶĚ&ŝŶĂŶĐĞ

Provost

Chemistry.and

Biochemistry.Department

Chair

WƌŝŶĐŝƉĂů/ŶǀĞƐƟŐĂƚŽƌƐ

EH&S.Director

EH&S.Associate

Director

ZĂĚŝĂƟŽŶͬ>ĂƐĞƌͬ>Ăď

^ĂĨĞƚLJDĂŶĂŐĞƌ

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;,Θ^>Ăď/ŶƐƉĞĐƚŽƌͿ

Vice.President.for

Research

ĞĂŶŽĨƚŚĞŽůůĞŐĞŽĨ

Arts.&.Sciences

Associate.Vice?President

ĨŽƌZĞƐĞĂƌĐŚ;/ŶƚĞŐƌŝƚLJͿ
CSB s Texas Tech University Case Study 17

8.2 THE GRANTING AGENCY’S ROLE IN LABORATORY SAFETY 

DHS is one of 19 federal agencies that collectively provide over $25.3 billion to academic 

institutions for scientific research (NSF, 2009), but not all of these agencies choose to include 

safety requirements or stipulations within their grant applications and cooperative agreements with researchers. DHS did not have safety provisions specific to the energetic materials 

research being conducted by Texas Tech within its cooperative agreement with NEU.

The Homeland Security Act of 2002 dictated that DHS would establish university-based 

center(s) to enhance homeland security. The Office of University Programs within DHS 

monitors the work in these Centers of Excellence, which support a variety of research, 

including but not limited to, microbial risk assessment, food system protection, and 

explosive-related threats. The Centers of Excellence are structured so that DHS has a 

direct cooperative agreement with the chair-university(ies) of the center, and the chairs 

subcontract work with core partners. The Centers receive a yearly grant, and DHS reviews 

the program plans of the chair-universities and core partners annually to assess accomplishments and goals for the following year. 

The cooperative agreement with NEU included stock language concerning some research 

practices, such as those involving human and vertebrate subjects. However, it included no 

particular provisions for the safety of researchers working with energetic compounds, with 

the exception of a general condition making researcher safety the university’s responsibility. 

The provisions for human and vertebrate subjects cite federal law mandating that researchers conduct their work under specified conditions. 

The CSB identified the grant funding body’s role in safety as a missed opportunity to 

influence positive safety management and behavior. Prudent Practices supports this finding 

in its latest edition: “When negligent or cavalier treatment of laboratory safety regulations 

jeopardizes everybody’s ability to obtain funding, a powerful incentive is created to improve 

laboratory safety” (NRC, 2011, p. 6). Stated more bluntly: “Whoever is in control of the 

purse is in control of the institution” (McCroskey, 1990, p. 472). The grant funding agency 

has the power to end a research contract/agreement and, thus, can play an impactful role in 

raising safety awareness and preparedness by the researcher and university. 

After the 2010 incident, the Office of University Programs in DHS added a new safety 

condition to the 2011 cooperative agreements with all universities funded by any of the DHS 

Centers of Excellence. This safety condition, the Research Safety Plan, has requirements that 

a contractor include these conditions in all sub-awards or subcontractors; specifically, that

UÊPossible research hazards associated with the types of research to be conducted under the 

award are identified;

UÊResearch protocols or practices conform to generally accepted safety principles applicable 

to the nature of the research;

UÊRecipient’s processes and procedures comply with the applicable protocols and standards;

UÊRecipient’s processes and procedures prevent unauthorized activities conducted in association with this award;

UÊFaculty oversees student researchers;

UÊResearch safety education and training to develop a culture of safety are provided;

UÊSecurity access control, where applicable; and

UÊIndependent review by subject matter experts of the safety protocols and practices is 

conducted.
CSB s Texas Tech University Case Study 18

9.0 KEY LESSONS

1. An academic institution modeling its laboratory safety management plan after OSHA’s 

Laboratory Standard (29 CFR 1910.1450) should ensure that all safety hazards, including physical hazards of chemicals, be addressed. 

2. Academic institutions should ensure that practices and procedures are in place to verify 

that research-specific hazards are evaluated and mitigated.

3. Comprehensive guidance on managing the hazards unique to laboratory chemical 

research in the academic environment is lacking. Current standards on hazard evaluations, risk assessments, and hazard mitigation are geared toward industrial settings and 

are not fully transferable to the academic research laboratory environment.

4. Research-specific written protocols and training are necessary to manage laboratory 

research risk.

5. An academic institution’s organizational structure should ensure that the safety inspector/auditor of research laboratories directly report to an identified individual/office with 

organizational authority to implement safety improvements.

6. Near-misses and previous incidents provide opportunities for education and improvement only if they are documented, tracked, and communicated to drive safety change. 

10.0 RECOMMENDATIONS 

10.1 OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

2010-5-I-TX-R1

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:
CSB s Texas Tech University Case Study 19

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)

10.2 AMERICAN CHEMICAL SOCIETY 

2010-5-I-TX-R2

Develop good practice guidance that identifi es and describes methodologies to assess and 

control hazards that can be used successfully in a research laboratory.

10.3 TEXAS TECH UNIVERSITY 

2010-5-I-TX-R3

Revise and expand the university chemical hygiene plan (CHP) to ensure that physical 

safety hazards are addressed and controlled, and develop a verifi cation program that 

ensures that the safety provisions of the CHP are communicated, followed, and enforced at 

all levels within the university.

2010-5-I-TX-R4

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.

BEYOND TEXAS TECH

The CSB is greatly concerned about the frequency of academic laboratory incidents in the United States. 

Since 2001, the CSB has gathered preliminary information on 120 different university laboratory incidents 

including: a UCLA staff research associate who was fatally burned while working with t-butyl lithium in 

2008, four injured at the University of Missouri in a June 2010 explosion involving hydrogen, and a June 

2010 fi re at Southern Illinois University that resulted in approximately $1 million in damage. In previous 

years, other institutions31 have attempted to collect data on laboratory incidents, but no nationwide 

reporting system for tracking near-misses and incidents exists; as a result, academia is missing a signifi cant 

opportunity to communicate, educate, and improve laboratory safety. The role of grant-funding bodies 

in laboratory safety requires further examination; the changes DHS made after the Texas Tech incident 

suggest that grant-funding institutions may play a critical role in infl uencing immediate safety change.

While this case study focuses on only one laboratory event, the CSB is confi dent that a number of issues 

raised by this incident are relevant to academia as a whole. With over 110,000 graduate students and 

postdoctoral researchers estimated to be working in academic laboratories (NSF, 2010), these identifi ed 

safety gaps and other issues deserve further examination and research in a larger, more comprehensive 

study on academic laboratory safety.

31For examples, see: The Laboratory Safety Institute Learning by Accident Volumes 1, 2, and 3,: 2005, http://labsafetyinstitute.org/index.html, Chemical 

& Engineering News Safety Notes Index 1976-1989 published by the American Chemical Society in 1991, and Steere, N.V., Ed “Safety in the Chemical 

Laboratory,” J. Chem. Education Vols. 1, 2, 3, 1967, 1970, 1974, and Renfrew, M. M., Ed. “Safety in the Chemical Laboratory,” J. Chem. Education 

Vol 4, 1981. 
CSB s Texas Tech University Case Study 20

11.0 REFERENCES

Advisory Committee on the Safety of Nuclear Installations (ACSNI). Study Group on Human 

Factors, Third Report: Organising for Safety; London: HMSO, 1993.

American Chemical Society (ACS), Safety in the Academic Chemistry Laboratory, 7th ed., 

Washington DC:ACS 2003.

American Institute of Chemical Engineers (AIChE). Safety Culture: What is at Stake?

http://www.aiche.org/uploadedFiles/CCPS/Resources/KnowledgeBase/Whats_at_stake_Rev1.pdf 

(accessed June 6, 2011).

American National Standard Institute (ANSI), Occupational Health and Safety Management 

Systems, ANSI/AIHA Z10-2005.

Center for Chemical Process Safety (CCPS). Guidelines for Hazardous Evaluation Procedures; 

3rd ed.; Center for Chemical Process Safety/AIChE, 2008. 

CCPS. Guidelines for Investigating Chemical Process Incidents; 2nd ed.; Center for Chemical 

Process Safety/AIChE, 2003.

Crowl, D.A. and Louvar, J.F., Eds. Chemical Process Safety: Fundamentals with Applications; 

Englewood Cliffs: Prentice Hall, 1990. 

Department of Energy (DOE). DOE Explosives Safety Manual, DOE M 440.1-1A, 

https://www.directives.doe.gov/directives/current-directives/440.1-DManual-1a/

view?searchterm=None, (accessed June 29, 2011).

Hanson, D.J. OSHA’s proposed exposure rule for labs offers much flexibility, Chemical and 

Engineering News. Aug. 24, 1986; pp 17-18.

“Health and Safety Standards; Occupational Exposures to Toxic Substances in Laboratories; 

Proposed Rule,” 51 Federal Register 14, July 24, 1986; pp 26660 – 26684.

Hill, R.H. & Finster, D.C. Laboratory Safety for Chemistry Students. New Jersey: John Wiley & 

Sons, 2010.

McCroskey, J. C., & Richmond, V. P. Motivating faculty. In Effective Communication for 

Academic Chairs. Hickson, M., III & Stacks, D. W., Eds.; Albany, NY: State University of 

NY Press, 1992; pp 159-182.

McCroskey, J. C. Fitting into the department. In Teaching communication: Theory, Research, 

and Methods, Daly, J. A., Friedrich, G. W. & Vangelisti, A. L., Eds.; Hillsdale, NJ: Erlbaum 

Associates, Inc., 1990; pp 471-479.

National Research Council of the National Academies (NRC). Prudent Practices in the 

Laboratory: Handling and Management of Chemical Hazards. Washington, DC: National 

Academies Press, 2011 (revised).

National Science Foundation (NSF), Division of Science Resources Statistics. Survey of Earned 

Doctorates: 2010. http://www.nsf.gov/statistics/nsf11306/ (accessed September 27, 2011).
CSB s Texas Tech University Case Study 21

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2010. 

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CSB s Texas Tech University Case Study 22

APPENDIX A — MODIFIED ACCIMAP DEPICTING THE 

CSB’S ANALYSIS OF THE INCIDENT
CSB s Texas Tech University Case Study 23

The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal agency 

whose mission is to ensure the safety of workers, the public, and the environment by investigating 

and preventing chemical incidents. The CSB is a scientific investigative organization; it is not an 

enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB 

is responsible for determining the root and contributing causes of accidents, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other government 

agencies involved in chemical safety.

No part of the conclusions, findings, or recommendations of the CSB relating to any chemical 

accident may be admitted as evidence or used in any action or suit for damages. See 42 U.S.C. 

§ 7412(r)(6)(G). The CSB makes public its actions and decisions through investigation reports, 

summary reports, safety bulletins, safety recommendations, case studies, incident digests, special 

technical publications, and statistical reviews. More information about the CSB is available at 

www.csb.gov.

CSB publications can be downloaded at www.csb.gov or obtained by contacting:

U.S. Chemical Safety and Hazard Investigation Board

Office of Congressional, Public, and Board Affairs

2175 K Street NW, Suite 400

Washington, DC 20037-1848

(202) 261-7600