INCIDENT REPORT. Purpose of Investigation: Gather facts to prevent future occurrences and ensure safe operations.

Transcription

1 E N VI RO NM E NT, H E AL T H & S AFE T Y E S T E S D R I V E E X T E N S I O N T C A M P U S B O X F CHAPEL HILL, NC ehs. unc. edu INCIDENT REPORT To: David Darr (Assistant Director Research Operations, Lineberger Comprehensive Cancer Center), Jeffery Maycock (Tissue Culture Facility Manager, Lineberger Comprehensive Cancer Center) From: Cathy Brennan (Assistant Director, EHS) Date: October 29, 2018 Distribution: Garry Coulson (Biosafety Officer, EHS), Darius Dixon (Executive Director, Facilities Operations Facilities Services), Greg Driver (Executive Director & University Engineer, Facilities Services), Mary Beth Koza (Executive Director, EHS/Risk Management) Purpose of Investigation: Gather facts to prevent future occurrences and ensure safe operations. Type of Incident: Burn from autoclave. Department: Lineberger Comprehensive Cancer Center Building Name: Lineberger Cancer Research Center (LCRC) Room Number(s): 1 st Floor hallway adjacent to loading dock Date of Incident: October 15, 2018 Brief Description of the Incident: Burn from steam due to autoclave operation. Incident Description: At approximately 9:37 am on Monday, October 15 th, a building fire alarm alert was received by EHS Fire Safety personnel for Lineberger Cancer Research Center. EHS Fire Safety personnel responded and after parking at LCRC loading dock was alerted by bystanders at adjacent Thurston Bowles Building loading dock that someone needed medical assistance. The injured person was in obvious distress and unable to communicate their health status. Bystanders stated that the injured person was burned by an autoclave. EHS Fire Safety personnel used radio communications to alert incoming fire department response that the fire alarm was set off by steam and their response now needed to become an EMS call for burn. CHFD was first on scene followed by EMS unit which began patient care. The Patient was transported to UNC Hospitals for further treatment.

2 The incident also produced a biohazard spill so the EHS Emergency Response Team was notified to report. The EHS Assistant Director reported to LCCC and determined that the injured person was an employee, a Laboratory Assistant working for the Tissue Culture Facility and whose duties included daily autoclaving of biohazard waste. At this time there was limited information regarding how the burn was sustained as there were no witnesses to the actual injury and the injured employee was already transferred to the hospital. Incident Investigation and Discussion: Initial investigation began at the scene during the biohazard spill clean-up. The autoclave (circled in red) is located on the 1 st floor of LCCC hallway as you walk in from the loading dock, adjacent to the elevator and drink/snack machines. The autoclave door was slightly open but jammed and could not be opened further by EHS personnel. Orange biohazard bags were visible within the autoclave. 2

3 A Facilities Services maintenance tech was requested to open door. Once opened it was apparent that the red door gasket was heavily damaged and missing in some areas. There were approximately 8 bags of biohazard waste in the autoclave. There was charring inside the chamber and what appeared to be melted plastic on sides of autoclave. 3

4 After removal of the bags, investigation of the autoclave chamber found the drain/strainer hole plugged (circled in red). In addition, the chamber gauge and jacket gauge were both reading high pressure even though they were not pressurized. 4

5 On Friday, October 19 th, C. Brennan spoke to two witnesses (#1 and #2) and on Tuesday, October 23 rd spoke to a third witness (#3) regarding the incident. Witnesses were returning from their break at Thurston Bowles and came upon the injured employee at end of Thurston Bowles loading dock adjacent to Lineberger dock. The injured employee was speaking on their cell phone and crying, and witnesses noticed the fire alarm in LCRC going off and what looked like black smoke coming out of building. Witness #1 went to front of LCRC to do a head count and called 911. Witness #2 and Witness #3 spoke to the injured employee who reported that they were burned, and that water had rushed out when they opened autoclave. Witnesses could see the employee s clothes were very wet and when they saw the EHS responder going into LCRC they flagged them down and told them that employee was hurt and needed an ambulance. It was at this time that the EHS responder radioed to dispatch that it was an EMS call. EHS obtained security camera footage of area to determine if anything related to the incident was captured on camera. The security camera is faced away from the autoclave towards the loading dock doors but captured the employee s approach to the autoclave. During the approach, the employee was not wearing the required Personal Protective Equipment (PPE). The employee had on long pants and closed toe shoes but did not have on a lab coat, apron, or safety glasses. Heat resistant gloves are seen on cart being pushed by the employee but not being worn. It is unknown whether the gloves were worn by the employee prior to attempting to open autoclave. After approaching the autoclave the employee goes out of view and then steam disrupts camera s image. On Tuesday, October 16 th, 2018, an inspector (A. Gunto) from the North Carolina Department of Labor (NCDOL) - Boiler Safety Bureau performed an inspection of the autoclave. The boiler in question is a 2001 Consolidated Mark II and had last passed inspection by the state on April 20 th, 2018 and had last quarterly preventative maintenance by UNC-CH Facilities Services on July 28 th,

6 During the inspection by NCDOL, the Supervisor of the injured employee who also runs the autoclave in question was interviewed. The Supervisor reported that training on the autoclave had occurred by a former employee who provided hands-on training over several sessions. The Supervisor stated that they were instructed to just press the On button and not indicate cycle type ( Fast, Fluid or Dry ). In addition, the Supervisor indicated that the cycle was 60 minutes but that the Controller countdown timer did not work and that they normally just waited a couple hours before opening. The Supervisor indicated that they would know if there was still pressure present if there was a high-pitched whistle when you started to open the door. 6

7 Three violations were found during the NCDOL inspection: 1. The vessel has a quick acting closure, as part of the door assembly that allows access to the vessel s chamber. It was determined during the incident investigation that the door on this vessel can be opened while there is pressure in the vessel s chamber. This vessel s door locking mechanism should not allow the door to open, unless there is no pressure in the chamber. 2. During the time of the incident investigation there was no pressure on this vessel. However, the chamber side pressure gauge read 15 psi and the jacket side pressure gauge read 8 psi. 3. The safety valve vent in this vessel is not piped to a safe location. EHS received an with an inspection report and violation detail via from A. Gunto on Wednesday, October 17 th. Items were forwarded to Facilities Services and LCCC for review. LCCC submitted a work order for removal of the autoclave from the current location and will replace with a newer model. An assessment is also currently taking place on whether the location of the autoclave should be moved to a more secure area instead of in an open hallway adjacent to an elevator. EHS reviewed the injured employee s training and determined that it was currently up to date but had some gaps over the employee s time at the University. Specifically, the employee was hired on February 19 th, 2018 and completed the EHS Lab Safety Orientation training on February 26 th, 2018 but did not complete the EHS lab worker registration form until September 6 th, 2018 (more than 6 months after starting as a Laboratory Assistant). In addition, the employee did not complete the online Autoclave Safety training until August 22 nd, Both of these trainings were completed after the employee had another autoclave related injury (August 7 th, 2018) from a different 3 rd floor autoclave in LCRC in which the left ankle was burned from a splash of hot water while 7

8 removing items. EHS made recommendations regarding completion of trainings and worker registration form as part of incident investigation report dated August 23 rd, As of the time of the completion of this report, Monday, October 29 th, the injured employee had not been interviewed in regard to the incident. As a result, the report will be updated as new details emerge. Based on current information obtained, it appears that the autoclave was overloaded, and the drain/strainer was clogged which led to the chamber over pressurizing and filling with hot water which sprayed out onto the employee when opened. This lack of appropriate specific training and understanding of how the autoclave operates led to the drain/strainer not being cleaned prior to each use which blocked the autoclave unit from exhausting. Lack of training also caused the autoclave to be opened while pressurized even though the gauges on front of unit indicated high pressure. Finally, a gap was identified where autoclave units that do not have a safety mechanism in place to prevent opening while pressurized should not be in operation on campus or pass inspection. Recommendations and Corrective Steps: 1 Recommendations LCRC needs to repair autoclave and have full inspection by vendor or remove and take out of service. Responsible Party Estimated Completion Date LCCC 11/15/2018 Completion Date Notes Work order submitted 2 3 Develop Autoclave Standard Operating Procedure (SOP) for posting on EHS website. Send out alert to lab Principal Investigators and Safety Supervisors. EHS Biosafety 10/19/ /19/2018 EHS Biosafety 10/19/ /19/ nc.edu/biolo gical/autocl ave/ 4 5 Determine if other autoclaves on campus are similar model and style and might also have lack of safety mechanism in place to prevent opening when pressurized. Create SOPs for each autoclave utilized in LCRC with specific operating instructions for each model. Train employees utilizing the SOP. EHS 10/16/ /16/2018 LCRC 11/15/2018 Taylor Campus Health autoclave has manual style door (Castle) 8

9 6 Autoclave Preventative Maintenance (PM) by Facilities Services should have sufficient details regarding what was checked, replaced or fixed to track issues with each autoclave. Implement into AIM. Facilities Services 12/31/ Autoclaves that do not have a safety mechanism in place to prevent opening when pressurized should not be in operation on campus. Any existing units such as these should be removed and taken out of operation. EHS / Facilities Services 12/31/2018 9