A previously confidential report prepared by the California Bureau of Investigations (BOI) reveals a reckless disregard for worker safety by a UCLA chemistry professor (and the university itself) which led to the 2009 death of research assistant Sheri Sangji, 23. Sangji was a new employee in a UCLA chemistry lab. She was hired primarily to set up lab equipment, but on Dec. 29, 2008 she was assigned to use a highly reactive liquid that spontaneously ignites when exposed to air. The BOI report calls into question UCLA's claims that the young woman was a trained and experienced chemist.
The LA Times' Kim Christensen was the first to report on Saturday (1/21) on the content of the BOI's special investigation. The BOI report, dated December 23, 2009, was used by the Los Angeles District Attorney in bringing felony charges against the UCLA Board of Regents and chemistry professor Patrick Harran for willful violations of worker safety regulations. Those charges were brought last month. Saturday's LA Times' story quotes UCLA's vice chancellor for legal affairs claiming that Sheri Sangji was an experienced chemist:
"It was not as if UCLA found a newbie who didn't know what she was doing and put her in a lab with no regard to the consequences...We didn't just pluck her off the streets and put her in a chemistry lab. She was a trained chemist."
The BOI report challenges those assertions. The victim
"was not following acceptable procedures for transfer of the pyrophoric reagent at the time of the incident" but, she had not "received the necessary training relative to making a transfer of the reagent."
The investigators spoke to Ms. Sangji's previous employer, Norac Pharma, which reported that in her four months of employment, she was "closely supervised and did not perform any independent lab work 'due to her limited laboratory experience.'"
Some of the most incriminating details involve unsafe practices passed on from the principle investigator and senior researchers to the staff:
"Contrary to the warnings offered by Aldrich [the manufacturer] it appears that Victim Sangji attempted to make multiple transfers of t-Butyllithium using the same syringe. Although a common practice in Dr. Harran's laboratory, multiple syringe use can result in plugged needles and frozen syringes due to hydrolysis or oxidation of the reagents and thus lead to excessive force being placed on the plunger of the syringe. Further the Victim's use of a 60ml syringe in an attempt to complete an approximate 53ml transfer of reagent, is contrary to both the procedures outlined by Aldrich, as well as prevailing scientific literature, which indicate that the syringe be at least twice the size of the intended transfer. The failure to follow the so-called two times rule, can cause the plunger to become unstable and creates a greater likelihood that the plunger can be inadvertently pulled from the syringe barrel. Additionally, the manual manipulation of the syringe plunger, confirmed as an accepted practice by Dr. Harran, is also contrary to the express warnings issued by Aldrich." (emphasis added)
A postdoctoral research in the lab, Paul Hurley, PhD,
"confirmed that he did not follow the Aldridge bulletin himself and did not believe that he had ever read the Bulletin. Further questioning relative to Dr. Hurley's actual practices revealed that many of the procedures that he employed when conducting research were, in fact, contrary to the procedures outlined by Aldrich."
As far as Sheri Sangji's training on using a pyrophoric substance----a compound that ignites spontaneously in air:
"The investigation revealed that procedures utilized by Victim Sangji on the date of the fatal incident were inconsistent with both the protocols outlined in the Aldridge Technical Bulletin AL-134 and accepted laboratory practice. In fact, Victim Sangji employed many of the same improper techniques used by Dr. Paul Hurley, which suggests that Dr. Hurley had provided some level of guidance during the Victim's completion of the initial reaction on October 17, 2008."
If UCLA is intent on sticking to its claims that Sheri Sangji was a "trained chemist," they'll have to figure out how to spin the fact that she was "trained" by UCLA agents to perform a procedure in a manner that led to her death.
The 95-page BOI report reveals numerous safety and management lapses that could have prevented Sheri Sangji's work-related death. It also provides a compelling example of why workplace fatality scenes must be treated as crime scenes----not simply "accident" scenes----until all relevent investigations are completed. The report notes that the day after the Dec. 29, 2008 incident,
"Deputy Fire Marshall Lutton, along with Dr. Harran and other personnel from UCLA's EH&S Department, returned to the incident scene and noticed that several items were missing or had been moved. ...It was later determined that Postdoctoral Researchers Dr. Hui Ding and Dr. Wei Feng Chen removed a number of solvent drums that were being improperly stored in the incident lab, at the instruction of Dr. Harran. ....However...it does not appear that Victim Sangji's fume hood was altered."
An arraignment date on the felony charges is set for February 2.
Looks like the CA BOI did a good job. FYI the Bureau of Investigations is part of Cal/OSHA (formally the Division of Occupational Safety and Health or DOSH)and conducts criminal investigations of safety and health incidents. Even if you have lots of letters after your name, following safety and health programs and practices is a must.