The 16 March explosion that maimed postdoc Thea Ekins-Coward at the University of Hawaii (UH), Manoa, resulted from her using a pressure gauge “not rated or designed” for use in a “flammable gaseous atmosphere,” according to a report issued on Monday by the Honolulu Fire Department. She used a digital gauge “to check the pressure within [a] tank” containing compressed hydrogen, oxygen, and carbon dioxide, the report continues. “When the OFF button was pressed, an electrical arc/spark created within the gauge detonated the flammable gas within the tank causing the explosion.”
The report classifies the explosion as “accidental,” although it also provides hints that the incident resulted from systemic failure rather than chance. An opportunity to reconsider the equipment was missed, for example. Ekins-Coward told the fire department investigator about an explosion that occurred “earlier in the week [when] she was conducting another experiment using” similar equipment, according to her witness statement in the report. “After reading the gauge, she pressed the OFF button and a small internal explosion occurred,” leaving “evidence of … soot and smoke stains.” But, said Honolulu Fire Department Battalion Chief Terry Seelig at a news conference, the “prior explosion had not been reported to the university. … Apparently it wasn’t of enough energy or significance to cause any damage or harm and was left unreported, so the first that the university laboratory managers … heard about it was while doing the investigation” of the 16 March explosion.
In addition, the report states that “[s]tatic shock also appeared to have been a problem as Ms. Ekins-Coward would get shocked on occasion when touching the tank. She brought this information to the attention of [lab head Jian] Yu who she said told her don’t worry about it.” At the news conference, however, UH spokesman Dan Meisenzahl discounted static as a factor in the explosions.
Why a procedure that—as Brian Taylor, dean of the UH School of Ocean and Earth Science and Technology, stated at a 17 March news conference—had “been used almost daily and without incident” for 8 years should produce such a disastrous result is still unclear. Ekins-Howard told the fire department investigator that Yu had designed the tank assembly, the report states. Yu, however, said that “the tank that failed was Ms. Ekins-Coward’s design,” the investigator writes in the report. “She bought the equipment (tank, digital gauge, pressure relieve valve, and fittings) between November 2015 and January 2016. … When the tank was assembled with its parts, a pressure test was done using the buildings [sic] air. … Several leaks were detected. So the tank assembly was taken to the Universities maintenance for help in stopping the leaks.”
The fire department investigation only looked into the specific events leading up to the 16 March explosion and cannot answer questions about wider causes, Seelig emphasized at the news conference. Meisenzahl said that he expects upcoming reports from two additional groups—the University of California (UC) Center for Laboratory Safety and the Hawaii Occupational Safety and Health division—investigating the incident will cast light on the broader issues of causation and suggest steps that need to be taken to prevent future such incidents.
The university has already established a new “chemical and physical safety committee … representative of all the schools and colleges that do research,” Meisenzahl continued. It will work with the other committees on campus involved in safety. UH, he added, already has “robust” safety protocols in place. “This is a university that secures hundreds of millions of dollars in research funding every year and you wouldn’t be able to do that if you had unsafe laboratories.”
Alas, as many catastrophic safety incidents and reports and the legal actions growing out of them clearly show, this is far from the truth, as important funders continue to ignore safety as a consideration for funding.
The UC report should be out by the end of April, Meisenzahl said, and ought to reveal a lot more about why a researcher participating in a long-running research project who had, according to statements at the 17 March news conference, received appropriate training ended up using a gauge that was, in Seelig’s words, “not suited to its purpose.”