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The National Research Council is beginning a yearlong analysis of what can be done to stop a rash of lab accidents on university campuses. In a relatively new approach, behavioral scientists will take part in the review. Link to article.

Developing an in-depth understanding of adverse events is “part of our collaborative approach” in striving for improvement in both safety and operational excellence. It is important to analyze why adverse incidents occurred.

Laboratory Director Paul Alivisatos, left, has introduced a set of incident analysis principles that focus on understanding not just the direct cause of an incident, but also the context in which decisions were made; underlying organizational strengths and weaknesses; and lessons learned. These principles were recently incorporated into PUB 5519-2 and should be applied when evaluating safety related incidents and other adverse events. Learn more about the Incident Analyses Principles and the Causal Analysis Program Manual (PUB 5519-2).

Walk into an office at Berkeley Lab today, and chances are you’ll see some employees sitting or standing in front of desks they can raise or lower by the push of a button. Adjustable, back-friendly office chairs are commonplace. On computer screens that were carefully positioned with the help of an ergonomics consultant, it’s possible to call up charts that show a steady and gratifying decline in repetitive stress injuries.

A great deal of the credit for this goes to ergonomists Mike White, Melanie Alexandre, and Ira Janowitz, who have been tireless advocates for aggressive measures to make the Lab a safer place to work. At the end of this month, Janowitz will retire from Berkeley Lab, where he has served as Ergonomics Program Manager since 2007, capping a long career at the University of California and in private practice as an expert in the analysis of work and the modifications needed, including equipment and training, to make workplaces safer and more productive.

Janowitz was an undergraduate mechanical engineering student at New York Polytechnic Institute in Brooklyn when he redirected his focus toward design of machines that were safer and more comfortable to use. So rare were courses on these topics that he had to transfer to another school, the State University of New York at Buffalo. When Ira graduated, he could not find a job doing ergonomics work. “In 1969,” he recalls, “nobody would hire a kid with a major in ‘Ergonomics.’”

He went back to school, earned two more degrees, and then spent 15 years as a physical therapist, gaining a hands-on understanding of musculoskeletal problems. Still, he wanted to find ways to prevent them in the first place. “Ergonomics tries to answer ‘how much is too much’ for any given activity,” he explains, “and that information is not only good for the person doing the job, but also for the manager assigning tasks and having responsibility for safety.”

In the 1960’s, repetitive stress injuries (RSIs) among office workers were seldom discussed —mechanical typewriters not only limited the speed of typing compared with a computer, but provided built-in mini-breaks with every line and new sheet of paper. Flat-screen heights, ergonomic keyboard adjustments, and mouse positioning were not issues, because none of this technology existed. The focus for heavy lifting was on physical strength and oversimplified formulae: “always bend your knees” rather than better design of shelves, handles, and mechanical aids. The concept of lifting with the spine tilted, but not bent, was out of the mainstream.

To the extent the workplace was harming workers, the focus was on treating damaged muscles and nerves. “It’s much better for the individual and the organization, for many reasons, to get in there before Jane Doe needs surgery for carpal tunnel syndrome,” says Janowitz. “But many employers had their heads in the sand or were dismissive. They thought that people raising ergonomics concerns were just trying to get out of work.”

In fact, the mounting incidence and costs of workplace injuries were running institutions afoul of occupational health regulators. In 1991, Janowitz was hired as a senior ergonomics consultant for the UCSF/UC Berkeley Ergonomics Program to apply his skills to consulting, research, and teaching. He stayed in that job for 15 years, based at the Program’s laboratory at the Richmond Field Station — the site of Berkeley Lab’s proposed Richmond Bay Campus.

Janowitz started working along with Mike White at Berkeley Lab 7 years ago. At the suggestion of their supervisor, Richard DeBusk, they set up a system of “Ergo Advocates” in every division to work closely with employees. White and Janowitz also pushed hard for more adjustable equipment, like the sit/stand desks. The team effort has paid off. Awareness of ergonomic issues has been woven into the effort to promote a safety culture at Berkeley Lab, and ergo-related recorded injury rates have fallen 50 percent since FY2007. Lower medical costs and lost time have more than offset the costs of ergonomic equipment. “We’ve run the numbers: the Ergonomics Program is saving the Lab approximately $1 million a year,” Janowitz says.

Janowitz is retiring at a time of tight budgets, and he worries that if his own position is not filled, the gains could be lost. “We don’t want to go back to 30-40 ergonomics-related injuries per year,’’ he says. Although he will be leaving Berkeley Lab, he expects to continue to work in ergonomics, but on a part-time basis. “I plan to be a half-time ergonomics consultant, half-time Grandpa,” he promises.

It takes guts to share your mistakes and near misses with your colleagues. Who wants to look foolish when they can keep mum, silently vowing not to repeat said mistake? The Materials Sciences Division (MSD) not only gets people to freely admit their mistakes and near misses, but it rewards the year’s best close call in an annual competition.

“We’ve learned a lot of things and identified some significant problems since we started the near-miss program six years ago,” said Rick Kelly, MSD safety coordinator.

It all started after a gas cylinder rolled off a gas cylinder cart in Paul Alivisato’s campus laboratory in 2006. This wasn’t the first time a cylinder had rolled off the cart. But it was the first time an injury happened because of it. Instead of reporting the cart so that it could be modified and made safe, lab personnel had worked around the problem. That behavior had to change. Creating the competition allowed for a fun way to learn from near misses, like the cart, and turn potentially embarrassing episodes into learning opportunities for all.

Now, every year MSD workers look to similar situations to make their workplace safer, Kelly says. Sharing what almost went wrong, or what did go wrong but did not result in injury has been a staple of the aviation industry for the last four decades. The Aviation Safety Response System (ASRS) collects voluntarily submitted safety incident/situation reports from pilots, controllers, and others to help maintain and improve safety in that industry. The ASRS was created after misunderstandings during a 1974 cockpit and control tower conversation resulted in a crash killing all on board.

ASRS has become an industry standard where concerns can be raised in a safe, non-punitive environment, just as it is with the near miss program. As long as the incident happened at an MSD facility, it is eligible for the annual competition, where winners are chosen using an applause-o-meter to gauge the loudest audience-generated response. Students and post-docs are the judges and the grand prize is a cash reward.

Last year’s entrants included a hot plate that was in the “off” position but actually was on “high,” discovery of a chemical stored in a glass jar that should have been in a plastic container, a clogged sink with unknown chemicals that nobody fessed up to, exposure to a concealed high-voltage power source, a clogged valve on a liquid nitrogen tank, and the improper delivery of volatile chemicals.

All of these situations could have escalated into something more dangerous. Some were mechanical and had nothing to do with operator error. Others arose from shortcomings during the performance of lab procedures. However, an open environment and “Just Culture” that promotes awareness and the ability to learn from past mistakes lifts the stigma associated with making mistakes and fosters a more effective safety culture.

The winner of the 2012 competition was Karl Walczak from the Division’s Joint Center for Artificial Photosynthesis. Coolant from a piece of equipment was leaking all over the floor so he closed the coolant valves, cleaned up the puddle of chilled water, poked around the inside of the machine for additional leakage, and posted a note explaining what he’d done. Crisis averted; he had eliminated a potential tripping hazard.

Months later inspectors noted that Karl had removed a metal cover on the device during his clean up, exposing a high voltage energized power transformer. Walczak realized he previously had been cleaning the water spill near a live power source. He admitted he should have better assessed the situation, like unplugging the device, before cleaning the spill.

The saying goes that hindsight is 20/20, where time and perspective allow us to see problems differently. The near-miss program encourages this type of analysis in a non-punitive environment. And, it makes the process fun.

Caption: A pressure-relieving lid didn't do its job and caused a container of "Piranha Etch" to rupture during the night, spewing caustic material throughout a closed fume hood. The takeaway is that the researcher has since developed a way to catalyze the chemical breakdown, thus preventing a potential gas-generating reaction.

Date: 4/22/13

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When Anna Javier walked in to her battery research lab in Building 62 last fall, she was startled by the condition of the package delivered just inside the door. “It looked,” she recalls, “like a truck had run over it.” She also knew the chemical inside that package, sodium ethoxide, to be a flammable solid:  Expose it to enough moisture in the air, and it will generate flammable gas. Quickly, she picked up the crushed cardboard box and placed it inside her laboratory’s fume hood, about five feet away. When Javier opened up the box, she found nestled in the inert packaging material a metal container meant to protect the glass bottle of sodium ethoxide inside. But the container was almost as badly damaged as the cardboard box, and the 10-inch bottle itself had apparently cracked. She cleared out any flammable materials nearby and contacted her safety manager Ron Scholtz. Although the package and its contents were now stored safely in the fume hood, a fire truck and a hazmat team were dispatched to assess the risk. The entire package was placed in a containment canister and taken to the hazardous waste disposal site.

A postdoc who is conducting research on block co-polymer materials for advanced batteries, Javier is accustomed to handling packages of chemicals, and her prompt action to isolate the damaged box assured there would be no further problems. So she was surprised to learn she was being lauded for her work with a Safety Spot Award. “I just did what I was supposed to do,” she says. “This was a highly corrosive chemical. If that package was more open than it was, the delivery people could have been exposed to it.” Javier’s conduct is being recognized, however, precisely because she “did what she was supposed to do.”  Her actions were cited for exemplifying how safety awareness and quick thinking are integral to work in a scientific laboratory.

The incident was reviewed in group meetings.  “We identified some weaknesses so we can improve our procedures,’’ says Scholtz.  One lesson learned from the case was to make sure that Transportation Services personnel know that packages should be inspected for signs of damage at the loading dock.  They should be reported to a safety manager and not be delivered if signs of damage are found. The incident also presented an opportunity to make sure Lab personnel are aware of other procedures meant to keep deliveries safe:

1. Make sure hazardous materials are delivered directly to a laboratory, not to an office. The electronic ordering system automatically writes-in a delivery address, which should always be checked and, if necessary, changed to that of a lab location.
2. Do not store packages of hazardous materials in offices or hallways.
3. Inspect all delivered boxes for damage before opening. Packages with obvious damage should be placed unopened in a fume hood and reported to a lab manager.
4. Wear chemical gloves, a lab coat, and safety glasses before opening chemical packages.
5. Open chemical packages, whenever possible, in a fume hood with the exhaust fan on.
6. Open chemical packages carefully, watching for leaks, loose caps, or broken glass.

Stop and immediately call x6999 to report any unusual problems when opening a package. Then notify a supervisor.

Whether it is energy-saving technologies for buildings, or discovery of an accelerating universe, a lot of good ideas are hatched at Berkeley Lab, and word does get around. Thanks to David Singer, who worked as a postdoc for four years in the Earth Sciences Division, Berkeley Lab’s safety culture has traveled with him to his new job in Ohio as an Assistant Professor in the Department of Geology at Kent State University.

“At Earth Sciences I worked with robust and well-maintained safety procedures, and I was keen to bring some of the Lab’s safety culture with me when I started my own lab from scratch,” says Singer. He set up safety guidelines and protocols based on Berkeley Lab EHSS documentation, as well as on protocols set up specifically for the Nanogeoscience Lab. For his new group he produced a lab-specific primer that supported Kent State’s own Office of Research Safety policies.

His primer is meant to serve as a contract for all researchers working in his new lab. It establishes an integrated safety management approach, which assures that waste and risk are minimized in the course of meeting project goals. Singer started his new position at Kent State last summer, and spent the fall semester outfitting his new lab. His research group will conduct work in environmental mineralogy and geochemistry, focusing on the fate and transport of metals and radionuclides in the environment. His group is conducting laboratory experiments to determine the partitioning of aqueous heavy metals and radionuclides onto mineral surfaces. Singer says he plans to share his primer with the Kent State safety committee and others in the research community to help spread the word and help them adapt these protocols and guidelines to their own laboratories.

How does an organization move the concept of safety culture from something hypothetical to an integral part of an organization’s fabric? That’s what the 15 members of the City of Berkeley’s Safety Committee wanted to know after hearing a presentation about how Berkeley Lab approached the subject.

Gathered around a conference table during a Jan. 9 meeting, the group took pride in its own strong safety record, but acknowledged there was definitely room to improve. “How did you get your culture to take root?” a city employee asked. The answer from Berkeley Lab’s Safety Culture Work Group Chair Mike Ruggieri was simple: Management set the tone and showed where it stands on the issue. Once employees realize management takes safety seriously, they made it a priority themselves.

This wasn’t the first time the City and Lab came together to discuss safety culture. Berkeley City Councilmembers Linda Maio and Gordon Wozniak, who had both worked at the Lab earlier in their careers, along with City of Berkeley Human Resources manager Margarita Zamora, visited the Lab in late 2012 for a tour and discussion. Maio and Wozniak knew from previous experience that safety culture was imbedded into all activities at the Lab. They came to see how their neighbors got there.

During that initial meeting the three asked Ruggieri if he would make a presentation to the municipality’s safety committee, comprised of department heads, union liaisons, and other management of the city’s 1,300 employees.

At that committee meeting Ruggieri explained that compliance enforcement can be used to improve safety performance, but at some point a plateau is reached.   To improve further, an organization needs to develop and sustain a mature safety culture that includes safety awareness in everyday business practices.  He pointed to the Lab’s Integrated Safety Management (ISM) as a successful part of the culture, where safety is incorporated into projects from the initial planning stages forward.

The Lab’s Safety Spot Award program, which recognizes employee exhibiting safe behavior with a certificate and cash award, was another example of a successful way to sustain the culture. The Berkeley committee especially liked how any Lab employee could nominate another for an award. The new Safety is Elemental pins, which are given to Spot winners, also resonated with the group.

The sharing of ideas energized both parties, with City of Berkeley employees brainstorming how they could improve their strong safety culture and the Lab delegation receiving validation that it is continuing to work toward a first-in-class culture.

This new year sees Berkeley Lab’s roadways and walkways busier than ever. There’s always the expected traffic from everyday business. Plus, construction at three major building sites and a temporary closure of McMillan Road between Buildings 17 and 71 due to a potential landslide are causing increased congestion.

A lot is happening and it’s a given we all have to be aware while driving and walking here on the hill. So what can we do as a community to make our roads and walkways safer? Drivers of construction vehicles have been given strict instructions to use their lowest gears and to not text or talk on cell phones while driving on the hill.  Most of these subcontractor drivers are complying, though I hear occasional accounts of some drivers – including both automobile and construction vehicle drivers – not heeding stop signs or driving through pedestrian-occupied crosswalks. And often I see improperly parked vehicles obstructing marked roadways and walkways.

I’d like to enlist your help to address these issues.  It will require both innovation and teamwork, where we are all watching out for each other. I encourage you to post your ideas and comments on this subject to our Safety Culture Forum. Let’s keep the conversation going on how we can all help each other make Berkeley Lab’s thoroughfares safer. The Forum is also a great platform to voice other Safety Culture related topics, ideas, and concerns.

Thanks for your help!

— Glenn Kubiak

Date: 1/9/13

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Eight years ago, Berkeley Lab scientist Thorsten Weber, left in photo, injured his back lifting a heavy steel lid across the top of his 500-pound reaction microscope and — in a strange way — we may all be better off for that.

With two prolapsed disks, the 6’ 4” German-born scientist has become as sharply focused on ergonomic safety inside the laboratory as he is on exploring the dynamics of atoms and molecules inside vacuum chambers.

 With help from EHSS ergonomist Melanie Alexandre, he has created a new partnership to prevent ergonomics-related injuries among scientists and staffers working with the unique equipment found throughout Berkeley Lab.

“Every day, I bring my bad back to the lab,” says Weber. “We want to work safely, and to take this seriously.”

In the office environment, a healthy new respect for ergonomics has led to redesigned keyboards, adjustable chairs and desks, computer glasses, and appropriate training to prevent repetitive stress injuries at workstations. Weber says the same attention to detail is needed to prevent injuries when working around laboratory equipment. “Ergonomics should not stop at the office,’’ he says.

Scientific labs are unusual environments, often filled with big, heavy, one-of-a-kind contraptions built with stainless steel pipes and chambers. Daily work around them can involve awkward body stretches to tighten a fitting; extended reaches to raise heavy objects; and pretzel-like contortions to make adjustments to out-of-the way switches, bolts, and gauges.  People can and do get hurt, and Weber is adamant: “these injuries are preventable.”

Weber says he struggled for a long time to develop a systematic approach to ergonomic issues in the laboratory, but his efforts did not bear fruit until he got help from Richard DeBusk at EHSS, who listened to his concerns and assigned Alexandre to work with him.  “I put my ‘laundry list’ on the table, and she helped me organize and realize suitable remedies,” says Weber. They took a project-management approach, identifying problems and solutions and then tracking their progress in meeting goals. Alexandre lined up experts and vendors. Sometimes the answer lay in buying ergonomically designed wrenches and power tools. Sometimes it was simply to purchase new step-ladders and stools. Sometimes the scientists had to build their own platforms from ubiquitous 80/20 aluminum frames. For jobs requiring a stretch forward to access hard-to-reach places, Weber’s Chemical Sciences Division colleagues designed and built a “leaning frame” to support a worker’s torso.

 “Scientists themselves have so many different priorities that they can’t do this alone,” says Alexandre, a Certified Professional Ergonomist working for EHSS. “They are busy. They have deadlines.” She sees her role as that of a facilitator, coordinator, and communicator. She tries to draw on experts from across divisions and outside the lab, building an interlocking network of expertise. “We’re not just helping people who are in discomfort,’’ Alexandre explains. “We are about understanding the human side of our interaction with equipment and machines.”

 Safety involving ladders, lasers, and hazardous materials has always been paramount at Berkeley Lab, and she works closely with division safety coordinators to make sure that “our brilliant new idea for ergonomic improvement doesn’t create a new and unexpected hazard.” It involves lots of meetings, she says, “with all the right people in the same room.”

In six short months of working with Alexandre, Weber said enormous progress has been made in addressing concerns that have worried him for years. So far in this collaborative effort, his group has spent $4,000 on safety equipment. “Melanie has helped us spend our scarce time and money wisely,’’ he says.

Every time he is reminded by a jolt of back pain, Weber is haunted by the notion that it could happen to someone else. Investments in a culture of safety, he says, are a bargain. “If only I hadn’t lifted that lid… It only has to happen once, and it can change your whole life.”  

“From day one you’ve taken safety seriously,” said Lab Construction Safety Engineer Mike Kincaid, who along with Don Beaton, senior construction manager of the Facilities Division presented the Award. 

Rodriguez credits his employer, Walters & Wolf, when it comes to his passion for safety. The LBNL subcontractor is responsible for the glass exterior walls at the new General Purpose Laboratory (Bldg. 33) construction project. In his 17 years at Walters & Wolf, he has become well acquainted with the importance of safety in the workplace, including JHA’s and site-specific training—knowledge that helped him meet the high safety standards set here at the Lab.

Rap may be an unorthodox way to raise safety awareness at a construction site, but Kincaid isn’t complaining. The clever rap is a great example of establishing, monitoring, and sustaining safety awareness on and off the construction site.  

I’m proud of our safety culture at Berkeley Lab.  We have a groundswell of support coming from all levels of every division. This broad participation manifests itself in a consistently strong safety culture as well as in new and innovative ways to keep the conversation on the subject relevant and meaningful.

I’d like to highlight three instances where crowd-sourcing types of initiatives have contributed toward the betterment of our safety culture.

Two years ago, an optional Lab-wide survey asked employees what safety culture meant to them. The 2,200 respondents proved it was a subject that mattered immensely. A working group then hosted a contest, asking members of the lab community to put forward a slogan and icon that represented the Lab’s commitment to a strong safety culture. Again, the numbers were impressive, with more than 150 entries submitted. The winning “Safety is Elemental” slogan and icon evocative of the Periodic Table came from within the Lab.

The Safety Concerns Program relies entirely on voluntary employee submissions to address potential or existing hazards within and outside of Lab buildings. Information about loose stairway treads, unclear roadway markings, and potentially inadequate ventilation systems all have been identified through the program. A self-monitoring approach like this should be applauded and demonstrates how employees care about their own and each other’s well-being. I’m a strong proponent of having approximately 4,200 pairs of eyes watching out for one another’s safety every day.

Modeled after the way the commercial aviation industry continuously works to improve safety, the Material Science Division’s Near Miss Program is in its sixth year.  It actually started in my Lab on campus when a gas cylinder rolled off a cart and injured an employee. The cart had been used hundreds of times with the knowledge that cylinders were prone to roll off and create a potential hazard. Instead of modifying the cart, users just dodged the rolling cylinders when they fell, not taking advantage of learning from those potential hazards. The Division now uses this example to fuel the Program, where near misses are turned into learning opportunities. Rick Kelly administers the program but it is the many students, post docs, and lab technicians who contribute and then vote on which near miss entrant should receive a Spot Award.

All three of these activities have become successful not because people are required to participate, but because they want to. This is further proof that a strong safety culture is the responsibility of every individual at the Lab. I’m confident that we have a rich culture here and I want to build upon that by asking each of you to think about how safety factors in to everything you do here at the Lab and beyond in your personal lives. Have a look at this website, too. It offers a wealth of resources.

— Paul Alivisatos 

It was a chance encounter on a Wednesday afternoon in late September that may have saved Xavier Permanyer’s life.

Mike Kritscher, left, is a Berkeley Lab engineer who works routinely on safety issues with scientists at the Advanced Light Source. He runs monthly safety circle meetings where Engineering Division staff and Lab scientists discuss safety matters. On that Wednesday he wanted to check-in with Permanyer, a recently hired mechanical engineer from ALBA, the synchrotron light source in Barcelona.

“I thought about giving him a phone call, but then thought, ‘I could use a stretch,’ and walked over to his office,’’ Kritscher remembers.

As they chatted, Permanyer decided on the spur of the moment to ask what he should do about this odd swelling in his ankle, which was making it harder to bike up the hill for him. “Maybe it was affecting my ability to work,” he thought. He rolled up his left pant leg.

“His ankle looked like a bratwurst,” recalls Kritscher. “It looked painful and worse than my own foot did, after I had broken it.”  

Permanyer had gone to his doctor the day before and was given a test for gout. The results were negative, but there was a rise in infection-fighting white blood cells. The doctor was not available to see him, so another appointment was set for Friday.

Kritscher saw the need to act quickly. He walked his new charge to his electric GEM car and they scooted up the hill to Health Services. “I knew we had help available right here, so there was no persuasion needed,” says Kritscher. At the clinic, Dr. Peter Lichty was emphatic: Take him to the emergency room. Do not delay! Kritscher contacted Doug Taube, an ALS chemist and safety team member, who volunteered to drive Permanyer to Kaiser Oakland, where he was admitted immediately.

“They told me that if they could not stop this infection, they would have to amputate,” Permanyer says. “At first, I thought it was just not possible. Only afterwards did I become scared. If it had gotten into my blood, I could have died.”

A week later, he was discharged after successful treatment with intravenous antibiotics. As is usually the case in such infections, the microbe was never identified, and the cause — likely a small cut on his foot — was not determined. What mattered was that the antibiotics worked. “They told me I was very lucky to have come there so quickly,’’ he recalls. “If I had waited until Friday, I don’t know if I would still have this foot. Sometimes small things make a big difference.”

This story has a happy ending. Permanyer gets to keep his foot, and for his efforts Kritscher won a Safety Spot Award from the Lab’s Safety Culture Initiative. The brass pin bears the phrase “Safety is Elemental,” which was coined, incidentally, by the ALS Communications Group. The lesson here: A vibrant safety culture is not just about wise precautions around the Lab. It’s about taking care of each other, at home and on the job.