INCIDENT REPORT INSTRUCTIONS Northwestern University ? Vice President for Research ? University Safety Committees ? Office for Research Safety ***A sample completed form is appended to these instructions. *** When to Submit an Incident report An incident report must be delivered to the Office for Research Safety within five days of the incident. Reports are reviewed by the Chemical and Biological Safety Committee, or the Radiation Safety Committee. ? An incident is defined as any unplanned and unwanted event that occurred during the performance of work activities and that resulted in or could have led to injury or material damage to property.
Incident repercussions range from minor (e. g. , a broken mercury thermometer) to significant (e. g. , a 5-gallon bottle of sulfuric acid dropped in a heavy-traffic hallway). ? An Incident Report is appropriate for “near misses,” incidents not resulting in personal harm or property damage, but which might have, under slightly different circumstances. ? The Incident Report requires responses from (I) the person involved, (II) any witnesses to the incident, and (III) the Principal Investigator/Supervisor. Attach additional pages if necessary to complete the report.
Reports that are not signed by the PI/supervisor will be returned for completion. The committees require input from the supervisor. See completed Example following the instructions. ? Commonly, there are multiple causes in any given incident—all of which should be identified. Provide a complete and detailed response to each question, making a serious attempt to identify all “root cause(s). ” The contributing factors were probably evident, but overlooked or unrecognized previously. These factors become more distinctly identifiable in light of the specifics of the incident A well-planned work process will include multiple layers of safeguards.
Once causes are identified at all levels, consider safeguards and procedures that might be changed to prevent future incidents. . ? This report is not intended to assign blame; it should be used as a tool to foster recommendations for procedural improvement. A well-prepared report will identify all work systems that need to be redesigned to compensate for foreseeable human errors. Information gleaned from these reports will also be used to improve safety policies. ? The Incident Report is required for all incidents, and must be submitted to the
Office for Research Safety within 5 business days of the incident. Delaying may result results in lost or forgotten details. Your department will be contacted by the Office for Research Safety if an incident report is not received promptly. Incident Response ? Please refer to the Emergency Response Training Fact Sheet Section 6. 3. 4 of Chemical and Biological Safety in Laboratories for definitions of incidental spills you can clean up yourself versus major spills that require assistance, either by ORS or an outside agency. When in doubt, contact ORS for help.
Both types of spill require an incident report. ? Emergency Phone Numbers and procedures may be found in your department emergency evacuation plan, your Safety Desk Book, your Employee Safety Handbook, or the Office for Research Safety web page: http://www. research. northwestern. edu/research/ors/emerg/index. htm The Incident Report Form is located at http://www. research. northwestern. edu/research/ORS/online_forms. htm under Laboratory Safety Forms. Incident Report Instructions and Sample Updated 4/18/2007 INCIDENT REPORT SAMPLE Northwestern University ? Vice President for Research ?
University Safety Committees ? Office for Research Safety ***Instructions on when and how to complete this form may be found at http://www. research. northwestern. edu/research/ORS/online_forms. htm under Laboratory Safety Forms. *** Hint: Save this file to your computer, complete your section, email a copy to the next person for their part, and when all information has been entered, printed, and signed by the Principal Investigator, return it to Tech, NG-71 . I. Report by person involved Name: __Josephine Doe____________ Department: ___Chemistry_________Date
Prepared: December 20, 2007__ How long at this job? _3 wks______Position/Title (e. g. , Grad Student, Technician, Post-doc) ___Graduate Student___ Location of Incident: ___Tech G222_________Date/time of incident: _December 18, 2007_ / Principal Investigator/Supervisor: ___Frank Nobel_________________________ 7:30 am_____ A. Describe how the incident occurred. 1. Explain the operation in which you were involved. What were you doing before the incident occurred? What was your goal? What were you doing at the time the incident occurred? What were the conditions of your work?
Is this a routine operation? I was washing a volumetric flask. I added a mixture of acid (hydrochloric and nitric) to the flask, a procedure typical in our lab. I was holding the flask and swirling the acid along the inner walls. 2. Describe the incident in detail. What happened? A reaction occurred inside the flask. I had capped it to prevent spillage. A pressure build-up blew the cap off the flask and sprayed acid on my face. In shock, I dropped the flask on the bench and it shattered, spilling acid on the surface. 3. Describe the sequence of events that followed the incident.
How did you respond? I ran to the eyewash at the sink and rinsed my face for approx. 15 minutes, holding my eyes open with my hands. I called UP and requested emergency assistance. Paramedics arrived about 10 minutes after that. 4. Describe any equipment, machinery, or instruments in use at the time of the incident and their potential contribution to the incident. No equipment involved. B. Did you sustain any injuries? What were they? How were they treated? Did you require medical care? Describe the severity of the injury. Page 2 of 5 Pages
Limited burns to my face on my forehead and eyelids. I was taken to the emergency room where my face was rinsed again and treated with topical antibiotic cream. I will have to avoid sunlight for a week since I sustained a second-degree burn. C. Was there any property loss or damage? Please elaborate. The flask was broken. The acid permanently stained the work surface. Acid was sprayed as far as 20 feet from the spill site. ORS cleaned the acid contamination. The lab was closed the next morning after the spill because no one could work in the area while ORS decontaminated it.
D. Safety Rules and Procedures. 1. Was the use of personal protective equipment (PPE) necessary during the given operation? Was the PPE worn? What did it consist of? I was wearing a lab coat and nitrile gloves but no eye protection. I should have been wearing safety glasses. 2. What type of training did you receive prior to engaging in this operation? Was the training adequate? What did it consist of? I received ORS general safety training when I entered the program my first year. No training since then. Also, no training in my lab as to specific procedures.
I believe I should have annual refresher training. 3. Are there any specific safety rules which apply to this procedure? Were they followed? Are they adequate? No specific rules established for cleaning of glassware. There are rules regarding PPE. Safety glasses are required and I will wear them from now on. 4. Other comments. I was working alone in the lab. I won’t do that again since I could have used help in locating the eyewash. E. Causal Factors 1. What do you perceive to be the causal factors behind this incident?
This could include: inadequate management oversight; lack of appropriate safety policy; proper equipment not used, required, or supplied; etc. Lack of a standardized procedure. An adverse reaction between the acid and contaminants was never addressed in training so I didn’t realize it could occur and how to adequately handle the situation. 2. What are your recommendations for preventing recurrence? Better awareness (training) about the reactions that can occur between chemicals. II. Other Individuals Involved/Witnesses where applicable 1. Name: __None____________________ Position_____________________ _
A. Description of Incident – Where were you and what were you doing when the incident occurred? What did you see? Page 3 of 5 Pages Incident Report Instructions and Sample Updated 4/18/2007 B. Additional comments or observations. 2. Name: __________________________ Position_____________________ _ A. Description of Incident – Where were you and what were you doing when the incident occurred? What did you see? B. Additional comments or observations. III. Report by Principal Investigator/Supervisor A. How and when did you learn of the incident? I received a phone call from the student the next day.
B. Contributing/Mitigating Factors – What do you perceive to be the causal factors behind this incident? This could include inadequate management oversight; lack of appropriate safety policy; improper procedure; proper equipment not used, required, or supplied; etc. There was a reaction between the acid and an organic contaminant in the glassware. The flask should not have een capped. The capping caused a pressure build-up to occur in the vessel. The student did not consider the possibility since we had not discussed glassware cleaning procedures. C. Immediate corrective action taken.
The use of acids for cleaning glassware will be closely evaluated to determine when a less hazardous cleaning agent can be used. To limit the potential for reaction, we will ensure that any gross organic contamination is removed by thorough rinsing and scraping before use of acid. Acid will be restricted to cleaning of trace contamination. When lab personnel clean with acids, regular venting will be performed to prevent pressure build-up. Also, the procedure will be done in a chemical fume hood, utilizing the horizontal sash as a physical barrier against sprays and splashes.
D. Additional remediation efforts to prevent future recurrence (and expected date of implementation). We will schedule an in-house training class to review the cleaning procedures and other lab safety policies, especially the rules about wearing of PPE and working alone. Page 4 of 5 Pages E. Comments The student was working an 11-hour day. Fatigue may have been a factor. Workdays will be limited to 10 hours at the most. Principal Investigator/Supervisor Signature: ____________________________________ Page 5 of 5 Pages