Chemical Fire: t-butyl lithium and Pentane + No PPE = Deadly accident

"Two months earlier, UCLA safety inspectors found more than a dozen safety deficiencies in the same lab"

Deadly UCLA lab fire leaves haunting questions

Federal and state safety agencies investigate after university officials failed to address lapses before a Dec. 29 chemical accident left a research assistant with fatal burns.

By Kim Christensen
March 1, 2009

UCLA's Molecular Sciences Building was mostly closed for the holidays on Dec. 29 as research assistant Sheri Sangji worked on an organic chemistry experiment.

Only three months into her job in the lab, the 23-year-old Pomona College graduate was using a plastic syringe to extract from a sealed container a small quantity of t-butyl lithium -- a chemical compound that ignites instantly when exposed to air.

• 

  Sheri Sangji -
  "She was brilliant, just so impressive,"

As she withdrew the liquid, the syringe came apart in her hands, spewing flaming chemicals, according to a UCLA accident report. A flash fire set her clothing ablaze and spread second- and third-degree burns over 43% of her body.

Eighteen excruciating days later, Sangji died in a hospital burn unit.

"It is horrifying," said her sister Naveen, 26, a Harvard medical student. "Sheri wasn't out doing something stupid. She was working in a lab at one of the largest universities in the world. She gets these horrific injuries and loses her life to these injuries and we still don't know how it happened or why it wasn't prevented."

Sangji's death was more than a tragic workplace accident. It also raised serious questions about the university's attention to laboratory safety.

"It was totally preventable," said Neal Langerman, a San Diego consultant and former head of the American Chemical Society's Division of Chemical Health and Safety, whose members were given a detailed account of the incident by a University of California safety official.

"Poor training, poor technique, lack of supervision and improper method. This was just not the right way to transfer these things," Langerman said. "She died, didn't she? It speaks for itself."

Two months earlier, UCLA safety inspectors found more than a dozen deficiencies in the same lab, Molecular Sciences Room 4221, according to internal investigative and inspection reports reviewed by The Times. Among the findings: Employees were not wearing requisite protective lab coats, and flammable liquids and volatile chemicals were stored improperly.

Chemical Safety Officer Michael Wheatley sent the inspection report to the researcher who oversees the lab, professor Patrick Harran, as well as to the head of the Chemistry and Biochemistry Department and a top UCLA safety official. The report directed that problems be fixed by Dec. 5.

But the required corrective action was not taken, records show, and on Dec. 29 all that stood between Sangji's torso and the fire that engulfed her was a highly flammable, synthetic sweater that fueled the flames.

Under scrutiny

The California Division of Occupational Safety and Health is investigating, as are the Office of the State Fire Marshal, the National Institute for Occupational Safety and Health and the U.S. Chemical Safety and Hazard Investigation Board. A spokeswoman for Cal/OSHA, the lead agency, said she could not comment on the investigation.

UCLA officials say they are cooperating with all of the agencies.

"We consider this a profoundly tragic accident, and the campus community is still reeling from the loss of Sheri as a member of the Bruin family," said Kevin Reed, vice chancellor for legal affairs.

Harran, the organic chemistry professor for whom Sangji worked, said he could not comment on the accident because of the pending investigations. But he said he's heartbroken.

"Words cannot convey my grief or that of those who work in my lab, and our pain cannot possibly compare with the immeasurable anguish felt by Sheri's family," he wrote in an e-mail. "Sheri's death is a tragedy that has left her friends, colleagues and co-workers here in our department devastated."

UCLA has launched a comprehensive review of lab safety protocols and has stepped up inspections and shortened the time allowed to correct serious violations. Chancellor Gene Block also established a campuswide lab safety committee and ordered enhanced accountability measures.

Such efforts are of little comfort to Sangji's family. Her parents, Shaukat Sangji, a small-business owner who lives in Toronto, Canada, with his wife, Maimoona, a Montessori schoolteacher, were too distraught to be interviewed, said Naveen, who relayed an e-mail message to The Times from her father.

"They say time will heal, but I know for sure nothing can heal this," he said. "This has completely destroyed our lives forever."

The experiment: She was trying to transfer up to 2 ounces of t-butyl lithium, which was dissolved in pentane, another highly flammable chemical, from one sealed container to another. It was the second time she had performed that procedure in Harran's lab, UCLA officials said.

"The barrel of the syringe was either ejected or pulled out of the syringe, causing liquid to be released," the UCLA accident report stated.

Sangji's rubber gloves caught fire, searing her hands. Her sweater, made of a synthetic material, was so flammable that Langerman, the chemical safety expert, compared it to "solid gasoline." It, too, was quickly engulfed.

The panicked young woman ran away from a nearby emergency shower instead of toward it, records state, costing her precious time.

"She might have been fine" had she quickly made it to the shower, said Russ Phifer, head of the American Chemical Society's safety division, who also reviewed the UC official's account of the accident.

A postdoctoral researcher, who UCLA officials say was just a few feet away, rushed to Sangji's aid and tried to smother the flames with a lab coat. Another ran in from an adjoining room, helped douse the fire, then called 911 and summoned Harran, Reed said.

"He said when he got there Sheri was sitting with her arms outstretched in front of her and someone was throwing water at her from a sink," said Naveen, who spoke with Harran later at the hospital. That account squares with the UCLA accident report.

From the Ronald Reagan UCLA Medical Center, Sangji was transferred to the Grossman Burn Center in Sherman Oaks.

It is unknown whether a typical cotton lab coat would have saved her. But even if it caught fire, it could have been removed much more easily than a burning synthetic sweater, safety expert Phifer said.

"I can't imagine why she didn't have protective clothing if she knew she was working with chemicals that dangerous," Sheri's friend Bruce said.

- On Jan. 16, she succumbed to respiratory failure, infection and other complications, according to a coroner's report.

Whole story at: LA Times - Link - Deadly UCLA lab fire leaves haunting questions