Lessons learned from a chemical fire

 

In December 2024, a group of undergraduate research students conducted an experiment in a shared research/shop space following a standard operating procedure (SOP) they had recently updated. One of the students had performed this work before; no supervisor was present.   

The experiment involved heating a chemical mixture on a hot plate inside a fume hood. The mixture overheated, ignited, and caused second-degree burns on a student’s hands. The student received medical care and has recovered.

What contributed to the incident?

Standard operating procedure (SOP)

  • The SOP used was missing key information on steps to take while stirring the mixture due to accidental deletion.
  • The temperature of the mixture was not monitored using a thermometer, as specified by the SOP.
  • The revised SOP had not been reviewed or approved by their faculty sponsor/supervisor. 

Training

  • The students had not been trained on the SOP and all the steps involved in the work.
  • The students did not recognize the signs of the mixture overheating prior to ignition.

Personal protective equipment (PPE)

  • The experiment proceeded even though the personal protective equipment (PPE) items for hand-protection listed in the SOP could not be located. In addition, there were not enough PPE items, such as lab coats, blast shields, and eye protection, for all the students to use.
  • Oven mitts, which are not suitable for this work, were substituted for heat-protective gloves. 

Equipment maintenance

The temperature displayed on the hot plate’s panel at the time of ignition was below the ignition point for the chemicals involved, but post-incident testing showed the hot plate far exceeded the intended temperature and ignition point of the chemicals. 

What went right?

  • A fire extinguisher was present in the room and easily accessible.
  • There was an SOP written and being used for the experiment being done.
  • Work was conducted in a chemical fume hood and students were working together collaboratively.
  • PPE was worn and partially protected the students during the incident.
  • Emergency medical assistance was sought immediately.
  • The incident was reported to the department, supervisor, and Environmental Health & Safety immediately. 

What can help prevent another incident like this?

ROOT CAUSES

ACTIONS TO TAKE GOING FORWARD
Risk assessment
  • Conduct a risk assessment for any work involving hazards prior to writing an SOP to identify the safety controls, such as PPE, training, and equipment, needed to mitigate risk as much as possible.
  • Identify the supervision or experience level needed for certain types of work to be performed.
Standard operating procedure Ensure all SOP documents are reviewed and approved by a supervisor prior to use, including when transferring information to new document templates.
Training
  • Provide documented training to all personnel and students on SOPs prior to work beginning.
  • Ensure all steps of the procedure are understood and provide an opportunity for questions to be addressed.
  • Establish expectations for when work cannot proceed, e.g., insufficient PPE supplies and tools.
PPE practices
  • PPE used is required to match the PPE identified in the SOP.
  • Any changes to PPE used must be approved by the supervisor prior to work. 
Equipment maintenance Check that equipment with hazards is working as expected prior to using it.
Supervisor/faculty oversight Ensure oversight of students or personnel with less experience in conducting work with hazardous materials or processes.

Safety resources

  • Identify appropriate PPE for the types of work conducted using the Lab PPE Hazard Assessment Guide.
  • Conduct risk assessments for any experiments planned, so potential incidents can be identified and appropriate controls put in place to mitigate the risk.
  • Document work practices for hazardous chemicals in SOPs and train personnel.
  • Develop equipment maintenance practices for any equipment with hazards. 

Contact

Please contact the Lab Safety Team with questions.

Chemical Safety
Fire & Life Safety
Research & Lab Safety