Patrick Harran to stand trial for the death of Sheri Sangji

"UCLA chemist to stand trial for safety violations linked to Sheri Sangji death"

by

Rebecca Trager

May 1st, 2013

Chemistry World

The chemist who supervised a research assistant who died from injuries sustained in a University of California, Los Angeles (UCLA) lab more than four years ago will go on trial in connection with her death. The case could set a precedent whereby university researchers could be held liable for unsafe laboratory practices.

Patrick Harran supervised Sheri Sangji, the UCLA research assistant who died in early 2009. Her death was the result of serious burns received while working on her own in Harran’s organic chemistry lab with the pyrophoric liquid t-butyl lithium.

The California Division of Occupational Safety and Health found that the incident was caused by inadequate training, and criminal charges were brought against both the university and Harran. UCLA settled the charges in July 2012 after agreeing to comprehensive corrective safety measures and also establishing a $500,000 (£322,000) scholarship in Sangji’s name at University of California, Berkeley, school of law.

Meanwhile, on 26 April Harran was ordered to stand trial on three criminal counts of violating occupational health and safety laws that led to Sangji’s death. Harran will return to court on 9 May for arraignment, and he faces up to four-and-a-half years in prison if convicted.

UCLA on the defensive

UCLA reacted defensively to the development. The school’s chancellor, Gene Block, called the incident that took Sangji's life ‘a terrible tragedy’, but stressed that it was ‘an accident, not a crime’. Block described Harran as ‘a talented and dedicated faculty member’, and pledged the university’s ‘unwavering’ support for him.

Sangji’s death led UCLA to create a Center for Laboratory Safety to support research in this field, and it also dramatically increased the number of lab inspections, from 365 in 2007 to almost 2400 in 2010.

‘Dr Harran is a highly paid researcher, and if he has a felony conviction on his record, his funding will dry up in a hurry,’ says Russ Phifer, executive director of the National Registry of Certified Chemists. ‘That is going to be a wake-up call for everyone else.’

Robert Latsch, a chemical and environmental health specialist at Case Western Reserve University, US, agrees that the case is a game changer. ‘The fact that a professor may well go to jail will become a catalyst and motivate people and institutions to change,’ he tells Chemistry World. But that change is likely not going to happen overnight.

In general, industry has a much stricter lab safety regime than academia. ‘There is a much more effective hammer, as in you are fired,’ Phifer says. In addition, industry research labs don’t have the turnover seen in academia, where graduate students do much of the work. ‘They are not constantly training new people,’ Phifer notes.

Another problem is that government tries to apply workplace safety rules to academic research labs, and it’s not necessarily a good fit. Researchers at universities often see themselves in a contractual relationship with the university rather than as an employee.

‘Academia doesn’t believe that the lab safety standards in industry apply to them,’ Latsch says. ‘They are not well informed on this at all.’ He describes the governance system in a private company as autocratic, versus the confederation seen in academic institutions.

A rare occurrence

Nevertheless, Phifer says that Sangji’s case marks the third such fatality in a US academic lab in about 15 years. ‘It is clear it is a very rare occurrence; if it happened more often, then this would not be the first case of a professor facing these charges.’

Perhaps the most horrific such accident occurred at Yale University in April 2011. Undergraduate student Michele Dufault died after her hair became entangled in a lathe as she worked alone in a school machine shop. Just a few months later, the US Occupational Safety and Health Administration concluded that there were several safety lapses.

There is also the case of Karen Wetterhahn, a chemistry professor at Dartmouth College who died in 1997 from mercury poisoning, after dimethyl mercury penetrated her latex glove in a research lab some 10 months earlier. An investigation by Wetterhahn’s colleagues revealed that material safety data sheets for dimethyl mercury recommended the use of rubber or chemically impervious gloves.

More recently, in January 2010, there was an explosion at Texas Tech University (TTU) that led to a graduate student losing three fingers, perforating an eye and sustaining significant burns. The incident occurred when the grad student and a colleague were working with a new energetic material, a derivative of nickel hydrazine perchlorate. A decision was taken to scale-up production of the material one hundred-fold, against lab protocol and without consulting their supervisor, with the end result being that the compound detonated.

In October 2011, the US Chemical Safety Board (CSB), an independent government agency charged with investigating serious chemical accidents, expressed concern over the frequency of these incidents in the US academic labs, and called for an overhaul.

Use the blog's search engine for much more on this story.

Sheharbano Sangji, Patrick Harran, UCLA case settled

"UC Regents strike plea deal in chemistry lab death at UCLA"

July 27th, 2012

Los Angeles Times

Felony charges against the University of California Regents stemming from the 2009 death of UCLA research assistant Sheharbano “Sheri” Sangji were dropped Friday in return for a pledge of comprehensive safety measures and the endowment of a $500,000 scholarship in her name.

“The Regents acknowledge and accept responsibility for the conditions under which the laboratory operated on December 29, 2008,” the agreement read in part, referring to the date that Sangji, 23, suffered fatal burns.

She was transferring about 1.8 ounces of t-butyl lithium from one sealed container to another when a plastic syringe came apart in her hands, spewing a chemical compound that ignites when exposed to air. The synthetic sweater she wore caught fire and melted onto her skin. She died 18 days later.

From the outset, UCLA and chemistry professor Patrick Harran, who is still charged in the case, have cast her death as a tragic accident and said she was a seasoned chemist who was trained in the experiment and chose not to wear a protective lab coat.

In late December, however, the Los Angeles County district attorney’s office charged Harran and the UC Regents with three counts each of willfully violating occupational health and safety standards.

Friday’s agreement, announced at a hearing in Los Angeles County Superior Court, does not affect Harran’s charges. University of California officials said Friday they stood by him and would continue to pay his legal expenses.

Harran was to be arraigned Friday, but that was postponed until Sept. 5 to allow the judge to weigh defense motions, including one this week that alleges the state’s chief investigator on the case, Brian Baudendistel, committed murder as a teenager.

Baudendistel, a senior special investigator for the California Division of Occupational Safety and Health, has denied that he is the person of the same name who pleaded no contest to first degree murder when he was 16.

But  Harran’s lawyers said in court papers this week that the district attorney’s office had matched Baudendistel’s fingerprints to the killer’s and that the two share the same birth date. Prosecutors have declined to comment on the allegation or the defense’s motion to quash Harran’s arrest because of it.

The motion contends that the Cal-OSHA investigator is the same Brian A. Baudendistel who, in January 1985 with two accomplices, lured Michael Myer from a bar in the Northern California town of El Dorado to a remote area to rob him of $3,000 worth of methamphetamine. As he rolled up on his motorcycle, Myer, 26, was killed by a shotgun blast. Another teenager admitted to being the shooter, but said Baudendistel had supplied the weapon.

And here is an interesting report from Chemical & Engineering News...

"Sheri Sangji case: The limits of oral transfer of knowledge"

by

Jyllian Kemsley

January 25th, 2012

Chemical & Engineering News

As others have also reported, a second Cal/OSHA report has surfaced on the circumstances surrounding the death of University of California, Los Angeles, researcher Sheharbano (Sheri) Sangji from a laboratory fire. The first report, which I covered extensively back in 2009, was the one that led to civil sanctions against UCLA. As is standard in a California workplace fatality, once the civil case was completed, it was turned over to Cal/OSHA’s Bureau of Investigations (BOI) to determine whether it might warrant criminal prosecution. The newly-available report is the one that the BOI sent to the Los Angeles County District Attorney, who filed criminal charges against UCLA and chemistry professor Patrick Harran.

The report paints a pretty damning picture of overall UCLA safety culture at the time of the incident. To quote from the report’s conclusions (report page 90):

    Based upon the investigation, it is apparent that the laboratory safety policies and practices utilized by UCLA prior to Victim Sangji’s death, were so defective as to render the University’s required Chemical Hygiene Plan and Injury and Illness Prevention Program essentially non-existent. The lack of adequate lab safety training and documentation, lack of effective hazard communication practices, and repeated failure to correct persistent and repeated safety violations within University labs, were all causal deficiencies that led to a systemic breakdown of overall laboratory safety practices at UCLA.

Much of the report just gives added detail to what was already known about the case or documents conventional wisdom about poor lab safety culture in academia. In one interview, postdoctoral researcher Paul Hurley noted that lab coats were seen as optional rather than required in every academic lab he’d worked in. “That’s how my experience has been pretty much everywhere I’ve been, apart from my current job actually,” the report quotes Hurley. Where does he work now? In industry.

The report does reveal, however, a bit more of how Sangji was supervised and trained. To recap the incident, Sangji was using a syringe to transfer about 53 mL of tert-butyllithium (tBuLi), a pyrophoric substance that ignites spontaneously in air, when the barrel came out of the syringe. The chemical splashed on Sangji, who was wearing neither a regular nor a flame-resistant lab coat, and set her clothes on fire. She was burned on more than 40% of her body and died of her injuries.

The report confirms that Sangji did not handle pyrophoric reagents as an undergraduate or during a few months of work at Norac Pharma. At UCLA, Sangji worked in Harran’s lab. Harran told the Cal/OSHA investigator that he observed Sangji do an initial experiment to gauge her experience and competency... Assuming that the experiment Harran referred to is the first entry in Sangji’s lab notebook–the second is her first tBuLi reaction–the procedure involved working in a glove bag and syringing no more than a few milliliters of air-sensitive, non-pyrophoric material. Although some of the fundamental techniques might have been the same, I think many people would argue that in scale and hazard that first reaction was a far cry from Sangji’s tBuLi experiments....

As for handling tBuLi, Harran reportedly told Sangji to ask Hurley for help. Hurley told the Cal/OSHA investigator that he didn’t follow standard operating procedures or other written protocols; rather, he was trained and in turn trained others by word of mouth.... Hurley also couldn’t recall the specifics of his interactions with Sangji. The way Hurley described handling pyrophoric reagents, however, echos some of what contributed to the lab fire that ultimately killed Sangji:

    Hurley said in the interview that “most people…more often than not did not clamp the bottle” and instead held it with one hand while syringing with the other. Aldrich recommends (pdf) clamping the bottle, which leaves both hands free to manipulate the syringe. (Sangji compounded this by using a 60-mL syringe with a short needle, so would have had to tip the bottle up to get the needle into the liquid while trying to handle a large syringe with one hand.)

    Hurley said that he always used plastic syringes. Aldrich does not specifically prohibit using plastic syringes, but it does recommend drying syringes in an oven, which effectively means that glass must be used. (Sangji used a plastic syringe. Another postdoc in the lab, Hui Ding, commented that plastic syringes can swell, making them difficult to operate.)

    Hurley said that he would use a syringe size as close to the reagent volume as possible. Aldrich recommends using a syringe at least twice the volume of the reagent volume, precisely to guard against taking the plunger out to the end of the barrel. (Sangji used a 60-mL syringe for 50 mL or more of material. Ding knew about the twice-the-volume rule.)

    Hurley said that he would physically pull on the plunger to pull up the reagent. Aldrich recommends using low-pressure, inert gas to push the material into the plunger rather than risk pulling too hard on the plunger and drawing in air. (It’s not clear which approach Sangji used. When Harran was interviewed by Cal/OSHA investigators in the civil investigation, he also said that he’d pull on the syringe. Aldrich scientist Mark Potyen has previously told me that plastic syringe plungers can’t be pushed up by low-pressure gas.)

(What’s not addressed in the report is the issue of transferring material by syringe versus a double-tipped needle, or cannula. On the day of the incident, Sangji was supposed to transfer a total of about 160 mL. For that amount, a cannula is the accepted practice rather than multiple smaller transfers. It’s not clear that anyone ever said that to Sangji. Certainly no one told her to read the Aldrich protocol.)

The Hurley interview clearly illustrates the limit of oral transfer of knowledge. As in a game of telephone, what gets passed on can change over time. Written protocols help guard against that. And making lab workers (re-)write protocols that faculty then review helps to ensure that everyone does, in fact, know what they’re supposed to do.

Other points of note: Sangji started in the lab in October, 2008. Hurley left the lab in November. According to the report, on the day of the incident in December, Harran knew that Sangji was planning to scale up the tBuLi reaction but told the investigator that he didn’t know by how much. Harran seems never to have discussed the hazards or use of tBuLi with Sangji.

Around the web today, I’ve seen a couple of people ask why the DA didn’t file charges against Hurley. My guess is that it comes down to the legal statute, California Labor Code Section 6425, which specifies “Any employer and any employee having direction, management, control, or custody of … any other employee.” Harran clearly fits that description–he hired Sangji, directed her work, and was ultimately in charge of his lab. I don’t see that it applies to Hurley, who was not explicitly assigned to supervise Sangji’s work and who was gone from UCLA by the time of the incident.

Last but not least, one caveat about the report: It is basically a summary of what the investigator found. The full package appears to involve five binders of information, which I do not have (nor, as far as I know, does anyone else outside of Cal/OSHA or the DA’s office). When reading the report, I think it’s important to remember that you’re not getting the full interview transcripts and we don’t know what the investigator may have left out. (I tried to get everything back in 2010, but was told that because the report was part of an ongoing criminal investigation, it was exempt from disclosure under California’s Public Records Act....

Charges filed in the death of Sheharbano Sangji  

Culpability in the lab

Who is culpable here? Looks like a "he said, she said" situation.

"Report faults professor, UCLA in death of lab assistant"

Cal/OSHA says Sheri Sangji was not properly trained to handle the chemicals that killed her. The university criticizes the findings.

by

Kim Christensen

January 21st, 2012

Los Angeles Times

Ever since Sheri Sangji was fatally burned in a December 2008 lab fire, UCLA officials have cast it as a tragic accident, saying the 23-year-old staff research assistant was a seasoned chemist who was trained in the experiment that went awry.

But Sangji was neither experienced nor well trained — if trained at all — in the safe handling of air-sensitive chemicals that burst into flame, ignited her clothing and spread severe burns over nearly half her body, according to a report on a Cal/OSHA criminal investigation obtained by The Times.

The 95-page report adds new detail to the circumstances surrounding Sangji's death and provides insight into the basis for felony charges filed last month against UCLA chemistry professor Patrick Harran and the UC Board of Regents. Based on labor code violations, the charges are thought to be the first stemming from an academic lab accident in the United States.

University officials have blasted the charges as "unwarranted," "outrageous" and "appalling" and say they contradict an earlier Cal/OSHA investigation that resulted in nearly $32,000 in Cal/OSHA fines but no findings of intentional, or "willful," violations.

The findings of the subsequent criminal probe, conducted by a different investigator, were far harsher.

The report states that UCLA, by repeatedly failing to address previous safety lapses, had "wholly neglected its legal obligations" to provide a safe environment in campus labs and that Harran was personally responsible.

"Dr. Harran simply disregarded the open and obvious dangers presented in this case and permitted Victim Sangji to work in a manner that knowingly caused her to be exposed to a serious and foreseeable risk of serious injury or death," the report by senior special investigator Brian Baudendistel states.

If Harran had trained his research assistant properly and assured that she wore clothing appropriate for the work, "Sangji's death would have been prevented," it said.

Harran's attorney, Thomas O'Brien, disputed those conclusions.

"Dr. Harran remains devastated by this tragic accident," he said. "There are numerous misstatements in that report, but I will refer you to the UC regents for any comments."

Harran and the Board of Regents are to be arraigned Feb. 2 in Los Angeles Superior Court on three counts each of willfully violating occupational health and safety standards. Harran faces up to 41/2 years in prison if convicted; the regents could be fined up to $4.5 million.

Kevin Reed, UCLA vice chancellor for legal affairs, said he "vehemently" disagreed with the findings. He said Sangji was well trained, had previously performed the experiment safely and successfully and chose not to use available protective gear.

"It was not as if UCLA found a newbie who didn't know what she was doing and put her in a lab with no regard to the consequences; there is just no evidence to support that," he said. "We didn't just pluck her off the streets and put her in a chemistry lab. She was a trained chemist."

Sangji, who graduated in 2008 from Pomona College in Claremont with a bachelor's degree in chemistry, had worked in Harran's organic chemistry lab for less than three months when the accident occurred.

She was transferring about 1.8 ounces of t-butyl lithium from one sealed container to another when a plastic syringe came apart in her hands, spewing a chemical compound that ignites when exposed to air. The synthetic sweater she wore caught fire and melted onto her skin. She died 18 days later.

Sangji had not used pyrophorics in her undergraduate work or during a brief stint at an Azusa pharmaceutical company just before she took the UCLA job, according to the Cal/OSHA investigative report, which was completed in December 2009 but not previously made public. Nor had she been properly trained in their handling by a senior researcher, as Harran said, according to the report.

When interviewed by Cal/OSHA, the researcher said he might have given Sangji some "general guidance" on the procedure but could not recall any formal training. The report also said the researcher's own methods were "contrary" to the chemical manufacturer's instructions and generally accepted lab standards.

"Despite Dr. Harran's assertions to the contrary, it is clear that Victim Sangji was not properly trained, if at all, in the procedures necessary for the safe handling and transfer of t-Butyllithium," the report noted.

Since Sangji's death, UCLA has instituted more rigorous lab inspections, issued more fire-resistant lab coats, enhanced training in the use of air-sensitive chemicals and established a Center for Lab Safety.


UCLA chem prof to plead "not guilty"

UCLA to appeal OSHA's finding in Sheri Sangji's death

No mea culpa from UCLA. The lawyers are in a frenzy to establish limited responsibility.

"UCLA appeals state findings in fatal lab fire"

Cal/OSHA had cited workplace-safety violations in the December death of staff research assistant Sheri Sangji. The school says it has made required changes and paid more than $31,000 in fines.

by

Kim Christensen

June 6th, 2009

The Los Angeles Times

UCLA has appealed state regulators' findings of serious workplace-safety violations in the fatal burning of a staff research assistant last year in a lab fire.

The California Division of Occupational Safety and Health found last month that Sheri Sangji, 23, was not properly trained and was not wearing protective clothing Dec. 29 when an experiment with air-sensitive chemicals burst into flames.

University officials say they have made the required changes and have paid the more than $31,000 in fines assessed by regulators.

Kevin Reed, vice chancellor for legal affairs, said the May 26 appeal will allow UCLA to stipulate that it admits no fault in connection with Cal/OSHA's findings, a move aimed at limiting the university's liability.

The appeal is necessary to make clear "that there was no citation or finding that can be used against the university in any future proceeding," Reed said in a statement.

Such proceedings might include lawsuits by labor unions or criminal action by prosecutors, Reed said in an interview. Cal/OSHA officials have said they routinely present their findings in death cases to district attorneys for review.

Workers' compensation rules may limit the family's legal options. But Sangji's sister, Naveen, said the family is pushing for an investigation by the district attorney. More than 1,300 people have signed an online petition urging one.

"We would like to see the district attorney take this up," said Naveen Sangji, a Harvard medical student who has been critical of the investigations by UCLA and Cal/OSHA. "It is time for an independent party to step up, someone who is not affiliated with UCLA."

Among other things, Cal/OSHA cited UCLA for not addressing deficiencies noted in an internal safety inspection two months before the fatal fire in professor Patrick Harran's organic chemistry laboratory, where Sheri Sangji worked, including a finding that workers were not wearing lab coats.

When the lab fire occurred, Sangji was transferring about 2 ounces of t-butyl lithium from one sealed container to another when a plastic syringe came apart in her hands, spewing a chemical compound that ignites when exposed to air.

The flash fire set ablaze her rubber gloves and synthetic sweater, causing serious burns over nearly half of her body. She died 18 days later.

Cal/OSHA's $31,875 fine included $18,000 for Sangji's lack of a lab coat, which might have kept her highly flammable sweater from catching fire.

Reed said in his statement that many of the corrective measures ordered by UCLA inspectors had been completed before the Dec. 29 fire but were not properly documented.

"Accordingly, the campus filed a technical appeal on these limited grounds," he said.

Although UCLA's appeal asserts that none of the safety orders cited by Cal/OSHA were violated, Reed said the legal maneuver "does not question the serious nature of the issues" the safety regulators raised.

"On the contrary," he said, "it is UCLA's goal to operate a laboratory safety program that is a model for other universities, and the campus implemented multiple and far-reaching improvements as a result of the comprehensive review ordered by the chancellor after the accident."


UCLA fined in Sheharbano Sangji death

Tert-Butyllithium yields a fatality

Sadly Sheharbano Sangji, research associate/laboratory technician, succumbed to her injuries from a laboratory accident at UCLA on January 16th. Ms. Sangji sustained severe burns from an accidental mishandling of tert-Butyllithium...an agent that ignites on exposure to air. Details of the accident are inconclusive but it may well be attributed to careless handling of the agent in an unsupervised laboratory. This situation will certainly tighten and rewrite safety and operation procedures in a laboratory environment especially when working in organic chemistry. I have had my share of laboratory mishaps and can appreciate laboratory safety.

Here is a very detailed source for links relating to Sheharbano Sangji, laboratory risks, and the chemical apparatus needed to work with volatile substances.

tert-Butyllithium Claims Fellow Chemist at UCLA