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A Tragedy Averted: IANM V6 Story

This story is included in the inaugural 2021 edition of Safety Partners’ publication, “Incidents, Accidents, and Near Misses in Laboratory Research.”

When I started my career working in animal research, the vivarium looked a little bit different than what we often see today in newer facilities. This company had a traditional cage wash for the animal care facility. We would pass the cages through the dirty side, they’d get washed, and then come out on the clean side. Then, we’d put them together and stack them on the bulk truck, a 6-foot tall stainless steel cart.

Then, finally, we would take the bulk truck to the walk-in autoclave, which was about 8 feet tall and 6 feet wide. It was built on a pass-through design with two doors, where one is closed as you load it. Once everything was in, we would hold down the button, and the door would slowly close. If you released the button before the door closed, the door would automatically retract.

One evening, a cage wash technician named Lindsey was moving the bulk truck into the autoclave when a cage fell off. She slid by the cart to the closed end to pick it up and restack it. While she was doing that, her supervisor Michelle walked by. Seeing that the autoclave was full, she pressed the button, and the doors began to close.

Lindsey saw this and started screaming, after seconds of no response, she started throwing things to get Michelle’s attention. Despite the cacophony of machines and sprayers that usually drown out everything in the cage wash room, she was able to yell and bang around loud enough for Michelle to hear her. Finally, Michelle released the button, and Lindsey was able to escape. She was lucky because she was only about 30 seconds away from being locked in there. These were old autoclaves, and there was no security release on the inside. Had she been closed in there, she could’ve been cooked to death.

The thought was horrific, and the incident served as a reality check for us. The facility had been operating for decades, and nothing like this had ever happened. We had a meeting to assess what happened and find a way to mitigate that risk moving forward. From then on, we stationed traffic cones nearby, and if someone entered the autoclave, they had to put the cone in the door track. We also had them put a sign over the top of the button that would let others know a person was in there.

This proved to be successful. Frequently, when you put in safety measures like this, people don’t always follow them. This situation, however, was terrifying enough that people paid attention, and we had 100% compliance for the duration of my time working there. I felt terrible for Lindsey, though. This was only her third week on the job, and she was brand new to the industry, and she nearly gets closed in an autoclave. That’s a reality check that sticks with you for life.

Read the rest of the stories in our latest edition of IANM, by signing up for our newsletter list here.

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