By Kim Smiley
Six were injured, two seriously, in an accident involving an open flame chemistry demonstration at a high school in Fairfax County, Virginia on October 31, 2015. At the time of the incident, the teacher was performing a well-known experiment to show the students how different chemical elements can change the color of a flame. According to students present in the classroom, the teacher was in the process of adding more flammable liquid to the experiment when a splash of fire hit students and the teacher.
A Cause Map, or visual root cause analysis, can be used to analyze this incident. The first step in the Cause Mapping process is to fill in an outline to document all the basic background information for an incident such as time, date, and location. Additionally, how the incident impacts the organization’s goals is listed on the bottom of the outline. For this example, the safety goal is clearly impacted by the injuries, but there are several other impacts that need to be considered as well such as the damage to the classroom, evacuation of the school and required emergency response. Fairfax County has also banned all open flame experiments pending a thorough investigation of this issue which can be considered an impact to the regulatory goal.
Once the Outline is complete, the Cause Map itself is built by asking “why” questions beginning with one of the impacted goals. Starting at the safety goal in this example, the first step would be to ask “why” were 6 people injured? These injuries occurred because people were burned because there was an uncontrolled fire in a classroom, people were near the fire and no protective gear was worn. (When there is more than one cause that contributes to an effect, the cause boxes are listed vertically and separated by “and” to show that all causes were required.) No information has been released to the public about why the students were sitting so near the open flame experiment without any type of safety barrier or why protective gear wasn’t worn, but these are both branches of the Cause Map that should be expanded during a complete investigation. If the same fire had occurred, injuries may have been prevented or at least been less severe if the students were farther away from the flames or if they had protective gear on to protect them from burns. It’s important to understand why the experiment was performed as it was in order to develop solutions that could prevent injuries in the future.
There has been a little information released about why the fire was uncontrolled during the experiment. Eyewitnesses have stated that the teacher was adding more fuel to the fire because it was starting to burn out. As liquid fuel was added, the fire spread unexpectedly and burning fuel splashed out of the experiment location onto students and the teacher performing the experiment. The specific details of what occurred during this specific fire have not been released and should be looked at during the detailed investigation. Once more information is known, the Cause Map could be easily expanded to incorporate it.
The Chemical Safety Board (CSB) is not investigating this incident, but has stated that it is gathering information on it. The recent accident appears to be similar to three accidents involving open flame experiments that injured children during an 8 week period in 2014. These three accidents all involved experiments using flammable liquid, a flashback to the bulk containers of fuel and fire engulfing members of the audience. Following the 2014 accidents, the CSB issued a safety bulletin titled “Key Lessons for Preventing Incidents from Flammable Chemicals in Educational Demonstrations”. Key lessons listed from the CSB safety bulletin that should be considered when planning open flame experiments are as follows:
– Do not use bulk containers of flammable chemicals in educational demonstrations when small quantities are sufficient.
– Implement strict safety controls when demonstrations necessitate handling hazardous chemicals – including written procedures, effective training, and the required use of appropriate personal protective equipment for all participants.
– Conduct a comprehensive hazard review prior to performing any educational demonstration.
– Provide a safety barrier between the demonstration and audience.