On 21 January, Kim Christensen of the Los Angeles Times
broke the story detailing the investigative report issued on 23 December 2009 by the California Division of Occupational Safety and Health into the circumstances leading to Sheri Sangji's death. Science
Careers has also obtained the 95-document, which made for a harrowing weekend of reading.
Through page after page of detailed interviews with UCLA officials, present and former members of Patrick Harran's lab, Harran himself, Sangji's college chemistry adviser, and her former employer, the investigator -- Senior Special Investigator Brian Baudendistel -- presents a nightmarish picture in the dispassionate language of bureaucracy. Reading it, one senses fury straining against the limits set by his official capacity. In the report's detailed, 3-page conclusion, his anger flashes hot.
Issued 2 years before the Los Angeles County district attorney
brought felony charges against Harran and the Regents of the University
of California, the report presents evidence that contradicts the
narrative that UCLA has been asserting since being charged.
Chancellor Gene Block has -- as in a January 6 statement
repeatedly called the fire that killed Sangji a "tragic accident."
Tragic? Without doubt. Accident? In Baudendistel's informed opinion,
no, not in the common vernacular sense of fortuitous and unforeseeable.
Not once in 95 pages does he use the word "accident" to refer to the
event, instead consistently referring to it as the "fatal incident" and
to Sangji as "Victim Sangji."
"Based upon the
investigation," Baudendistel writes,"it is apparent that the laboratory
safety practices utilized by UCLA prior to Victim Sangji's death, were
so defective as to render the University's required Chemical Hygeine
Plan and Injury and Illness Prevention Program essentially non-existent.
The lack of adequate lab safety training and documentation, lack of
effective hazard communication pracitces, and repeated failure to
correct persistent and repeated safety violations within University
labs, were all causal deficiencies that led to a systematic breakdown of
overall laboratory safety practices at UCLA."
Harran," Baudendistel continues, "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."
Kevin Reed, UCLA's vice chancellor for legal affairs, further laid out the university's description of the events during a radio interview on 28 December
Sangji "tragically did not follow training" to wear a lab coat, which
was "university policy," Reed says. "We don't know why." Baudendistel
offers a possible explanation: "The testimony obtained in this case
clearly establishes that University accepted the fact that many
Principal Investigators [including Harran] consistently failed to
enforce the use of personal protective equipment within their labs as
'part of the culture.' In fact, as the University's former Manager of
Chemical Safety, William Peck, candidly admitted, '...It was kind of
common knowledge that laboratory people don't use the proper PPE
[personal protective equipment] when they are in the lab ... it was hard
to convince the professors that they needed to ... and if the
professors didn't enforce it, nobody did.'"
also asserted that Sangji was a "professional chemist" with "great
skill and experience" when she joined Harran's lab. But in fact she had
received her bachelor's degree in chemistry just four months prior to
beginning work at UCLA. During the intervening time she had worked at
Norac Pharma in Azuza, California. "According to records obtained from
Norac Pharma," Baudendistel writes, "Victim Sangji was closely
supervised and did not perform any independent lab work 'due to her
limited laboratory experience.'"
post doesn't afford room to summarize the detailed information
Baudendistel presents on the technical inadequacies -- quite apart from
the lack of protective apparel -- of the reportedly unorthodox method
and inappropriate equipment that Sangji used to handle an extremely
hazardous substance. There's no space to fully address the inadequate
training she had received for the task she was attempting. So, as a way
of concluding this blog post, here's the final sentence of
Baudendistel's approximately 44,000 word account: "If Dr. Harran had
utilized a standard operating procedure as required and would have
properly trained Victim Sangji, and assured that clothing appropriate
for the work was worn to protect her from inadvertent exposure to tert
-Butyl lithium, Victim Sangji's death would have been prevented."