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Science Careers Blog

January 23, 2012

California State Report: "UCLA Wholly Neglected Its Legal Obligations to Provide a Safe Working Environment"" in Sangji Case

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." 

"Dr. 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.'"

Reed 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.'"  

This blog 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."

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