Table 3 Organizational factors.

Peripheral liveware

Near-miss response

Two near misses occurred in the same research group three years before the accident. The first time, nitrogen was generated just before the completion of the reaction product and an explosion was heard. The second time, the students made a mistake when scaling up and set the measurement unit to 30 g. These near misses were not documented as lessons learned and were not disseminated to the entire university

A day before the accident, electrostatic sparks were observed several times in ungrounded metal equipment, e.g., a “cracked sound” within the 1-gallon pressure vessel when the same digital gauge’s on/off button was pressed; however, the cause was not investigated and analysed, thereby losing the opportunity to prevent the accident

Experiment discontinuation criteria

If a high-risk situation is observed in the event of a near miss, all work, including that with high-risk chemical substances and processes, must be discontinued, and all procedures must be investigated thoroughly

Operational status of the safety management system

The environmental health and safety inspector had conducted a safety audit/inspection of 118 chemical laboratories prior to the accident, but the principal investigator did not take corrective action in many of the cases

The laboratory safety inspection conducted with the environmental health and safety office’s “Laboratory Safety Inspection Checklist” was not comprehensive and was reduced to a mere formality. The use of gas storage tanks was not confirmed, and it was necessary to have a section dedicated to compressed gas

The chemical hygiene plan did not include comprehensive risk assessment guidance for the laboratories

The chemical hygiene plan did not elaborate on how researchers should best handle safety regulations and practices

There was no obligation to undergo laboratory safety training that was provided online and in-person by the environmental health and safety staff. There was also video training offered for undergraduate students, but the need for hazard assessment before starting research in the laboratory was not mentioned

There was no policy or procedure to ensure that laboratory-specific safety trainings for individual laboratories are conducted regularly

There was no documented procedure and approval process for any changes to experimental plans

Some laboratories lacked or did not have standard operating procedures for handling hazardous substances, implementing hazardous work or having protective barriers or emergency procedures

University environment

The inspection was reduced to a mere formality and carried out in the absence of the principal investigator because the principal investigator considered it a violation of academic freedom

Lab safety inspection lacked cooperative aspects, such as inspecting the laboratory in the absence of the researcher

The environmental health and safety office was stipulated to supervise chemical hygiene, but it was not under the authority of the vice president for research, and there was no authority to close the laboratory

Many researchers underestimated the chemical, biological and physical hazards and the need for personal protective equipment

Involvement of external organizations affecting the safety of the university

The laboratory standards of the Occupational Safety and Health Administration did not address the physical hazards

Funding agencies did not demand risk analysis of studies that used explosive substances

Funding agencies did not have a policy to limit the quantity of high-energy compounds that could be synthesized and lacked guidelines for assessing the risks in the laboratory