Lab death prompts CSIRO upgrade

The tragic death of a CSIRO lab team member in an airlock last December has prompted the organisation to make sweeping changes to its lab equipment and staff procedures.

CSIRO launched an investigation immediately after the death of Set Van Nguyen, a long-standing member of CSIRO's Geelong-based Australian Animal Health Laboratory (AAHL) team, who is believed to have suffocated in a room that held low temperature storage units using liquid nitrogen.

Acting CSIRO Chief Executive Dr Ron Sandland described the incident as "a tragedy for Mr Nguyen's family, colleagues, and the organisation." "Workplace deaths should never happen, and we are deeply sorry this incident occurred," Sandland said. "We believe CSIRO has an obligation to the family and colleagues of Set Van Nguyen to learn from this tragedy such that a similar event never happens again. The recommendations of the inquiry are being taken extremely seriously."

The committee of inquiry, headed by CSIRO Entomology chief Dr Jim Cullen, met frequently and during the course of the inquiry 36 staff were interviewed.

The inquiry identified a series of failures of the laboratory's complex engineering and control systems, coupled with inadequacies in relation to staff being alerted to and understanding the seriousness of these failures.

The laboratory systems are designed with high levels of duplication and backup, so it is very rare for failures to occur in multiple systems, CSIRO said.

The inquiry recommended the lab adopt 24 changes, of which three were already implemented by the time the report was completed. A further eight recommendations relating to the broader operation of CSIRO were made and are now being discussed and actioned within the organisation.

The key recommendations related to changes and reviews of some engineering systems, alarms, sensors, software, staff procedures and communication.

AAHL Acting Director Dr Stephen Prowse said the following recommendations had been implemented to date:

• Installation of an additional flashing warning light at the entrance to the liquid nitrogen rooms to indicate oxygen levels below 19.5 per cent, and a system to prevent access to the room when the oxygen falls below this level.
• Modification of alarms in the liquid nitrogen rooms to ensure that the alarm can be heard from within and outside the airlock.
• Formalised staff training in relation to changed liquid nitrogen room procedures.

In addition, a system has been set up to bar entry to the rooms when airflow to the rooms drops by 20 per cent of its normal level.

Prowse said the report would be carefully examined and further changes would be made in the next months in response to the recommendations.

Separate inquiries by the coroner and Comcare are progressing, and are expected to be completed later this year.