UD- J'l'Ll rom: [Chili-42 USE. 2623M: i ll: 

 

 

 

 

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Incident report, January 30, 2008 [prepared lfii Eel-42 laboratory:

 

 

 

    

  failed during the pre-run.
Autoclave failure was discovered when support staff attempted to empty autoclave the morning of January
ibii?]  who in turn contacted F-SE (Four Seasons . I - 'e - ring). On January 30 at
We]  nptvaccinated :fo  

:autocl ave and attempt-repairs. Because. the material in the. autoclave {one pan of tissue culture materials
from infected cells, one-pan of scissors and forceps from infected mice neer'opsies, one bag of mbuse cages
Efrem infected mice, one be of bedding from. infected mice, and onebag elf-used laundry .was infectious and
the run had not completed, {i?at?oinnel :"arternpted'ito open the autoclave-from the side, so that the
materials in the autoclavecould he removed and-the autoclave-disinfected.prior to attempted repairs by
employee. run would-ner?cpea?f?
slab re uested thati'the'inner The attempt to 
cor no? the FSE employee
a present. 3m lovee subsequently closed the clean side door and entered 
(?53332  -- sin-person inside the lab and informed her of what had. happened. She instructed him to
back to the

(bl(3l142 use. 
 

  

 

'speakto he let:- director (myself) who was also in the-of?ce area. I escorted the FSE emplo 
lab an a? t' - 'rther noti?cation, which he did. 1 called  
(blt?l arrived ?only thereafter-

        
 

   

Due to strong. exhaust in the area of the autoclave, any material that may have escaped through the open

clean-side door'was likely'to be drawn upward-10Lde {he-exhaust. The autoclave and surrounding area was

disinfected using Micro-Chem and 70% FSE employee was directed to theabe-r?cryeait- 

shower {adjacent to the autoclave area). I?lis outer clothes were bagged and later autoclaved. His shoes and 262mm?

personal items 1, watch, etc.) were disinfected with 70% New outer clothes were provided by

ah) ill escorted the-ESE employee to the clinic for

Ines . 1? ?ts-area was ?150 disinfected With 
{cicajz42 use. zezami

     
  

@5142 USC. 

 

   

 

 

 

 

Remediation: Autoclave needs to be ?xed so the (b39142 ab personnel are able to control the opening of
doors including during a failure during?building construction. On
every other autoclave in building oor is insideanddoor Z'is oursidc (clean). Thegg 

desienati ns-are reve - - - ve I 'e i described. The manual
override controls need to be modi?ed so that the doors can be correctly identi?ed. IFSE ersonn?el need'to'be
better trained on this issue. Lastly, while the lab director, ESE building supervisor, and re
vaccinated, the-FEE employeenaes. not, at additional SE. employees is recommended. -

(bicaizet'z use. zezath) ?494) Mel-J -

   
 

  
  

     
   

 

 

 

 

Accession Number: Specia191714 Page: 168 Sean Date: 2014?09?17 COPY

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FACILITIESPLANNING INCIDENT REPORT
Manager: Date and Time of Call: ciiaorzotis
wits" I 02:00 am. pm.

gangs ?'ocation:

Facility it Bidg# i Fitters Rooms Other
to 34203.0 262 ih
Raybat Ii ii i at I

Incident Location
?fditferent from calleHS}

Facilitv? RUYDEI Bloom Floodligmi Easel Ewl Other

Incident Description
{Check all that air-phi}

Fire I Ci Chemical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Security Related CI Mechanical
Bomb Threat . Winner (Please describe]
Weather-R elated Potentch Exposure'to FSE employeeand Autoclave'tech (bii?i

 

 

Incident Summary:

While readying a pass-through autoclave tor repetr,wes- attempting to open the side door
of this autoclave using manual con-rots ess area. Thisaction allows access to the
chamber or the autoclave from the  side forlaboratorian] to remove contaminated
materials. This a tion also allowslibi Ito decontaminate interior of the autoclave thus making it
ready for repair-shaving forgotten the manual controls from this autoclave -. -.- -
mistakenly seuenced the door nonnaliy'and op . . . -  side door as a reach.
are st- 

was on the side of the laboratory waiting for to manually open the
what had occurred. took appropriate actions to reducerelimlnate possible exposure to personnel.

 

  
   
   
   

  

Immediate Remedvr Repair Time:

Repairs for the original request have been completed. Additional signage Is in place to notify all service
technicians-of the-current manual operational de?ciencies ofthie autoclave.

initial. Noti?cations
Was one called? Yes 13 no

 

 

 

 

 

 

Was-Security called? Yes No titles Femorohio called? Yes i3 No

 

Long Term Remedy:

The Getinge Company was noti?ed of the manufacturing de?ciencies for the manual functions of
this piece or equipment. service'representative for Getinge, was dispatched to
examined the autoclave. He sent an incident reporttCompany Engineering 
review. Gatinge Company will be communicating with and CDC regarding the
necessary actions and measures needed to remedy the current problem. All Departments
involved in this report will be updated when manual functions and other repair actions, if needed.
are completed by Gettnge Company.'A copy of Getinge Company incident report is available if
required. Note: Automatic operations or this autoclave are functioning normain at present.

 

 

. [bii?i
Signgtu re: I .. . I
one c.1322 rel. o1raooa. Addba'Acrchet so Eicotionic View. attends

 

 

 

 



 

 

 

Accession Number: Specia191714 Page: 169 Scan Date: 2014-09-17 COPY