Anatomy of an incident-Multiple failure of safety systems under stress

Most laboratories are mostly safe most of the time. It has been said that laboratory safety does not follow Murphy's law - what can go wrong will usually not go wrong, and so flawed and incomplete safety systems are maintained until too late.1 Unusual, high-stress situations can reveal the flaws and inadequacies at the cost of an incident. Here, I describe one such incident: how a day of electrical shut down in the laboratory, a continuous alarm, the presence of non-staff contractors, language barriers and lack of clear channels of communication lead to a failure to properly evacuate and properly investigate the source of the alarm. The development of new procedures and systems proofed against these problems is also described, as well as their implementation.