Several major incidents associated with biological containment labs have occurred over the years, raising concerns about lab safety, potential leaks, and risks of disease outbreaks. These incidents often involve the accidental release of pathogens or failures in containment measures.
Human performance and human error plays a significant role in many of the major incidents associated with biological containment labs. In fact, a large portion of these incidents can be traced back to mistakes made by personnel or failures in following proper safety protocols. Human error is critical to highlight because even with the best infrastructure and technological safeguards, the effectiveness of a containment lab heavily relies on the people working within it.
Here are some of the most well-known incidents:
1. Marburg Virus Lab Accident (1967)
- Location: Marburg, Germany
- Pathogen: Marburg Virus
- Incident: Lab workers were exposed to the virus, which had been brought in from Uganda via infected monkeys. The virus spread to lab workers, causing several deaths.
- Impact: This was the first known outbreak of Marburg virus, a haemorrhagic fever similar to Ebola, and it underscored the dangers of handling unfamiliar pathogens.
2. Smallpox Escape in Birmingham (1978)
- Location: University of Birmingham Medical School, UK
- Pathogen: Variola virus (Smallpox)
- Incident: A medical photographer, Janet Parker, contracted smallpox from a laboratory in the same building where research on the virus was being conducted. The virus escaped due to faulty ventilation. Parker later died, and this was one of the last smallpox-related deaths in the world.
- Human Error: The virus escaped due to a combination of faulty ventilation and human error in lab maintenance and oversight. The research being conducted on smallpox in a shared building with other medical facilities created a vulnerable situation. Adequate safety protocols were not followed.
- Importance: The incident showed that lapses in oversight, even in something as simple as building maintenance or failing to separate high-risk work areas, can have deadly consequences. Vigilance in enforcing and following biosecurity measures is essential.
- Impact: Led to stricter controls on smallpox research and lab safety worldwide.
3. Sverdlovsk Anthrax Leak (1979)
- Location: Sverdlovsk (now Yekaterinburg), Soviet Union
- Pathogen: Bacillus anthracis (Anthrax)
- Incident: A military lab accidentally released anthrax spores, which led to at least 66 confirmed deaths (though estimates suggest the number could be higher). The incident was caused by failure to replace a filter in a venting system.
- Human Error: The anthrax spores were released when workers failed to replace a critical air filter in the laboratory’s ventilation system. This failure allowed spores to be discharged into the surrounding area.
- Importance: This case demonstrates how a single point of failure (not replacing a filter) can result in a catastrophic event, especially when proper procedures for checking and maintaining equipment are neglected. The human element of ensuring safety standards are met is crucial.
- Impact: Highlighted the risks of bioweapons programs and led to suspicions about the Soviet Union’s biological warfare activities.
4. SARS Lab Escapes (2003–2004)
- Locations: Singapore, Taiwan, Beijing, China
- Pathogen: Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV)
- Incidents: Several separate incidents occurred where researchers were accidentally infected with the SARS virus due to lapses in lab safety. In Singapore and Taiwan, the incidents were contained with no major spread. However, in Beijing, multiple workers were infected, and the virus spread to others outside the lab, resulting in at least one death.
- Human Error: In several of the incidents (Singapore, Taiwan, Beijing), researchers were infected with SARS due to lapses in safety protocols. In some cases, it was due to mishandling samples, improper use of personal protective equipment (PPE), or exposure during routine lab work.
- Importance: The repeated incidents show how individual lapses in judgment or failure to strictly follow protocols can result in infection and the potential spread of deadly diseases. Proper training, attention to detail, and strict adherence to protocols are vital.
- Impact: Raised global concern over lab containment practices, especially in high-level labs working with dangerous pathogens.
5. Ebola Lab Contamination (2004)
- Location: Russian Research Facility, Vector Institute
- Pathogen: Ebola Virus
- Incident: A researcher was accidentally infected with the Ebola virus and died. The exact cause of the incident is unclear, but it occurred during laboratory work involving the virus.
- Human Error: The researcher who became infected and later died may have been exposed through a needle stick or some other breach in safety procedures during lab work. In high-containment labs, even minor errors can lead to lethal consequences.
- Importance: This case highlights the importance of minimizing human error through rigorous training, constant vigilance, and the use of advanced safety measures, especially when handling deadly pathogens like Ebola.
- Impact: Highlighted ongoing safety issues in high-containment facilities, even in established research centres.
6. Foot-and-Mouth Disease (2007)
- Location: Pirbright Laboratory, UK
- Pathogen: Foot-and-Mouth Disease Virus (FMDV)
- Incident: An outbreak of foot-and-mouth disease was traced to a research facility. The virus escaped through defective drainage, which contaminated nearby livestock.
- Human Error: Investigations revealed that the virus escaped from a facility due to faulty drainage and lapses in oversight. Maintenance and monitoring of waste handling systems were neglected, allowing the virus to escape into the environment.
- Importance: It highlights how human error, such as poor oversight and maintenance of infrastructure, can lead to unintended pathogen releases. Routine checks, strict adherence to containment protocols, and proper training are critical for preventing such incidents.
- Impact: Resulted in stricter biosecurity measures in agricultural and research labs.
7. H5N1 Influenza Contamination (2014)
- Location: U.S. Centers for Disease Control and Prevention (CDC), USA
- Pathogen: H5N1 (Avian Influenza)
- Incident: The CDC accidentally shipped live H5N1 influenza virus instead of a benign strain to a U.S. Department of Agriculture lab. The mistake was discovered before any potential outbreaks occurred.
- Human Error: Live H5N1 influenza virus was accidentally shipped from a CDC lab instead of a harmless strain. This mistake occurred due to failure in following proper labelling and shipping protocols.
- Importance: This incident underscores the danger of complacency and how even a well-established organization like the CDC can suffer from procedural errors. Human oversight at every stage of pathogen handling is essential to prevent potentially disastrous mistakes.
- Impact: Resulted in internal reviews and a temporary halt to work on dangerous pathogens at the CDC. It also led to increased scrutiny on handling highly pathogenic organisms.
8. Zika Virus Mishandling (2016)
- Location: Oswaldo Cruz Institute, Brazil
- Pathogen: Zika Virus
- Incident: A lab worker was infected with the Zika virus after an accident involving a needle. This occurred during the height of the Zika virus outbreak in Brazil.
- Human Error: A researcher was accidentally exposed to the Zika virus after a needle-stick injury. This happened despite the presence of safety protocols, suggesting either complacency or a failure to properly adhere to best practices.
- Importance: The incident shows how hands-on lab work can be dangerous, and meticulous attention to safety is required when working with pathogens, especially during an ongoing public health crisis. Human error, such as incorrect handling of lab tools, can result in exposure to the virus.
- Impact: Raised concerns about lab safety practices in the middle of an ongoing public health crisis.
9. COVID-19 Wuhan Lab Controversy (2020)
- Location: Wuhan Institute of Virology, China
- Pathogen: SARS-CoV-2 (COVID-19)
- Incident: There has been ongoing debate over the origins of SARS-CoV-2, with some speculating that the virus may have accidentally leaked from a high-level containment laboratory. While no conclusive evidence has been found to support this theory, it remains a subject of investigation and discussion.
- Impact: Led to a global focus on lab safety, transparency, and the importance of stringent biosecurity measures in research facilities.
These incidents highlight the critical importance of strict safety protocols in high-containment laboratories (BSL-3 and BSL-4 labs), where dangerous pathogens are studied. Proper containment, rigorous safety training, and infrastructure maintenance are essential to prevent the accidental release of infectious agents.
Managing Human Performance in High Hazard Industries
The UK has been a global leader in managing human performance in high-hazard industries, thanks in part to its Control of Major Accident Hazards (COMAH) Regulations. These regulations emphasize the importance of human factors in preventing catastrophic incidents in industries like oil and gas, and chemical processing.
The Human Factors Delivery Guide for COMAH sites states that the underlying Human Factors principles within it will be applicable to the management of human performance in other high-hazard sites, which goes beyond COMAH and can extend to biological containment laboratories. However, this structured Human Factors risk management framework is not yet common for this sector.
Human Reliability for Biological Containment Labs
Human Factors Safety Critical Task Analysis (SCTA) is aligned with the HSE’s Human Factors Roadmap in the Human Factors Delivery Guide for COMAH sites, and has become the standard for detailed, structured systematic Human Reliability Assessment. It entails:
- Identifying and prioritizing critical tasks linked to the highest severity events.
- Selecting a task to analyse.
- Doing a systematic detailed on-site task analysis, e.g. Hierarchical Task Analysis.
- Using failure modes as guidewords to anticipate what human failures could occur, how they can occur and their consequences.
- A Performance Influencing Factors (PIF) Analysis to understand the factors that either drive up the likelihood of failure or reduce the likelihood of failure.
- Applying the Hierarchy of Control and optimising PIFs.
SCTA has the potential to proactively anticipate low frequency and high consequence events, like those listed at the start of this article. It can also improve general safety, quality, production and human well-being.
Some critical tasks to explore could include:
- The donning of PPE
- The use and maintenance of Microbiological Safety Cabinets
- Handling spills and fumigation
- Storage, selection and transportation of samples
- Manipulation, measuring and actions around the handling of pathogens
- Waste and disposal management
- Maintenance Inspection and Testing (MIT) of HEPA filter systems, airflow management and alarm settings.
If you’re interested to learn more about SCTA, we have written up a related SCTA case study of preparing a trolley for the autoclave, which was to sterilise equipment for a sterile environment: https://www.humanreliability.com/2024/05/systems-critical-task-analysis-a-case-study-for-quality-improvement/
Summary
In summary, human error is a consistent factor in many biological containment lab incidents. It underscores the necessity of robust safety cultures, comprehensive training, and multiple redundancies to prevent human mistakes from escalating into public health risks. Human Factors for COMAH is a mature and structured framework for human performance risk management, which shows a lot of potential for other high hazard industries, like those using biological containment labs.
ChatGPT co-authorship: I’ve written the blog with the assistance of ChatGPT. It was especially helpful in researching and summarizing the incidents related to biological containment labs, so I hope the details are correct there. By asking it further questions I selected parts of what it wrote, edited it and stitched it together with sections of my own writing.
If you want to learn more about the SCTA process, sign up for our free HFCTR mini-course. In just 30 minutes, you’ll get an introduction to the different stages of SCTA process. Click here to find out more!
We’re also excited to announce the upcoming launch of our SYSTEMS Critical Task Analysis course. This course is ideal for those outside the COMAH industry who want to apply the SCTA methodology within their sector. Sign up here to be notified when it goes live.
