Implementing and enforcing the laboratory's stop work and restart policy and procedures in conjunction with peer reviews for new processes and experiments should help prevent future accidents due to a lack of recognition of potential reactions and hazards. This abnormal event points out the need to call appropriate personnel when an abnormal event occurs. Safety personnel recommended all cleaning products be treated as potentially reactive mixtures.

There is no such thing as an "always safe" cleaning solvent, including water. The reactivity and safety hazards of all materials must be considered, and only materials properly evaluated for the particular process involved must be selected.

In the future, proposed processes and experiments need to be reviewed for potential hazards. Both a chemical engineer and chemist interviewed recognized the potential reactions and hazards when carbon and magnesium oxide or carbon and aluminum oxide are heated to above 1400° C. However, other staff members did not have the same degree of understanding of the potential reactions and hazards involved. The technician was instructed to clean the interior surface of the furnace top before the results of samples taken were analyzed because it was assumed that the support/spacer plate used during the process was an aluminum oxide plate. A peer review of proposed processes and experiments would have provided a needed potential reactions and hazards review.