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from the cracked-some-eggs...-noggins-next? dept.
In a letter to nearly 1,000 patients, University Hospitals in Ohio says that a tank's remote alarm system, meant to alert an employee to temperature swings, was disabled for an unknown length of time. That led to the destruction of around 4,000 frozen eggs and embryos, double the original estimate:
Hospital officials say they doesn't know who turned the remote alarm off or how long it was disabled. They also said they were aware the tank in question needed preventative maintenance. Some of the eggs and embryos had been stored there since the 1980s. The hospital's investigation is ongoing.
"Right now we do not know whether it's mechanical or human or [a] combination," said James Liu, chairman of the department of obstetrics and gynecology at University Hospitals.
He says he doesn't think anyone intentionally disengaged the alarm. "Because it is a computer, we think it's unlikely that there was any kind of external force that was working to hack the computer or anything like that. We think it's unlikely," Liu said.
Previously:
Freezer Malfunction May Have Damaged Up to 2,000 Frozen Eggs and Embryos
Two Fertility Clinic Freezer Failures Occurred in a Single Day
(Score: 5, Informative) by rleigh on Wednesday March 28 2018, @06:32PM
There is no refrigeration, and there are no heat exchangers, in liquid nitrogen storage tanks. They are nothing more than a large stainless steel dewar with a few inches of liquid nitrogen at the bottom. While the bottom box or two of a stack might be immersed in liquid, most are in nitrogen vapour above the liquid at -196℃. The top of the tank narrows to form a neck, which is sealed by a lid with a huge compressed syrofoam plug a foot or so thick.
There are only two ways that such a tank can fail. The first is the tank being physically damaged, resulting in a loss of vacuum in the dewar walls, a leak, or a damaged plug which results in loss of nitrogen or the insulation. The second is a failure to keep the nitrogen levels topped up. So long as there's even the smallest hint of liquid in the tank and the lid is left on, the vapour temperature will remain at ~-196, but as soon as it's gone the temperatures will rise quickly.
The failure here is not simply the alarm being disabled. It's the fact that the tank was allowed to go dry, and it wasn't picked up on by manual inspection. It takes just a few minutes to do a daily inspection of an entire roomful of tanks; all you have to do is take the lid off and shine a torch inside to check the level. It's a couple of minutes per tank at most. This isn't a technology failure; it's a process failure. The alarm is to alert when abnormal events happen like the tank leaking, or someone forgets to fill it up; it should never, ever, go off if a routine process is followed to maintain the tanks. Someone, or someones, didn't do their job, and no one else checked up that the job had been done. Which is both a failure on an individual level and a management level.