KI’s freezer fiasco investigated: A chain of failures

A chain of combined technical and organisational shortcomings caused the freezer breakdown at the Karolinska Institute during the Christmas holidays, destroying more than 47,000 samples. This was the conclusion of an internal investigation.

The problem started when the supply of liquid nitrogen to the cryotanks, where large amounts of biological research material were stored, was blocked due to an oxygen level alarm on the morning of 22 December. This took place during maintenance work carried out by an external technician.

After the work was completed, the technician instructed that the alarm should be reset, but this was not done. As a result, the valve remained closed, and the nitrogen supply was blocked, according to the report.

Text messages and emails about the alarm were sent to the phone numbers and email addresses registered for this purpose, and service team members have confirmed that they received the alarm message. “However, as service work was being carried out, no action was taken,” KI writes in a press release.

The report highlights several ambiguities about the so-called freezer hotel, where each research group is believed to have been responsible for installing cryogenic freezers and for the alarms.

“In retrospect, it is clear that the arrangements for operation and management of the freezer hotel were based on trust between the parties, and that too much responsibility was probably placed on the research groups,” says Matti Sällberg, Dean of KI South, in the press release.

“Unfortunately, over time, this resulted in a blurred understanding where one hand did not know or question what the other was doing.”

The breakdown was discovered on 27 December. By then, an estimated 34,400 biobank samples, 3,800 animal model samples, 2,600 cell line samples and 6,300 manipulated/edited cell line samples had been destroyed. The material had been collected over several decades.

The report proposes a number of measures to achieve a more robust freezing infrastructure at KI with a more clearly defined allocation of responsibilities.

Annika Östman Wernerson, KI’s Vice-Chancellor, notes in a comment that the university needs to take a more comprehensive approach to mission-critical facilities and infrastructure.

“It is a question of mandate, allocation of responsibility, resources and organisation. We have seen shortcomings in all these areas for a long time, and the reason for this turning out so badly is due to a chain of these shortcomings coinciding,” she says.

The internal investigation, led by KI’s Head of Security, Magnus Håkansson, will now be followed up by an external independent review by Anna Beskow, Head of Uppsala Biobank at Uppsala University. KI’s investigation will also be scrutinised by IVO, the police and Kammarkollegiet.

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