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RD Safety AnalysisPeer Review
James Stine Los Alamos National Laboratory
ISM Best Practices Workshop Aurora, Colorado
September 12-13, 2006
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Presentation Outline

• Primary Lesson Learned
• Review of the Accident.
• Lessons Learned.
• Communication

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Primary Lesson Learned

• DX-2 met IWM standards as defined by the
  Laboratory.
• Wrote quality Integrated Work Document (IWD).
• Sit-down review
• Involved all of the workers including students

• However, this was still insufficient to protect
  DX-2 workers.
• The IWD is the starting point of the critical
  safety analysis not the end

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Accident Background

• Two workers were performing an organic synthesis
  of a non-energetic material from a literature
  preparation.

• There was an unexpected violent reaction causing
  glass cuts to both workers.
• Both workers were wearing safety glasses with
  side shields protecting their eyes from injury.

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Expected Synthesis Reaction

• Workers trusted literature preparation from
  peer-reviewed journal article.
• Although intermediate was energetic, final
  product was inert.
• Side reaction product and intermediate were
  energetic.

Desired inert product

• Inert
• Energetic

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Unexpected Side Reaction

• However, literature preparation made no mention
  of
• Side reaction product and intermediate were
  highly energetic.

Desired inert product

• Inert
• Energetic

Energetic side product
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Corrective Actions Peer Review

• Implemented Peer Review with laboratory notebook
  documentation.
• Researcher can address specific reaction.
• Peer reviewer performs a critical safety analysis
  of immediate, specific activities.
• Reviewers are knowledgeable peers.
• Peer Reviewer addresses reaction, associated
  hazards, mitigation, and stop/hold points.
• Safety analysis documented in laboratory notebook.

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Lessons Learned
The IWD is only the starting point of critical
safety analysis No IWD can possibly assess
details of this type of operation it can only
define the scope and safety envelope. Critical
analysis must be continually applied during
planning and performing the work at hand.
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Additional Corrective Actions

• Additional controls.
• Improved shielding.
• Additional and improved PPE.
• Started Advanced Energetic Materials Working
  Group whose primary focus is on safety.
• Comprises workers throughout Lab in synthesis and
  composite energetic materials.
• Meets regularly to talk about work activities,
  lessons learned, PPE, etc. This Group augments
  peer review.
• Investigating other safety improvements.
• Remote manipulators.
• Real time spectroscopic analysis.

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Could Other Operations at LANL be Similar

• Symptoms that may flag opportunities for safety
  improvement.
• Is the IWD perceived as all you need to initiate
  work?
• Is the worker focus on the paperwork?
• Is your pre-job briefing primarily centered
  around the science?
• Is your Plan Of The Week just a scheduling
  exercise?
• Are assumptions being made about where the
  hazards are?
• Should there be stop/hold points in the
  operation?
• Are such things as literature preparations, SME,
  etc critically assessed for safety?
• Do workers tend to add contingency so that new
  operations can be performed under an existing IWD?

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Enhancing Critical Safety Analysis

• Peer review with notebook documentation is
  working for chemical synthesis operations.
• However, the critical safety analysis can be
  achieved for other operations.
• Checklists, batch sheets, run sheets may be
  better suited to document review for other
  operations.
• Must be graded to the breadth and consequences of
  error of the IWD.
• Concept applied to a wide variety of operations
  synthesis to firing site.
• Created Peer Review course to train Peer
  Reviewers
• Formalized process.
• Part of course is to do analysis.

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Added Benefits

• Critical analysis enhances safety for your work
  activities.
• Engages the workers.
• Embedded in the way work is done.
• An integral part of daily operations.
• Broadens and hones critical analysis skills in
  workers.
• Applies scientists analysis skills to safety
  too.
• On the path to changing behaviors and safety
  culture.

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Communication

• Lessons learned communicated
• Members of the Group
• Associate Directors
• LANL Director
• LASO
• Students
• Lessons learned workshops