Wednesday, March 30, 2005

Board cites new lab incidents, improvements

Board cites new lab incidents, improvements

ROGER SNODGRASS,, Monitor Assistant Editor

Safety issues continue to devil Los Alamos National Laboratory, according to the only independent federal observers with access to classified operations.

There have been incidents of concern, said a representative of the Defense Nuclear Facilities Safety Board in a telephone interview this morning, but the laboratory is making visible progress in its safety program.

"It's a long road ahead," said DNFSB Site Representative Charles Keilers, "But from the beginning of January to now, some things are really on the upswing, including management attention and management awareness of operational issues."

The Defense Nuclear Facilities Safety Board reported earlier this month that two workers were exposed for an hour to unexpectedly high levels of airborne contamination while working at the Radioactive Liquid Waste Treatment Facility at Technical Area 50.

Although they were wearing protective equipment, the workers might have been exposed to plutonium uptake, depending on the level of protection afforded by their respirators.

High measurements were found after they exited from a vault where they were cleaning an old leak, the March 11 report said.

About a year-and-a-half-ago, a tank that was meant to hold caustic waste from the nearby Plutonium Facility developed a leak.

While waiting to replace the tank, a temporary work-around called for the waste to be pumped through the tank more frequently so that only the lower half of the tank below the leak was used.

The replacement plan called for the underground vault to be decontaminated and repainted before the new tank was installed

The incident occurred after the workers had started cleaning up paint chips in the underground vault, wearing equipment appropriate to the ambient radioactivity previously sampled for the room.

Two accidents involving students in the Radiochemistry Laboratory at Technical Area 48 were reported by the DFNSB in January.

One involved a broken vial containing a low-level radioactive liquid combined with a hazardous chemical. The other occurred when a 19-year-old student dropped a wrench and caused an arc on an uninterruptible power supply.

Another problem was reported by DNFSB at the Radioactive Liquid Waste Treatment Facility in January, after an operator was sprayed by treated wastewater.

With the exception of the possible plutonium uptake - which awaits further test results - none of the incidents has caused personal harm.

Keilers said they afford educational opportunities for fixing the shortcomings in the laboratory's safety program that still needed improvement.

The laboratory's non-essential operations were suspended in July, after a false alarm from a security incident was followed by an eye-blinding laser accident involving an intern.

Activities gradually resumed over a seven-month period after rigorous safety reviews, assessments, training and safety management adjustments.

An article on the laboratory's website this morning announced approval earlier in the month of a plan for a new Operational Efficiency Program related to the continuing safety project.

"Operational Efficiency is the institutional commitment and get-well plan to address areas of high risk," Laboratory Director Peter Nanos described the project, which is designed to fix secondary problems that were not addressed during the laboratory shutdown.

A DNSFB report from February noted that managers who are responsible for plutonium, tritium and radiography operations had started a series of classes developed by the Institute of Nuclear Power Operations for nuclear power plant managers.

The training acknowledges human imperfection and the importance of learning and strengthening the organization in response to individual human errors.

"People make mistakes, but safety nets can keep something bad from happening," Keilers said. "If you work in an environment heavy on blame, you won't get people to be forthcoming and may miss the chance to fix the institution in a way that could catch the next event before it happens again."

The most important statement in the original posting is the last paragraph. Having an abusive intimidating environment leads to nonreporting, better "faux" statistics, and the ultimate collapse of an organization.
"19-year-old student dropped a wrench"?? This is national news?? We need DOE and whatever contractor to have a realistic attitude. Of course, LANL should be as safe as humanly possible. We should constantly look for ways to truly improve (like shielding the top of the power supply). But our contractor needs to stand up to DOE and say 'Mistakes happen, we are investigating and adding targeted safeguards'. However, if there is a problem with wrenches- it doesn't really help to count chemicals and check door locks. A simple sheet of plastic might have been the best solution.

Often LANL (and other large entities) safety solutions lack common sense- i.e. fill out this paper in triplicate, get six signatures and call the fire department before entering the laser lab... Please, add realistic low tech solutions first. Regarding the laser incident, we should have added (enforced?) a rule that employees don safety glasses to even enter a laser area. Then add a bin of glasses by each door. (low tech) Train people to gently remind each other- should someone forget the glasses.

LANL's goal/promise is 12000 people who collectively never make an error. The best approach to a safety problem is to come up with the most straight-forward, doable solution that works. Knee jerk complexity is NOT an answer.
I agree with Keilor's that blame is not the way to get people to come forward with safety problems and to provide the opportunity to fix them.
Nanos's firings in the laser incident are a heads up to managers that failing to insist on safety rules being followed will cost them their jobs. Until managers quit retaliating against those who report safety problems, there will be no reported safety problems, and I sm aware of managers who are still doing just that. That is the cultural problem with LANL -- retaliation as a way to silence any problems, safety, security or anything else.
Simplicity is a good idea as well, but some of the substances we deal with just don't allow a simple approach. They need a structured, planned approach for real safety.
"The laboratory's non-essential operations were suspended in July, after a false alarm from a security incident was followed by an eye-blinding laser accident involving an intern."

So, what's the latest on the "eye-blinding laser accident"? Has it been upgraded from a 500 micron spot to a full eye-blinding?
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