Friday, April 29, 2005

Fact: this accident did happen

Was having to assess our Laboratory operations this past year necessary? Every story usually has an alternative viewpoint.

I participated on the laser accident investigation team. I could not believe what I was told regarding the accident - here was a Principal Investigator operating a Class IV Nd:YAG laser system (high peak power invisible, infrared radiation) without wearing laser protective eyewear! This action conflicts with the most basic rule of laser safety. Operation included running the system to produce laser light, not just pulsing flashlamps with an inactive Q-switch.

Finding someone who would operate a Class IV laser system without protective eyewear was bad enough. What scared me more, however, was that a few other coworkers/ colleagues shared his safety philosophy with respect to laser operations. The way I read the rules, I cannot even be at my computer station off in some corner of the lab without protective laser eyewear while a Class IV system is running in spite of any confidence I might have in how well the beams are managed. In the case of this accident the laser light was poorly managed.

How do we discover these egregious safety behaviors before they result in accidents? Fact: this accident did happen; among the Laboratory laser community we found somebody who would operate a Class IV laser system without protective eyewear. I ask myself if there are like minded workers out there who are in a position to compromise safety, security, procurement, environmental compliance, (pick your favorite topic)…

At least some degree of self assessment was warranted. I submit these opinions as a private citizen. Hopefully they add another perspective to “the real story”.

Thomas P. Turner


Comments:
Thomas:

I don't disagree with you. The laser incident should never have occured. The fact that it did illustrates a huge deficiency in adherance to safe practices in the location where the accident happened.

That is not the same, by any means, as justification for shutting down the entire laboratory for 7 months.

The group, and perhaps the whole division in which the lasr incident occured should have been shut down, the problem identified, and fixed.

What happened instead was operational insanity.
 
I agree also that this was a terrible accident.

However, these types of accidents do occur in other labs and universities. The response to this unfortunate accident of shutting the lab down was unique to LANL. Do you really think that we will never have another unfortunate accident like this again now, ever?
 
Take a look at the report, if they'll let you. Cremers had been doing the same experiments the same way for more than 10 years. He would generate a laser-induced breakdown at some distance and collect the light with a lens. He won all kinds of LANL awards. No one cared to report the safety violations. In 10 years the responsibility had spread all over the lab.
 
Just saw ENRON. It’s a documentary that begins with Ken Lay rewarding corruption, shows the Bush family support of the company and paints a picture that shows why the company was forced to rape the California electric ratepayers. You all have to see it, particularly the parts about the big lies, now, with the benefit of hindsight, very obvious. It made me think about LANL printing the “World’s Greatest Science” on everyone’s business cards. I’m sure that the guys who haven’t given up on cold fusion or who invited Randall Mills to speak at LANL were entitled to those cards. Not too many people have dared to question the use of that phrase. Has it occurred to anyone what such a practice tells about LANL culture?
 
"like minded workers out there who are in a position to compromise safety"

Almost everyday I see bicyclists, walkers and joggers sharing poorly laid out "Laboratory" roads with heavy industrial and commuting traffic. I'd venture to estimate that this risk is far greater than the 10 years of Cremer being foolish with lasers. I know of someone killed on a bicycle on a Lab road; has anyone been killed by a Lab laser?
Our society's, the Lab's and DOE's response to risk and safety is very illogical and unbalanced. The mix of bicycles, pedestrian and motor vehicle traffic on Lab roads continued unabated during the big "shutdown". Did anyone notice; did anyone care? I'm not sure what the shutdown was really about but I doubt it was about safety.
 
Dear 08:55,

Have you not seen any of the DuPont STOP Training presentations? The purpose of this horribly expensive training is to prevent all injuries and occupational illnesses. The operative word is all. Who in their right mind could ever seriously believe that training could prevent all injuries? Moreover, training does not prevent occupational illnesses. A healthy environment prevents illnesses. If people have to work in building with leaky roofs and moldy ceilings, for example, they are going to get sick. If they work in labs without proper ventilation, they are going to get sick. The employer is responsible for the condition of the facilities, and the employer is the one held responsible for occupational illnesses.

For information on DuPont's great safety record

http://www.paceorganize.org/PRdupont_july12_2004_1.htm
 
Exactly, how much are we paying for STOP? Anyone?
 
Hey,

I am for saftey and to be honest
am very afraid of lasers and people
who use them. I am trying to defend
what happened at all. The people in
the lab should be let go. However,
I have been to over 50 Universities and I can tell you the stuff I saw was
far far more unsafe than anything I
saw at Los Alamos. I also know of professors who lost complete eye-sight in one eye. The incidents
do happen at Universties. Of course
the do not shut down the entire campus. One thing about the laser people at the universities say is that they feel that it is actually safer
to not use eye-protection as you can
see better where stray beams are and
such. I really do not know. I just
stay outside those labs.
 
Imagine if the larger world really worked this way! Everytime somebody got a DWI, we shut down the state of New Mexico while each resident was compelled to take another driver's test. Of course we all recognize how absurd that approach would be and we would not support such an action for long. Strangely, as Gary asserts, at LANL perception can be more important than truth. Strangely, such an arbitrary approach was adopted anyway. The solution, or course, is to get back into the real world where risks (laser injury etc.) are balanced against benefit (national security). Meanwhile, those involved should be punished if guilty, and the incident reviewed and lessons learned widely published so that we can get back to business and minimize such accidents in the future. If, indeed, the risks do not justify the benefit, then LANL should close its doors forever. Nobody ever said freedom was cheap, or that nuclear weapons work was without hazard. Pete has provided that Nation with some fine theater that has distracted everybody involved from the tasks at hand.

Scott
 
Tom's analysis is reasonable, and I agree that in the aftermath of this accident, it would have been irresponsible to carry on as if nothing had happened. There is a large gap, however, between "carry on as if nothing had happened" and what we actually did. Somewhere in this gap is the "right" thing to do.

I'm curious: how did PNNL and Savannah River react when, literally within a few days of our self-imposed paralysis, there were fatal accidents at both facilities? Anybody got good data there? I have colleagues at both places, and they don't give the impression of having had morale-devastating responses -- but the grass is always greener. There may be lessons to be learned from the way they handled things. Or maybe not.
 
Tom-
your accident report, which I have read at least three times, was a mixed bag. While your group did a pretty good job of laying out the physical details of the event, the report is tragically degraded by reference to two previous accidents (the "acid splash" and the chlorine dioxide explosion). These other accidents were completely unrelated, with regard to both physical detail and experimenter carelessness. When I asked Dr. Taratino why these references were included, he responded quite honestly: they took place underneath the same division director. This has little to do with laser safety and much to do with meting out punishment. I am saddened.

-- Bernard Foy
 
While the mistakes made in the Craemers lab were egregious, no one who routinely works with Class IV lasers will agree with the assessment that simply not wearing eyewear is cause for alarm. The fact is, you do need to occasionally see what is going on without utterly blocking the beams. Some labs also have beams that span the visible and are tunable, making perfect OD eyewear for the situation kind of impossible. Of course, eyewear should be worn as much as possible, but it should not be relied on in lieu of good alignment procedure and beam management. If I ever see a burn spot on my eyewear, I will have made a huge mistake.

Even with eyewear, staring upstream and trusting a q-switch to hold off is incredibly foolish, and telling a student to follow that procedure is beyond contemptable.
 
I worked at a company (Harris Corporation) that built acousto-optic laser Q switches, similar, I believe, to the ones in Cremer's lab. These are transparent optical "bricks" (ours were made from fused quartz) with a piezoelectric transducer bonded to the side. When RF (usually in the 25-50 MHz range) is applied to the transducer, it sets up acoustic waves through the fused quartz which modulates the index of refraction in a random manner. Coherent light (laser radiation) passing through gets its wavefronts scrambled and becomes incoherent, suppressing laser amplification.

We tested these devices by dumping the Q-Switched laser beam into a beam dump made of firebrick. Periodically we had to move the bricks because the constant bombardment would melt and glassify the surface, making it reflective and scattering a high power beam across the lab. A single shot from the Q-Switched laser could ignite the wooden shaft of a cotton swab. You bet we used eye protection!

The great stupidity of this accident was the total, absolute, inexcusable stupidity of the PI in not knowing the fundamental mode of operation of a Q-Switch.

A Q-Switch is an intra-cavity device that spoils the "Q" of the cavity on command. The lasing pulse of a flash lamp pumped laser (sans Q-Switch) follows the flash lamp output - about a 1.5 to 2 microsecond pulse. A Q-Switch is placed inside the cavity, generally between the between the lasing rod and the 100% mirror. When RF is pumped into the Q switch, it suppresses lasing in the cavity, allowing the full optical pulse to pump the laser rod to saturation. The RF is then switched OFF and the entire rod is dumped in a few passes of the cavity, generally a few nanoseconds. What the Q-Switch does then, is take a relatively slow (microsecond scale pulse) and compress it into a very high peak power fast (nanosecond scale) pulse. Energy is conserved, but peak power is amplified many, many times.

So how does this relate to the accident? The PI thought that by turning off the RF to the Q-Switch he was suppressing lasing. WRONG! WRONG! WRONG! He was suppressing laser pulse compression. This total disregard for understanding the basics of the scientific apparatus he was using is the most damning indictment of him as a scientist. He was justifiably fired, and I hope the student sues him into bankruptcy for criminal negligence.

David W. Thomson
 
Tom,

What was the outcome of your investigation? Have the issues been corrected? Is the experiment now being done safely and properly monitored?

It has been more than nine months since the laser accident. I wonder how many other hazardous laser operations were studied during that time, and how many serious deficiencies were discovered. Can you provide any information?
 
The laser reaction was horrible. The defense of the PI for what he did is horrible. The firing of the people in the chain of command was probably warranted given the fact that no one was walking around and taking people to task for not wearing protective eye ware, like they did in my college freshman chemistry class where I was finally told if I didn't wear mine I would not be allowed to take the class. Had the management of C division taken safety as seriously as my college chemistry lab department, the accident, the student's serious injury and Mr. Creamers firing could have been averted.
The shutdown of the entire laboratory was ridiculous. Punishing the whole for the sins of a few is always a bad idea. My guess as to why it was done is for drama. It was Nanos's attempt to show he was doing things about safety and security in spite of evidence to the contrary. It worked for a while. He was able to transfer blame from himself to the employees, but after employees began to speak out, it became clear that top management had to bear at least some responsibility for not having the proper systems in place.
Brad Holian was correct that LANL has a fine safety record for what was reported. Unfortunately, a lot is not reported, both of accidents and near misses in both safety and security. Behavioral based safety and the STOP program exist to punish those who have and/or report accidents, not to remove hazards from the environment. The result no one wants to report accidents at LANL, just as happened at DOW where the STOP program started.
Even Nanos' own chief-of-staff had a serious cut on the ad building stair well and bled all over the place. In fact, I believe she was on her way to the "butthead" talk. She arranged to be taken to the emergency room at the hospital, rather than to Occupational Health as required by LANL. A janitor was called to clean up the blood. Fortunately the janitor was smart enough to know that blood required special clean-up techniques and called the proper authorities preventing any more people from being exposed. How can one trust a director who allows his staff to supress safety reports. If the truth came out, I suspect we would learn that LANL has a lot more accidents than we know about.
On the other hand, the current movement is to more accident suppression, not less.
 
Small correction to my previous post. The STOP program and the unreported accident problem came from DuPont, not DOW.
 
To 4/30/05 @12:13:22PM Doesn't the last paragraph of your posting need to be placed under comments re "Why Does Nanos Continue to be Protected?" Why wasn't this incident made public by the director's office?

Was anyone fired over this? Why did GPN's CHIEF-OF-STAFF go to the LA Medical Center instead of to Occupational Medicine? What did this chief-of-staff fear? Why?
 
Thanks to Turner for his post. Cremers could only be excused because "everyone was doing it", which is to say, he couldn't be excused. It has to stop sometime... and he was guilty as sin, per the report, which I read.
As to why LANL is different from other places which have accidents, it is because LANL has ISSM and managers "walk the spaces" programs, which were being checked off. In other words, LANL managers were lying about their compliance with LANL's own safety programs.
When a culture is found to be lying about its safety programs, something must be done; the lies must stop. The question is whether LANL has changed, today... Has it?
 
It is easy to say that managers were walking their spaces and signing off on adverse safety situations they saw but didn't report. However, this assertion is baseless and a fabrication born either of avarice or ignorance. The assertion certainly not supported by actual data. You should get your facts straight or your verbosity and sententia will always exceed your actual knowledge.
 
As a member of the group that laser accident PI was in, I feel compelled to correct some technical errors and the derived conclusions in a recent post. David W. Thomson, in his 4/30/2005 11:17:21 AM post, discusses in some detail “Q-switching,” and essentially concludes that the PI was a moron: “This total disregard for understanding the basics of the scientific apparatus he was using is the most damning indictment of him as a scientist.” Although he states that he worked at a company that makes acousto-optic Q-switches (AO-QS), Mr. Thomson displays some level of ignorance both of typical pulsed laser technology, and also of the published details of the accident. The report states that the laser is a Quanta Ray INDI. As is typical of pulsed YAGs, the output pulse length is ca. 8 ns – which can only be achieved by electro-optic Q-switches (EO-QS). AO-QSs produce much longer pulses – typically 100s of ns. One does not turn off the RF on an EO-QS – there is no RF. What the PI reportedly believed he did was to suppress the firing of the Q-switch. The record is not definitive as to how that was done; it may have been done by unplugging the trigger cable.

Whether he unplugged the cable or turned off the trigger source, this should have prevented lasing. However, it was an egregious lack of good judgment, one that will likely haunt the PI for the rest of his live. The best analogy is looking down the barrel of a loaded gun. I think we’d all agree that the gun shouldn’t go off by itself, but we’d also agree that it’s a terrible idea to do that. It’s the opposite of fail-safe – it’s fail-certain-injury.

I’ll let those out there who are perfect and have never made a poor decision crucify the PI for this error. Far worse, in my mind, was his propensity to not wear laser eyewear, especially as it influenced his students to do likewise. However, he had lots of company at LANL, in the DOE complex, in academia, and in industry as far as not complying with ANSI Z136.1 in this regard. If you doubt this, please look at the February 2005 DOE report on laser accidents in the complex. All six eye injuries over the past five years involved not wearing laser eyewear. Does that excuse the PI? No, but he shouldn’t be considered some sort of horrid 6-sigma safety abomination.

Scott R. Greenfield
 
Firing the laser without eye protection was a stupid thing, sure it was. But if that is the -worst- accident to happen at LANL lately, then, you are not even close to some of the accidents that took place at Rocky Flats.
 
If the LASER incident was representative of LANL's dominant culture, than I can easily understand it taking some 7 months to straighten out the mess, a lot of bruised egos, and the subsequent increase in retirements.

If you've ever been through a top level administration change at a major university, you know the drill can take a year or more. If not, Univ. of Hawai'i is an example of recent back to back reorgs and there's a lot of laundry on-line.


-do not look into LASER with remaining eye-
 
Makes me wonder that if there are people here this careless with lasers, how many are there that are careless with far more dangerous devices.....
 
6:05am poster.

The laser incident is not representitive
of the saftey culter at LANL. LANL has
the best saftey record in the DOE complex.
Look at the Dec issue of Physics Today. There you will see the facts.
Get the facts before you say something.

By the way what the hell are talking
about with U of H. I know some faculty
there and their labs where not shut down
for 7 months. They continue to do their
work. By the way I have visited at least
100 universities over the years and man
some of those places are unsafe. I know
of professors blinded. Also
I was told at one school that they will
never use eye protection because you
cannot see the stray beams. You never
hear about, say the entire Stanford campus
being shut down when someone loses a finger or gets burned in lab.
 
Thomas, Didn't you supervise Todd and John in DX? Perhaps you can comment on why you missed warning signs there?
 
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