Wednesday, June 01, 2005
MONITOR STAFF REPORT
A post-doctorate and an undergraduate student working in TA-9 were treated for minor injuries and released from Los Alamos Medical Center.
A gram-level amount of a chemical called diamino tetrazole was being weighed when it suddenly exploded in a student's hand about 10:40 a.m. on Friday.
The student had an injury akin to a firecracker going off in the hand and may require some additional treatment, LANL spokesperson Kevin Roark said in an interview this morning.
Another student received some minor scratches to the face from shattered glass.
I glad that all the correct procedures were used and that both students are OK.
They really should eliminate these "spokesmen" for LANL, who simply add to LANL's reputation for lies and double speak.
You clearly must be a pencil-pusher. To state that "if 'everyone did what they were supposed to do', there would be no accident" is absurd and reflects a lack of experience with experimental operations. I know you will probably wet your pants when I tell you this, but, yes ACCIDENTS DO HAPPEN! And, NO, there does not have to be someone at fault!
In any given experimental operation, there is a finite probability that something will go wrong. You CANNOT reduce the risk to a zero probability level, despite what managers tell you! It is impossible!
Therefore, according to mathematical laws as we know them, if you do a given experiment long enough, eventually an accident will happen. The key is to reduce the finite probability of an accident occurring as much as possible and to reduce the potential consequences as much as possible. That is exactly what happened here. It could have been much worse if it were not for the post-doc correctly following previously implemented safety procedures.
"[As Roark corrently stated: "Accidents do happen." What a revelation! Roark said; the mystery is why the accident happened when the chemical composition doesn't even carry the danger of explosion. (It should have. Amino tetrazole is the explosive used to inflate air bags in you car. Diamino tetrazole is a slightly more energetic version of this compound (six nitrogens as opposed to five).
I glad that all the correct procedures were used and that both students are OK.]"
In my opinion the procedures used may have been approved, but they were not correct. If diamino tetrazole is an explosive compound, a gram quantity should not be handled bare handed in a glass beaker.
This accident happened so it is clear that the procedures used to protect the employees were inadequate. LANL has spent the better part of a year reviewing hazards and revising controls to mitigate them. I wonder how many other accidents are out there waiting to happen.
Larry, I'm not sure if you realize this or not, but people handle pounds of explosive "bare-handed". It is a much more complex risk analysis and problem than you think it is. You cannot just label something "explosive" and assume all explosives are alike and require the same procedures. That is quite naive.
"Larry, I'm not sure if you realize this or not, but people handle pounds of explosive "bare-handed". It is a much more complex risk analysis and problem than you think it is. You cannot just label something "explosive" and assume all explosives are alike and require the same procedures. That is quite naive."
I do realize that people handle pounds of explosives bare-handed. I did so for 28 years on the firing point. I am not so naive that I don't understand that you should handle "powder" differently in the lab. It does not take much greater control to handle all powder is if it were PETN.
I stand by what I said about the procedure being inadequate. If the procedure addressed the fact that the reaction could have broken the beaker no one would have been hurt.
"Larry, why are you so eager to jump all over those guys without any experience in an explosives chemistry lab or specific knowledge of the circumstances? Really the only ones qualified to review those procedures, I would think, would be other explosive chemists. I imagine
all the explosive chemists at LANL are already fully engaged in the analysis of this specific incident. Let's reserve judgement and give the guys in DX-2 the benefit of the doubt until we know all the facts. I'm sure you would appreciate the same courtesy if an incident happened on your firing site."
Please forgive me. I had no intention to place blame on the people doing the work, nor did I realize I did so. I was trying to point out that an accident happened while following a Laboratory approved procedure. Accidents happen, and nothing the Lab has done during the past eleven months prevented this one.
I don't want my comments to change the direction of this thread so if you or any others want to continue this discussion off-line, please write me at firstname.lastname@example.org.
Larry Creamer, DX-1 Retired.
And the attitude that "accidents do happen" is far too typical of LANL. Accidents happen because of people, and if this accident was "expected" why was a UGS student performing it?
Your rudeness and arrogance casts LANL in a very poor light; in contrast to the 6:35 post which is informative and helpful to the discussion.
I'm not entirely sure you know what you are talking about. What difference does it make what the source of accidents are? If, as you suggest, they are do to human error, then it seems the only solution to achieve zero risk level is to either (1) not allow humans to perform the work or (2) not perform the work at all. Either solution is not viable, therefore your comments really have no added value.
In the real world, experimental work has to get done and ACCIDENTS WILL HAPPEN. I'm both sorry and concerned that you are not able to understand that. Hopefully you're not management...
Many of you who are commenting on this and the other thread regarding the accident are going to feel quite foolish when the facts of this case come out. Let's just say for now it appears that EVERYTHING was done as it was supposed to be done per the IWD and literature, by a HIGHLY EXPERIENCED POSTDOC, not an undergrad, and that this accident occured through no fault of anyone in DX-2, DX, or LANL. I would be shocked and awed if those of you jumping all over DX were to come back and apologize, or if the media updates people on what really happened.
As for Kevin Jones, those of you who have an issue with him over the CREM situation may or may not have a beef with him, I have no idea. But to jump all over him regarding this accident is not appropriate. Kevin's responsibility as RDL is to sign off on facility issues on the IWD, not the procedures. That is up to the author of the IWD, the workers, and the RLM. On a side note, my interactions with Kevin have shown him to be a logical, no nonsense guy. He sees a lot of the problems that are in DX, but when you are at the bottom of a huge pile of garbage that has been building for years, it sometimes takes a long time to dig out.
You can believe that the people who wrote these IWD are the best in the field and know what they are doing. Additionally, these are reviewed by knowledgeable, disinterested parties, not someone from the same team. If there was a problem with the procedures, it would have been caught.
Just think for a moment about the sheer amount of explosives that are synthesized by many people at this laboratory. Seriously. Take all of the years, all of the people, and all of the batches made, and you have what probably amounts to an astronomical amount of explosives. And how often are there accidents? Exactly. I would argue you are more likely to get killed driving home from work than have an accident synthesizing HE at LANL.
Some people get it (dug for one). But boy, some of you really don't.
"The statement "accidents do happen" is not arrogance. It's honesty. If humans weren't a constant source of errors, we wouldn't need backspace keys on our keyboards. At any given moment, our brains are juggling thousands of things, and the one element that we're not considering could be the thing that gets us hurt. After the fact, our attention focuses in like a laser beam on the "if onlies," but it's a pointless exercise. All you can do is exercise diligence and deal with incidents as they arise. All the people trying to use this accident to score debating points should find some other amusement."
George Kistiakowsky was in charge of explosives safety during the Manhattan Project. He said that in industry people safely handle large quantities of explosives daily under carefully controlled conditions. He also said that in explosives you only get one chance to make a big mistake.
When I was a safety officer, the purpose of an accident investigation was not to assign blame (names were never mentioned). We tried to learn what caused the accident and what we could do to make sure that the same thing did not happen again.
Today, accountability and punishment seem to be most important in accident and compliance investigations, as has been demonstrated during the past ten months.
We need to be able to return to the days when preventing furure accidents was most important.
Larry Creamer, DX-1 Retired
I'll admit, Kevin is not the worst manager I've seen at Los Alamos, but he has no business running DX for the simple reason that he has no experience in the type of work done (or more correctly NOT dnoe) there. He also has some serious problems with common sense ethics (CREM incident). Since such ethics problems are still evident in his reporting chain, particularly with Susan, I can only surmise that their collective and convenient lack of ethics is the very reason that he was promoted. Kevin is no fool and he has done very well for himself. I expect that trend will continue. I expect that he will continue to sign documents that he does not understand in the slightest (don't we all these days?). I also expect similar "accidents" to continue unabated in LANL and DX for some time to come because experience is not valued in the slightest and the new generation of employees are mindlessly following procedures that cannot possibly protect them from the wide variety of hazards they will encounter.
My hope is that the LANL of the future will turn (slowly) away from the idiot-level-IWD, paper-pushing, process-based, legal-CYA, systems of Kevin Jones, Pete Nanos, Fred Tarantino, Sue Seestrom et al. back toward a model of management where scientists and genuine subject matter experts like Kistiakowsky et al. saved the world by charting unknown territory. I expect that is a vane hope.
"My hope is that the LANL of the future will turn (slowly) away from the idiot-level-IWD, paper-pushing, process-based, legal-CYA, systems of Kevin Jones, Pete Nanos, Fred Tarantino, Sue Seestrom et al. back toward a model of management where scientists and genuine subject matter experts like Kistiakowsky et al. saved the world by charting unknown territory. I expect that is a vane hope."
I wish DOE would allow LANL to go back to the old SOPs we used for so many years.
Larry Creamer DX-1, Retired
"Fascinating blog. Sometime in the future, when Mandarin is more widely accepted than English, and the North Koreans have the most complete archives of early 20th century blogs, a scholoar may ask, what do RDL, IWD, RLM, PETN stand for. (I think HE refers to high explosive. Is that correct?)"
LANL has 132 81/2 x 11 pages of acronyms. You can find them at:
Larry Creamer DX-1, Retired
"Interesting answer for acronyms. There is apparently no racial discrimination among Work Documents; they are Integrated. There are 3 uses of HE and one for PETN. Still don't know what RDL and RLM represent. The scholoars [sic] dealing with the 20th (21st?) blogs still need some help with RDL and RLM."
I have no idea what is integrated in the work documents, but I'm sure that people are not.
HE high explosives - Correct
HE hoist, electric - incorrect
HE human error - maybe
The acronym list must not be up-to-date. RDL is responsible division leader, and RLM is responsible line manager. Does that help? I thought not. It didn't help me.
Larry Creamer DX-1, Retired