Thursday, November 03, 2005

Occurrence Report for the DX-1 incident

Submitted by Anonymous:

I am attaching a copy of the Occurrence Report for the DX-1 incident.
It might be of some use as it shows up many of the LANL problems in a
very clear light.

Glad to see the blog going on. It is a bit cleaner without all the
anonymous postings.

Please post this anonymously. That avoids all the personal sniping.


Does this look like a failure by the workers, or a failure by management? We are fair-and-balanced here on The Blog; you be the judge:


"Additionally, the contributing cause described above was driven by what appears to be a work environment of mistreatment and reprisal within the Inert Section, an environment which DX-1 management failed to identify and act upon. According to a number of Techs within the Inert Section, the Section Supervisor had a history of making disparaging and inappropriate remarks to all three Techs involved in the event, and engaged in preferential treatment when making work assignments. The Fabrication and Inspection Team Leader had been informed of the Inert Section Supervisor's mistreatment multiple times by both E1 and E2 yet had failed to take effective action to address the problem."
Anonymous said:
“I am attaching a copy of the Occurrence Report for the DX-1 incident.
It might be of some use as it shows up many of the LANL problems in a
very clear light.”

Actually, while the report does show problems that were present in 2003 and may continue today, it does little to help you understand this accident because the OR was so poorly written.

In Section 15, Description of Occurrence: BACKGROUND:, E1, E2, and E3 are clearly defined, but the writer does not clearly differentiate between the Team Leader and the Technician Supervisor. The writer is not consistent in use of the term “supervisor”. Sometimes it refers to the Technician Supervisor, and at other times it refers to the Team Leader. In one case, I think the writer was talking about both people. When you read the report, keep in mind that the Technician Supervisor was on sick leave on September 30, 2003 (pre-job briefing) and on October 2, 2003 (day of the accident). Every statement about the “supervisor” on those two days must be about the Team Leader. The report is not clear about the attendance at the critique on October 6, 2003. Was the Technician Supervisor there?

Section 22, Description of cause:, states that there was “a failure by any of the involved employees to stop work”. Section 15 clearly states that when the employees felt discomfort they stopped work, exited the work area and reported their concern to the Team Leader who sent them back into the room to complete the task after telling them to tighten the respirator straps. They re-entered the room to finish the job and found the fumes were “again overwhelming” and stopped work again. The failure to stop work rests on the Team Leader who somehow convinced the workers that they could safely complete the task.

On October 3, 2003, the workers were told by the DX Industrial Hygienist that they had used the wrong respirator cartridges. The incident should have been reported to DOE then, not a year and a half later, and an immediate investigation started.

Larry Creamer
DX-1 Retired
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