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R&D Safety Analysis: Peer Review. James Stine Los Alamos National Laboratory. ISM Best Practices Workshop Aurora, Colorado. September 12-13, 2006. Presentation Outline. Primary Lesson Learned Review of the Accident. Lessons Learned. Communication. Define scope of work. Lessons
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R&D Safety Analysis:Peer Review James Stine Los Alamos National Laboratory ISM Best Practices Workshop Aurora, Colorado September 12-13, 2006
Presentation Outline • Primary Lesson Learned • Review of the Accident. • Lessons Learned. • Communication
Define scope of work Lessons learned Analyze hazards 5 Perform work Develop/ implement controls 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
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.
Cl-+NHNH2 Cl-+NHNH2 N NaNO2 NH2 N Na2CO3 H2N H2N N3 NHNH2 HCl, 0ºC N N Δ NH2 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
Cl-+NHNH2 Cl-+NHNH2 N NaNO2 NH2 N Na2CO3 H2N H2N N3 NHNH2 HCl, 0ºC N N Δ Cl-+NHNH2 NH2 N N3 N3 N3 N N N H 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
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.
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.
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.
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?
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.
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 scientist’s analysis skills to safety too. • On the path to changing behaviors and safety culture.
Communication • Lessons learned communicated: • Members of the Group • Associate Directors • LANL Director • LASO • Students • Lessons learned workshops