Anatomy of an Incident

Transcription

1 Anatomy of an Incident Michael E. Cournoyer LA-UR March 13,

2 2

3 Accident pyramid 3

4 Five-step process of Integrated Safety Management 4

5 Anatomy of an incident! The incident occurs! The incident is investigated! Causal factors are determined! Conclusions are drawn! Corrective actions are developed! Lessons Learned are communicated 5

6 The incident occurs 6

7 Before The incident occurs After 7

8 The incident is investigated 8

9 The incident is investigated 9

10 The incident is investigated NA--LASO-LANL-CHEMLASER : Light Fixture Fire 11:13 The Acrylic Lens Ignites 11:00 Light Bulb Burst 11:07 The Acrylic Lens Melts 11:23 A Small Fire Starts 11:00 11:25 10

11 The incident is investigated The metal halide lamp is designed around a sealed tube with an electrode in each end The Arc Tube temperature range is between 1000 C and 1300 C This type of metal halide lamp (ANSI M59/S) is position dedicated 11

12 The incident is investigated Lamp position is horizontal The fixture had an acrylic lens The acrylic material has a flash point > 250 C and an Auto- Ignition temperature > 400 C. 12

13 Causal factors are determined NA--LASO-LANL-CHEMLASER : Light Fixture Fire Engineering 2 LLs on This Zero Accidents Management The Lens Material Was Acrylic LL Policy LTA Policy Not Enforced Error in Material Selection Design Output LTA Management Methods LTA MOV LTA Inspection LTA Required Inspection Was Not Established The Wrong Bulb Was Installed. The Lens Material Was Acrylic The Wrong Bulb Was Installed. Property Damage Inspection Would Identify Wrong Bulb & Lens Material Corrective Maintenance LTA Preventive Maintenance for Equipment LTA Preventive Maintenance Was not Established for the Bulb That Failed. Equipment Defective, Failed or Contaminated Failed Material End of Life Failure Bulb Exploded The Wrong Bulb Was Installed. Man Power Check of Work Was LTA Skill Based Errors Wrong Action The Wrong Bulb Was Installed. 13

14 Causal factors are determined 25 Incident Causal Factors Frequency Management Man Power Equipment Engineering 14

15 Conclusions are drawn A wrong metal-halide lamp bulb caused a small fire. The acrylic lens material exacerbated the incident. The engineer should have required lenses that are compatible with metalhalide lamp. The worker should have known that he or she was installing the wrong bulb. 15

16 Conclusions are drawn The worker s supervisors should have checked the workers task and discovered that the wrong bulb was installed. The worker s manager should have monitored the workers task. Implementing Lesson s Learned from two previous incidences could have prevented the small fire. 16

17 Corrective actions are developed Position metal-halide lamp all in one direction Store only one type of metal-halide lamp bulbs Replace acrylic lens with lenses that are compatible with metal-halide lamp Iterate the importance of management monitoring programs 17

18 Lessons Learned integration with work performance Lessons Learned (LLs) Process Managers Workers Start Identify improvement opportunities Communicate relevant Lessons Learned to workers Incorporate improvements into Work Processes Perform Work Evaluate work to identify lessons learned Share Lesson Learned End LLs Coordinator Communicate key Lessons Learned to managers Lessons Learned Archive Capture Lessons Learned Screen Lessons Learned Monitor Lesson Learned 18

19 Defense in Depth 19

20 Slip simulator training 20

21 Year ADPSM Employees Total Trained* With S/T/F Injuries *None of the Trained Employees Had an Injury Operated by Los Alamos National Security, LLC for the U.S. Department of Energy's NNSA 21

22 P-Value for a Chi Square Test Injury (Slip, Trip, Fall) Trained Yes No Yes No Х 2 = The P value is 6.5E-05 This result is significant at p < 0.05 The associaaon between rows (groups) and columns (outcomes) is considered to be extremely staasacally significant Operated by Los Alamos National Security, LLC for the U.S. Department of Energy's NNSA 22

23 Lessons Learned integration with work performance 23

24 Lessons Learned integration with work performance Metal halide light failures - Small fires start when burning diffuser falls to ground, 2012-SR- SRNS-0004, 2012 Metal halide bulb fails, shatters outer glass envelope, hot glass shard chars wood crate, 2015-FSO-FNAL-022,

25 Lessons Learned integration with work performance Assign a Metal-Halide Lamp Subject Matter Expert (SME) Have the Metal-Halide Lamp SME make an inventory of metal-halide lamps Have managers perform an inspection of metalhalide lamps in their areas of responsibility 25

26 Lessons Learned integration with work performance Have the Metal-Halide Lamp SME revise the Metal-Halide Lamp procedure such that corrective actions have been incorporated Have the Metal-Halide Lamp SME supervisor review Metal-Halide Lamp procedure 26

27 Lessons Learned integration with work performance Replace all metal-halide lamps with light-emitting diode (LED) lamps. LED lamps have a lifespan and electrical efficiency that is comparable to metalhalide lamps. LED lamps contain no mercury. 27

28 Lessons Learned integration with work performance No ballast bypass or rewiring is required. LED lamps operate at < 93 C, are thermally regulated and may be positioned at any angle. In addition the operating life is 2 and half times longer than metal-halide lamps: 50,000 hr life vs 20,000 hr. 28

29 Predicting the future 29

30 How the people involved saw it before the accident 30

31 How the investigator sees it after the accident 31

32 Fire the person who reported It 32

33 Latent organizational conditions Managers going around telling there workers to be safe is difficult to track. Tracking preventive maintenance, safety meeting attendance, and chemical container inventory is easy to track Management Man Power Equipment Engineering 33

34 What do you work on first? Injury Factors Jun 06 - May % 15 75% Factors % 25% 0 Chemical Agent Ergonomic Slip/Trip/Fall Struck against/by Other Lift/Push/Pull 0% Frequency Cum. Frequency

35 Safety improvements are hard to prove Redundant defenses improve safety margins, but also increase complexity. Flawed defenses and safety hazards become more difficult to detect. Redundant defenses make safety improvements more difficult to identify as well. 35

36 Improvement can t be measured Injury Factors Jun 06 - May % 15 75% Factors % 25% 0 Chemical Agent Ergonomic Slip/Trip/Fall Struck against/by Other Lift/Push/Pull 0% Frequency Cum. Frequency Frequency Last 12 Months Cum. Frequency Last 12 Months 36

37 Summary! A wrong type of metal-halide lamp bulb exploded causing a small fire.! Latent organizational conditions created error-likely situations and weaken defenses.! Corrective action included standardizing the type of metalhalide lamp bulbs, replacing acrylic lens with lenses that are compatible with metal-halide lamp, and adding the inspection of metal-halide lamp to management monitoring programs.! A significant improvement to the task consists of replacement of metal-halide lamps with LED lamps.! This improvement was shared through a Lessons Learned Program. 37

38 Conclusions! Latent organizational conditions that create error-likely situations and weaken defenses have been identified and controlled.! Incorporating corrective actions selected from the DOE CAT provide corrective based on decades of incidences.! Effective improvements have been implemented that reduce or eliminate the risk of another metal-halide lamp fire incidents.! This increases technical knowledge and augments operational safety. 38

39 Acknowledgements! The author would like to acknowledge the U.S. Department of Energy and LANL's Plutonium Science & Manufacturing directorate for support of this work.! The author would like to acknowledge James D. Jurney (MET-2) for information on the Light Fixture Fire incident. 39