slide1
Download
Skip this Video
Download Presentation
R&D Safety Analysis: Peer Review

Loading in 2 Seconds...

play fullscreen
1 / 13

R&D Safety Analysis: Peer Review - PowerPoint PPT Presentation


  • 150 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' R&D Safety Analysis: Peer Review' - alban


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

R&D Safety Analysis:Peer Review

James Stine

Los Alamos National Laboratory

ISM Best Practices Workshop

Aurora, Colorado

September 12-13, 2006

slide2

Presentation Outline

  • Primary Lesson Learned
  • Review of the Accident.
  • Lessons Learned.
  • Communication
slide3

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
slide4

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.
slide5

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
slide6

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

slide7

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.
slide8

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.

slide9

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.
slide10

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?
slide11

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.
slide12

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.
slide13

Communication

  • Lessons learned communicated:
    • Members of the Group
    • Associate Directors
    • LANL Director
    • LASO
    • Students
    • Lessons learned workshops
ad