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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

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R d safety analysis peer review

R&D Safety Analysis:Peer Review

James Stine

Los Alamos National Laboratory

ISM Best Practices Workshop

Aurora, Colorado

September 12-13, 2006


R d safety analysis peer review

Presentation Outline

  • Primary Lesson Learned

  • Review of the Accident.

  • Lessons Learned.

  • Communication


R d safety analysis peer review

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


R d safety analysis peer review

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.


R d safety analysis peer review

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


R d safety analysis peer review

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


R d safety analysis peer review

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.


R d safety analysis peer review

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.


R d safety analysis peer review

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.


R d safety analysis peer review

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?


R d safety analysis peer review

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.


R d safety analysis peer review

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.


R d safety analysis peer review

Communication

  • Lessons learned communicated:

    • Members of the Group

    • Associate Directors

    • LANL Director

    • LASO

    • Students

    • Lessons learned workshops


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