R&D Safety Analysis:Peer Review

ISM Best Practices WorkshopAurora, Colorado

September 12-13, 2006

James Stine

Los Alamos National Laboratory

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

Presentation Outline

Primary Lesson LearnedDX-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

Define scopeof work

Define scopeof work

AnalyzehazardsAnalyzehazards

Develop/implementcontrols

Develop/implementcontrols

Performwork

Performwork

Lessonslearned

Lessonslearned

5

Two workers were performing an organic synthesis of a non-energetic material from a literature preparation.

Accident Background

• 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.

Expected Synthesis ReactionWorkers trusted literature preparation from peer-reviewed journal article.

• Although intermediate was energetic, final product was inert.

• Side reaction product and intermediate were energetic.

H2N NHNH2

Cl- +NHNH2 NaNO2

HCl, 0ºC Δ

Na2CO3

• Inert• Energetic

Desiredinert product

N

N

N N

NH2

NH2

H2N N3

Cl- +NHNH2

Unexpected Side Reaction

However, literature preparation made no mention of:• Side reaction product and intermediate were highly

energetic.

H2N NHNH2

Cl- +NHNH2 NaNO2

HCl, 0ºC Δ

Na2CO3

• Inert• Energetic

Desiredinert product

N

N

N N

NH2

NH2

N

N

N N

N3

H

H2N N3

Cl- +NHNH2

N3 N3

Cl- +NHNH2

Energeticside 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 ActionsAdditional 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 AnalysisPeer 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