To: LANL
From: Charles F. McMillan
Date: July 13, 2015
Subject: Release of Joint Accident Investigation Team Report – Arc-flash Event
On May 3, 2015, a Los Alamos National Laboratory (LANL) employee was seriously injured by an arc-flash while doing preventive maintenance work at an electrical substation that supports Technical Area 53 (TA-53). I am pleased to report that the employee has been released from the hospital, although he has not returned to work. I hope you will continue to extend your support and best wishes as he progresses through the recovery process.
Immediately after the incident, a Joint Accident Investigation Team (JAIT) comprised of personnel from LANL, the U.S. Department of Energy (DOE), and Los Alamos National Security, LLC (LANS) began investigating the root causes of the accident. The JAIT will release its report soon. The report outlines 13 Judgments of Need (JONs) that are being addressed. The findings in the report are intended to help prevent similar accidents here and at other national laboratories in the future. I commend the JAIT for its thorough and thoughtful work. I encourage every employee to read the JAIT report so that we may all learn and benefit from it.
In summary, the report underscores that our Laboratory has an Integrated Safety Management (ISM) process that can help us all do our work safely; but the report points out that, in the broadest sense, we may not be adequately and consistently implementing these processes. Specifically, with regard to the May 3 arc-flash accident, we did not adequately consider the potential hazards that arose from a change in work scope; we did not establish physical barriers; we did not consistently require all electrical workers to validate zero voltage; and some workers were not wearing proper personal protective equipment (PPE).
As an immediate result of the accident, interim guidance for electrical work was issued even as the JAIT was conducting its investigation. The Laboratory is taking further actions to ensure that our ISM processes are being appropriately implemented—with specific focus on medium and high-hazard operations—and that our work planning takes into account the possibility of intentional or unintentional changes to work scope.
There is nothing more important than the safety and security of every employee at the Laboratory. I have met with Laboratory managers to ensure that this value is shared and acknowledged in every organization across the Laboratory. As you know, we initiated a requirement for ongoing, interactive engagements in all work areas by managers, from the PAD-level to the group level. These manager engagements will support employees by creating opportunities for dialogue and hands-on interactions. Such interactions can enable our safety processes to account for hazards and risks associated with the job, including unforeseen circumstances such as human error, situational awareness, or equipment failure. These engagements will also help employees fully understand the work they are performing and the hazards they face, and that ISM processes are appropriate and will be adequately implemented. Perhaps most important of all, these interactions will underscore that every Laboratory worker has the authority and responsibility to stop work if they see something that is potentially unsafe, or believe that some aspect of the work is unsafe. This authority and responsibility extends to any area of the Laboratory, not just areas where a worker might normally work.
The JAIT report reminds us that even robust safety processes may not be effective if they are not properly implemented. I am confident that the Laboratory has a committed, talented workforce that can work together to place our safety, security, and operational performance on par with our science and mission delivery. Thank you for your continued commitment to a safe and secure workplace.
From: Charles F. McMillan
Date: July 13, 2015
Subject: Release of Joint Accident Investigation Team Report – Arc-flash Event
On May 3, 2015, a Los Alamos National Laboratory (LANL) employee was seriously injured by an arc-flash while doing preventive maintenance work at an electrical substation that supports Technical Area 53 (TA-53). I am pleased to report that the employee has been released from the hospital, although he has not returned to work. I hope you will continue to extend your support and best wishes as he progresses through the recovery process.
Immediately after the incident, a Joint Accident Investigation Team (JAIT) comprised of personnel from LANL, the U.S. Department of Energy (DOE), and Los Alamos National Security, LLC (LANS) began investigating the root causes of the accident. The JAIT will release its report soon. The report outlines 13 Judgments of Need (JONs) that are being addressed. The findings in the report are intended to help prevent similar accidents here and at other national laboratories in the future. I commend the JAIT for its thorough and thoughtful work. I encourage every employee to read the JAIT report so that we may all learn and benefit from it.
In summary, the report underscores that our Laboratory has an Integrated Safety Management (ISM) process that can help us all do our work safely; but the report points out that, in the broadest sense, we may not be adequately and consistently implementing these processes. Specifically, with regard to the May 3 arc-flash accident, we did not adequately consider the potential hazards that arose from a change in work scope; we did not establish physical barriers; we did not consistently require all electrical workers to validate zero voltage; and some workers were not wearing proper personal protective equipment (PPE).
As an immediate result of the accident, interim guidance for electrical work was issued even as the JAIT was conducting its investigation. The Laboratory is taking further actions to ensure that our ISM processes are being appropriately implemented—with specific focus on medium and high-hazard operations—and that our work planning takes into account the possibility of intentional or unintentional changes to work scope.
There is nothing more important than the safety and security of every employee at the Laboratory. I have met with Laboratory managers to ensure that this value is shared and acknowledged in every organization across the Laboratory. As you know, we initiated a requirement for ongoing, interactive engagements in all work areas by managers, from the PAD-level to the group level. These manager engagements will support employees by creating opportunities for dialogue and hands-on interactions. Such interactions can enable our safety processes to account for hazards and risks associated with the job, including unforeseen circumstances such as human error, situational awareness, or equipment failure. These engagements will also help employees fully understand the work they are performing and the hazards they face, and that ISM processes are appropriate and will be adequately implemented. Perhaps most important of all, these interactions will underscore that every Laboratory worker has the authority and responsibility to stop work if they see something that is potentially unsafe, or believe that some aspect of the work is unsafe. This authority and responsibility extends to any area of the Laboratory, not just areas where a worker might normally work.
The JAIT report reminds us that even robust safety processes may not be effective if they are not properly implemented. I am confident that the Laboratory has a committed, talented workforce that can work together to place our safety, security, and operational performance on par with our science and mission delivery. Thank you for your continued commitment to a safe and secure workplace.
Comments
"...Perhaps most important of all, these interactions will underscore that every Laboratory worker has the authority and responsibility to stop work if they see something that is potentially unsafe, or believe that some aspect of the work is unsafe. This authority and responsibility extends to any area of the Laboratory, not just areas where a worker might normally work..."
Unless they were inexperienced, how likely was it that the majority of the 9 LANS LANSCE employees involved were completely unaware of their individual "authority and responsibility to stop work if they see something is potentially unsafe"? If they were experienced and aware of their "authority and responsibility to stop work", why didn't these workers exercise this "authority and responsibility"?
Stated to the Science and Engineering Advisory Council (SEAC) in 1997
Dr. Victor Reis, Former Assistant Secretary for Defense Programs, U.S. Department of Energy, DP-1
China?
It is easy to express a workers "authority and responsibility" after a horrible accident. This safety policy requires historically positive Senior LANS management follow through to be effective. Was fear of workplace reprisal a contributing factor for the LANS employees decision not to speak up or stop work?
It is easy to express a workers "authority and responsibility" after a horrible accident. This safety policy requires historically positive Senior LANS management follow through to be effective. Was fear of workplace reprisal a contributing factor for the LANS employees decision not to speak up or stop work?
July 17, 2015 at 7:24 AM
Or, perhaps they simply did not recognize the situation as being unsafe?
"...Or, perhaps they simply did not recognize the situation as being unsafe?..."
The Director has not made any inference suggesting, "they simply did not recognize the situation as being unsafe"