Lessons learned from occurrences involving procedures at Los Alamos National Laboratory in 1994 Page: 3 of 7
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LESSONS LEARNED FROM OCCURRENCES INVOLVING PROCEDURES
AT LOS ALAMOS NATIONAL LABORATORY IN 1994
Candace K. Frostenson
Los Alamos National Laboratory
Los Alamos, New Mexico
This study used the Department of Energy (DOE) Occurrence Reporting and Processing System (ORPS) data to
investigate occurrences reported during one year at Los Alamos National Laboratory (LANL). ORPS provides a
centralized database and computerized support for the collection, distribution, updating, analysis, and validation of
information in occurrence reports about abnormal events related to facility operation. Human factors causes for
occurrences are not always defined in ORPS. Content analysis of narrative data revealed that 33% of all LANL 1994
adverse operational events have human factors causes related to procedures. Procedure-caused occurrences that
resulted in injury to workers, damage to facilities or equipment, or a near-miss are analyzed.
Scope and Limitations
This study used the Department of Energy (DOE)
Occurrence Reporting and Processing System (ORPS)
(EG&G, 1991) data to investigate occurrences reported
during one year at Los Alamos National Laboratory
(LANL) and found that 33% of all LANL 1994 adverse
operational events have human factors causes related to
procedures. Other non-procedural human factors
contribution to accidents, such as spatial misorientation,
lack of attention, complacency, misdiagnosis, or fatigue,
were not included in the scope of this analysis.
Occurrence Reporting and Procedural Requirements
LANL is managed and operated for the DOE under a
contract to the University of California (UC). All DOE
facilities comply with DOE Order 5000.3B Occurrence
Reporting and Processing of Operations Information
requirements to notify DOE Headquarters of any
emergency, unusual, or off-normal events within certain
time limits, to investigate the root cause of each event,
and to ensure that corrective actions are completed to
prevent recurrence. UC 1995 Contract Performance
Measures for management of LANL also require
trending of the environmental, safety, and health report-
able occurrence data related to facility operation.
In addition, DOE Order 5480.19 Conduct of Opera-
tions Requirements for DOE Facilities specifies that
preparation, verification, and validation of operations
procedures should receive high-level attention. Opera-
tors should have procedures with them and follow them
in a step-by-step manner. Procedures should be refer-
enced during infrequent or unusual evolutions when the
operator is not intimately familiar with the procedure
requirements or when errors could cause significant
adverse impact to the facility.
LANL's nuclear, high explosive, chemical processing,
and waste management operations are only a small part
of the DOE system of national laboratory research and
development facilities referred to as "the complex".
Events and causal factors at LANL are representative of
occurrences throughout the DOE complex. Noncompli-
ance with conduct of operations requirements is associ-
ated with high safety risk in DOE facilities.
Human performance factors related to procedural
compliance is considered in DOE occurrence investiga-
tions. Even equipment/material problems often have root
causes related to human factors in noncompliance with
procedures for quality assurance, installation, mainte-
nance, or surveillance. Human factors causes for
occurrences are not always clear-cut, but this paper
demonstrates how ORPS can be used for human factors
research and content analysis of narrative data.
Description and Use of ORPS
ORPS is an interactive computer system, designed to
support DOE-owned or operated facilities in reporting,
processing, and dissemination of readily accessible
information concerning abnormal events and occurrences
related to facility operation. ORPS provides a central-
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Frostenson, C.K. Lessons learned from occurrences involving procedures at Los Alamos National Laboratory in 1994, article, July 1, 1995; New Mexico. (digital.library.unt.edu/ark:/67531/metadc619818/m1/3/: accessed March 24, 2018), University of North Texas Libraries, Digital Library, digital.library.unt.edu; crediting UNT Libraries Government Documents Department.