Lessons learned from occurrences involving procedures at Los Alamos National Laboratory in 1994 Page: 4 of 7
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ized database and computerized support for the collec-
tion, distribution, updating, analysis, and validation of
information in the occurrence reports. The system is
managed by the System Safety Development Center at
the Idaho National Engineering Laboratory (INEL)
under the direction of the DOE's Office of Nuclear
The ORPS database is designed to categorize occur-
rences and allow search and investigation of the
relevant data embedded in narratives. Potential for
analyzing data accumulating in the system is enormous.
From 1991 through 1994, there are over 25,000 separate
occurrences reported in ORPS. Statistical, content, and
lessons learned analyses are possible, yet ORPS users
are currently more concerned with meeting input
requirements than with use of the system as a research
tool. Consequently, quantitative studies are usually
descriptive rather than inferential.
Root Cause Analysis of Occurrences
A DOE problem occurrence itself is always defined in
terms of either people, procedures, or hardware. All
ORPS reports assign a root cause to the occurrence.
Root cause analysis is a logical chain of cause and
effect reasoning that must have a solution that meets
three root cause criteria: the solution must prevent
recurrence, be within control (be feasible), and meet the
program goals and objectives (Gano, 1991).
Root cause categories can be searched in ORPS
according to equipment/materials problem, procedure
problem, personnel error, design problem, training
deficiency, management problem, or external phenom-
ena. Of these, even equipment/material problems or
procedure problems may ultimately have root causes
related to human factors. Human factors can impact
most categories of occurrences.
CONTENT ANALYSIS METHOD
This study first used field search capabilities of ORPS to
focus on occurrences at LANL during the calendar year
1994. A total of 267 reports were retrieved. A word
search for "procedur@" was then conducted on the
narrative data from the "Description of Cause" field in
the targeted reports. Eighty-nine reports, or 33% of the
total, cited "procedur@" in the description of cause.
Human factors causal categories defined by the ORPS
database were recorded.
Because corrective actions are assigned to address the
acknowledged root cause of an occurrence, the word
search was repeated for the "Corrective Action " field.
Of the fifty occurrences that were assigned corrective
action related to procedures, a final sort yielded twenty-
six reports with a "Final Evaluation" field and lesson
learned containing the key word " procedur@".
Content analysis of ORPS reports is necessary for
synthesis of meaningful lessons learned for the DOE
complex. Narratives of the 26 reports were read in
detail . Content was analyzed for common cause factors,
related events, or facility-specific incidence of occur-
rences related to procedures. Many causes are repeated
in unrelated occurrences in the LANL ORPS reports
which cited "procedur@" in the final evaluation.
Lessons learned about procedures from LANL occur-
rences in 1994 were grouped into operational "bins":
Transportation, Shipping, and Receiving
Facility Access Control
Installation Of Equipment
Experimental Research and Development
Bins were determined by the accumulation of more than
one occurrence in any general area of Laboratory
operations regardless of location of facility.
LANL managers and workers could have prevented
almost a third of the DOE 5000.3B reportable occur-
rences in 1994 with development, review, and correct use
of procedures in research and development and other
operations support activity. The following causal catego-
ries related to procedures were cited in 89 LANL
occurrence reports in 1994:
* Management policy not adequately defined,
disseminated, and enforced
* Inadequate administrative control
* Defective or inadequate procedure
* Personnel error related to inattention to detail
* Personnel error related to violation of a requirement
* Insufficient refresher training on procedures
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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/m1/4/: accessed October 19, 2018), University of North Texas Libraries, Digital Library, digital.library.unt.edu; crediting UNT Libraries Government Documents Department.