Investigation of a “Sharps” Incident

Journal Article · Wed Aug 03 00:00:00 EDT 2016 · Journal of Chemical Health and Safety

DOI:https://doi.org/10.1016/j.jchas.2016.07.005· OSTI ID:1337115

Cournoyer, Michael Edward ^[1]; Trujillo, Stanley ^[1]; Schreiber, Stephen Bruce ^[1]

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1. Los Alamos National Lab. (LANL), Los Alamos, NM (United States)

Special nuclear material research, process development, technology demonstration, and manufacturing capabilities are provided at the Los Alamos National Laboratory Plutonium Facility. Engineered barriers provide the most effective protection from radioactive and hazardous materials. The Worker Safety Security Team augments these passive safety feature by investigating incidents to identify appropriate prevention and mitigation measures. “Learning Teams” facilitate employee feedback loop and integration toward process improvement. Here, this article reports an investigation of a “Sharps” incident and reviews a case study of a technician that cuts his left thumb while making a gasket. Causal analysis of the sharps incident uncovered contributing factors that created the environment in which the incident occurred. Finally, latent organizational conditions that created error-likely situations or weakened defenses were identified and controlled. Effective improvements that reduce the probability or consequence of similar sharps incidents were implemented.

• Research Organization: Los Alamos National Lab. (LANL), Los Alamos, NM (United States)
• Sponsoring Organization: USDOE
• Grant/Contract Number: AC52-06NA25396
• OSTI ID: 1337115
• Alternate ID(s): OSTI ID: 1416791
• Report Number(s): LA-UR--16-27314
• Journal Information: Journal of Chemical Health and Safety, Journal Name: Journal of Chemical Health and Safety; ISSN 1871-5532
• Publisher: Elsevier
• Country of Publication: United States
• Language: English

Related Subjects

61 RADIATION PROTECTION AND DOSIMETRY
Sharps
apparent cause
human error
incident
latent organizational conditions
process improvement