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Title: Investigation of a “Sharps” Incident

Abstract

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.

Authors:
 [1];  [1];  [1]
  1. Los Alamos National Lab. (LANL), Los Alamos, NM (United States)
Publication Date:
Research Org.:
Los Alamos National Lab. (LANL), Los Alamos, NM (United States)
Sponsoring Org.:
USDOE
OSTI Identifier:
1337115
Alternate Identifier(s):
OSTI ID: 1416791
Report Number(s):
LA-UR-16-27314
Journal ID: ISSN 1871-5532
Grant/Contract Number:  
AC52-06NA25396
Resource Type:
Journal Article: Accepted Manuscript
Journal Name:
Journal of Chemical Health and Safety
Additional Journal Information:
Journal Name: Journal of Chemical Health and Safety; Journal ID: ISSN 1871-5532
Publisher:
Elsevier
Country of Publication:
United States
Language:
English
Subject:
61 RADIATION PROTECTION AND DOSIMETRY; incident; human error; apparent cause; process improvement; Sharps; latent organizational conditions

Citation Formats

Cournoyer, Michael Edward, Trujillo, Stanley, and Schreiber, Stephen Bruce. Investigation of a “Sharps” Incident. United States: N. p., 2016. Web. doi:10.1016/j.jchas.2016.07.005.
Cournoyer, Michael Edward, Trujillo, Stanley, & Schreiber, Stephen Bruce. Investigation of a “Sharps” Incident. United States. doi:10.1016/j.jchas.2016.07.005.
Cournoyer, Michael Edward, Trujillo, Stanley, and Schreiber, Stephen Bruce. Wed . "Investigation of a “Sharps” Incident". United States. doi:10.1016/j.jchas.2016.07.005. https://www.osti.gov/servlets/purl/1337115.
@article{osti_1337115,
title = {Investigation of a “Sharps” Incident},
author = {Cournoyer, Michael Edward and Trujillo, Stanley and Schreiber, Stephen Bruce},
abstractNote = {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.},
doi = {10.1016/j.jchas.2016.07.005},
journal = {Journal of Chemical Health and Safety},
number = ,
volume = ,
place = {United States},
year = {Wed Aug 03 00:00:00 EDT 2016},
month = {Wed Aug 03 00:00:00 EDT 2016}
}

Journal Article:
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