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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
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. 2016. "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 = 2016,
month = 8
}

Journal Article:
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  • Primitive xenolithic clasts, often referred to as “dark clasts”, are well known in many regolith breccias. The Sharps H3.4 ordinary chondrite contains unusually large dark clasts up to ~1 cm across. Poorly-graphitized carbon (PGC), with Fe, Ni metal and described as “carbon-rich aggregates”, has been found in these clasts (Brearley, 1990). We report detailed analyses of carbonaceous matter in several identical Sharps clasts using FTIR, Raman, C-XANES, and TEM that provide insight on the extent of thermal processing and possible origin of such clasts. We also prepared acid residues of the clasts using the HCl/HF method and conducted mass spectrometric analysismore » of the entrained noble gases. Carbonaceous matter is often used to infer thermal history due to its sensitivity to thermal processes. The FTIR spectra of the acid residue from the Sharps clast suggest that carbonaceous matter in the clast contains less hydrogen and oxygen compared to acid residues from typical type 3.4 ordinary chondrites. The metamorphic temperatures obtained by Raman spectroscopy ranges between ~380 °C and ~490 °C. TEM observations indicate that the clasts experienced a peak temperature of 300 °C to 400 °C, based on the carbon d 002 layer lattice spacing of C-rich aggregates. These estimates are consistent with an earlier estimate of 330 ± 50 °C, that is also estimated by the d 002 layer lattice spacing (Brearley, 1990). It should be noted that the lattice spacing thermometer is based on terrestrial metamorphose rocks, and thus temperature was probably underestimated. Meanwhile, the C-XANES spectra of the C-rich aggregates show high exciton intensities, indicative of graphene structures that developed at around 700–800 °C following an extensive period of time (millions of years), however, the surrounding matrix areas experienced lower temperatures of less than 300–500 °C. Noble gas analysis of the acid residue from the Sharps clasts shows that the residue is almost identical with some material reported in carbonaceous chondrites, i.e., heavily enriched in the Q-gas component as well as HL-gas from presolar diamonds and Ne-E(H) from presolar SiC. These results indicate that the C-rich aggregates in the Sharps clasts formed under relatively high temperature conditions, up to 800 °C, and were subsequently mixed with lower temperature matrix, probably in a different parent body, before they were incorporated into the final Sharps lithology by collision.« less
  • Bulk compositions of 19 chondrules and one matrix-rich sample from H3.4 Sharps were determined by instrumental neutron activation analysis. Samples were characterized petrographically, and mineral compositions were determined by electron microprobe analysis. There is constancy among ordinary chondrite (OC) groups in the compositional interrelationships of different chondrule types; e.g., in H3 as well as L3 and LL3 chondrites, porphyritic chondrules are more refractory than nonporphyritic chondrules. Precursor components of H3 chondrules are closely related to those of LL3 chondrules. The mean Ir/Ni, Ir/Co and Ir/Au ratios of H3 chondrules differ from the corresponding ratios of LL3 chondrules at the 99%,more » 90% and 79% confidence levels, respectively. The ratios in H3 chondrules exceed those in LL3 chondrules by amounts similar to those by which H whole-rocks exceed LL whole-rocks. These data suggest that there are primary systematic differences in bulk composition between H and LL chondrules. These differences support the inference that chondrule formation occurred after major nebular fractionation events had established the observed bulk compositional differences among OC groups.« less