Investigation of a “Sharps” Incident

Cournoyer, Michael Edward; Trujillo, Stanley; Schreiber, Stephen Bruce

doi:10.1016/j.jchas.2016.07.005

Title: Investigation of a “Sharps” Incident

Full Record
Other Related Research

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:

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

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

Publication Date:: Wed Aug 03 00:00:00 EDT 2016

Research Org.:: Los Alamos National Laboratory (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:: 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.

Copy to clipboard


                    Cournoyer, Michael Edward, Trujillo, Stanley, & Schreiber, Stephen Bruce. Investigation of a “Sharps” Incident.  United States.  https://doi.org/10.1016/j.jchas.2016.07.005

Copy to clipboard


                    Cournoyer, Michael Edward, Trujillo, Stanley, and Schreiber, Stephen Bruce. Wed .  
"Investigation of a “Sharps” Incident".  United States.  https://doi.org/10.1016/j.jchas.2016.07.005.  https://www.osti.gov/servlets/purl/1337115.

Copy to clipboard


                    
@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}

}

Copy to clipboard

Journal Article:

Free Publicly Available Full Text

Accepted Manuscript (Publisher)

Accepted Manuscript (DOE)

Publisher's Version of Record

https://doi.org/10.1016/j.jchas.2016.07.005

Other availability

Search WorldCat to find libraries that may hold this journal

Save / Share:

Export Metadata

Save to My Library

Similar Records in DOE PAGES and OSTI.GOV collections:

Investigation of a light fixture fire

Journal Article Jurney, James D. ; Cournoyer, Michael E. ; Trujillo, Stanley ; ... - Journal of Chemical Health and Safety

Metal-halide lamps produce light by discharging an electric arc through a gaseous mixture of vaporized mercury and metal halides. Metal-halide lamps for use in spaces with lower mounting heights can produce excessive visual glare in the normal, higher field-of-view unless they are equipped with prismatic lenses. Should the bulb fail, high internal operating pressure of the arc tube can launch fragments of arc tube at high velocity in all directions, striking the outer bulb of the lamp with enough force to cause the outer bulb to break. This article reports an investigation of a light fixture fire and reviews amore »« less
https://doi.org/10.1016/j.jchas.2016.03.005

Full Text Available
Error-Based Accidents and Security Incidents in Nuclear Materials Management

Conference Pond, Daniel J ; Greitzer, Frank L

Hazard and risk assessments, along with human error analysis and mitigation techniques, have long been mainstays of effective safety programs. These tools have revealed that worker errors contributing to or resulting in accidents are often the consequence of ineffective system conditions, process features, or individual employee characteristics. At Los Alamos National Laboratory (LANL), security, safety, human error, and organizational analysts determined that the system-induced human errors that make accidents more likely also are contributing to security incidents. A similar set of system conditions has been found to underlie deliberate, non-malevolent deviations from proper security practices—termed breaches—that also can result inmore »« less
Performance Analysis: Work Control Events Identified January - August 2010

Technical Report De Grange, C E ; Freeman, J W ; Kerr, C E ; ...

This performance analysis evaluated 24 events that occurred at LLNL from January through August 2010. The analysis identified areas of potential work control process and/or implementation weaknesses and several common underlying causes. Human performance improvement and safety culture factors were part of the causal analysis of each event and were analyzed. The collective significance of all events in 2010, as measured by the occurrence reporting significance category and by the proportion of events that have been reported to the DOE ORPS under the ''management concerns'' reporting criteria, does not appear to have increased in 2010. The frequency of reporting inmore »« less
https://doi.org/10.2172/1018766

Full Text Available
Accident investigation of the electrical shock incident at the PG and E PVUSA site Davis, California

Technical Report Jacobson, L ; Moskowitz, P D ; Garrett, J O ; ...

This report summarizes the findings of the Accident Investigation Team (Team) assembled in response to a request from Pacific Gas and Electric Company (PG and E) to the US Department of Energy (DOE) to understand the events surrounding the electric shock of a worker at the PVUSA site in Davis, California and to provide recommendations to prevent such events from recurring. The report gives complete details on the sequence of events surrounding the accident and identifies 27 facts related to accident itself. Four technical deficiencies in the electrical systems which require further investigation were identified. The Team believes that themore »« less
https://doi.org/10.2172/188526

Full Text Available
The {open_quotes}ASR{close_quotes} story where we are and how we got there: A history of Sandia National Laboratories maintenance employee safety committee

Conference

The Area Safety Representative (ASR) Team is an employee based safety committee that was originated in the latter part of 1994. It was introduced by the Operations and Engineering Center ES&H Coordinator who had heard about an employee based safety program implemented at the EG&G Corporation. This information was the first step in creating Sandia`s Maintenance `Area Safety Representative` (ASR) Program. An advertisement went out from the ES&H Coordinator to all the Maintenance Organizations asking for individuals who would be interested in performing as a volunteer safety representative for their section. The interest was moderate but effective. The committee consistedmore »« less
Full Text Available

Similar Records