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Title: Lessons learned from occurrences involving procedures at Los Alamos National Laboratory in 1994

This study used the Department of Energy (DOE) Occurrence Reporting and Processing System (ORPS) data to investigate occurrences reported during one year at Los Alamos National Laboratory (LANL). ORPS provides a centralized database and computerized support for the Collection, distribution, updating, analysis, and validation of information in occurrence reports about abnormal events related to facility operation. Human factors causes for occurrences are not always defined in ORPS. Content analysis of narrative data revealed that 33% of all LANL 1994 adverse operational events have human factors causes related to procedures. Procedure-caused occurrences that resulted in injury to workers, damage to facilities or equipment, or a near-miss are analyzed.
Authors:
Publication Date:
OSTI Identifier:
104948
Report Number(s):
LA-UR-95-2084; CONF-951092-3
ON: DE95015301
DOE Contract Number:
W-7405-ENG-36
Resource Type:
Conference
Resource Relation:
Conference: Human Factors and Ergonomics Society meeting, San Diego, CA (United States), 9-13 Oct 1995; Other Information: PBD: [1995]
Research Org:
Los Alamos National Lab., NM (United States)
Sponsoring Org:
USDOE, Washington, DC (United States)
Country of Publication:
United States
Language:
English
Subject:
05 NUCLEAR FUELS; 99 MATHEMATICS, COMPUTERS, INFORMATION SCIENCE, MANAGEMENT, LAW, MISCELLANEOUS; 42 ENGINEERING NOT INCLUDED IN OTHER CATEGORIES; LANL; OCCUPATIONAL SAFETY; HUMAN FACTORS; HUMAN FACTORS ENGINEERING; MANAGEMENT; ACCIDENTS; REMOTE HANDLING