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.
- Research Organization:
- Los Alamos National Lab. (LANL), Los Alamos, NM (United States)
- Sponsoring Organization:
- USDOE, Washington, DC (United States)
- DOE Contract Number:
- W-7405-ENG-36
- OSTI ID:
- 104948
- Report Number(s):
- LA-UR-95-2084; CONF-951092-3; ON: DE95015301
- Resource Relation:
- Conference: Human Factors and Ergonomics Society meeting, San Diego, CA (United States), 9-13 Oct 1995; Other Information: PBD: [1995]
- Country of Publication:
- United States
- Language:
- English
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