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Operated by Los Alamos National Security, LLC for the U.S. Department of Energy's NNSA
British Occupational Hygiene Society
LA-UR-17-22603
Michael Brandt, Dr.PH, CIH, PMP Associate Director for
Environment, Safety, and Health Day 3
April 27 Session 14a 13:40-14:25
OH 2017 Conference Harrogate, UK
April 24-27, 2017
“Operational Leadership” – Sustaining Improved Environmental, Safety, and Health Performance
2
Agenda: • Introduction to Los Alamos National
Laboratory – Role / Mission / Location / People
• Event Learning • Problem Statement – 3 Common
Causes • Problem Solution – Operational
Leadership • Data analysis/Metrics • Operational Leadership Actions • Healthy Safety Culture • Summary and Conclusion • Leadership Lessons • Questions
Introduction to Los Alamos National Laboratory
Role
Mission
Location
People
Los Alamos National Laboratory | 3
The role of Los Alamos in global security
Los Alamos National Laboratory | 4
• Kansas City Plant
• Lawrence Livermore National Laboratory
• Los Alamos National Laboratory
• Nevada National Security Site
• Pantex Plant
• Sandia National Laboratories
• Savannah River Site
• Y-12 National Security Complex
Nuclear Security Enterprise
- 1/17 - 1/8
Role
Los Alamos National Laboratory | 5
Mission Los Alamos delivers science and technology to protect our nation and promote world stability
The world remains a dangerous place….LANL‘s mission is to reduce the dangers inherent to a complex global society
As the nation’s premier national-security science laboratory, we certify the safety, security, and effectiveness of the nation’s nuclear deterrent
- 4 of 7 weapons systems
We deliver national-security mission solutions to NNSA, DoD, and IC
- Our science and imagination saves lives by solving complex problems others can’t
We rely on high-performance computing, leading-edge experimental facilities, and the world’s brightest minds to accomplish our mission
Los Alamos National Laboratory | 6
LANL Site: • Roughly the size of Paris • 40 square miles • 1,230 bldgs (42 yr av age)
• 13 nuclear facilities • 268 mi of roads • 34 mi electrical lines • 63 mi gas lines • 1 power plant
Annual Budget = $2.5B
Location
Unique Characteristics: • 37 historical buildings • >2,000 archeological sites
• 4 endangered species • 8 Pueblos • 3 Counties • Multiple mesas
Los Alamos National Laboratory | 7
37% Ops/ Business 21% R&D 11%
Engineering
6% IT 14% Student/ Post-Doc
8% Crafts 3% Pro-Force
People
11,000 Employees:
• 39% live in Los Alamos - remaining commute
• 46 average employee age
• 67% male / 33% female
• 44% minorities
• 66% hold university degrees - 28% undergraduate - 17% Master’s - 21% PhD
Nitrate salt event at the WIPP site in February 2014 – eroded public trust that we can safely execute our National security mission
Event 1 description
Panel 7 Room 7 Los Alamos National Laboratory | 9
Los Alamos National Laboratory | 10
Event 1 details
Nitrate salt event at WIPP – Largely a result of an unhealthy safety culture
3 general causes contributing to event
Management Responsibility
and Engagement
Risk Management Process and Controls Commensurate with
Hazards
Worker Involvement
Los Alamos National Laboratory | 11
Arc-flash event May 2015 – the impacts got personal Event 2
description
Los Alamos National Laboratory | 12
Event 2 details Arc-flash event – Largely a result of human performance
3 general causes contributing to event
Risk Management Process and Controls Commensurate with
Hazards
Management Responsibility and Engagement
Worker Involvement
Los Alamos National Laboratory | 13
1. Worker involvement in work planning is inconsistent/incomplete Workers shift to: • Be personally responsible for performing work safely
• Raise safety concerns
• Anticipate error-likely situations and take action
2. Line management not always engaged in work planning and execution Line managers shift to: • Be responsible and accountable for operational outcomes
– be present in the field • Anticipate and prevent events using hazard controls
• Encourage workers to question/pause work as necessary
3. Risk management process/controls not followed/executed Risk management process shifts to: • Anticipate what “must go right” to perform work safely
• Identify and evaluate hazards
• Tailor controls to work being performed
Event learning consistently yields three common themes Events problem statement
Los Alamos National Laboratory | 14
Risk Management Processes
Problem solution Enable these positive behaviors
Make conditions conducive to these components
Focus on 3 of the 8 guiding
principles of ISM and VPP
Los Alamos National Laboratory | 15
How do you check, balance, and course correct your management decisions and safety actions? and How can you focus your efforts to achieve the largest return?
An expert is someone who has succeeded in making decisions and judgements simply through knowing what to pay attention to and what to ignore . . . . . . . .Edward de Bono
Risk management process
Anticipate and prevent
potential risks
Analyze, integrate,
and prioritize actions
Manage and monitor
responses
Los Alamos National Laboratory | 16
Continuous improvement pays off – but do we accept positive trending and stop investigating?
Los Alamos National Laboratory | 17
1.12
0.13
0
1
2
3
4
Jun-
06
Feb-
07
Oct
-07
Jun-
08
Feb-
09
Oct
-09
Jun-
10
Feb-
11
Oct
-11
Jun-
12
Feb-
13
Oct
-13
Jun-
14
Feb-
15
Oct
-15
Jun-
16
Feb-
17
Rat
e pe
r 200
000
hour
s
LANS TRC and DART Rolling 12-month Rates thru February 17
(excludes subcontractors)
TRC 12 Month Rolling DART 12 Month Rolling
3.37
1.07 These numbers
represent PEOPLE
Not when worker safety is at stake – but where to focus efforts?
Lab-wide safety performance
30%
51%
65%
74%
83% 88%
91% 93%
96% 97% 98% 99% 100%
0%
20%
40%
60%
80%
100%
0
20
40
60
80
100
120
140
Stru
ck A
gain
st/B
y
Slip
/Trip
/Fal
l
Cont
act w
ith B
io/C
hem
/Haz
/Tox
icSu
bsta
nce Li
ft/P
ush/
Pull
Repe
titiv
e M
otio
n/Cu
mul
ativ
eTr
aum
a
Caug
ht In
, On,
Und
er O
r Bet
wee
n
Volu
ntar
y M
otio
ns
Bite
/stin
g
Mot
or V
ehic
le A
ccid
ent
Cont
act w
ith E
lect
rical
Cur
rent
Fore
ign
Mat
ter i
n Ey
es
Tem
pera
ture
Ext
rem
es
Trai
ning
/Qua
lific
atio
n
Noi
se E
xpos
ure
Cumulative Frequency
Num
ber o
f Inj
urie
s LANL Recordable/Non-Recordable Injury by Source - March 2016 thru February 2017
Non-Rec Rec
Los Alamos National Laboratory | 18
Lab-wide injury source data
Five common sources account for >80% of site injuries – indicating where to
focus our ESH resources to eliminate these sources and improve performance
Sounds logical, but how do we explain the
serious electrical event?
30%
39%
47%
54%
61%
68%
74%
79%
84% 87%
90% 92%
94% 96% 97% 98% 99% 99% 100%
0%
20%
40%
60%
80%
100%
0
20
40
60
80
100
120
140
ADPM
ADES
H
ADBI
ADM
ASER
ADCL
ES
ADPS
M
ADEP
S
ADW
ADN
HHO
ADE
PADC
AP
ADTI
R
ADTS
C
DIR
ADX
PADS
TE
ADEM
NO
N-L
AB
PADG
S
PADO
PS
Cumulative Frequency
Num
ber o
f Inj
urie
s LANL Recordable/Non-Recordable by Organization - March 2016 thru February 2017
Non-Rec Rec
Los Alamos National Laboratory | 19
Lab org injury data
The arc-flash involved skill-of-craft workers in the construction and maintenance organization. These
workers sustain ~30% of total injuries across the site.
Los Alamos National Laboratory | 20
23%
43%
60%
68%
73%
78% 82%
87% 91%
94% 96% 98% 99% 100%
0%
20%
40%
60%
80%
100%
0
5
10
15
20
25
30LA
BORE
R
PIPE
FIT
TER
ELEC
TRIC
IAN
SHEE
T M
ETAL
WO
RKER
CARP
ENTE
R
IRO
NW
ORK
ER
OPE
RATI
NG
ENGI
NEE
R
PAIN
TER
TEAM
STER
MAI
NTE
NAN
CE
SUPE
RIN
TEN
DEN
T
SE P
ROFE
SSIO
NAL
ASBE
STO
S W
ORK
ER
ROO
FER
Cumulative Frequency
Num
ber o
f Inj
urie
s Craft Injuries by Worker Type - March 2016 thru February 2017
Non-Rec Rec
Construction and maintenance org injury source data by skill-of-craft
17% of construction and maintenance injuries are to electricians
Los Alamos National Laboratory | 21
What is the electrical safety worker exposure risk?
Let’s examine the electrical event data for insight
75K Work Evolutions
24K 1K Entries 1.2K Compliance Inspections
760 Excavation Permits 360 IWDs for R&D Electrical Work 1,840 IWDs for Facility Electrical Work
data reported per year
Electrical safety risk identification
1.5K Energized Electrical Workers
Los Alamos National Laboratory|22
73
64
60
46
0
10
20
30
40
50
60
70
80
2013 2014 2015 2016
Num
ber o
f Inc
iden
ts
Calendar Year
All Electrical Incidents
Electrical safety metric demonstrates a negative slope of decreasing events over time
Lagging indicator
Despite the decline of electrical safety incidents over the last four years – we still had the serious arc-flash injury and a couple of near misses
Arc- flash event
and
RLUOB near-misses
Los Alamos National Laboratory | 23
92 13 20
305
41 33
255
13 2 44 36 75 145
14
1616
86 36 58 11 1 7
144 27 0
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Jan
13
Apr
13
Jul 1
3
Oct
13
Jan
14
Apr
14
Jul 1
4
Oct
14
Jan
15
Apr
15
Jul 1
5
Oct
15
Jan
16
Apr
16
Jul 1
6
Mon
thly
ESI
Nor
mal
ized
to
LAN
L To
tal W
ork
Hou
rs
Electrical Severity Index (ESI) From 0 to 310,000
0-30 = no risk to worker 31-1749 = medium risk
>1750 = high concern and risk Monthly ESIRolling 12 Month AVG
4379
The DOE complex-wide Electrical Severity Measurement tool categorizes only one incident of significant concern
Ergo desk cord
AET power strip
Forklift hits 13.8 kV wires
277 V shock NEC violation R&D work
no LOTO
RLUOB 77 V shock
and 480 live work
Substation Arc-flash
Pharos - R&D conduit
cut during D&D -
moderate exposure w/
no injury
Lagging indicator
So, are the root causes associated with low risk and high risk events different?
Los Alamos National Laboratory | 24
Why do TRC/DART rates continue to decline while electrical events continue to trend upward?
0
2
4
6
8
10
12
Jun 06 Jun 07 Jun 08 Jun 09 Jun 10 Jun 11 Jun 12 Jun 13 Jun 14 Jun 15 Jun 16
Num
ber o
f ele
ctric
al e
vent
s
Electrical Events vs. LANL TRC/DART Rates Electrical Incidents Reported Rolling TRC Rolling DART Linear (Electrical Incidents Reported)
Leading indicator
Management and worker corrective action is warranted
Los Alamos National Laboratory | 25
2013 2014 2015 2016
Number of incidents receiving a more concerning rank of 3, 4, 5 per calendar year Concern Ranking from 0 to 5 (0 = least / 5 = most)
4 total
7 total
ten 3’s
three 3’s
six 3’s
two 3’s
two 4’s
one 5 one 4
Subjective measure of all elements contributing to an electrical incident - work control, human error, significant equipment failure, etc.
6 total
11 total
two 4’s
one 4
serious concerns declining to zero in
2016
Systematic data review revealed that the occurrence of major events requires: 1. A high risk condition must exist 2. Hazard controls must fail 3. These two factors go unchecked
Pharos
Arc-flash
RLUOB
480 live work
R&D no
LOTO
Forklift
NEC violation
Emerging negative trend
mid-level concerns
on the rise in 2016
So what are we doing about
this new insight and leading indicators?
Los Alamos National Laboratory | 26
Healthy Culture
Integrated Safety
Management (ISM)
Human Performance Improvement
(HPI)
Voluntary Protection Program
(VPP)
Work Planning
Institutional Risk
Management - Metrics - MOVs
Safety Leadership Workshop
(SAFE)
More than 60 Health and
Safety Programs
Operational Leadership Campaign
Los Alamos National Laboratory | 27
Including electrical safety
Worker perception of safety culture – 2016 survey results trend upward
Los Alamos National Laboratory | 28
– More than 2,000 survey responses • growing levels of trust within organizations • increased comfort with raising issues/pausing work • increased perception of mistakes as learning opportunities • strong manager and employee commitment • strong organizational emphasis on injury prevention
– Opportunities for growth • Strengthen role of employee worker safety teams to address the most
challenging issues that confront the Laboratory • Raise worker knowledge about Safety and Security Improvement Plans • Effectively communicate improvement initiatives, worker safety team
activities, and recognition of successful work
Healthy safety culture
Los Alamos National Laboratory | 29
LANL is continuously improving as a learning organization Summary and Conclusion
1. Adapt and course correct as managers and employees –Continue to use metrics to focus improvements –Understand and apply lessons learned from event causal analysis –Identify predictive indicators and apply knowledge obtained from
• near-miss events • emerging data trends
2. Recognize that the construction and maintenance workforce is a population at high-risk
–High volume of work activities –Inherent risk associated with type of work
• sources of high energy and plant construction –Unusual and non-routine work being performed
3. Ensure that existing risk management processes and tools are being fully implemented
–Use mistakes as opportunities to learn
Success will be realized when we respond urgently to pre-cursors (both positive and negative) and act deliberately to prevent events
Las Conchas Fire 2011
Nitrate Salt Event at WIPP 2014
Arc-Flash 2015 Tc-99 Exposure Event 2012
Los Alamos National Laboratory | 30
Lessons in Leadership
Los Alamos National Laboratory | 31
Operational Leadership commitment is expressed all the way back to the founding of the Los Alamos mission
“Each employee can do more to protect
himself and his fellow workers than all
the rules in the world, and it is of
utmost importance that each of us feel
at all times, the responsibility of
safeguarding himself and others.”
. . . J.R. Oppenheimer 1945
LANL’s proud legacy