Working man's analysis of incidents and accidents with explosives at the Los Alamos National Laboratory, 1946--1997

摘要

At the inception of the Laboratory hectic and intense work was the norm during the development of the atomic bombs. After the war the development of other weapons for the Cold War again contributed to an intense work environment. Formal Standard Operating Procedures (SOPs) were not required at that time. However, the occurrence of six fatalities in 1959 during the development of a new high-energy plastic bonded explosive (94% HMX) forced the introduction SOPs. After an accident at the Department of Energy (DOE) plant at Amarillo, TX in 1977, the DOE promulgated the Department wide DOE Explosives Safety Manual. Table 1 outlines the history of the introduction of SOPs and the DOE Explosives Safety Manual. Many of the rules and guidelines presented in these documents were developed and introduced as the result of an incident or accident. However, many of the current staff are not familiar with the background of the development. To preserve as much of this knowledge as possible, they are collecting documentation on incidents and accidents involving energetic materials at Los Alamos. Formal investigations of serious accidents elucidate the multiple causes that contributed to accidents. These reports are generally buried in a file and, and are not read by more recent workers. Reports involving fatalities at Los Alamos before 1974 were withheld from the general employee. Also, these documents contain much detail and analysis that is not of interest to the field worker. The authors have collected the documents describing 116 incidents and have analyzed the contributing factors as viewed from the standpoint of the individual operator. All the incidents occurred at the Los Alamos National Laboratory and involved energetic materials in some manner, though not all occurred within the explosive handling groups. Most accidents are caused by multiple contributing factors. They have attempted to select the one or two factors that they consider as the most important relative to the individual doing the work. The value of SOPs was an obvious conclusion apriori. The introduction and use of SOPs reduced the probability of serious accidents. The second conclusion was less obvious in that it appears that the SOP did not adequately provide all the controls necessary for 16% of the events. Violations of SOPs, always considered as a potential contributor, was assigned as the major contributor in only 10 incidents.