Causal analysis of a glovebox glove breach

Abstract

Programmatic operations at the Los Alamos National Laboratory Plutonium Facility (TA-55) involve working with plutonium and other highly toxic, alpha-emitting materials in gloveboxes. Evaluating the glovebox configuration, the glovebox gloves are the weakest part of this engineering control. Recognizing this vulnerability, the TA-55 Glovebox Glove Integrity Program (GGIP) was developed to minimize loss of confinement of the glovebox through an opening in the glove, i.e., a breach or failure. A key element of this program is to perform causal analyses of breaches and failures. In the following report, the causal analysis methodology is defined below, and one case study is presented. The contributing factors that caused a marble size hole in glovebox glove during the repair of an auger are analyzed. Underlying conditions, decisions, actions, and inactions that contribute to the event are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.