Abstract
Special nuclear material research, process development, technology demonstration, and manufacturing capabilities are provided at the Los Alamos National Laboratory Plutonium Facility. Engineered barriers provide the most effective protection from radioactive and hazardous materials. The Worker Safety Security Team augments these passive safety feature by investigating incidents to identify appropriate prevention and mitigation measures. “Learning Teams” facilitate employee feedback loop and integration toward process improvement. This article reports an investigation of a “Sharps” incident and reviews a case study of a technician that cuts his left thumb while making a gasket. Causal analysis of the sharps incident uncovered contributing factors that created the environment in which the incident occurred. Latent organizational conditions that created error-likely situations or weakened defenses were identified and controlled. Effective improvements that reduce the probability or consequence of similar sharps incidents were implemented.
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