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Lessons learned from occurrences involving procedures at Los Alamos National Laboratory in 1994

By C.K. Frostenson

Abstract

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

Topics: 42 Engineering Not Included In Other Categories, Management, Accidents, 05 Nuclear Fuels, Lanl, 99 Mathematics, Computers, Information Science, Management, Law, Miscellaneous, Human Factors Engineering, Remote Handling, Human Factors, Occupational Safety
Publisher: Los Alamos National Laboratory
Year: 1995
DOI identifier: 10.1177/154193129503901515
OAI identifier:
Provided by: UNT Digital Library
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