Anatomy of an Incident
Michael E. Cournoyer
LA-UR-16-20647
March 13, 2016
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Accident pyramid
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Five-step process of
Integrated Safety Management
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Anatomy of an incident
!  The incident occurs
!  The incident is investigated
!  Causal factors are determined
!  Conclusions are drawn
!  Corrective actions are developed
!  Lessons Learned are communicated
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The incident occurs
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Before
The incident occurs
After
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The incident is investigated
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The incident is investigated
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The incident is investigated
NA--LASO-LANL-CHEMLASER-2015-0001: Light Fixture Fire
11:13
The Acrylic Lens Ignites
11:00
11:07
Light Bulb Burst The Acrylic Lens Melts
11:23
A Small Fire Starts
11:00
11:25
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The incident is investigated
•  The metal halide lamp is
designed around a sealed
tube with an electrode in
each end
•  The Arc Tube
temperature range is
between 1000°C and
1300°C
•  This type of metal halide
lamp (ANSI M59/S) is
position dedicated
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The incident is investigated
•  Lamp position is
horizontal
•  The fixture had an
acrylic lens
•  The acrylic material
has a flash point >
250°C and an AutoIgnition temperature
> 400°C.
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Causal factors are determined
NA--LASO-LANL-CHEMLASER-2015-0001: Light Fixture Fire
Engineering
Management
2 LLs on This
The Lens Material
Was Acrylic
Zero Accidents
LL Policy LTA
Policy Not
Enforced
Management Methods LTA
Error in Material Selection
MOV LTA
Design Output LTA
The Wrong Bulb
Was Installed.
Inspection LTA
Required Inspection
Was Not Established
Inspection Would Identify
Wrong Bulb & Lens Material
Corrective Maintenance LTA
Preventive Maintenance
for Equipment LTA
Preventive Maintenance Was
not Established for the
Bulb That Failed.
Property Damage
The Lens Material
Was Acrylic
Defective, Failed
or Contaminated
Check of Work
Was LTA
Failed Material
Skill Based Errors
End of Life Failure
Equipment
Bulb Exploded
The Wrong Bulb
Was Installed.
Wrong Action
Man Power
The Wrong Bulb
Was Installed.
The Wrong Bulb
Was Installed.
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Causal factors are determined
Frequency
25
Incident Causal Factors
20
15
10
5
0
Management
Man Power
Equipment
Engineering
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Conclusions are drawn
•  A wrong metal-halide lamp
bulb caused a small fire.
•  The acrylic lens material
exacerbated the incident.
•  The engineer should have
required lenses that are
compatible with metalhalide lamp.
•  The worker should have
known that he or she was
installing the wrong bulb.
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Conclusions are drawn
•  The worker’s supervisors
should have checked the
workers task and
discovered that the wrong
bulb was installed.
•  The worker’s manager
should have monitored the
workers task.
•  Implementing Lesson’s
Learned from two previous
incidences could have
prevented the small fire.
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Corrective actions are
developed
•  Position metal-halide
lamp all in one direction
•  Store only one type of
metal-halide lamp bulbs
Replace acrylic lens with
lenses that are compatible
with metal-halide lamp
•  Iterate the importance of
management monitoring
programs
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Lessons Learned integration
with work performance
Managers
Start
Identify
improvement
opportunities
Communicate
relevant
LessonsLearned
toworkers
LLsCoordinator
Workers
“LessonsLearned”(LLs)Process
Communicate
keyLessons
Learnedto
managers
Incorporate
improvements
intoWork
Processes
PerformWork
Evaluatework
toidentify
lessonslearned
ShareLesson
Learned
Lessons
Learned
Archive
CaptureLessons
Learned
ScreenLessons
Learned
MonitorLesson
Learned
End
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Defense in Depth
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Slip simulator training
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UNCLASSIFIED
ADPSM
Total With S/T/F
Year Employees Trained* Injuries
2011
481
0
8
2012
484
229
8
2013
491
385
5
*None of the Trained Employees Had an Injury
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P-Value for a Chi
Square Test
Injury (Slip, Trip, Fall)
Trained
Yes
No
Yes
0
614
No
21
800
Х2=15.9385
ThePvalueis6.5E-05
Thisresultissignificantatp<0.05
TheassociaAonbetweenrows(groups)andcolumns(outcomes)
isconsideredtobeextremelystaAsAcallysignificant
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Lessons Learned integration
with work performance
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Lessons Learned integration
with work performance
•  Metal halide light failures
- Small fires start when
burning diffuser falls to
ground, 2012-SRSRNS-0004, 2012
•  Metal halide bulb fails,
shatters outer glass
envelope, hot glass
shard chars wood crate,
2015-FSO-FNAL-022,
2015
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Lessons Learned integration
with work performance
•  Assign a Metal-Halide
Lamp Subject Matter
Expert (SME)
•  Have the Metal-Halide
Lamp SME make an
inventory of metal-halide
lamps
•  Have managers perform
an inspection of metalhalide lamps in their areas
of responsibility
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Lessons Learned integration
with work performance
•  Have the Metal-Halide
Lamp SME revise the
Metal-Halide Lamp
procedure such that
corrective actions have
been incorporated
•  Have the Metal-Halide
Lamp SME supervisor
review Metal-Halide Lamp
procedure
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Lessons Learned integration
with work performance
•  Replace all metal-halide
lamps with light-emitting
diode (LED) lamps.
•  LED lamps have a
lifespan and electrical
efficiency that is
comparable to metalhalide lamps.
•  LED lamps contain no
mercury.
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Lessons Learned integration
with work performance
•  No ballast bypass or
rewiring is required.
•  LED lamps operate at <
93 °C, are thermally
regulated and may be
positioned at any angle. In
addition the operating life
is 2 and half times longer
than metal-halide lamps:
50,000 hr life vs 20,000
hr.
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Predicting the future
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How the people involved saw
it before the accident
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How the investigator sees it
after the accident
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Fire the person who reported It
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Latent organizational conditions
•  Managers going around
telling there workers to
be safe is difficult to
track.
•  Tracking preventive
maintenance, safety
meeting attendance,
and chemical container
inventory is easy to
track.
25
20
15
10
5
0
Management Man Power Equipment Engineering
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What do you work on first?
Injury Factors
Factors
Jun 06 - May 14
20
100%
15
75%
10
50%
5
25%
0
Chemical Agent
Ergonomic
Slip/Trip/Fall
Struck against/by
Frequency 06 - 14
Other
Lift/Push/Pull
0%
Cum. Frequency 06 - 14
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Safety improvements are hard to
prove
•  Redundant defenses
improve safety margins,
but also increase
complexity.
•  Flawed defenses and
safety hazards become
more difficult to detect.
•  Redundant defenses make
safety improvements more
difficult to identify as well.
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Improvement can’t be measured
Injury Factors
Factors
Jun 06 - May 15
20
100%
15
75%
10
50%
5
25%
0
Chemical Agent
Ergonomic
Slip/Trip/Fall
Struck against/by
Other
Lift/Push/Pull
Frequency 06 - 14
Frequency Last 12 Months
Cum. Frequency 06 - 14
Cum. Frequency Last 12 Months
0%
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Summary
!  A wrong type of metal-halide lamp bulb exploded causing a
small fire.
!  Latent organizational conditions created error-likely situations
and weaken defenses.
!  Corrective action included standardizing the type of metalhalide lamp bulbs, replacing acrylic lens with lenses that are
compatible with metal-halide lamp, and adding the inspection
of metal-halide lamp to management monitoring programs.
!  A significant improvement to the task consists of replacement
of metal-halide lamps with LED lamps.
!  This improvement was shared through a Lessons Learned
Program.
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Conclusions
!  Latent organizational conditions that create error-likely
situations and weaken defenses have been identified
and controlled.
!  Incorporating corrective actions selected from the
DOE CAT provide corrective based on decades of
incidences.
!  Effective improvements have been implemented that
reduce or eliminate the risk of another metal-halide
lamp fire incidents.
!  This increases technical knowledge and augments
operational safety.
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Acknowledgements
!  The author would like to acknowledge the
U.S. Department of Energy and LANL's
Plutonium Science & Manufacturing
directorate for support of this work.
!  The author would like to acknowledge
James D. Jurney (MET-2) for information on
the Light Fixture Fire incident.
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