
Safety lapses hobble Los Alamos National Lab’s work on U.S. nuclear warheads - okket
http://www.sciencemag.org/news/2017/06/near-disaster-federal-nuclear-weapons-laboratory-takes-hidden-toll-america-s-arsenal
======
pdkl95
> the staff had become “de-sensitized” to the risk of a serious accident.

Yet again serious problems happen due to the Normalization Of Deviance. We
really need to find a way to create working conditions that encourage
correcting problematic situations immediately before the behavior becomes
normalized.

Regarding the management/other problems... I encourage everyone in ever
industry that is ever involved with _safety_ (i.e. most industries) to see
Richard Cook's short talk about "Resilience in Complex Adaptive Systems"[1].

[1]
[https://www.youtube.com/watch?v=PGLYEDpNu60](https://www.youtube.com/watch?v=PGLYEDpNu60)

~~~
cryptonector
I'm picturing workers who have never spent time on wikipedia reading about
nuclear accidents, much less in any books.

The list of nuclear accidents is hair-raising. The thought that a co-worker
might assemble a near-critical mass nearby is... beyond hair-raising. Where
the heck are they getting these guys, and what are they telling them?!

~~~
ncallaway
They are normal people, who follow normal psychological patterns.

In your root cause analysis, 99% of the time the answer should not be "human
error". An error that one human makes will be repeated in the future by
another human.

The problem is setting up patterns and processes in the working environment
that are aware of these human limitations and that work around them. The air
travel industry is a _great_ example of what happens when you don't simply
blame the human, but look to fix the true problems that caused the human to
make a mistake.

~~~
ythn
> The air travel industry is a _great_ example of what happens when you don't
> simply blame the human, but look to fix the true problems that caused the
> human to make a mistake.

Contrast to my company:

Our phones require you to dial "9" to get out of the building, and then "1" to
dial long distance. A lot of my coworkers are foreign and in the process of
trying to dial a cell phone number (international or otherwise) accidentally
dial "911". When they realize their mistake, they hang up, not having grown up
in America and learning to stay on the line and tell the operator that you
made a mistake.

Company response? Threatening emails, verbal and written company-wide wrist
slaps, and stickers on every phone that say not to hang up if you dial 911 or
you'll get in trouble.

As a result people are now afraid of dialing long-distance numbers and so they
simply avoid it.

Imagine if the company had instead tried to correct the true issue causing the
errors (poor phone routing numbers)?

~~~
ams6110
In many (all?) parts of the US, even if you stay on the line and tell the
operator that the call was a mistake, you'll still get a visit from the
police. The thinking is that someone who got a chance to dial 911 but then is
discovered by a captor might be coerced into saying the call was a mistake. So
they send the police to invesitigate ALL 911 calls -- hangups, mistakes,
everything.

~~~
ncallaway
Interesting. I definitely made this mistake as a child. My dad's cell phone
number started was 915-XXXX. I misdialed once and dialed "911".

I explained that it was a mistake, and they said not to worry about it and
hung up. No officer was dispatched.

I wonder if something has changed since I made that mistake, if it's just
inconsistent across the country, or if there is some discretion of the
dispatcher to decide that the child probably did make a mistake.

~~~
mjcl
I don't think anything has changed; I made test-calls to 911 (to confirm the
call was routed properly) when commissioning new phone systems and never had
police dispatched. I'd tell the operator that I was testing and wanted to
confirm that they were showing the correct phone # and address.

~~~
boomboomsubban
It is something that every state and county could decide.

------
nerdponx
_The investigation further revealed that the penalties imposed by the
government on the private firms that make America’s nuclear weapons were
typically just pinpricks, and that instead the firms annually were awarded
large profits in the same years that major safety lapses occurred. Some were
awarded new contracts despite repeated, avoidable accidents, including some
that exposed workers to radiation._

The author buried the lede.

~~~
ChuckMcM
I don't think the author was trying to create a conversation about the
misalignment of the lab's management and safety. The article goes out of its
way to sensationalize industrial accidents with "NUCLEAR RADIATION" to
construct a narrative of uninformed fear of anything associated with nuclear
material.

It reminded me a bit of some of the Discovery Channel's shows where they
stress that if this multi-million ton container ship doesn't stay between the
two entrance markers to the harbor, it kill everyone on board and probably
destroy millions of dollars in goods. The entrance markers are 5 miles apart.
The fact is accurate, the narrative is not.

If you want to be really scared go read the OSHA reports on any of DOW's
chemical plants. I would be willing to wager that more people have died in the
last 5 years of industrial accidents at their plants than all of Los Alamos.
The Union Carbide Bhopal disaster killed over 2,000 people, one accident.

The point is the article was not written to compare the risk of accidents at
Los Alamos to that of other similarly sized industries, nor was it written to
highlight the misalignment of lab management with safety goals. It was written
to characterize nuclear materials as scary and dangerous and carefully avoids
any way for the reader to compare that risk with other risks they are both
familiar with and are not concerned about.

In short, it is anti-nuclear propaganda.

~~~
crucini
On the topic of scary chemical plants: check out the Chemical Safety Board's
videos on Youtube. Mostly computer-animated recreations of serious industrial
accidents.

~~~
dmix
Wow these are a great way to communicate risks in workplace safety. Here's an
example video:

[https://www.youtube.com/watch?v=41QMaJqxqIo](https://www.youtube.com/watch?v=41QMaJqxqIo)

This is a great idea. I wish more of the more serious post-mortems were this
thorough in our industry. But I guess people rarely die, they just have
millions of peoples data leaked or result in serious service interruptions, so
we don't have much of an incentive.

------
andyjohnson0
_" they gathered eight rods painstakingly crafted out of plutonium, and
positioned them side-by-side on a table"_

The unpleasant death of Louis Slotin [1] is an example of the risks these
people were taking.

[1]
[https://en.wikipedia.org/wiki/Louis_Slotin#Criticality_accid...](https://en.wikipedia.org/wiki/Louis_Slotin#Criticality_accident)

~~~
rtkwe
The radiation dosage section of that article is a mess and I think shows a
limitation of wikipedia. The writers managed to not use the same unit in any
two consecutive sentences and sometimes not even with in the same sentence and
don't bother providing any way to relate the different units.

~~~
bitJericho
So... fix it?

------
andyjohnson0
_" The resulting blue glow — known as Cherenkov radiation — has accidentally
and abruptly flashed at least 60 times since the dawn of the nuclear age,"_

I'm not a physicist, but as far as I know the blue flash generated by a
criticality is caused by gases in the air fluorescing. Cherenkov radiation is
a different phenomena.

Edit: Seems to be confirmed by [1]
[https://en.wikipedia.org/wiki/Criticality_accident#Blue_glow](https://en.wikipedia.org/wiki/Criticality_accident#Blue_glow)

~~~
arethuza
"Cherenkov radiation could also be responsible for the "blue flash"
experienced in an excursion due to the intersection of particles with the
vitreous humour within the eyeballs of those in the presence of the
criticality."

That's a pretty alarming idea!!

~~~
tjohns
It's actually a well known effect.

Astronauts have reported seeing flashes of light when they close their eyes in
space. It's believed to be caused by Cherenkov radiation from cosmic rays
traveling through the vitreous humour of their eyes.

Source:
[https://www.nature.com/nature/journal/v228/n5268/abs/228260a...](https://www.nature.com/nature/journal/v228/n5268/abs/228260a0.html)
[https://www.ncbi.nlm.nih.gov/pubmed/12678106](https://www.ncbi.nlm.nih.gov/pubmed/12678106)

------
FTA
Another recent incident involving LANL and nuclear waste:
[http://www.latimes.com/nation/la-na-new-mexico-nuclear-
dump-...](http://www.latimes.com/nation/la-na-new-mexico-nuclear-
dump-20160819-snap-story.html).

Essentially, they used a chemically incompatible kitty litter in bins of
nuclear waste (I read another article somewhere that went more in depth about
how the decision to switch went down...unfortunately I can't find it quickly,
but I recall it had something to do with a lack of clarity in communication).
That bad reaction caused the bin to explode underground in the Waste Isolation
Pilot Plant and release radioactivity.

Shortly before this event, there was a truck that caught fire underground at
the waste repository, shutting down operations. I think that event happening
kept the amount of workers exposed in the bigger incident down.

From my experience, safety in these sorts of situations is more of a burden
than a lifestyle from a worker perspective. Holding individuals _and_ their
superiors accountable--not only those that do not follow safety practices but
also supervisors--I think is the only way safety will actually be fully
practiced.

------
pinewurst
"Atomic Accidents" by James Mahaffey is an entire book of essentially
criticality accidents. Well worth reading and entertaining in an often sick
way.

~~~
cmiles74
"Command and Control: Nuclear Weapons, the Damascus Accident, and the Illusion
of Safety" by Eric Schlosser enumerates accidents related to nuclear weapons,
many of which do not end in criticality due to sheer luck in most cases.
Illusion of safety indeed.

[https://www.amazon.com/dp/B00C5R7F8G/ref=dp-kindle-
redirect?...](https://www.amazon.com/dp/B00C5R7F8G/ref=dp-kindle-
redirect?_encoding=UTF8&btkr=1)

~~~
programd
And also "A Review of Criticality Accidents", a short but action packed read
referenced in the article. Nuclear materials are deadly in the most unexpected
ways.

[https://www.orau.org/ptp/Library/accidents/la-13638.pdf](https://www.orau.org/ptp/Library/accidents/la-13638.pdf)

~~~
pinewurst
That's a really good read too.

------
dracodoc
The report didn't tell the background about the private firms managing the
lab, this is a much cleaner report:
[https://www.aps.org/publications/apsnews/201006/losalamos.cf...](https://www.aps.org/publications/apsnews/201006/losalamos.cfm)

Another related story [https://www.washingtonpost.com/world/national-
security/safet...](https://www.washingtonpost.com/world/national-
security/safety-lapses-undermine-nuclear-warhead-work-at-los-
alamos/2017/06/17/87f051ee-510d-11e7-b064-828ba60fbb98_story.html)

~~~
ms013
It's been a pretty slow, sad unraveling of LANL (and to some degree the other
two DP labs). The latest stories are pretty predictable given the transition
from UC to LANS about a decade ago (I left the lab after the transition, since
it was a morale mess - I really enjoyed my time there for about a decade
before the change though). Things were already bad before that - the whole
change of management from UC was in part due to a string of safety and
security issues. Interestingly, I believe the issues that are currently being
reported about have roots that trace all the way back to the last facility for
doing that sort of work that got shut down up near Denver (Rocky Flats). The
issues today are hardly new or novel - there has been some serious rotting
going on within the NW complex since the Cold War began to wind down almost 30
years ago.

------
Pyxl101
I wonder if anyone has considered building faux plutonium rods that can
simulate criticality events. That is, they're packed with electronics and
lights that display to you how much radiation they're giving off, and how
close they are to going critical. They'd be electronic devices that measure
each other's position. Accelerators could tell if they're dropped or banged on
something. You'd also pair them with a faux radioactivity meter (Geiger
counter), and perhaps a faux radiation dosage badge.

"Huh, if I bang these rods on each other, I see a flash of lights showing it
was 50% to critical, I hear the Geiger counter jack up, and my radiation badge
measures that I've just instantly received a year's worth of radiation. Ouch."

Maybe if technicians could experience first-hand how easy it is for these
plutonium rods to go critical, they might be more wary of mishandling them.
It's understandable how a person could become desensitized to the risk of
something that they've never seen happen, where the threshold of that event
occurring is not intuitively known.

When I'm driving my car in a high performance way, I can feel when I'm
beginning to push the bounds of its traction. I can feel when antilock
breaking kicks in. I get to experience the threshold where something bad can
begin to happen. With fissile material, perhaps it is a problem that workers
never get to experience the threshold boundary at all until it's too late.

------
pcunite
Getting people to believe in the dangers of things they can not touch, taste,
see, or hear is often difficult.

~~~
m_mueller
according to reports it's tasteable (metallic) and visible (blue light). The
problem is just, when that happens it's too late.

------
chadcmulligan
There's a few things abut training and so on here - but the problem is that
plutonium rods should never be somewhere they are not meant to be imho. So to
remove the risk when a rod is put somewhere it must be in a special stand that
holds plutonium rods, the stand has little holes spaced the correct distance
apart so criticality can't occur. The rule then is easier - plutonium rods
will always be somewhere they should be. Also maybe paint them blue or
something.

Edit: upon thought if I was anywhere that had a rod laying on a table I'd get
the hell out of there as soon as possible, cause it's just a recipe for
disaster

------
jessaustin
Also relevant: [https://apps.publicintegrity.org/nuclear-negligence/light-
pe...](https://apps.publicintegrity.org/nuclear-negligence/light-penalties/)

------
sverige
>PF-4 is also the only place where existing cores removed randomly from the
arsenal can be painstakingly tested to see if they remain safe and reliable
for use in the nuclear stockpile. That work has also been blocked, due to
PF-4’s extended shutdown, according to internal DOE reports.

I wonder if having another facility that can perform this work wouldn't
provide the right incentive for the underperforming unit to improve.
Competition is a healthy thing. Knowing that there is another lab that is
doing the work to specifications should provide good motivation to improve.

~~~
HarryHirsch
Competition in search for excellence is a dangerous tool, management
implements a metric and the departments optimize for the metric no matter what
the long-term goals are. This is how Sears became run into the ground:
[http://www.salon.com/2013/12/10/ayn_rand_loving_ceo_destroys...](http://www.salon.com/2013/12/10/ayn_rand_loving_ceo_destroys_his_empire_partner/)

Armed forces around the world rely on _esprit de corps_. The British SAS don't
have to compete against Navy Seals to know they are the best, they know
already.

~~~
TallGuyShort
Of course if something analagous to the SAS selection course was used for
hiring at these labs, methinks you wouldn't see sloppy work either.

~~~
HarryHirsch
Also the training. In special forces each serviceman is trained beyond the
immediate job duties. If the commander or anyone with special skills dies
during a mission someone else must step up immediately to replace them and of
course they all had the requisite training.

You'd ask just how a nuke technician could even think of getting close to
assembling a critical mass. Are they really that dumb? Have they never been
told?

------
doggydogs94
Most of these problems are what I call "paper safety" noncompliance (e.g.
somebody not taking a refresher safety class on time). The problem will be
solved by employees taking even more mind numbing safety training. You can
also apply these principles to security violations.

------
Nomentatus
Without genuine selflessness, homeostasis or worse is inevitable. This is why
in Japan you traditionally find the most enlightened Zen monks not teaching,
but cooking or supervising the kitchen - because that's the prime point of
safety vulnerability for a monastery.

------
ianai
Seems like the contractors over that facility should be removed? What does it
take to lose a government contract?

~~~
davidmr
As a former DOE lab employee, I can't even begin to imagine the hassle of
changing operating contracts, although LANL has really been putting forth
extraordinary effort to get the DOE to try.

What's most irritating is that the DOE use a broad brush and go overboard
where it's easy and clearly don't do enough where it's hard. I had to attend
ladder training before I was allowed to climb down under the 4' floor in my
computer room and the rule was made that we had to use ladders all the time.
You can't even fit the ladders in the tile holes, but the rule was on the
books because it was "safe!". There were so many of those boneheaded rules,
but these boneheads are allowed near plutonium to photograph it for no
scientific purpose? Grrrrr

~~~
kevin_thibedeau
You go full union and work to code, refusing to do anything until they provide
a suitable ladder.

------
ekianjo
I think they misuse the word "critical" in the first paragraph. Surprising for
Science.

~~~
charonn0
Do you mean in the 2nd paragraph? I think they're using it correctly.

[https://en.wikipedia.org/wiki/Critical_mass](https://en.wikipedia.org/wiki/Critical_mass)

------
droithomme
I am very offended by the improper use of the term "accidental". Nothing
described here was accidental at all. It was intentional. Insisting this is
based on accidents, perhaps requiring endless more 'training', is
counterproductive when the described acts were done with full awareness by
qualified individuals who knew better. More training won't fix that. Therefore
the solution of more training is doomed to fail.

What should happen, in my opinion, is the University of California, and all
contractors and corporations, and employees and workers, should be fired,
banned from industry permanently, and the entire system replaced, because none
of this, as the article points out, are isolated incidents, but rather are
systematic and endemic problems.

