Subject:  Near-Miss Occurrence on January 4, 2001

This memo is intended to describe a near-miss accident (NMA) that occurred on  4 January of this year.  Mankind, through the ages, has tried to avoid accidents, but only through thorough reporting and documenting of NMAs can this objective be obtained.  It is all about safety.  This has always been the goal at Pantex.  Not only is it desirable from the standpoint of preventing injuries and saving lives, but it is also a DOE mandate that all NMAs be reported in a timely fashion (DOE Order RM4093441, rev. 1).  This requires the need to provide a complete written description of the NMA and the procedures and policies that were implemented to mitigate the occurrence.  Fulfilling this reporting requirement in a timely fashion is the intention of this memo.  Its all about timely reporting.

The whole sequence of events was initiated when the Division Manager was phoned in the middle of the night (actually, 11:54 pm.) and told that a NMA had occurred in Bldg. [   ].  The call had been made by one of the personnel of the XXX Department when s/he determined that something was amiss.  At that time it was determined that someone had failed to notice that HE was scheduled to be stored in the building, but the temperature level inside the building was too high and a compatibility label (CL) was missing.  HE storage is all about temperature and compatibility.  (Compatibility is defined as the interaction (usually adverse) of one kind of material with another.)  In this case, compatibility was not an issue.  Facts surrounding this event had been in the discovery stage since the NMA, but now they can be reported in their entirety.

No injuries to personnel, no adverse impacts to the environment or off-site personnel or property, nor any real safety hazards to equipment, facilities or personnel occurred, but the incident was considered important enough to be classed an NMA.  A determination was made by root-cause analysis (RCA), performed by a task-group headed by White and composed of  Smith, Jones, and Black from Dept. ZXY, that only one label had been applied to the box containing the HE instead of two, as required, or one of the labels had been accidentally torn off or the wrong cover had been put on the box.  These hazard and compatibility designating self-adhesive plastic-laminated four-color temperature-sensitive commercially-printed embossed labels are mandated by DOE Order MY77056.1.

Accordingly, as an interim stop-gap action, an administrative control (AC) has been implemented by administrative personnel in the Explosives Material Movement Control Center (EMMCC) that require Production Technicians (PCs) and Facility Managers (FMs) to count the number of CLs on each box.  Training and Development Technologies Dept. (T&DTD) will design, test and implement a course for the cognizant affected personnel via Departmental Training Representatives (DTRs) in each department.  It is planned that a plant-wide directive (PWD) to all plant personnel will be promulgated soon and formally implemented into flow-down documents (FDDs) so everyone will be informed of the proper procedure to be followed in the future. 

Failure to Use Compatibility Labels (CL) Can Cause Death

Directives:

• Accordingly, as an interim stop-gap action, an administrative control (AC) has been implemented by administrative personnel in the Explosives Material Movement Control Center (EMMCC) that require Production Technicians (PCs) and Facility Managers (FMs) to count the number of CLs on each box.  

• Training and Development Technologies Dept. (T&DTD) will design, test and implement a course for the cognizant affected personnel via Departmental Training Representatives (DTRs) in each department.  

• It is planned that a plant-wide directive (PWD) to all plant personnel will be promulgated soon and formally implemented into flow-down documents (FDDs) so everyone will be informed of the proper procedure to be followed in the future. 

The Cause of the Problem:

A determination was made by root-cause analysis (RCA), performed by a task-group headed by White and composed of  Smith, Jones, and Black from Dept. ZXY, that only one label had been applied to the box containing the HE instead of two, as required,  or one of the labels had been accidentally torn off or the wrong cover had been put on the box.  These hazard and compatibility designating self-adhesive plastic-laminated four-color temperature-sensitive commercially-printed embossed labels are mandated by DOE Order MY77056.1.

The Incident:

The whole sequence of events was initiated when the Division Manager was phoned in the middle of the night (actually, 11:54 pm.) and told that a NMA had occurred in Bldg. [   ].  The call had been made by one of the personnel of the XXX Department when s/he determined that something was amiss.  At that time it was determined that someone had failed to notice that HE was scheduled to be stored in the building, but the temperature level inside the building was too high and a compatibility label (CL) was missing.  HE storage is all about temperature and compatibility.  (Compatibility is defined as the interaction (usually adverse) of one kind of material with another.)  In this case, compatibility was not an issue.  Facts surrounding this event had been in the discovery stage since the NMA, but now they can be reported in their entirety.

Dangers & Reports:

No injuries to personnel, no adverse impacts to the environment or off-site personnel or property, nor any real safety hazards to equipment, facilities or personnel occurred, but the incident was considered important enough to be classed an NMA.  

This memo is intended to describe a near-miss accident (NMA) that occurred on  4 January of this year.  Mankind, through the ages, has tried to avoid accidents, but only through thorough reporting and documenting of NMAs can this objective be obtained.  It is all about safety.  This has always been the goal at Pantex.  Not only is it desirable from the standpoint of preventing injuries and saving lives, but it is also a DOE mandate that all NMAs be reported in a timely fashion (DOE Order RM4093441, rev. 1).  This requires the need to provide a complete written description of the NMA and the procedures and policies that were implemented to mitigate the occurrence.  Fulfilling this reporting requirement in a timely fashion is the intention of this memo.  Its all about timely reporting.

Failure to Use Compatibility Labels (CLs) Can Kill

Directives:

• Production Technicians (PCs) and Facility Managers (FMs) 

  • You MUST count the number of CLs (compatibility labels) on each box stored in any Pantex building.  

  • There must be two proper labels.   Proper labels are  plastic-laminated and self-adhesive.  Commercially-printed and embossed, they are temperature-sensitive.  This means that messages or print appear in four different colors depending on the temperature.

  • Explosives Material Movement Control Center (EMMCC) issued this administrative control (AC) after an unlabeled box created a near-miss accident (NMA; see "The Incident" below).

• Every department that handles explosive materials

  • The Training and Development Technologies Dept. (T&DTD) will soon teach a course in each department on the handling of dangerous materials, including the importance of compatibility labels (CL).  

  • Your Departmental Training Representative (DTR) will tell you when the course is offered.

• All plant personnel

  • You will soon receive flow-down documents (FDDs) describing safety procedures to be followed in handling explosive materials.  

  • This will be a plant-wide directive (PWD).

Missing Compatibility Labels Cause a Near-miss Accident:

DOE Order MY77056.1 requires Pantex personnel to label boxes of high explosives (HE) with the proper hazard and compatibility labels.  Proper labels are  plastic-laminated and self-adhesive.  Commercially-printed and embossed, they are temperature-sensitive.  This means that messages or print appear in four different colors depending on the temperature.

Jim White led a task-group of Smith, Jones, and Black from Dept. ZXY.  Doing a root-cause analysis (RCA), they found that only one label was applied to a box containing high explosives (HE) instead of the required two labels.  They speculated that one of the labels may have been accidentally torn off or the wrong cover might have been put on the box.  

The Accident:

Late on the night of 4 Jan. 2001, someone in the XXX Department informed Security that something was amiss in Bldg. YY.  Security investigated and called the Division Manager at 11:54 pm to inform him that a NMA (near-miss accident) had occurred.  

Apparently XXX Dept. personnel failed to notice when HE arrived for storage in Bldg. YY.  They failed to recognize the arrival of HE, because the boxes were not properly labeled with required CLs.  "Compatibility" refers to the dangerous interaction between chemicals or materials.  This did not cause the NMA.  The heat in the building caused the NMA.

Dangers & Reports:

Because the NMA occurred late at night, it did not injure anyone, nor did it damage facilities or equipment.  

DOE Order RM4093441, rev. 1 requires that all NMAs be investigated and reported.  Naturally we would all like to prevent accidents.  Reporting NMAs should prevent the same kind of accident from occurring again.  

Even when, as in this case, the NMA does not cause death, injury, or damage, investigating and reporting NMAs delays work and is expensive.  

Please work as though your life is at stake; it is, every day.