Since 1996, I have served as a safety consultant to Los Alamos National Laboratory. In that capacity, I have provided guidance to senior executive team members, two past laboratory directors, and the current director. I have also provided safety training for laboratory staff and management.
The laboratory exists within a complex nuclear industry with extraordinarily high consequences for error; as a result, the public demands nothing less than this institution’s total commitment to achieving the best safety and operational records possible.
There is a simple rationale for Director Nanos’s standard and expectation of excellence in all things: The higher the hazards and risks of an operation, the more important it is to develop the highest standards for operating procedures and performance, and to implement those standards consistently.
It’s easy to become complacent about safety. “Experts” fall into the trap of expertise: As they become more familiar with safety hazards, they perceive the risks as being lower than they really are. Such underestimation leads, in turn, to a false sense of confidence and the gradual erosion of standards. The result? Safety loses its prominence and preeminence, and individuals fail to focus on the big-picture priority of safety.
The consequences of anything less than a full commitment to excellence in safety are clear and often tragic. Certainly, in a culture of excellence, there is no room for carelessness with, or willful disregard of, important standards and processes. But on a more fundamental level, data points on an injury and illness chart represent human beings and pain and suffering for them and their families.
Organizations that succeed in achieving greatness do not shy away from looking at the hard facts, but instead confront those facts and use them to drive continuous improvement. Here, in my view, are the hard facts about safety at Los Alamos:
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▸ The laboratory’s safety performance is good. Everyone working at the laboratory, and those who support it, should be proud of that record. However, 250–300 significant injuries still occur each year. That situation must improve, and I cannot imagine a reason for not working hard to make that improvement happen. Safety excellence requires it.
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▸ For about four years, the laboratory’s safety performance has been on a plateau. This stagnation is inconsistent with the continuing performance improvement achieved by both private industry and the Department of Energy during the same time period. One hallmark of an excellent organization is continuous improvement in results. Because results follow systems, the laboratory must improve its safety systems if it is to improve its safety results.
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▸ There have been several recent serious incidents and injuries. The laboratory concluded that a pattern of near misses and security incidents over the past year has caused increasing concerns at DOE, the National Nuclear Security Administration, the University of California, and LANL. Some of those have had the potential to cause serious permanent injury or death. One significant root cause in a few of the incidents was failure to follow and implement accepted industry standards. A failure to implement management systems that ensured uniform high quality was another significant root cause for losing focus on safety.
Confronting these hard facts about safety is the first step in achieving the lab’s goal of excellence in not just science, but also operations and safety. We have to face the present before we can look toward our future.
Excellence in science, operations, and safety is not exclusionary. Rather, the three areas of excellence are interdependent, and Los Alamos must pursue all of them to fulfill its national security mission. That task requires the wholehearted commitment, dedication, attention, and awareness of every single individual working at the laboratory. It demands a culture of excellence—the product of not one great decision, but a million correct decisions made every day. The stakes are too high to permit anything less.
