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An Analysis of Incidents involving Explosives at the Los Alamos National Laboratory 1951-1999

机译：1951 - 199年洛杉矶阿拉莫斯国家实验室爆炸物的事件分析

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This paper presents an analysis of 164 incidents involving explosives covering the period 1951 to 1999. The analysis is made at the operator level, i.e. the person most directly affected by the consequences. Four categories were used to analyze the incidents; these were 1) type of operation, 2) status of a written procedure, 3) factors that contributed to the incident (limited to two), and 4) severity of the consequence. Examples of incidents involving these categories and factor will be discussed. It is shown that the operator was a significant contributor in over 40% of the incidents. The lack of, inadequacy of, a governing Standard Operating Procedure (SOP) or that the incident was more violent than predicted contributed in about 50% of the incidents. The conclusions indicate that procedures make a significant contributor to safety, but human error is an equal contributor and must be considered in a safety program. It is argued that efforts should be directed equally to formalized procedures and to insuring a high level of worker involvement.
机译：本文介绍了涉及涉及涉及1951年至1999年期间的爆炸物的164个事件的分析。分析是在运营商层面上进行的，即最直接影响后果的人。四类用于分析事件;这些是1）操作类型，2）书面程序的状态，3）因素导致事件（限制为二），4）后果的严重程度。将讨论涉及这些类别和因素的事件的例子。结果表明，运营商是超过40％的事件的重要贡献者。管理标准操作程序（SOP）缺乏，不足，或者事件比预测的事件更加暴力，贡献了大约50％的事件。结论表明，程序对安全作出了重要贡献者，但人为错误是一个平等的贡献者，必须在安全计划中考虑。有人认为，努力应该与正式的程序相同，并确保高水平的工人参与。

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