SLAC Today is available online at:
http://today.slac.stanford.edu
In this issue:
From the Director: We Can Do This
Sector 30 PVC Pipe Incident Investigation Final Report
Word of the Week: "Insertion Device"
Photo of the Day: Firefighters Conduct High Angle Rescue Drill
2008 Events: Save the Dates

SLAC Today

Friday - November 9, 2007

(Photo - Persis Drell)

From the Director: We Can Do This

The accident investigation board that sought the cause of the Sector 30 pipe explosion has completed their report. The process that led to this report has been outstanding and I am very grateful to the committee for all their hard work.

The report points to significant weaknesses in our safety culture here at SLAC and the assessment is well founded. If safety is truly to be a core value of this institution, along with outstanding science, we must have very high standards for achieving safety and science. Even more challenging, we must be willing to admit when our behaviors don't meet our own expectations. We need to be our own harshest critics.

The report correctly points out that "the laboratory has not yet managed to implement fully ISMS [Integrated Safety Management System] in practical and meaningful terms by means of a comprehensive planning and control process for all work." But even more importantly and critically, the report goes on to say: "Even though there have been long standing issues with work planning and control…SLAC management has not made development and implementation of comprehensive work planning and control processes a priority…As of the date of the event at Sector 30, effective performance standards were not in place; therefore there is no mechanism to hold line managers accountable for implementing safe and compliant... work." The report focuses on subcontractor work; In his cover letter to the report, Steve Williams, the chair of the accident investigation board, expressed his concern that the problem is broader at the site.

This incident resulted from a failing of management and leadership at the laboratory. We did not make implementation of comprehensive work planning a priority. We did not set the same clear expectations for safety performance as we do with our science performance.

We can do this. We have outstanding examples, many of them highlighted in the SAFE07 campaign, where the mission was accomplished and the work was done safely. In the recent BaBar upgrade, the Beamline 12 construction, the FFTB preservation, the LAT Integration and the LCLS Injector Installation, to name just a few, the management set very clear expectations for safety as well as for achievement of the mission, and they were successful. It doesn't have to be mission or safety. We want a culture of mission and safety. It is up to the management of the laboratory, starting with me and going down to the first line supervisor in the field, to ensure that the expectations of safety and accountability for performance are clearly set for every worker at the lab. I will look forward to keeping you informed as we develop the corrective action plan in a way that optimizes our ability to deliver on the long term cultural changes needed at the laboratory. These actions will be the first steps towards an accident-free laboratory.

Sector 30 PVC Pipe Incident Investigation Final Report

(Photo - Pipes at Sector 30)
The PVC pipe (right) that exploded at Sector 30 on September 13, 2007. At left is a neighboring pipe that was damaged by the explosion. (Please note that the time stamp is off by one hour.)

On September 13, 2007, a pipe exploded at Sector 30 along the SLAC linac. Very fortunately, no one was seriously injured in this incident. To determine what led up to this accident and to help ensure that such an accident does not happen again, Acting Director Persis Drell appointed a committee to investigate the causes of the incident. The final report of this committee has now been released.

The committee conducted a rigorous review to find the causes of the incident and how such incidents can be prevented in the future. One of the main goals of the investigation was to find the "root cause:" The most fundamental condition that, if fixed, would have prevented the accident and probably a whole class of similar situations.

The committee determined that the root cause of the accident was poor planning at several critical junctures. A part of the job, the installation of a pressure gauge on the steel pipe, was overlooked, and a last-minute fix went awry. If the work on the pipes had been well planned from the beginning and through to completion, the event would almost certainly have been prevented. Planning and thought are needed prior to all work, not just this specific case.

Insufficient planning is a recurring theme at SLAC, and outside reviewers have told us before that we need to pay more attention to work planning and control. We have made a lot of progress, but we clearly need to do more.

There are four other causal factors described in the report. Together they refer to how SLAC communicates requirements with subcontractors for work, communicates to other members of the SLAC community also doing work, and over-relies on “skill of the craft” for catching a subtle hazard.

A two-page Executive Summary and the full report are available on the ES&H website. The report also contains recommendations for moving forward.

Word of the Week:
"Insertion Device"

An insertion device (ID) is a magnet or series of magnets "inserted" into the beam path of a synchrotron or other light source to generate synchrotron radiation. At the Stanford Synchrotron Radiation Laboratory, three kinds of IDs are used: bending magnets, wigglers and undulators. These devices force the beam of electrons to bend or oscillate back and forth, which causes them to give off radiation in the form of x-rays.

Photo of the Day: Firefighters Conduct High Angle Rescue Drill

(Photo - firefighters climbing hill)
Click on image for larger version.

On Tuesday morning, Palo Alto firefighters, including SLAC's Station 7 personnel, provided special training for their Fire Academy recruits in high angle rescue procedures above Building 104 in the Research Yard.

2008 Events:
Save the Dates

Human Resources is busy planning events for SLAC employees for the holiday season and 2008. Mark your calendars for these exciting upcoming events!

Annual Holiday Party
Wed., December 19, 2007

Jump into the holiday season with a scrumptious buffet luncheon. This year the festivities will begin at 11 a.m. to accommodate all employees. Feast on turkey with all the trimmings (vegetarian items available too!), swing to music, watch a holiday movie or win a raffle prize (if you are lucky!). Our Master of Ceremonies will be Neil Calder.

Ten Year Service Awards
Tues., January 29, 2008

Employees with ten years of service as of 2007 and their supervisors are invited to a luncheon and awards celebration at SLAC.

20-30-40-50 Year
Service Awards Banquet
Thurs., February 28, 2008

Employees with 20, 30, 40 or 50 years of service as of 2007 will be honored at a festive dinner at the Stanford Faculty Club.

Kid's Day
Fri., August 15, 2008 (tentative)

Plan to bring your kids to this annual event, featuring fun-filled, hands-on workshops to introduce kids to the science and work we do at SLAC.

SLAC Family Day
Sat., September 20, 2008

Held every other year, this event is a day of games, great food and fun for all ages. Come by yourself or bring your whole family.


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