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From the Director: Eye Injury at SLAC

(Photo - Persis Drell)
(Photo by Brad Plummer.)

Last Thursday, a serious incident occurred in one of SLAC's research laboratories at the PULSE Institute for Ultrafast Energy Science. A trained and qualified laser operator removed his protective eyewear to perform a laser alignment procedure. A stray laser beam entered his eye and burned his retina, causing a localized blind spot in his peripheral vision. The individual was extremely fortunate that his injuries were minor and he is expected to recover. However, the injury could have been much more severe, including possible loss of eyesight. Removal of the eyewear was against the SLAC laser safety policy, the laser facility posting signs, and the facility's Standard Operating Procedure document.

Commendably, the individual promptly sought medical attention, reported the incident, and all laser operations in that laboratory were stopped. While it would be easy to look at this event as an isolated case where someone made an unfortunate choice and removed the last barrier of protection, we cannot and must not dismiss it as such. We must and will learn from this event. Lab management responded rapidly and issued a laser research stop work order throughout the laboratory for all Class 3B and 4 lasers in research labs, as SLAC community members saw in the all-hands notification last Friday morning. Lab staff are currently working through a process to restart the affected laser labs. Prior to authorizing restart of these laser facilities, the engineering, administrative and personal protective equipment, or PPE, controls are all being reviewed to ensure they are properly understood, in place and implemented.

Lab management, with help, support and oversight from Stanford University and the Stanford Site Office, have initiated a full investigation of the incident that will be broken into two parts with two different teams and two different time lines. The first team will begin immediately and do an in-depth analysis of the laser incident itself. This investigation will identify root cause(s), examine whether the causal factors that contributed to this incident exist elsewhere in the lab, and provide recommendations to prevent recurrence of similar events. I anticipate their report within a month.

The second team will look at the much broader issues of the culture of safety at SLAC as well as the organizational systems and processes that we use to establish and ensure the safety of all work at SLAC, including users and students. This review will occur over the next 90 days. Throughout these actions, I expect us to be our own harshest critics and to be open and welcoming to how we can improve our processes and procedures. The investigative teams will include experts from the greater laboratory complex and the Department of Energy in addition to our own staff.

As we go forward, everyone at the lab must keep in mind that our ability to deliver effectively on our science mission strongly depends on our ability to plan and execute all work, including research activities, safely and effectively. Please reflect on this recent incident in the context of your own jobs and how you perform your work. If you are a supervisor, you have a particular obligation to discuss this with your staff and how it applies to their work.

We are looking forward to a remarkable period of discovery from our scientific programs which will only be achieved if we actively and consistently keep our safety and that of our colleagues foremost in mind.

I also want to take this opportunity to remind everyone that this laboratory has come a long way from, for example, the PVC pipe explosion of September, 2007. There is no question that SLAC is a much safer work place than we were two years ago. However this accident is a reminder that we still have a long way to go! We will get there!

—Persis Drell
SLAC Today, October 2, 2009