Lessons From Los Alamos
What would you do if one morning you drove into the company parking lot and saw not one, but several cars sporting bumper stickers proclaiming, "Striving for a Work-Free Safe Zone"?
That sticker has been sighted recently in the desolate, high desert country of New Mexico, home to Los Alamos and the Los Alamos National Laboratory. Fifty-nine years ago the A-bomb was born in Los Alamos. This year a series of safety and security snafus have attracted investigators and reporters like a magnet.
In this issue of ISHN's e-newsletter, we look at Los Alamos's summer of discontent for lessons in how to deal with a safety backlash.
Every safety pro deals with anti-safety attitudes. Where do you start to assess the problem? James Reason, a British psychologist and author of "Human Error" offers sound advice: Don't look for one root cause, a single failure that led to the crisis. Look for a series of problems that evolved over time.
So like an archeologist, start digging for details. What's the history behind the safety culture you're investigating?
In the case of Los Alamos, tension crackled from the start. You had the idealism and technical genius of Dr. Robert Oppenheimer and his team of 500 scientists, and the vast political consequences of creating the world's most destructive weapons â€” Little Boy and Fat Man â€” which were understood better by Gen. Leslie Groves, director of the Manhattan Project.
Analyze what you unearth. As Stephen Covey writes in "The Seven Habits of Highly Effective People," try a little empathy. Look at the conflict from the eyes of the workforce and management.
At Los Alamos, there are now 8,500 employees, including some 1,500 Ph.D.s. They're a proud lot, of course, praised as weapons wizards and high priests of the nation's technical supremacy.
"We carry great pride in the scientific work that has been done," said the chairman of the board of regents for the University of California, which has operated the lab for its entire 61-year history.
These scientists and engineers want to be left alone to work their 60- to 80-hour weeks. No distractions. No one peering over their shoulder.
They value a close-knit, campus-like atmosphere to bounce around ideas. Keep it casual and collegial.
Actually, these wizards and priests aren't much different from your workforce when you get down to the basics. They're proud of their skills. Resistant to micro-managing. They want a relaxed work environment.
And many are stressed-out over schedules, deadlines, and conflicting priorities.
"People who are highly stressed are trying to do a good job," reported an auditor from the Defense Nuclear Facilities Safety Board after visiting the Los Alamos lab earlier this year.
Management at Los Alamos isn't that different from yours, either.
The boss is under the gun to produce results. Retired Navy Admiral Pete Nanos was hired as lab director in 2003 to put the house in order. Two former police officers hired by the lab to investigate charges of lost or stolen equipment and credit card theft had been fired. The former cops claimed cover-up, were rehired, and the Los Alamos director resigned.
Nanos wasted no time launching a new safety initiative. "Taking the Next Steps" was rolled out at an all-employee meeting.
According to a Los Alamos public affairs bulletin posted on the Internet, Nanos used the meeting to review serious and near-hit incidents. A fall from a ladder fractured the leg of a subcontractor. Electrical mistakes nearly killed a group of workers. He said 316 laboratory workers were hurt during the past year, with 71 forced to take time off from work.
"We're not up to my standard," he said. "I hope we are not up to your standard."
The new boss said he was sending a message. "Take note. We are setting our standards and people are going to be held to those standards."
WHO PUSHES THE BUTTONS?
In safety you need to understand where management is coming from â€” the pressures and politics driving decisions. What separates cultures like Los Alamos and NASA from most workplaces is the omnipresence of politics.
At Los Alamos, the retired admiral has quite a crowd looking over his shoulder. It includes the University of California Board of Regents, the Department of Energy, the National Nuclear Security Administration, the Senate Armed Services Committee, the House Energy and Commerce Committee, watchdog groups and the national press.
Nanos took many of the steps you'd expect to reshape an organization's culture.
He led senior executives on a retreat. Held all-employee meetings. Revised the code of ethics. Insisted on high standards and accountability. Demanded involvement by top managers. Brought in a consultant to mentor managers on spotting hazards during walk-arounds. Urged workers and managers to spend more time "giving close and critical attention to work conditions and hazard controls."
Then this past July, the boss's new standards â€” and his standing with his "stakeholders" â€” took a couple of direct hits.
A pair of computer Zip discs and two external hard drives containing classified information were reported missing. Days later, a 20-year-old intern suffered serious eye damage after finishing work on a series of experiments using a high-power, pulsed laser. "Everyone was under the impression that the laser was off," said a lab spokesman. It wasn't, and the woman suffered bleeding at the back of her left eye from a lesion 1/50th of inch wide.
Any safety pro could tell you what happened next, especially in a high-risk, highly political workplace like Los Alamos. Anger, accusations, hyperbole. A chain reaction of a different sort rattled through the lab.
The secretary of energy shuts down nearly all classified work at the country's 24 DOE laboratories.
The University of California's vice president for laboratory management likens Los Alamos scientists to school kids. "It's cool to flaunt authority, and you intimidate the other kids trying to do their schoolwork," he tells a reporter.
A Texas congressman declares at a special hearing that a public library has better security over its CDs and DVDs.
"There's something about the Los Alamos culture that we have not yet beaten into submission," the head of the National Nuclear Security Administration tells the hearing.
Headline writers try to help him figure it out, calling Los Alamos's culture "toxic," "closed" and "arrogant." Employees are complacent "cowboys" with "cavalier" attitudes of indifference.
Nanos weighs in himself, suspending 19 workers and claiming employees are in almost "suicidal denial" over problems. He fires off an email to all employees: "This willful flouting of the rules must stop, and I don't care how many people I have to fire to make it stop. If you think the rules are silly, if you think compliance is a joke, please resign now and save me the trouble."
Dozens of lab scientists ask for retirement literature in the next few days, according to one press report.
And then those bumper stickers appear.
Less than month after what one press account hyped as a "spectacular series of security and safety breaches," lab director Nanos said the culture at the lab had turned a corner.
Top officials had met "eyeball to eyeball" with employees. Work was suspended while workers received security, safety and environmental risk training. A science museum operated by the lab, for example, found its evacuation announcement wasn't loud enough and employees needed to be more careful when moving tables and chair for special events, the museum's director told a reporter.
"There's a lot of blame to go around," said the university's VP of lab management. Discipline would be meted out at all levels, promised Nanos.
About 80 percent of the workforce now have a new respect for the importance of safety and security, he told reporters.
"We can work with that," he said.
For how long? Sustainability is always the $64,000 question in safety. At Los Alamos, culture clashes between science and politics have simmered for decades. Now you have backs against the wall everywhere. Employees scolded like children and heavily-pressured managers vowing discipline if not firings. And a widely-held belief that realpolitik rules: the lab's world class science output trumps safety and security "priorities."
If this was your workplace, how confident would you be that the true root causes of safety and security problems had been exposed to work on?
Dave Johnson is the ISHN E-News editor. He can be reached at firstname.lastname@example.org, (610) 666-0261; fax (610) 666-1906.
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