PNNL

Abstract

Hazard and risk assessments, along with human error analysis and mitigation techniques, have long been mainstays of effective safety programs. These tools have revealed that worker errors contributing to or resulting in accidents are often the consequence of ineffective system conditions, process features, or individual employee characteristics. At Los Alamos National Laboratory (LANL), security, safety, human error, and organizational analysts determined that the system-induced human errors that make accidents more likely also are contributing to security incidents. A similar set of system conditions has been found to underlie deliberate, non-malevolent deviations from proper security practices—termed breaches—that also can result in a security incident. In fiscal-year (FY) 2002, LANL's Security Division therefore established the ESTHER (Enhanced Security Through Human Error Reduction) program to identify and reduce the influence of the factors that underlie employee errors and breaches and, in turn, security incidents. Recognizing the potential benefits of this program and approach, in FY2004 the Department of Energy (DOE) Office of Security Policy (DOE-SO) funded an expansion of ESTHER implementation to the causal assessment and reporting of security incidents at other DOE sites. This presentation will focus on three applications of error/breach assessment and mitigation techniques. One use is proactive, accomplished through the elimination of contributors to error, whereas two are reactive, implemented in response to accidents or security incidents as well as to near misses, to prevent recurrence. The human performance and safety bases of these techniques will be detailed. Associated tools—including computer-based assessment training and web-based incident reporting modules developed by Pacific Northwest National Laboratory—will be discussed.