The Mysterious Case of the Vile Vials

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The Mysterious Case of the Vile Vials

• Michael Knazovich, Manager
• Emergency Plans and Support, SNL
• Eugene McPeek, Manager
• Emergency Operations, SNL

2
The Mystery Begins

• Tuesday, July 28, 2009
• Small plastic vial found near the Sandia
  cafeteria.
• Emergency Response Team responds.
• Field tests indicate no chemical or radiological
  hazardous materials.
• Routine response?

3
The Plot Thickens !

• Tuesday Afternoon, July 28
• Two similar vials found on Kirtland Air Force
  Base (KAFB) several miles away from SNL.
• USAF Security cordons off area, KAFB staffs their
  EOC and notifies the Office of Special
  Investigations and FBI.
• Sandia EOC is staffed.
• Possibility of distribution of unknown materials
  for unknown purposes?
• Potential personnel exposures?
• Workforce communication
• FBI sends the 3 vials to the NM Scientific
  Laboratory Division lab for analysis.

4
More Vials Found !

• Wednesday, July 29, 2009
• More vials found at SNL and KAFB
• Another member of the Sandia workforce opens a
  vial
• Stronger workforce communication

• Sandians are advised to not handle unknown items
  and to report any suspicious items found to
  Sandia Security at.

5
More of Those !_at_ Vials

• Wednesday, July 29
• More vials are found on SNL and KAFB property
• TV and print media become interested
• Tech experts assemble possible x-ray
  diffraction samples?
• Dumpsters a source?

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The First Clue

• Friday, July 31
• Strong evidence that its the garbage truck
• The truck services SNL and KAFB dumpsters
• Who is the source?
• Pollution Prevention provides map of all SNL
  dumpster locations
• News release issued
• 3rd workforce communication

7
Bring In the Detectives

• Tuesday, August 4
• Detailed photos sent to SNL Corporate
  Investigations, ESH Coordinators, and lab owners
• Interviews of possible sources

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No Luck

• Wednesday, August 5
• Photos and interviews result in dead end.
• At the end of the day, plan to prepare and send a
  link to all members of the workforce showing the
  best vial photos and asking for help in
  identifying the source.

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The Answer !

• Thursday, August 6
• During preparation of the communication to the
  members of the workforce, a media relations staff
  member recognizes a name on one of the vial
  photos.
• A phone call to the person confirms the vials
  were left over from an experiment and contained
  non-hazardous materials.
• The vials were disposed of in their building
  dumpster.

10
Termination and Recovery

• Friday, August 7
• Follow up interviews confirm factual accuracy
• Lab results from NM Scientific Laboratory confirm
  no health hazard
• Monday, August 10
• EOC conducted Termination and Recovery meeting
• Recovery Manager appointed
• Emergency incident terminated

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Follow Up

• Next Several Weeks
• Formal critiques conducted
• Opportunities for Improvement
• Vials went to commercial landfill
• All the materials were not non-hazardous from a
  disposal standpoint
• Coordination with NM Environmental Department
• Lean Six Sigma Structured Improvement Activity
  (SIA) for Response to Suspicious Items
• Future State
• Action Items

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Lean Six Sigma (LSS)Structured Improvement
Activity (SIA)

• Responding to a Suspicious Item

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Charter Summary For SNL EM Response to Discovery
of Suspicious Item
Project Mission Conduct a LSS Structured
Improvement Activity (SIA) to improve the process
for responding to the discovery of a suspicious
item (orphan material) on SNL property.
SIA Dates October 26-29, 2009
Champion/Sponsor Sidney Gutierrez
(Champion) Robert Brandhuber (Sponsor) Douglas
Bloomquist (Sponsor)

• Objectives
• Map current process for responding to the
  discovery of a suspicious item
• Analyze current process
• Identify improvement opportunities
• Ensure improved process allows for safe handling
  of material containing biological hazards, in
  addition to the more traditional hazards
  (chemical, radiological, explosive, etc. )

Team Leaders Robert Miltenberger Eugene McPeek

LM21 Facilitators Lisa Cordova (Black
Belt) Pamela Schorzman (Green Belt)
Team Members Dann Ward John Walter Carol Bonney
Chris Mullaney Dave
Castillo Michael Roth Terry Cooper Bess
Campbell-Domme

• Project Scope Information Process reviewed will
  start with discovery of the suspicious item and
  end with the decision on the disposal path for
  the item.

• Customer Demands Constraints
• New process must address response to potential
  biological hazards
• Project to improve process is currently unfunded
  

• Return on Investment
• Improved safety for individuals in contact with
  suspicious items.
• Select correct disposition path based on all
  hazards that are present.

Business Objective Tie Reduce potential for
fines from incorrect disposition path decisions
and support zero accident injury goal.
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Accomplishments

• Created future state process which includes
• EM isolates item after preliminary screening and
  no owner found
• Safety management team formed to address further
  characterization. Defined stakeholders (managers
  of the safety disciplines, environmental, waste,
  facilities, as appropriate)
• Chain of custody form and field data transmitted
  to safety management team
• Item not opened in uncontrolled environment
• Disposition determined by offsite lab analysis

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Action Plan

• Identified Opportunities for Improvement
• Developed Action Plan (Action, Owner, Due Date)
• Briefed Director on LSS Results
• Implement Corrective Actions