This week, I had the pleasure of attending the DOE Laser Safety Officer (LSO) Workshop which is always a nice chance to meet colleagues from all over the complex and affiliated univerities. I’m sad I missed the LSO Axe Throwing Competition (PROTIP: never gamble with the guy from NIST, he will hustle you). But just like people have been subjected to Philisms for years and years, my colleagues have their own versions. I am pleased to share this one because it comes with an illustrative story.
“ALL administrative controls will fail over time. The question is how long do you get until that happens.” – Jaime King, Lawrence Livermore National Laboratory LSO, 2026 (and likely everytime he teaches a training class)
Once upon a time, at a DOE facility far far away, there was a laser lab that was built to make a rather fancy high power system that would then be slotted into another even larger system on the other side of the world. The intention was to build it on optical benches that were on air transport pallets so the whole thing could be transported in a single piece. In terms of alignment work, this would be a huge time savings in installation. There was one teensy, weensy problem: once they built it in the lab, it wouldn’t fit out the hall door. But this is DOE and this wasn’t going to stop them, so they decided to remove an exterior wall and replace that with a roll up cargo door.
Now, this is a DOE facility and DOE does things the DOE way which means some serious controls and interlocks you might not get in other places. As a general rule, if you have a door to a laser lab, that door is going to be interlocked. The project manager made the argument that this door was only ever going to get used once. When this laser went out that door, it was never coming back and they weren’t building another one to ship. With that argument, the administrative control of a lock on that roll up door, key held by the project manager, was agreed to. The laser was completed and shipped. Mission successful, high fives and promotions all around!
~ONE DECADE LATER~
The lab where the fancy laser was built was a very nice clean room facility and research abhors unused space with special capabilities. It had been reused to make a new laser space. A young researcher who decided to start filling in the boxes on my checklist for an Archtypical Injury was working on their system. They fired up the laser, opened the shutter and then decided to leave the lab to go to the bathroom, get coffee, etc. The laser was was interlocked to the room door with functional lighted indicator signs at the door to communicate the work status in the room. The researcher had the ability to do an temporary interlock override to re-enter the lab, as there was a vestibule protecting the door entry area from stray beams and they had appropriate laser safety eyewear.
Meanwhile, on the outside of the building, a facilities person was trying to correct a deficiency finding from a totally different inspection. A roll up door had been identified in an audit which indicated that not only had it never been serviced, per records it didn’t seem to exist in the maintenance inventory at all. Facilities person eventually found the correct key from the corrent building manager to open that rusting lock and then open the roll up door to service it. Other than accumulated dust and dead spiders, roll up door functioned perfectly like it had hardly been used.
The researcher then returned to their lab and resumed work. They had a back of the head itching sensation that something was wrong but couldn’t quite place what. They then noticed that their lab “seemed too bright”. After looking around for a bit, they noticed that an entire wall seemed to be missing. They had no idea that a roll up door was even there, that was just a wall to them. Because the original installation of the roll up door was never interlocked, it was now more or less open beam out of their lab and into the world. If the facilities person had gone inside the building and connected which interior door matched the space with the roll up door on the outside, they might have known there was an active laser in that space. But there’s no reason for them to have done that.
Now, typically, when you discover you have an uncontrolled beam there are some very simple things you should do. Immedieately.
- Turn off the beam or close the shutter.
- Secure the space.
- Notify your Laser Safety Officer of the incident.
What you should not do is skip directly to step 3 and do it by taking out your personal phone, taking a picture from inside your lab, inside the secured area of a national laboratory, and send it to your LSO’s email asking “WTF?!?!”
In so doing, researcher managed to have both a laser safety AND a security incident all at once. Bravo.
On a positive note, no one was hurt but it did demonstrate how administrative controls decay with time. They depend on details and sticking to them. If knowledge starts to fade, the clock is ticking.