To improve safety standards at the Rocky Flats, Colorado, nuclear weapons plant, managers of the facility revised the procedure for changing a light bulb in a criticality beacon, which warns workers of spontaneous nuclear accidents. Replacing the bulb, which used to be a 12-step process that took 12 workers 4.15 hours to complete, became a 33-step procedure that takes at least 43 people 1,087.1 hours to complete.

The steps call for a lead planner to meet with six other people at a work-control meeting; talk with other workers who have done the job before; meet again; get signatures from five people at the work-control meeting; get the project plans approved by separate officials overseeing safety, logistics, environmental, maintenance, operations, waste management, and plant scheduling; wait for a monthly criticality beacon test; direct electricians to replace the bulb; and then test and verify the repair.

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