Jan 10, 2008

Special Report Order

Department of Energy
National Nuclear Security Administration
Washington, DC 20585


January 4, 2008
OFFICE OF THE ADMINISTRATOR
Dr. Michael R. Anastasio
Laboratory Director
Los Alamos National Security, LLC
Mail stop A100
Los Alamos, New Mexico 87545

Dear Dr. Anastasio:

On January 22, 2007, Los Alamos National Security, LLC (LANS) submitted a report into the Department of Energy (DOE) Office of Enforcement Noncompliance Tracking System documenting potential noncompliances with nuclear safety requirements associated with two separate events in January 2007. The events involved hand injuries sustained by workers conducting glovebox activities at Technical Area 55 and Chemistry and Metallurgy Research facilities. Instead of launching its own investigation, the National Nuclear Security Administration (NNSA) agreed that LANS would investigate these two events. On February 23, 2007, LANS issued its investigation report. With receipt of additional information from you. to include the preliminary results of medical testing, the serious nature of these events are now understood in that one of the workers may exceed the annual regulatory exposure limit of 5 Rem Total Effective Dose Equivalent.

Nuclear safety performance at Los Alamos National Laboratory (LANL) over the past several years has been inadequate. Changes in contractor senior management, organizational structure, and safety programs aimed at correcting systemic nuclear safety and cultural issues prior to LANS assuming responsibility for LANL in June 2006 have not led to sustained performance improvement. In my February 16, 2007, letter to you on a safety enforcement matter that indicated systemic problems persisted, I stated, "My expectation is that the prompt and aggressive completion of corrective actions focused at resolving underlying causes will be one of your highest priorities. This expectation will serve as the standard to which I will hold you during future enforcement deliberations, should they become necessary.''

Although the hazards associated with these glovebox activities were known and understood, required hazard controls were either ineffective or not implemented. The NNSA expects workers to be protected from hazards in gloveboxes and that management oversight assures that workers follow requirements designed to protect them from these hazards. To this end, NNSA has considered how best to approach the potential noncompliances associated with the glovebox hand injuries in January 2007. Our review of documents provided by LANS demonstrates the need for improved management oversight of work activities, corrective action implementation, work control, and medical response. Based on your investigation report including judgments of need and the causal analysis, the Department is best served by deferral of formal enforcement action at this time, in favor of enabling you to focus management attention on identifying the broad deficiencies which led to these events. Your effort in this regard should extend to all glovebox activities. Corrective actions need to be comprehensive in order to achieve sustained improvement in nuclear safety performance.

Therefore, pursuant to 10 C.F.R. 820.8(b), Special Report Orders, you are required to submit a report to me with a copy to the DOE Office of Enforcement within 90 days of receipt of this Order that addresses the following:
  1. A detailed matrix or table that maps corrective action plan items to each of the causal factors identified in the causal analyses for the two separate events.
  2. The complete corrective action plans and any modifications as they are approved. For the corrective action plans, address the following:
    • Commitments necessary to ensure successful outcomes of the corrective action plans.
    • A list of all organizations involved in the corrective action plans and the identity of the responsible managers for these plans in those organizations.
    • The sequence and schedule of corrective actions and over what time period they will take place.
    • The resources needed to complete the corrective actions.
    • The resource commitment alignment with the sequence and schedule for corrective action implementation (i.e., future fiscal year funding profile that assures timely completion of corrective actions).
  3. For each corrective action, the detailed closure descriptions that demonstrate full resolution of problems identified in the causal analysis.
  4. A copy of the extent of condition review report used to determine the scope and
    depth of the problems identified in causal analyses.
  5. The latest dose estimate for each worker involved including the date of each dose estimate.
  6. A description of how new knowledge gained from these events will be used in the future, including the following:
    • A summary of how LANL will ensure it will not need to relearn the same lessons in the future.
    • An explanation of how the nuclear safety culture has improved because of the corrective actions taken in response to these events.
    • An explanation of how LANL shared the lessons learned from these events with others both within and external to the laboratory.
  7. An explanation as to why the LANS management assessment program did not adequately identify precursors to the January 2007 glovebox hand injuries.
  8. A list of specific corrective actions taken to improve the LANS management assessment program.
  9. A summary of significant changes in LANL glovebox operations supported by the extent of condition reviews, causal analysis(es), and how those changes have been or are being brought about by the corrective actions. Include a rationale as to why these changes will aid in prevention of future glovebox events.
After the 90 day period stated in this Special Report Order (SRO), NNSA and the DOE Office of Enforcement will evaluate the effectiveness of actions taken to address these concerns. This evaluation will be based on: (1 ) the LANS response to the information requested; (2) progress in implementing Noncompliance Tracking System identified corrective actions', (3) recent nuclear safety performance; and, (4) input from the NNSA Los Alamos Site Office (LASO). We expect Los Alamos National Security to communicate and work closely with LASO to assure all line management program expectations are met.

You may request reconsideration of this SRO within 10 days of issuance. If after 10 days you have not requested reconsideration, the SRO becomes effective as written. Refusal or failure to comply with any provision of this SRO may result in action to enforce the SRO. Additionally, failure to implement and sustain effective corrective actions to improve nuclear safety performance in glovebox activities could lead to future enforcement action. Further, failure to take effective steps to address the underlying organizational behavior and safety culture deficiencies could lead to enforcement action under the quality improvement provisions of 10 C.F.R. 830, Nuclear Safety Management.

Sincerely,
Thomas P. D'Agostino
Administrator


cc: Marjorie Gavett, LANS
Richard Azzaro, Defense Nuclear Facilities Safety Board

[Download the PDF here.]

32 comments:

Anonymous said...

This is the stuff that some people live for here at LANL. I'm sure Mike will soon have hundreds of people working to fulfill NNSA's latest demands for this investigation. Constructive work is not what LANL is about any longer.

Anonymous said...

I can't believe that anyone at LANL really likes this stuff. This adversarial approach, this reign of terror, is not the best way to win friends and influence people. Safety is important, but I think it should be achieved by positive thinking and collaboration, not hanging people out to dry. I submit that if you spend all your time reading procedures and looking over your shoulder for auditors you will be less safe. What is needed is more time learning how to do the job correctly, not CYA paperwork.

Anonymous said...

71% and dropping.

Anonymous said...

Mike states in the First Line Managers training that these accidents would not have happened if the first line manager position had been in place.

Anonymous said...

"the serious nature of these events are now understood in that one of the workers MAY [caps mine] exceed the annual regulatory exposure limit of 5 Rem Total Effective Dosc [sic] Equivalent."

And it took them a year to figure out how assemble all the all-encompassing, so general as to be meaningless phrases in those five paragraphs? Somebody needs to give DOE a new bureaucrateez phrase combiner to make what appear to be English language sentences. This inefficiency is unacceptable.

Anonymous said...

The accident might not have taken place if the managers and supervisors hadn't been trying to figure out to satisfy requirements for unneeded and counterproductive documentation. And if they are now burdened with trying to meet these new requirements, they'll be even less likely to see potential future problems. Job security is provided for ever more Monday morning quarterbacks. The people doing the hands-on work have less and less chance of not getting injured.

Anonymous said...

Is this what we can expect for the near future at LANL? This will only serve to lower morale and cause much distrust,(which already has proven to make LANL a less desirable place to work).

Anonymous said...

A nine point list, huh? With sub-bullets? pursuant to 10 C.F.R. 820.8(b)? Great, just what we needed! That will surely improve safety & security at LANL!

NNSA: your Lawyers and Admirals at work. (TM)

Pinky and The Brain said...

9:33,
If you cannot operate safely under NNSA safety requirements your operations should be halted right now. Are they?

Anonymous said...

For the game to be fair, I think that LANL staff should be allowed to create regulations that NNSA must follow.

Any suggestions?

Anonymous said...

It looks like Tom is reaching for the big hammer and I don't blame him. He needs these facilities and workers to accomplish his mission. A few of the comments here are evidence of the "systemic" safety problems Tom refers to.

Anonymous said...

This complex, new request from NNSA's Tom D'Agostino should result in some new "strategic hires" for the Lab Legal department. Guess will need to move out some more scientists so we can bring in more lawyers.

Anonymous said...

The biggest systemic safety problem is NNSA/DOE. Glad you're on a first-name basis with "Tom." You must be at headquarters. Does Tom know the difference between a big hammer and a small hammer? Does he know the difference between a hammer and a screwdriver? Has he used a hammer enough to have ever smashed his thumb? How many reports did he have to write to supposedly guarantee it would never happened again?

Anonymous said...

It looks like our new LANS managerial class is well represented by the comments of 11:29 AM.

Anonymous said...

Another "good guy" bails from LANL, a least for a while. We'll miss you Jack!


Monitor, Friday Jan11th, 2008

P-Division says bon voyage to Shlachter

By Kelly LeVan Monitor Managing Editor

Colleagues of longtime laboratory employee Jack Shlachter congregated at the Physics Auditorium Wednesday afternoon to honor – and occasionally roast – their division leader.
Shlachter is retiring the helm of P-division in order to head to Vienna to work for the Preparatory Commission for the Comprehensive Nuclear-Test-Ban Treaty Organization (CTBTO). He plans to return to Los Alamos National Laboratory in two-and-a-half years.

Several of Shlachter’s coworkers took the stage to express their gratitude and affection, each throwing in a little wit as well.

Juan Fernandez of P-24 (plasma physics group) spoke of Shlachter’s enduring ping-pong prowess, mentioning also his strength working with people.

Scott Wilber from P-25 (subatomic physics group) echoed Fernandez’s sentiments, calling Shlachter a “truly unique individual … He truly cares about every person in the division.”
Acting Chief of Staff Stephen Glick added that even while Shlachter commonly put in 50-70 hours per week at the lab, “when Jack was through here, he served the community with the same energy and dedication.”

Each of P-divisions groups, as well as the Chief Financial Officer division (CFO), purchased Shlachter a gift, and every single gift-box contained a sweater – in honor of their leader’s uniform of choice: a sweater and a pair of jeans.

“I should mention that I get cold a lot,” Shlachter joked, before thanking his colleagues for attending the good-bye party.

“I appreciate you coming out,” he said. “I know you all have some science to do.”
Shlachter, who has worked at LANL since he took a post-doc position in 1979, said that division leaders don’t always get to do as much science as they might prefer to, and “sometimes the only thing that kept me going through the difficult times was the people. You made it worthwhile.”

One of the many highlights of the afternoon was a presentation of “Yogurt Security,” a 10-minute skit about airport security starring Pat Beck, senior generalist in Human Resources. The play, also featuring Larry Gibbons and Kelly LeVan, was personalized by playwright Robert Benjamin and the thespians to include references to Shlachter and his family’s upcoming travels.
The play is also showing at the Los Alamos Little Theater for the next two weekends, preceding “The Devil and Daniel Webster.”

Shlachter has spent most of his adult life in Los Alamos. He first met his wife at the Los Alamos Little Theater in 1980, where they both played parts in Neil Simon’s “The Good Doctor.” He and Kate raised two children on the Hill, Orli, 12, and Dov, 15.

He worked his way up through the ranks at LANL and has served as division leader since 2005. He has also served as a rabbi at the Los Alamos Jewish Center.

“Jack is an extremely talented individual and it’s been a privilege to work with him,” said acting division leader Robert (Doug) Fulton in an interview after the event. “Everyone takes something positive away from working with Jack. I have something to aspire to.”
Fulton said Cris Barnes has stepped up as acting deputy division leader.

Anonymous said...

Seen on a LANL blackboard today:
I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.I will not allow glovebox incidents to occur at LANL.......

Anonymous said...

For Pinky at 11:20. You assume LANL folks even can figure out what the NNSA requirements are, let alone if meeting the requirements will assure safety. The best they can probably hope for is that their supervisors are knowledgable and competent and interested in their welfare.

"Therefore, pursuant to 10 C.F.R. 820.8(b), Special Report Orders, you are required to submit a report to me with a copy to the DOE Office of Enforcement within 90 days of receipt of this Order that addresses the following:
A detailed matrix or table that maps corrective action plan items to each of the causal factors identified in the causal analyses for the two separate events."

Pinky and The Brain said...

9:33 implies operations are not safe because, as you also imply, no one can make sense of the NNSA's safety requirements. I'm simply asking why operations are not paused right now if they are not safe.

Anonymous said...

Anyone who works in gloveboxes know there is a potential for glove breaches. It is a shame that these workers received uptakes but this type of risk goes with the territory.

Anonymous said...

Can't they build a better glove-box?

Anonymous said...

"Anyone who works in gloveboxes know there is a potential for glove breaches. It is a shame that these workers received uptakes but this type of risk goes with the territory."

Maybe at LANL, but other sites, some where much more glove box work is done, seem to find it unacceptable and manage it much better.

Anonymous said...

11:20 am: "If you cannot operate safely under NNSA safety requirements your operations should be halted right now. Are they?"

Who is the "you" you are referring to? A fully trained and concerned employee, or the yahoo down the hall who slept through all the training and decdided he doesn't need to listen to all those "safety jerks" who try to hinder his work? PF-4 is full of them.

Anonymous said...

2:34 pm: "I'm simply asking why operations are not paused right now if they are not safe."

"Operations" are not "safe" or "not safe." Employee actions are sometimes not safe, depending on the employee. Jerks get injured by their jerk actions.

- PF-4 Safe Worker

Anonymous said...

From a letter on enhanced oversight of PF-4 to DFNSB in 1994:

The summary results of the special assessment were provided to Defense Programs on December 23, 1993. The results indicated 647 noncompliance out of 1998 requirement statements (line-by-line assessments) for TA-55. Most of these noncompliance (459) were in the area of radiation protection. LANL determined that none of the noncompliance posed a serious threat to health and safety, and corrective actions for the noncompliance were initiated.


14 years later are we on schedule for Compliance 2030?

Anonymous said...

9:25- what sites are you talking about? please show us the statistics or some kind of reference, LANL has the only fully functional Pu processing facility left in the country.

Anonymous said...

"LANL has the only fully functional Pu processing facility left in the country."

Open your eyes to the rest of the world - how about nuclear power plants, fuel reprocessing facilities, waste management facilities, LLNL, etc. And what about other countries? There are gloveboxes everywhere. Do you think they'd have an American Glovebox Society if only LANL had gloveboxes?

Anonymous said...

I don't take anything that D'Ag says seriously. He is "us".

In the "Pogo" sense of the word.

Anonymous said...

...I'm simply asking why operations are not paused right now if they are not safe..."

They are safe. Therefore the requirements are met.

Anonymous said...

"...seem to find it unacceptable and manage it much better..."

Your source?

The JUMF again?

Pinky and The Brain said...

I feel very reassured!

Anonymous said...

...and Chicken Little is afraid of the sky...

Anonymous said...

The dumb cluck wouldn't stick his head in the sand like everyone else.