There was another event at PF-4 during the week of 3-28-08. Unless I somehow missed it, this event still has not been publicly acknowledged by the lab. Let's first take a look at what happened in PF-4, then what was said in the Senate hearing.
From the March 28, 2008 DNFSB weekly report for LANL:
"Plutonium Facility (TA-55): On Thursday, TA-55 had a valid glove-box over-temperature alarm during a furnace operation that resulted in a fire department response. The facility appears to have responded appropriately and is critiquing the event and the response next week.From the April 4, 2008 DNFSB weekly report for LANL:
[...]
"Formality of Operations: LANL needs to execute on a number of proposed institutional initiatives to improve worker safety and the site's overall nuclear safety posture. These principally involve four areas: safety bases, integrated work management, quality assurance, and formality of operations. The last focuses on operations, engineering, maintenance, and training.
"Implementation of formality of operations appears to be slipping. Last week, LANL submitted to NNSA a revised schedule and draft criteria-for-success for a two-phased implementation of formality of operations. "Core" implementation would constitute a minimum state of compliance with applicable requirements and may include interim compensatory measures that are no longer required once "mature" implementation is achieved."
"Plutonium Facility (TA-55): Last week, operators were conducting normal plutonium operations in two furnaces and post-modification function-testing on a third furnace that was in an abnormal configuration that heated the glove-box more than normal. In this condition, rising ambient glove-box temperature exceeded the thermal detector setpoint of 190° F, prompting an alarm. Personnel exited to the corridor and upon assessment of the situation made a conscious decision to re-enter the room to de-energize the 3 operating furnaces in the alarmed box. There was no damage or material release. The Fire Department responded.What does that all mean? The bottom line is the work was not planned. Thanks and kudos to the person who re-entered the room to shut off the furnaces, but had the work been planned the furnaces would have been switched off when the alarm sounded.
"Follow-up investigation identified issues with the configuration management of over-temperature controls for furnace operations: some interlocked over-temperature alarms were found to be disabled; over-temperature set-points were higher than necessary; and the abnormally-configured furnace was operating without one of its normally-installed temperature sensors. In response to this event, facility management has suspended all furnace operations. Identified corrective actions include evaluating, baselining, and formalizing configuration control for alarm status and set-points for all furnace controllers; and establishing formal pre-operational checks to ensure proper equipment configuration and system line-ups. Operating groups must present corrective actions to a board that will evaluate their adequacy and approve resumption (site rep weekly 3/28/08)."
By the way, how much plutonium was in that glovebox when the alarm sounded?
Given that context, here is what Director Anastasio had to say about safety at the hearing:
"The confluence of an aging infrastructure; demanding increasing standards for safety, security, and the environment; a recent focus on near-term deliverables; and declining operating budgets are squeezing out science at the laboratory."Increasing safety standards squeezes out science? Alrighty then! We know where he stands.
NNSA Administrator Tom D'Agostino was more in touch with reality, though even he did not refer to safety problems at PF-4 in the present tense. Here is what he told the committee:
"We actually have very good evidence from when we moved material out of Rocky Flats on how difficult it is to reestablish a capability dealing with special materials. It took us much longer than expected and cost a lot more money than we ever expected it to cost. I'm talking in particular in this case about the plutonium mission."And finally, here's a quote from a hearing three years ago.
From NNSA Principal Deputy Administrator Jerry Paul (May 5, 2005):
"While much of the public attention to events leading to the laboratory stand down focused on the supposedly missing classified media, we in NNSA felt that inattention to safety procedures at the laboratory presented a greater problem. Together they led us to believe that a culture of non-compliance existed within the laboratory. A careful review of leading indicators for operations of hazardous facilities, that is, events that are precursors to low probability-high consequence accidents, suggested that laboratory performance had been declining. Some employees simply were not complying with regulations or working with regulatory agencies or bodies, including NNSA and the rest of the Department of Energy."What progress has been made since then?
27 comments:
Check this out.
http://www.washingtonpost.com/wp-dyn/content/article/2008/04/25/AR2008042503115.html?hpid=opinionsbox1
"While much of the public attention to events leading to the laboratory stand down focused on the supposedly missing classified media, we in NNSA felt that inattention to safety procedures at the laboratory presented a greater problem. Together they led us to believe that a culture of non-compliance existed within the laboratory. A careful review of leading indicators for operations of hazardous facilities, that is, events that are precursors to low probability-high consequence accidents, suggested that laboratory performance had been declining. Some employees simply were not complying with regulations or working with regulatory agencies or bodies, including NNSA and the rest of the Department of Energy."
They "felt," they "believed," and a "careful review" "suggested." When safety becomes a religion and "feelings" and not facts influence decisions, bad decisions result. At this point, only people who can't find a job anywhere else, have to remain in the area because of family obligations, or have skills that won't transfer and are too old to retrain will be found at LANL.
Complying with regulations is not necessarily the safest way to approach a task, but it's the way it has to be done at LANL if you want to keep your job, unless you want to take twice as long to get the job done. ("Alternative" methods are always possible, but it might require giving a complete education to an overseer who still may not allow them.)
It's best for young people to just stay away from LANL, if they can, until NOAA or some other entity takes over a part of LANL where something useful is being done under rational safe conditions.
Compliance is all that NNSA and LANS care about at this time. Complete and utter compliance at all times with all situations or you may lose your job. Compliance with the smallest of matters. Compliance with more and more policies issued on a daily basis for which you might be fired for not following to the letter.
Compliance uber all!
When you see a culture of compliance completely dominate an institution, you know that this is not the sort of place at which you want to work. Operating safely and securely is one thing. Having a culture of compliance that rules every little thing done at the lab is a whole other subject. The culture of compliance and it's associated CYA attitude at LANL is slowly killing the place.
Oh, we the folks at TA_55 were well aware of this incident as all our furnace operations were suspended. No Pu in the furnace at the time so PLEASE don't use the title COOKING WITH PLUTONIUM because its very misleading.
Do you mean there was no Pu in the third furnace? The DNFSB report appears to say that two of the furnaces did contain Pu at the time.
"Last week, operators were conducting normal plutonium operations in two furnaces and post-modification function-testing on a third"
The 3rd furnace DID NOT contain Pu. My understanding after being debriefed a million times is that it was a new furnace operation undergoing functional testing. This was the first time it was simultaneously heated along with the other 2 furnaces. Another contributing factor was the airlock being shut,which supposedly slowed down air circulation and caused the GB to overheat. I'm not saying they didn't properly characterize their furnace operations but lets not make a mountain out of a mole hill. The GB overheated, we rolled fire trucks...This is why we have heat sensors in the GBs in order to mitigate these circumstances.
It seems to me that the only thing being "cooked" here is a "story" cobbled together by Frank Young, including bits of NNSA speculation from the Nanos era. I suppose the idea is that any time anything unpredicted happens at LANL it must be evidence that we are all a bunch of incompetents. Wrong!
I agree with previous posters that compliance and byzantine procedures are creating a situation that is sinking the lab in paperwork without increasing safety. The lab workers are not to blame for this.
What the heck does science have to do with safety on an operation that's done many times over. Sounds like a BS'er begging for money play to me or maybe it' just more finger pointing.
Increasing safety standards squeezes out science? Alrighty then! We know where he stands.
Pinky/Frank,
Without going back through all this, it seems it's recalled that your initial experience a TA-55 was as a tech rep for an equipment vendor. Check-off lists, to which specific potential hazards can be added, are required before contracts for non-lab persons are awarded. It would seem you should be able to get a copy of the approval paperwork, unless it was too long ago, that contained a evaluation of the work you were going to be doing. That might enable you to get the names of the LANL personnel you worked with, who could help with your desire to know what, if any, exposure you had. Also, did your employer at the time request an evaluation of the hazards to its employees might be exposed?
"It seems to me that the only thing being "cooked" here is a "story" cobbled together by Frank Young, including bits of NNSA speculation from the Nanos era. I suppose the idea is that any time anything unpredicted happens at LANL it must be evidence that we are all a bunch of incompetents. Wrong!
"I agree with previous posters that compliance and byzantine procedures are creating a situation that is sinking the lab in paperwork without increasing safety. The lab workers are not to blame for this."
I know the post was a little long, but you might like it if you actually read it. I didn't say you were "a bunch of incompetents", nor did the DNFSB reports. You also don't dispute any of the facts.
Finally, rather than whine about NNSA safety requirements have you done anything to improve them?
7:21 pm: "Finally, rather than whine about NNSA safety requirements have you done anything to improve them?"
You've got to be joking. NNSA is not interested in anything but "compliance." "Improvement" is not in their vocabulary. If you get nothing else about NNSA, you need to get this. As an organization, they do not tolerate contractors who complain or worse, have better ideas than they do.
Fair enough, 8:13 PM. I've never had the pleasure of working for the NNSA.
"I know the post was a little long, but you might like it if you actually read it. I didn't say you were "a bunch of incompetents", nor did the DNFSB reports. You also don't dispute any of the facts."
(4/27/08 7:21 PM)
I did read it, laborious as it was. I didn't say you said we were a bunch of incompetents. Read it again. I said "I suppose the idea is that any time anything unpredicted happens at LANL it must be evidence that we are all a bunch of incompetents." The phrase "I suppose the idea is" means that incompetency was implied, not that it was stated explicitly. As for facts to dispute, there is nothing to dispute other than your presentation. So let's look at that in detail. You begin with:
"Plutonium Facility (TA-55): On Thursday, TA-55 had a valid glove-box over-temperature alarm during a furnace operation that resulted in a fire department response. The facility appears to have responded appropriately and is critiquing the event and the response next week."
This does not seem particularly egregious. It says people responded appropriately. Other posters who were close to the incident have confirmed that it wasn't a real problem, only an unpredicted event in a safe dry run of a new system. Then you proceeded to:
"What does that all mean? The bottom line is the work was not planned."
So what? Shit happens. That does not mean it was serious incident or that the people who were conducting the test were incompetent or unconcerned with safety, as implied. Then you proceeded to describe Anastasio's take on it:
"Increasing safety standards squeezes out science? Alrighty then! We know where he stands."
This implies that Anastasio doesn't care about safety, which I think is wrong. Anastasio was merely saying that compliance is a burden, a fact all LANL scientists have been complaining about. Actually, I think it is admirable that Anastasio was sticking up for the scientists' position, even if it was lip service. Then you proceed to:
"NNSA Administrator Tom D'Agostino was more in touch with reality..."
as if LANL people are not grounded in reality, but NNSA is. What a joke. Then we have some Nanos era brilliance:
"Together they led us to believe that a culture of non-compliance existed within the laboratory."
So the implication of this tenuous and cobbled chain of logic is that a recent event at PF-4, since it was unplanned, is continuing evidence that LANL is unconcerned about safety, ungrounded in reality, and still has a culture of non-compliance.
None of that was ever true. It was just hype made up by Nanos, NNSA, and the media to make management look good, workers look bad, and to excuse the ridiculous shutdown. And now you are apparently buying into it and promoting it.
Who is Frank Young?
2 things: 1. non-associative evaluation: "safety is a burden" is neutrally said: "safety costs reduce the funds available for science". I doubt Anastasio meant more than that (plus a concern that there be enough funding for science). 2. non- compliance will remain a feature at LANL as long as two other features continue: intelligent, thinking staff who thereby make LANL valuable contributor to national security, and NNSA compliance directives that fail to include the basis, rationale and data supporting the conclusion that the directive contributes necessarily to safety relative to the burden it imposes on accomplishing work -- even exempt staff can't meet deadlines that require more than 168 hours a week!
This blog came to a standstill at PF-4 in TA-55.
LOL 5:11.
"intelligent, thinking staff who thereby make LANL valuable contributor to national security"
"NNSA compliance directives that fail...contributes...to safety"
Can you show either of these two points are true!!!
"None of that was ever true. It was just hype made up by Nanos, NNSA, and the media to make management look good, workers look bad, and to excuse the ridiculous shutdown. And now you are apparently buying into it and promoting it."
4/27/08 10:41 PM
Good comment, 10:41. Thanks for taking the time to go through it.
LOL 5:11.
"intelligent, thinking staff who thereby make LANL valuable contributor to national security"
"NNSA compliance directives that fail...contributes...to safety"
Can you show either of these two points are true!!!
4/28/08 8:59 PM
8:59,
5:11 could show it very clearly if s/he had access to all the "push back" e-mails that have been sent into cyberspace at LANL with no effect. Any worker and supervisor who have had to revise a work document simply because of a new requirement of a compliance directive are working with a diminished margin of safety. Safe work is enhanced when supervisors spend their time with those they supervise, not sitting in their offices trying to modify without degrading their work control documents.
wait for the second event in PF-4 to come out...about a week ago....another furnace event...cracked a window...no release...no injuries...a test run of a furnace...but a real GB
bullshit 8:16.
The PF-4 incident that occurred WAS in real GB. Honest!!!! How can you now say "but a real GB." LOL.....
Even if this new incident was true, which I doubt it is, then BFD. Cracked windows happen! You crack a window then change them out. End of story.
Thank you for your comment, 7:39 PM. I'm working on a post about this second furnace event right now, so any further details you can send would be very helpful.
The glass I saw on gloveboxes was quite thick. Can you tell us if the glass is leaded and approximately how thick it is? Did the fire department respond again? Thanks!
4/27/08 12:02 PM,
Thanks, I've been looking into that. By the way I was not there as tech rep. That's a good thing for PF-4 since my company's products were mostly low quality imports.
If you could give me a name, phone number, and/or email address of the person who maintains these records it would be a big help.
Finally, I suppose I need to keep repeating this; the is exposure is real, the question is what was I exposed to. I've identified the pipe the leak came from, I've been promised by the lab I'd be told what leaked from that pipe, and I've waited for over two years for an answer.
The control systems on the induction furnaces that do the melts are pretty crude and home-brewed by staff. For the most part, a human watches the process. They do get the job done though. Look at the years of successful production, at least 25 that I know of.
How long does it take to crack GB glass starting with an empty furnace?
5/4 9:524pm: "How long does it take to crack GB glass starting with an empty furnace?"
At what rate of heating? With what else in the glovebox? With what specific heat assumed for the glovebox itself, its geometry, and its contents? With what heat extraction rate through ventilation? As stated, your question is meaningless.
OK, don't forget the induction heating crucibles also heats the conductive window frames and the somewhat conductive shielding glass.
Hey thanks for the fuck off. I work in PF-4 as well but the event was kept hush hush for a while, just got word of it. Just trying to counter-act all the negative pubicity surrounding TA-55. GB glass cracks around 190 F btw.
The furnace ops were "released" through our new FOD screening process but don't think it would have prevented what happened. Oh well, who gives a shit anymore since pit production is temporarily (or is it indefinitely?) shut down. >;P and not because of the furance issue.
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