April 11, 2008
Response to NNSA Special Report Order on glovebox safety delivered
The Laboratory responded Thursday, on schedule, to a Special Report Order from Tom D'Agostino, administrator of the National Nuclear Security Administration, that was delivered to the Laboratory on January 4, 2008. The Special Report Order is focused on details of two separate glovebox accidents from January 2007 that involved worker injuries and radiological exposures.
The Special Report Order directed the Laboratory to respond with information on any corrective actions taken as a result of inquires into the circumstances of the accidents, and to outline current exposure dose estimates. The order also directed the Laboratory to provide information related to lessons learned, management assessments, improvements to nuclear safety, and any significant changes to glovebox operations.
In his cover letter to D'Agostino in response to the Special Report Order, Laboratory Director Michael Anastasio said, "I share your strong commitment that our corrective actions must be effective, and this commitment remains one of my highest priorities. [Los Alamos National Security] is implementing a formal corrective action plan that, when fully executed, will improve our ability to protect workers from glovebox hazards and will provide assurance that workers are following the processes and procedures designed to protect them. Many actions in this plan are now complete."
In the response the Laboratory acknowledges that, "the need for improvement cannot start with reactive activities associated with an accident. Rather, proactive activities such as a vigorous performance assessment program are critically important in finding and addressing precursor issues before they result in safety events. [The Laboratory] thus understands the human and financial toll on the institution that results from adverse safety events, and is placing its resources on those processes that will assist in avoiding these events."
The response provides detailed information to NNSA demonstrating that all identified causal factors have been addressed by one or more corrective actions. It contains the most current revision to the corrective action plan, a schedule that identifies the organizations involved in and resources required to complete the actions, and a description of the closure process. The response also outlines the root causes of the accidents, and how the Laboratory looked for similar conditions Labwide and took appropriate actions. Current dose estimates and medical treatment information is provided in the response, along with the each worker's status. Both injured employees have returned to work.
In conclusion the response states that the Laboratory understands what happened and why, and has taken appropriate corrective actions based on the causes of the two events, and has processes in place to assure both the effectiveness and sustainability of those corrective actions; and that the Laboratory understands the significance of these events, the impact they have had on the involved workers and their families, the challenges they have presented to the Laboratory and the reasons for NNSA's concerns. It further states that Anastasio and his senior management team pledge that progress toward improving the Laboratory's nuclear safety performance must continue and that the Laboratory can not assume that the task is complete.