[DNFSB LETTERHEAD]
August 7, 2003
The Honorable Linton Brooks
Administrator
National Nuclear Security Administration
U.S. Department of Energy
1000 Independence Avenue, SW
Washington, DC 20585-0701
Dear Ambassador Brooks:
The staff of the Defense Nuclear Facilities
Safety Board (Board) has reviewed the incorporation of safety into work
planning at the Los Alamos National Laboratory (LANL). LANL categorizes its work as either facility
(i.e., involved in creating a new facility or maintaining, or altering an
existing facility) or nonfacility, which includes research and development.
The Hazard Control Plan is the central
document LANL requires for identifying hazards, describing controls, and
authorizing work. For nonfacility work
the Board observed that LANL requirements are implemented in quite different
ways in different divisions and at times do not result in complete
identification of significant hazards and practical controls in the Hazard
Control Plan. LANL requirements do not
necessarily lead to an adequate involvement of subject matter experts,
including engineers, in design. Hazards
judged to have moderately low frequencies of occurrence may not be subject to
an appropriate safety review. An
accident on January 8, 2002, involving chlorine dioxide in nonfacility work
demonstrated the need for improvements in work planning requirements. Only minor changes have been made in work
planning requirements so far.
The Board notes that the facility work under
subcontract from LANL to a new support services contractor is undergoing a
transition and shows promise of significant improvement. Changes in senior management also appear to
be facilitating changes in work planning.
Finally, the Board understands that LANL’s new director has chartered
and chairs a Nuclear Safety Executive Board.
The enclosed issue report is forwarded for your use and his, as
appropriate, in revising LANL’s work planning requirements.
Sincerely,
John T. Conway
Chairman
c:
The Honorable Beverly Ann Cook
Admiral George Pete Nanos
Mr. Mark B. Whitaker, Jr.
Enclosure
DEFENSE
NUCLEAR FACILITIES SAFETY BOARD
Staff Issue Report
June 17,
2003
MEMORANDUM FOR: J.
K. Fortenberry, Technical Director
COPIES: Board
Members
FROM: V.
Anderson
SUBJECT: Work
Planning and Practices at Los Alamos National Laboratory
This report documents a review of
requirements and practices related to activity-level work planning at Los
Alamos National Laboratory (LANL). This
review was conducted by members of the staff of the Defense Nuclear Facilities
Safety Board (Board) D. Burnfield, A. Jordan, W. Von Holle, and V. Anderson,
assisted by outside expert D. Volgenau.
Work planning is defined by the Department
of Energy (DOE) in DOE Guide 540.4-lB, Integrated Safety Management System
Guide, as: “The process of planning a defined task or activity. Addressing safety as an integral part of
work planning includes execution of the safety-related functions in preparation
for performance of a scope of work.
These functions include (1) definition of the scope of work; (2) formal
analysis of the hazards bringing to bear in an integrated manner specialists in
both environmental, safety and health (ES&H) and engineering, depending on
the specific hazards identified; (3) identification of resulting safety controls
including safety structures, systems and components, and other safety-related
commitments to address the hazards; and (4) approval of the safety
controls.” Tasks and activities can
range from the relatively simply and routine to those complex enough to benefit
from project management as a means of assuring that safety is addressed.
LANL distinguishes between “facility work,”
which it defines as “any combination of engineering, procurement, erection,
installation, assembly, disassembly, or fabrication activities involved in
creating a new facility or in maintaining, altering, adding to,
decontaminating, decommissioning, or rehabilitating and existing facility” and
“nonfacility work,” which includes, but is not limited to, research and
development (R&D). The review
focused on the general aspects of work planning for facility and nonfacility
work. LANL uses separate institutional
processes, directed through Laboratory Implementing Requirements (LIRs), to
plan facility and nonfacility work.
Work Planning Process for Facility Work. The
Board’s staff reviewed several completed work packages for facility work. The staff found that some were cumbersome,
not task-specific, and did not clearly identify controls for hazards.
The LIRs governing the conduct of facility
work and maintenance skill-of-the-craft work have not been updated since
1999. The work planning process has
changed, but these changes have been implemented through various notices not
intended to have long-term standing, such as a December 2000 notice requiring
operational safety meetings and in-the-field training. More permanent, institutionally consistent
direction in work planning improvements, such as a change to the LIRs for work
planning, would solidify the process laboratory-wide.
There is a new subcontractor, KSL Services
Joint Venture, for facility work.
Several of its new staff members have proven records in improving work
practices at other sites in the defense nuclear complex. Based on presentations by subcontractor
personnel, they appear to understand that such improvements are necessary and
are in the process of developing corrective actions.
Work Planning Process for Nonfacility Work.
Nonfacility work encompasses a broad spectrum of activities ranging from
simple to highly complex, and worker familiarity with these activities ranges
from a great deal of experience to none at all in the case of new
activities. LIRs entitled Safe Work
Practices and Documentation of Safe Work Practices are intended to define
the safety documentation required for all nonfacility work. The key document required is a Hazard
Control Plan (HCP).
Adequacy of Hazard Control Plans and Their
Implementation―According
to LIR, Safe Work Practices, an HCP at a minimum “defines the work,
identifies the hazards associated with the work, and describes the controls
needed to reduce the risk posed by the work to an acceptable level.” An HCP is intended to communicate
effectively the hazard control system for a defined activity; however, the
staff’s review of the HCPs revealed that they do not always document the
hazards and controls adequately. For
example, HCPs for Technical Area (TA)-8-23 radiography operations with
radioactive materials were reviewed.
These HCPs did not identify the hazard of lightning, although the work
instructions did discuss lightning protection.
In addition, the control listed for nuclear criticality was simply to
avoid the presence of a critical mass of fissile material in the building,
while, in practice, a less restrictive limit was used to protect against
criticality.
The observed deficiencies in HCPs may be, in
part, due to the limited training in performing hazard analyses given to personnel
writing the HCPs. The Board’s staff
found that required HCP training is only four hours long, and refresher
training is not required.
The practices related to implementation of
controls could also be improved. For
example, in work performed for the Advanced Test Line for Actinide Separations,
workers do not generally review the controls immediately prior to beginning
work. On a positive note, workers did
report that there is an effective system in place allowing them to stop work
should a potentially unsafe or unclear situation arise.
Engineering in the Design of Nonfacility
Work―The LIR Engineering
Standards provides requirements and guidance for the identification of
codes and standards for the design of systems for nonfacility work. However, there is no link from the safe work
practices LIRs to Engineering Standards, so a researcher developing a
process might not know that Engineering Standards exists. Engineering Standards states that it
shall be implemented for programmatic work, which is typically nonfacility
work, but then states that none of its requirements shall apply to programmatic
work unless prior consensus approval has been obtained from programmatic
groups. Making such requirements
optional in all cases precludes consistent, high-quality implementation at
LANL. For some nonfacility work,
requiring codes and standards listed in Engineering Standards would
improve the safety, reliability, and operability of the equipment.
Level and Timing of Reviews Required―The safe work practices LIRs and Laboratory
Implementation Guides (LIGs) specify different levels of subject matter experts
(SMEs) review based on “initial risk,” which is determined by referring to a
table that considers both the potential severity of the consequences of
identified hazards and the likelihood of such consequences. For work categorized as having high initial
risk, the LIR requires that the HCP be submitted to the ES&H SMEs and
independent peer(s) for concurrence, while work categorized as having a medium
initial risk requires only consultation with either ES&H SMEs or
independent peer(s). No SME or peer
reviews are required for lower-risk activities. There are no requirements for the timing of reviews. HCPs are required to be completed and
approved prior to the start of experimental work, not following design and
prior to fabrication and assembly of experimental equipment.
This approach presents several
difficulties. For example,
determinations of the likelihood of consequences are subjective in nature. Only limited guidance is provided on how to
determine likelihood in the context of nonfacility work at LANL, and in some
cases, there may be little supportable basis for making such a
determination. Therefore, the risk
ranking is subjective. In fact, as
discussed with LANL personnel in February 2002, several authors of HCPs
interviewed by the Board’s staff in conjunction with a review of the January
2002 accident involving chlorine dioxide were uncertain about how to assign
risks.
In addition, the limited guidance on
likelihood determination that does exist leads to the assignment of relatively
low risks. For example, the guidance
can be interpreted as stating that if the probability of death is roughly 1 in
1,000 or less, this risk is “medium,” meaning only consultation with either an
ES&H SME or an independent peer is required; concurrence is not
necessary. A better approach would be
to determine the need for reviews based on the potential consequences of
hazards, ignoring likelihood if the event is considered credible.
Involving only ES&H SMEs and independent
peers, as implied by the LIR, excludes other SMEs, such as engineers and
crafts, who can make valuable contributions.
Observations Common to Facility and
Nonfacility Work. An effective system to capture
laboratory-wide lessons learned from the work planning and execution process
does not appear to exist at LANL for either facility or nonfacility work. This has probably resulted primarily from
not having someone clearly assigned this responsibility for the laboratory as a
whole and from not closing out work packages in a timely manner.
LANL Initiatives to Improve Work Planning. As
a result of LANL’s investigation of the chlorine dioxide accident of January
2002 and in response to a review by DOE’s Office of Independent Oversight and
Performance Assurance, LANL has been reviewing the way it incorporates safety
into work planning for nonfacility work.
The Safe Work Practices Improvement Focus Team established in October
2002, and a Hazard Consolidation Team has been reviewing requirements and field
practices As a result of recommendations from these teams, minor changes were
made to the LIRs on safe work practices in February 2003, but these changes did
not fully address the issues described above.
Subsequent to the on-site review by the
Board’s staff, the Safe Work Practices Improvement Focus Team issued its
report. The team’s report cited many of
the same issues the Board’s staff has observed: laboratory safe work practices
are not always fully implemented; the decision to utilize SMEs is incorrectly
based on risk, not hazard; and personnel in a position to approve HCPs are not
required to have the requisite knowledge, skills, and abilities. The report also discussed the usefulness of
requiring a summary chart of hazards and their relation to controls in HCPs,
among other recommendations. The
Board’s staff is concerned that the implementation plan proposed by the team
appears to be cumbersome, leading to a concern that important changes will not
be made quickly.
The new director of the laboratory has
chartered and chairs a Nuclear Safety Executive Board (NSEB). The purpose of the NSEB is “to strengthen
the Laboratory’s nuclear safety posture by elevating to the attention of senior
executive management the details of issues that have or could have nuclear
safety implications.” It is hoped that
with the additional high-level attention to worker protection provided by the
NSEB, work planning will improve.
During the staffs review, it was apparent that both line managers and
workers were enthusiastic regarding the potential for positive change in the
work planning and execution processes portended by the recent improvement
initiatives. As previously noted, the
new site maintenance contractor appears to be working with LANL to
significantly improve the facility work planning process.