[DNFSB LETTERHEAD]
December 14, 2004
The Honorable
Spencer Abraham
Secretary of Energy
1000
Independence Avenue, SW
Washington, DC
20585-1000
Dear Secretary
Abraham:
The Defense Nuclear
Facilities Safety Board (Board) issued Recommendation 2004-1, Oversight of
Complex, High-Hazard Nuclear Operations, on May 21, 2004. On July 21, 2004, the Department of Energy
(DOE) accepted Recommendation 2004-1. The enclosed technical report, DNFSB/TECH-35, Safety
Management of Complex, High-Hazard Organizations, provides background information and ideas for implementing the
Recommendation.
The report explores
organizational aspects of safe operations with the intent of helping to identify
how DOE could better organize itself to enhance safety, particularly nuclear safety. Academic research on organizations involved
in operations with the potential for high-consequence accidents and lessons
learned from major accidents and near-misses are summarized. The foundations for nuclear safety within DOE
are then described, and a set of organizational attributes are proposed for
safely managing operations that can lead to high-consequence, low-probability accidents.
The report then describes DOE’s proposed
safety management changes and explains why the Board regards those changes as
cause for concern. The proposed
organizational attributes are applied to evaluate DOE’S safety management of
its high-hazard operations. Finally,
suggested improvements to DOE’s safety management of these operations are
presented.
The ideas presented
in the report are not intended to represent the only way to satisfy the Board’s
recommendation, but to provoke innovations and new solutions for a sustained organizational
shift that should better ensure the safe management of high-hazard nuclear operations.
Sincerely,
John T. Conway
Chairman
c: The Honorable Linton Brooks
Mr. Mark B. Whitaker, Jr.