[DNFSB LETTERHEAD]
May
31, 2005
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) conducted a review of the fire protection
program at Los Alamos National Laboratory (LANL) and its oversight by the National
Nuclear Security Administration Los Alamos Site Office (LASO). Although LANL and LASO have increased their
attention to fire protection and taken some actions to improve fire protection,
resolution of issues has been piecemeal. The Board believes that a more comprehensive,
multi-year approach fully identifying and prioritizing fire protection issues would
lead to greater assurance of adequate fire protection at LANL.
Recent actions related to fire
protection by LANL and LASO include: a
re-validation of all open fire hazard analysis recommendations; a review by
LASO of inspection, testing, and maintenance; the hiring of an additional LASO
fire protection engineer; the completion of a Baseline Needs Assessment; and
the on-going partial upgrade to the site-wide fire alarm system. Subsequent to the review by the Board’s
staff, LANL management authorized additional staffing and increased funding for
its fire protection program. However, it
is likely that more fire protection staffing will be needed.
As detailed in the enclosed
report, some of the other significant issues that need to be addressed include:
incomplete documentation and delays in the completion of inspections, tests, and
maintenance; fire hazard analyses recommendations not all completed on a timely
basis; no formal plan to address the Baseline Needs Assessment for fire and
emergency services; no long-term contract for fire and emergency services with
Los Alamos County; fire alarm systems in several defense nuclear facilities
still requiring upgrades after completion of the partial site-wide fire alarm
replacement project.
While the individual actions
taken recently to address fire protection are commendable, it is not clear that
all deficiencies and desirable changes in fire protection have been identified
and prioritized. Therefore, pursuant to
42 U.S.C. § 2286b(d), the Board requests a
report within 90 days of receipt of this letter describing the strategy that
will lead to timely resolution of all fire protection deficiencies and achieve
site-wide improvements in the laboratory’s fire protection program for defense
nuclear facilities. This strategy should
involve a multi-year project plan similar to those developed by LANL under the
Operations Efficiency Project for other major institutional issues. This report should include a discussion of
lessons learned at other DOE sites that have experienced similar challenges in
fire protection, an estimate of engineering resources required and a projection
of when all fire protection upgrades will be completed.
Sincerely,
A. J.
Eggenberger
Acting Chairman
c: Mr. Edwin L. Wilmot
Mr.
Mark B. Whitaker, Jr.
Enclosure
DEFENSE
NUCLEAR FACILITIES SAFETY BOARD
Staff
Issue Report
April
29, 2005
MEMORANDUM FOR: J. K. Fortenberry, Technical Director
FROM: C. March
SUBJECT: Fire Protection at Los Alamos
National Laboratory
This report documents a review
by the staff of the Defense Nuclear Facilities Safety Board (Board) of fire
protection at Los Alamos National Laboratory (LANL). This review was focused on site-wide and
programmatic issues.
Staff members C. March, F.
Bamdad, A. Jordan, and C. Keilers met with laboratory personnel and
representatives of the National Nuclear Security Administration’s (NNSA) Los Alamos
Site Office (LASO) to discuss the status of previously identified issues, and
to assess the adequacy of elements of the fire protection program relied upon
to ensure fire safety at LANL’s defense nuclear facilities. Subsequent to this site visit, the staff
obtained and reviewed additional documentation, and held telephone discussions
to clarify specific issues.
Following the staffs site visit,
LANL’s Deputy Director issued a memorandum dated March 23, 2005, summarizing
some of the shortcomings of the laboratory’s fire protection program and
identifying needs or tasks to address them. The memorandum further directed that the following
actions be taken to address some of the shortcomings in the fire protection program:
! Increase staffing for the
program by two, and provide additional funding in the current year.
! Increase the budget for the
program in fiscal year (FY) 2006 to $3 million, a 50 percent increase over the
budget for FY 2005.
! Prepare a follow-up report on
the corrective action plan to address maintenance issues.
This action by the laboratory
addresses some of the immediate needs and problems associated with the fire protection
program. As discussed below, however,
additional issues and capital improvements, such as response to the Baseline
Needs Assessment and remaining work on the site-wide fire alarm system, have
yet to be addressed. While LANL now
appears to recognize the need for a comprehensive long-term effort to address
these deficiencies, that effort needs to be sustained and warrants higher
management priority than it has received in the past.
Staffing
Deficiencies in the Fire Protection Program. The fire protection program has a number of identified
deficiencies, including insufficient manpower available to accomplish the minimum
required engineering tasks for fire protection. This condition manifests itself in numerous
ways, including the following:
! Planning and scheduling are
inadequate, resulting in fire hazard analyses (FHAs) being prepared with short
completion schedules.
! There is little time to follow
up on project-specific reviews and verify that proposed changes and
modifications to projects have been implemented.
! Trending reports are prepared
quarterly for such items as past-due inspection, testing, and maintenance
activities, but insufficient time is available to analyze the data, identify
the root causes of trends, and prepare corrective actions to address deficiencies.
! Insufficient time is available
for day-to-day direct interaction with facility and programmatic organizations,
such as fire protection personnel visiting facilities on a regular basis to
identify emerging issues, and to validate ongoing compliance with fire
protection requirements and maintenance of appropriate fire protection features.
!
Self-assessments
of the fire protection program are not being conducted as required by
Department of Energy (DOE) Order 420.1A, Facility Safety.
! Work on program enhancements,
such as updating and expanding the program manual and procedures to address
known deficiencies and gaps, is performed only as time is available, resulting
in incomplete, piecemeal guidance.
Insufficient staffing is likely
a root cause of many of the other deficiencies. LANL estimates that the equivalent of seven
and one-half fire protection engineers and five technicians are needed to
maintain the fire protection program, exclusive of system and design
engineering. The staff presently
consists of three fire protection engineers, one engineering manager and four technicians.
As discussed previously, LANL management
committed to increasing fire protection staffing by two engineers and one
technician, following the site visit by the Board’s staff. Increasing staff appears to be a prerequisite
for LANL’s taking the next steps of systematically analyzing fire protection
issues and developing a comprehensive plan for addressing these issues.
A recent reorganization brought
fire protection engineering under the Emergency Operation Management Office,
along with the Emergency Management and Response and the Hazmat groups. This appears to be a positive change, focusing
resources for fire protection and emergency operations within a single
organization, and providing higher-level management visibility to fire
protection issues. This change also
eliminated a conflict of interest that may have been present when fire
protection engineering was managed by an organization that also was responsible
for operating facilities.
A
remaining
organizational issue is that fire protection engineering for the Plutonium Facility
and the Chemistry and Metallurgy Research building reports to the Nuclear
Materials Technology (NMT) division, which is responsible for the facilities,
and not to the fire protection group. As site fire protection group
staffing concerns are addressed, the organization should ensure that these
facilities benefit from independent fire protection reviews.
Inspection,
Testing, and Maintenance. LANL has had a long-standing
problem with completing inspection, testing, and maintenance of fire protection
systems on a timely and consistent basis. The backlog of maintenance items related to
fire protection was reduced during the past year. However, there still appears to be a large
inventory of buildings with delinquent inspection, testing, and maintenance of
heat detectors, smoke detectors, manual pull stations, and fire alarm
notification devices.
A review of fire protection maintenance
conducted by LASO, issued in April 2004, contained 12 recommendations and 6
observations. These ranged from minor
items, such as providing adequate clearance around a fire hydrant, to more
significant issues, including laboratory personnel defeating safety systems (i.e.,
fire doors). The lack of required maintenance
records and on-time maintenance was also noted. Ten of the findings from the LASO report
warranted LANL’s issuing a Price Anderson Amendments Act Non-Compliance Report.
Thirty-three specific corrective actions
were identified to address the deficiencies, in parallel with a root-cause
analysis. Eight of these corrective
actions were open at the time of the staff’s on-site review, and may take more
than a year to complete. The root-cause
analysis may result in additional corrective actions when completed.
An ongoing review of fire
protection inspection, testing, and maintenance by LANL indicates that up to
2,000 pieces of fire protection equipment lack sufficient detail in the site Master
Equipment List and maintenance records to determine appropriate test criteria
or preventive maintenance activities. Further, historical records on previous work
are not available for most equipment. Many of these records are required by National
Fire Protection Association (NFPA) standards so that system engineers can
perform trending to anticipate impending failures or the need for equipment
replacement or enhanced testing requirements.
While improvements have been
made, the outstanding issues associated with fire protection inspection,
testing, and maintenance are similar to those observed
by the Board’s staff during its last review in August 2003.
Status
of Fire Hazard Analyses and Recommendations. LANL has experienced continuing problems with timely
preparation and updating of FHAs. Furthermore, FHA recommendations have not been
implemented promptly.
The LANL fire protection group
recently completed an effort to verify and validate existing FHA issues,
develop corrective action plans for addressing the associated
recommendations, and ensure that these plans
are tracked to completion. Open
deficiencies and recommendations include such issues as inadequate fire alarm
systems, various areas lacking automatic suppression, and means of egress not complying
with code. In some cases, even simple
recommendations, such as removing and controlling oxyacetylene welding
equipment in the basement of the Plutonium Facility, have not been fully
implemented.
While it appears that FHAs for
nuclear facilities are current, no FHA update process or maintenance schedule
has been established to ensure their continuing accuracy. For example, the FHA for the Weapons
Engineering Tritium Facility has not been updated to delete hazards that have
been removed from the facility.
Fire Department Baseline
Needs Assessment. LANL completed a Fire Department
Baseline Needs Assessment in June 2004. This document is intended to identify
staffing, training, and equipment needs for the Los Alamos Fire Department
(LAFD) in support of laboratory activities as well as Los Alamos County, since
the laboratory contracts for its fire department services from the county fire
department. The Baseline Needs
Assessment included 17 recommendations. It should be noted that a number of these
recommendations date back to the 1993 and 1995 Baseline Needs Assessments. Significant observations and recommendations include
the following:
! The LAFD does not comply with
the requirements of NFPA 17 10, Standard for the Organization and
Deployment of Fire Suppression Operations, Emergency Medical Operations, and
Special Operations to the Public by Career Fire Departments, regarding deployment and
response time. An increase in minimum
staffing levels from 28 to 45 on-duty persons is recommended.
! Three fire stations need to be
replaced with new facilities capable of housing recommended on-shift staffing
levels, apparatus, and equipment compliant with NFPA standards.
! Implementation of the joint fire
and police communications, alarm monitoring, and dispatch operations at the
emergency operations center needs to be completed.
! Upgrading of LAFD emergency
medical services from basic life support to advanced life support is
recommended.
! Installation of remote fire
alarm monitoring terminals in fire stations needs to be completed.
! Programs for wildland and forest
stewardship, and fuels mitigation, should be carried out in accordance with
LANL’s wildfire management plan.
! The LAFD’s fire preplanning
documentation familiarity tours need to be enhanced.
Many of these recommendations
reflect recognition of the remote location and difficult access that challenge
responses to LANL emergencies. Effective
mutual aid is at least 1 and more likely 2 to 4 hours away. Therefore, the LAFD and LANL need to be
self-sufficient for the initial phases of a fire or emergency response.
LASO and LANL are also
continuing to discuss the need and capabilities for hazardous materials
response by the fire department. Currently, LANL has a separate hazardous
materials response group, which is fully trained and capable and responds to
emergencies at the laboratory; indeed, emergencies have occurred recently at
LANL’s nuclear facilities, such as the Chemistry and Metallurgy Research
building. However, these personnel are
not readily available during off-shift hours and are frequently not on site
because of other duties. A
hazardous
material response capability within the LAFD would likely require additional
LAFD staffing.
Currently, there is no
corrective action plan in place to address the findings and recommendations of
the Baseline Needs Assessment. LANL
intends to issue a plan by September 2005. Differences between LASO and LANL evaluations
of minimum required LAFD staffing levels will need to be resolved as part of
this effort.
Fire
Department Response Contract. LANL and Los Alamos County have
not had a long-term contract for services in place since 1997. Since that time, the laboratory has contracted
with Los Alamos County using 90-day extensions to the 1997 contract. This situation has resulted in a host of
issues associated with such matters as long-term staffing, long-term plans for
upgrading and replacement of equipment and facilities, and the ability of the
LAFD to respond adequately as anticipated in the safety bases of nuclear
facilities. A new contract is in the
final review process at LANL and is expected to go to DOE-Headquarters for
procurement approval in the near future. A final contract could be in place as soon as
the summer, depending upon the results of final negotiations between LANL and
Los Alamos County. The current contract
negotiations are based on the LAFD capabilities and LANL needs established in
1997, and are intended to formalize the ongoing 90-day extensions to the 1997
contract. This contract does not reflect
the results of the Baseline Needs Assessment and will need to be modified in
the future to implement its recommendations.
Partial
Site-Wide Fire Alarm Replacement Project. The partial site-wide fire alarm replacement project, part
of the Cerro Grande fire recovery effort, is currently well under way. Final designs for the current work are
expected by July 2005, with all planned installations to be completed by
January 2006. Full operation of the
updated system is expected by April 2006. However, lower-priority work such as that at
some nuclear facilities (e.g., the Plutonium Facility and the Weapons
Engineering Tritium Facility) will not be addressed; thus, some facilities will
still have fire alarm systems of questionable long-term reliability, and others
will still have code deficiencies or be connected to the existing site security
system.
No formal project has been
established to complete the required upgrades. LANL’s project staff has estimated that an
additional $42 million will be required to upgrade the fire alarm equipment to
comply fully with the requirements of NFPA. The acquisition strategy needs to be
identified to achieve timely closure.
Wildland
Fire Protection.
The Wildland Fire Management Plan has not been updated to
meet the requirements of DOE Order 450.1, Environmental
Protection Program. NNSA and LANL cut finding for the
2005 work on continued forest thinning and repair of vulnerable fire roads,
leaving this planned effort incomplete. The result is the potential for unnecessary
wildfire threats to nuclear facilities.