The accident victim was a healthy 35-year-old male with no history of alcohol or drug abuse and no known medical conditions, other than severe nearsightedness. The victim consistently wore corrective lenses when working.
The victim was initially observed by lay rescuers to groan and have shallow, gasping respirations prior to respiratory arrest. Pulse was noted to be absent whenever checked. Because lay rescuers assumed that gasping sounds indicated the victim was breathing, and because of the potential back injury (i.e., arched back), CPR was not initiated. A number of Building TA-21-209 employees who were interviewed indicated that they were certified in CPR. However, in some cases, their CPR certification had expired.
The building employees who first responded to the accident did not confirm that the power was off before removing the victim from the pit.
The lay rescuers did not ask building personnel to confirm that power had been cut before administering first aid-CPR, and building personnel did not volunteer this information to onsite lay rescuers. They did indicate that physical signs, such as no lights within the building, were proof enough to allow safe removal of the victim from the sump pit. The emergency medical technicians en route to the scene did inquire, through the 911 radio dispatcher, whether the power was cut. They were assured that it was cut by one of the facility building managers.
Two 911 calls originated from the office area of Building TA-21-209 at the same time. The 911 operator indicated to the initial caller that he would have to terminate the 911 call in order to radio emergency response personnel.
The Los Alamos Fire Department ambulances do not have advanced cardiac life support capability.
Emergency response to LANL is provided by the Los Alamos Fire Department. Specifically, the Fire Department is under contract with DOE to provide both fire and emergency medical services to LANL. All firefighters are certified by the state as emergency medical technicians, all of whom are trained and certified in the use of defibrillators. Each ambulance is assigned one "Intermediate," an emergency medical technician with additional training and certification to start intravenous lines, administer intravenous fluids, give subcutaneous epinephrine, and administer inhaled medications. Intermediates are not permitted to administer cardiac medications. Within the Los Alamos Fire Department, there are no paramedics and no emergency medical technicians certified to administer cardiac medications; the four emergency medical technicians are certified in advanced cardiac life support. Los Alamos Fire Department ambulances are fully equipped with all equipment and medical supplies that Intermediates are permitted to use. However, the ambulances do not have advanced cardiac life support capability. Los Alamos Fire Department personnel, as well as physicians involved in emergency response operations at Los Alamos, indicated that they receive many emergency calls for cardiac problems, including heart attacks or cardiac arrests.
The victim was intubated at Los Alamos Medical Center at 9:58 a.m. He was administered cardiac medications consisting of bretylium, epinephrine, and lidocaine, in that order, between 10:00 a.m. and 10:05 a.m. At 10:06 a.m., the victim reverted to normal rhythm pattern, but no pulse was detected. After an additional dose of epinephrine, the victim had a palpable pulse between 10:07 a.m. and 10:10 a.m. Normal blood pressure resumed shortly after 10:10 a.m.
The accident victim's pupils had been noted to be fixed and dilated prior to resuscitation. Following resuscitation, they were observed to be smaller (4 mm diameter) and reactive. Corneal (blink) reflexes were intact, but other reflexes were absent and the injured worker was unresponsive, with no purposeful movements. Muscle jerks were initially observed, as well as movements of the eyes; these were interpreted by the medical staff as possibly representing seizure activity. The accident victim was administered dilantin, an anti-seizure medication. He was also administered an intravenous steroid and other supportive medications. A tomographic scan of the head showed no abnormality. On that evening, the accident victim had an approximately seven-hour period of relatively low blood pressure (systolic blood pressure <100 mm Hg; diastolic blood pressure <60 mm Hg; mean arterial blood pressure <73 mm Hg).
On January 18, 1996, a decision was made to transfer the accident victim to the Burn and Trauma Unit (Burn Unit) of the Bernalillo County Medical Center of the University of New Mexico, Albuquerque, for long-term evaluation of and care for both his central nervous system and his burns. He was transported by helicopter without incident.
At the Burn Unit, the extent and severity of burns were estimated (Figure 2-9). A large oblong third-degree burn was noted on the inner front surface of the left thigh. A second oblong third-degree burn was noted on the outer posterior surface of the upper left thigh and adjacent buttock. Smaller second-degree burns were noted in the middle of the left buttock, on the palmar side of the left hand at the base of the thumb, and on the palmar side of the right hand at the base of the
Figure 2-9
fourth and fifth fingers. A minor burn of the right foot was noted at Los Alamos Medical Center, but not at the Burn Unit. The total second- and third-degree burn area was six percent of body surface area, an extent not considered to be life-threatening.
The victim was transferred to a total health care facility on February 5, 1996. As of the closeout of the Board, the victim was still comatose.
The Department of Energy and the Occupational Safety and Health Administration have promulgated requirements to protect construction personnel from accident, injury, and illness.
During planning for the Waste Stream Corrections Project, the ESH Identification Project Summary identified the proposed project as a construction activity. On or about September 21, 1995, Service Request #02447 was approved and issued for "Waste Stream Corrections." Standing Work Order #06006SLA, "Waste Stream Corrections," was issued on October 3, 1995, for Laboratory-wide Waste Stream Corrections work. The Board reviewed applicable rules, regulations, and orders regarding safety requirements for construction activities, as defined by Occupational Safety and Health Administration (OSHA) and DOE.
OSHA and DOE have promulgated rules, regulations, and orders designed to provide assurance that personnel employed in construction occupations will be protected from accident, injuries, and illnesses. DOE Order 5480.4, Environment, Safety and Health Standards, incorporates OSHA requirements as contained in 29 CFR 1910, General Industry, and 29 CFR 1926, Construction, as mandatory DOE standards. OSHA Construction Safety regulations contained in 29 CFR 1926.20(a)(1) define construction-related activities as "construction, alteration, and/or repair, including painting or decorating."
DOE Order 5480.9A, Construction Project Safety and Health Management, April 13, 1994, defines construction activities as "any combination of erection, installation, assembly, demolition, or fabrication activities involved to create a new facility or to alter, add to, rehabilitate, dismantle, or remove an existing facility." The order further defines construction as also including "the alteration and repair (including dredging, excavating, and painting) of buildings, structures, or other real property, as well as construction, demolition, and excavation activities conducted as part of environmental restoration or remediation efforts."
DOE Order 4330.4A, Maintenance Management Program, October 17, 1990, defines maintenance as "Day-to-day work that is required to maintain and preserve plant and capital equipment in a condition suitable for it to be used for its designated purpose and includes preventive, predictive, and corrective (repair) maintenance."
The hazards of crystalline silica dust in the work area had not been evaluated.
Various OSHA construction regulations (1926.57(a), 1926.55(a), 1926.55(b), and 1926.55) require employers to take necessary actions to limit workers' exposures to hazardous substances, and may include engineering controls or the use of respiratory protection devices. In addition, sampling is required to determine the concentrations of contaminants in the workplace. JCI personnel had requested the JCI Maintenance Group to notify them when the organization would be conducting activities that could present a potential for personnel exposures to crystalline silica. JCI personnel stated that they had not been contacted prior to the work in Building TA-21-209 and, consequently, had not evaluated the feasibility of engineering controls or conducted workplace air sampling to determine airborne concentrations or the need for respiratory protection during jackhammering operations.
LANL Industrial Hygiene personnel stated that jackhammering operations would be the type of dust-producing activity that presents the potential for exposures to crystalline silica. JCI Environment, Safety, and Health (ESH) personnel had received information from Technical Area 54 regarding previous personnel exposures to crystalline silica, and were in the process of identifying those work activities that presented the potential for such exposures. JCI ESH personnel noted that several work activities that could present a hazard to workers (e.g., trenching and vegetation removal) had already been evaluated. Some of the evaluations were hampered by wet weather, which moistened the soil and lowered dispersion of dust.
Neither the Laboratory nor the contractor conducted surveys to determine whether personal protective equipment would be required.
LANL and JCI personnel stated that neither organization conducted surveys or assessments of the Building TA-21-209 workplace to determine whether personal protective equipment would be required during sump excavation activities there, since they had not been notified of the proposed work activity. Additionally, neither LANL nor JCI conducted surveys in the basement of Building TA-21-209 before proceeding with the installation of the sump to determine whether hazards associated with opening excavations were present. 29 CFR 1926.651(b) requires LANL and/or JCI to determine the estimated location of utility installations prior to excavation activities. This includes utilities such as sewer, telephone, fuel, electric, water lines, or any other underground installations.
No preliminary hazard analyses were conducted.
Finally, JCI craft personnel stated that preliminary hazard analyses were not conducted during any phase of the Waste Stream Corrections Project. JCI craft personnel also stated that they were not aware of either the requirement or the form for completing the preliminary hazard analysis until after the accident at Building TA-21-209 on January 17, 1996.
The Board identified many issues related to training.
Training of the personnel involved in the work being performed at the Building TA-21-209 accident site was evaluated against requirements found in the orders and standards, as well as requirements applicable to LANL and JCI. The Board looked at training issues and developed its factual statements from information derived from interviews, document reviews, and process/procedure analyses. The following factual statements reflect training issues:
The contractor regarded the excavation work as a routine, non-complex task.
JCI management personnel stated that the Standing Work Order was created to allow routine, non-complex tasks to be performed without creating a specific job ticket or work order for each task. They also stated that the sump pump installation subtask during which the accident occurred could have been executed under the Standing Work Order without a job ticket being created. An FSS-9 tailored work order form was prepared for the sump pump installation subtask, but typically the form is primarily used for cost-tracking purposes.
JCI management personnel stated that there is no written procedure that requires a work order or task package to be assigned to a specific level in the JCI organization. It was also stated that it is the supervisor's responsibility to assure that the data provided with the work package is sufficient to allow the execution of the technical requirements of the work in a safe manner.
In the case of the task that led to the electrical shock accident, three JCI foremen were involved in executing the work: the pipefitter, electrical, and mason foremen. The lead supervisor for this job was the pipefitter foreman. Both the pipefitter foreman and the electrical foreman received a copy of the work package for the sump pump installation subtask; however, the mason foreman did not. The JCI mason foreman stated that he received a telephone call from the pipefitter foreman on or about January 11, 1996, that verbally informed him of the requirement to construct four sump pump pits in the basement of Building TA-21-209. He further stated that he did not receive anything in writing defining the work.
The question of whether an excavation permit is needed for work inside a building has been a longstanding issue.
JCI senior management stated that the applicable JCI procedure requires an excavation permit for any digging either outside or inside a building. The procedure requiring excavation permits for excavations located inside buildings was not being implemented, although JCI senior management was unaware of this fact. The controversy over when an excavation permit is required for excavations located inside buildings has been a longstanding issue at working JCI management levels. The issue has never been resolved. On the day of the accident, this issue was raised between the foremen and the utility specialist within JCI for similar work being performed at Fire Station #1. After a significant amount of confusion and differing opinions, the foreman and the specialist concluded that no excavation permit was required.
Other issues arose regarding utility location surveys, safety reviews, and use of design drawings.
Other issues arose regarding utility location surveys, safety reviews, and use of design drawings. The JCI General Manager stated that a utility location survey would not have been effective in locating an underground electrical cable or other stored energy source because of the presence of the steel reinforcing bars imbedded in the concrete, which would hinder ascertaining the locations of such electrical sources. When asked if the levels of safety reviews would have been different if the work had been categorized as construction rather than maintenance, the JCI General Manager stated that, in accordance with JCI procedures, it would have been the same. However, JCI procedures do indicate a different level of safety review and hazard analysis, depending upon whether the work is classified as construction or maintenance.
JCI and LANL management systems do not require the preparation of detailed design drawings of modifications to electrical and other stored energy systems as required by LANL Administrative Requirement 1-14 and DOE Order 6430.1A, General Design Criteria. In addition, as-built drawings are not prepared to reflect modifications to electrical or stored energy systems unless specified and funded in the work order by charge account.
Only preliminary design drawings were prepared for the work that led to the accident.
SFE personnel prepared preliminary design drawings for assigned work packages. These drawings did not contain dimensions, were not to scale, and were primarily intended to illustrate the approximate location of required utility connections, such as drain piping. The drawings prepared for the sump construction activity indicated the general location of four sump pits in the basement floor of Building TA-21-209. These locations were selected based on their proximity to drain piping to which the pumps would be connected, and not by physical dimensions from fixed structures.
SFE management personnel stated that the scope of their contract with LANL did not require detailed design drawings for the various work packages, including the sump construction in Building TA-21-209. They further stated that they did not have access to the LANL data bases required to produce detailed design drawings. In addition, they had no institutional knowledge of the facilities required to develop detailed design drawings and specifications related to construction projects. This statement conflicts with the "General Notes" section of the SFE-prepared drawing entitled Building TA-21-209 Basement Piping Modifications, Project ID FMU70-009, which states "LANL engineering drawings used for reference in this project are as follows: R-2594, C-31988, C-32008, C-32009, C-32010, C-32011, C-32012, C-31964, and C-31965."
SFE management personnel also stated that they believed that LANL, specifically ESH-18, would develop, or cause the development of, detailed design packages for each task based on the preliminary drawings provided by SFE management. However, ESH-18 personnel stated that SFE personnel were co-located with ESH-18 and knew that the preliminary designs were acceptable to both ESH-18 and Operations and Maintenance Services (FSS-9).
The project on which the accident occurred involves three Laboratory support organizations.
Three LANL support organizations are involved in Waste Stream Corrections Project implementation at the Laboratory. ESH-18 is responsible for providing environmental expertise to LANL facility line organizations that have responsibility for ensuring compliance with Clean Water Act regulations. FSS-6 is a LANL project and design engineering support organization that manages large construction projects. The third support organization is FSS-9, which provides engineering support for maintenance, operations, and minor modifications.
The LANL NPDES permit came up for renewal in 1991. During the renewal process, which began in 1990, LANL management committed to an assessment of waste streams flowing to NPDES outfalls, so that the EPA could properly process the permit for the outfalls. ESH-18 created the Waste Stream Characterization Project to manage the assessment and the followup actions needed to comply with the NPDES requirements at LANL. This compliance assessment was conducted over three years and identified all of the waste streams contributing to outfalls at LANL.
To perform the NPDES compliance assessment, ESH-18 used the services of a Basic Order Agreement contractor, SFE. A final report was issued at the end of March 1994 that identified and characterized all waste streams at LANL. The report provided recommendations for modifications and/or other actions required to comply with the environmental regulations. The recommendations were forwarded to Division directors, who were expected to correct the deficiencies in their facilities.
ESH-18 assisted the facility managers, FSS-9, and FSS-6 by recommending design alternatives to meet the environmental regulations because the facility operations organizations had limited funding and staffing to correct the deficiencies. In some cases, ESH-18 helped facility managers by providing funding for completing the modifications.
The project team leader had determined that the scheduled completion date would not be met.
Some deficiencies were corrected by the line organization, and the 25 percent and 50 percent completion milestones were met. In August 8, 1995, however, the ESH-18 Project Team Leader determined that LANL would not meet the EPA schedule commitments (October 1996 completion) at the current rate of progress. LANL management determined that this was an institutional problem and should be resolved as a project. Initially, management considered submitting the NPDES project requests for $5 million in the General Plant Projects budget. The proposal was taken to the Facility Managers Council for comment. The Facility Managers Council recommended that the projects be submitted in the General and Administrative budget. The $5 million Fiscal Year 1996 General and Administrative budget proposal was approved instead at $3.4 million. This money was allocated to the ES&H Division budget, and the Waste Stream Corrections Project was formed by ESH-18, which was also assigned responsibility for managing its implementation.
Correspondence within FSS-6 showed that there were serious concerns about being able to complete the work in the remaining time. One of the FSS-6 staff wrote, "My estimate is that it will be almost impossible to get this work done by the deadline (October 1996), even if they started last month." Funding was also a concern, as expressed in another note: "Our original approach was based on an $8 million to $10 million problem, which was then revised to $5 million, and now is $3 million to $3.5 million. In the next few weeks, we will be meeting with ESH-18 to clarify the approach, especially since there are some changing factors."
An environment, safety, and health support organization was selected to manage the project.
FSS-6 and ESH-18 staff met in late August to get the project organized and started since "time was of the essence." The WSC Project Team Leader made it clear that ESH-18 intended to manage the project. The use of FSS-6 Basic Order Agreement contractors was considered for some of the larger efforts. FSS-6 project managers offered to manage the overall project and provide project controls and engineering, but were turned down. The Waste Stream Corrections Project Team Leader preferred to use ESH-18 and SFE engineers in conjunction with an FSS-9 work coordinator to direct field work, rather than the FSS-6 "construction inspectors." The Waste Stream Corrections Project Team indicated in a meeting with the FSS-6 project managers that field-directing much of the work with FSS-9 work coordinator would be simpler and more cost effective. In a meeting on August 28, Waste Stream Corrections Project staff indicated there was a concern that there might be FSS requirements with this level of design, which would not add value. FSS indicated that it would actively work with ESH to assure that FSS was maximizing the effectiveness of G&A funds and not doing anything that did not add value. The issue was not resolved.
In October 1995, the Waste Stream Corrections Project Team grouped approximately 2,000 compliance actions into a service request (#02447). A Standing Work Order (#06006) was established based on a determination that the work involved relatively minor modification and construction work. The project team also decided that the scope of effort required to resolve these issues was within the technical and managerial capability of the Waste Stream Corrections Project Team.
Lead responsibilities for such functions as project management and design were also assigned to the environment, safety, and health support organization.
The decision to keep the project management function within ESH-18 was made in August 1995. On December 4, 1995, the Waste Stream Corrections Project Team Leader informed FSS-6 that the design activity would be assumed by the Waste Stream Corrections Project engineers and that there was no further need of support from FSS-6 at present.
Prior to the decision to manage the corrective actions, the Waste Stream Corrections Project Team had responsibility for resolving only those issues that involved analytical or administrative activities. The Waste Stream Corrections Project Team had not previously performed field engineering activities related to the design, construction, and turnover of facility modifications. However, the Waste Stream Corrections Project Team Leader had engineering experience in field modification work prior to coming to work at LANL.
The ESH-18 Group Leader, who supervises the Waste Stream Corrections Project Team Leader, was informed by the Team Leader of the decision to assume the design responsibilities for completing the corrective actions. The ESH Division Leader was informed about the transfer of responsibility for field implementation of the 2,000 deficiencies to his organization.
The Waste Stream Corrections Project Team decided to use SFE because of their previous support in the assessment and scoping of the corrective actions, and because SFE was readily available through a contract with ESH-18. ESH-18 prepared a tasking agreement with SFE to support the field modifications needed to resolve approximately 2,000 deficiencies.
The Facility Management Unit model places much responsibility on the facility managers.
LANL management has established a Facility Managers Council to discuss, evaluate, and resolve methods and issues in order to achieve effective implementation of facilities management. The Council is made up of Laboratory Division directors, who own the facilities, and the facility managers, who report to the Division directors. The council developed a model that breaks down the Laboratory's facilities into 21 Facility Management Units. Each Unit defines roles and assigns responsibilities for managing the facilities.
In September 1995, the Facility Managers Council adopted a memorandum of understanding that transferred maintenance accounts to the facility managers and likewise assigned responsibility for management of the funds. In addition, the memorandum of understanding assigned the Division directors ("owners") responsibility for maintenance management in their assigned facilities. The memorandum of understanding also held facility managers accountable for management of maintenance within established standards and applicable requirements for their Facility Management Units.
Director's Policy 124, "LANL Director's Policy for Facility Management," was issued October 5, 1995. This policy supports the Facility Management Unit plan and establishes that:
- Approve the established operating envelopes and establish the authorization agreement
Procedures that implement the Facility Management Unit program, as defined in the memorandum of understanding and/or the Director's Policy, have not been issued.
The Laboratory's graded approach to determining the management level of an activity eliminated some process controls from the task.
The #06006 work package was designated as a Management Level 4 (ML-4) activity by FSS-3 using the "Graded Approach to the Conduct of Maintenance," Laboratory Standard LS121-01.0, as the reference for making the determination. The work package controls used for the sump modifications were consistent with the ML-4 requirements established in the Configuration Management Plan, which controls the design activities of FSS-6.
ML-4 work performed in FSS-6 does not require a technical baseline according to the Configuration Management Plan, 002-CMP, Rev. 0. The technical baseline contains: (1) system and design specifications, (2) design and as-built configuration, and (3) start-up and operational activities. This baseline is the reference set of technical data and is controlled through the configuration management process by the project leader. Table 2 of the Configuration Management Plan excludes the requirement to identify the technical baseline for ML-4 activities. This eliminates the process controls described above.
Within the Laboratory, there are multiple systems for determining the management level of an activity. The FSS-6 classification procedure uses different criteria than the procedure used by FSS-3 for the work done in Building TA-21-209. However, the FSS-6 procedure is not applicable to other Groups within FSS or to other Divisions, such as ESH. Similarly the "Design Management Procedures" used in FSS-6 are not applicable to others. ESH-18, which has no design process procedures, is not required to comply with those of FSS-6.
The Laboratory Assessment Office conducted five internal reviews between 1994 and 1995.
Between 1994 and 1995, the assessments listed below were conducted by the Laboratory Director's independent oversight organization, the Laboratory Assessment Office. This office is chartered by Program Requirements Document 111-01.0. These assessment reports are representative of issues being identified by LANL and their applicability to the electrical accident of January 17, 1996:
The current major accident investigation was the fifth to be conducted since October 1992.
Between October 1992 and January 17, 1996, five major accident investigations were conducted at LANL. Three of these accidents occurred between December 1994 and January 17, 1996, a period of 13 months.
Craft workers told the Board they feared recrimination if they raised safety issues.
The Board was approached by craft workers because of their concerns about recrimination when raising safety concerns. The union stewards indicated that there is reluctance on the part of the workers to raise safety issues on the job because of the fear of recrimination. Further, craft workers indicated that they cannot raise safety issues, because they have been trained not to "question blue badges" and warned that if they cannot do the job, other workers would be found who would do it.
The policy of the Department, as adopted from the OSHA standards, is that "No contractor shall discharge or in any manner discriminate against any employee by virtue of the filing of a complaint, or in any other fashion exercising on behalf of himself or herself or others in any action set forth in these standards."
The Facility Representatives at the Area Office are assigned so many collateral duties that they cannot fulfill their primary mission of observation and monitoring.
The Facility Representative Program performs day-to-day oversight of contractor line management in their assigned facilities to ensure that: (1) the facilities are operated safely and efficiently; (2) the contractor's management system is effectively controlling its conduct of operations; and (3) effective lines of communications between DOE and its operating contractors are maintained during periods of normal operation and following events in accordance with DOE orders and requirements.
The Facility Representative Program Manual, Revision 2, April 1995, states that Facility Representatives should be spending 60 to 80 percent of their time observing operations activities in the facilities to which they are assigned. It also states that the Facility Representatives should be free of collateral duties and programmatic influences. LAAO management utilizes the Facility Representative Program to provide DOE with day-to-day monitoring of LANL facilities, operations, and maintenance activities. AL sent a memorandum to Don Pearman, Jr., Associate Deputy Secretary for Field Management (FM-1) on December 1, 1994, that identified the need for 30 Facility Representatives at LAAO. The current authorized staffing level is 11.
The LAAO oversight program does not focus on construction activities. The LAAO Facility Representatives are not generally involved in the design and construction of projects under their cognizance. The LAAO Environment and Projects Division, which has construction oversight responsibilities, limits its activities to the review of cost and schedule tracking of General Plant Projects and Line Item construction projects, through monthly progress reports submitted by the Laboratory, meetings between LANL/LAAO/AL, and some field oversight of General Plant Projects and Line Item construction activities.
In December 1994, the Facility Representative assigned to the Tritium Facilities at LANL completed the Facility Representative qualification program for the Weapons Engineering Tritium Facility in Technical Area 16 (Building TA-16-205). He was immediately assigned to a Type B Investigation Board for an accident investigation at Technical Area 48 until February 1995. His availability to be in the Tritium Facility at Technical Area 21 was also impacted when he was reassigned to Technical Area 55 in April 1995.
In November 1995, the Facility Representative was assigned to a Type A Investigation Board, which convened because of a forklift accident. This investigation concluded in late January 1996. In addition to these activities, the Facility Representative has participated in three readiness assessments, including one at the Mound facility, over the past 13 months. In all, due to various interferences, the Facility Representative has spent only four weeks observing activities at Building TA-21-209 and has conducted only five walkthrough surveillances.
The Facility Representative's oversight is usually based on reviews of activities in the field against maintenance and operating procedures, as well as other applicable requirements. Broad direction for surveillance is provided in a Standing Instruction, such as "observe maintenance activities." The Facility Representative is expected to prepare for these surveillances by referring to the Facility Operations Branch Appraisal Guide and by reviewing applicable requirements. By using personal experience and judgment, the Facility Representative decides which elements of maintenance will be observed.
When the Facility Representative encounters deficiencies, the LANL Facility Manager or designee is immediately notified verbally. Generally, issues are not documented by memorandum until the quarterly report, unless they are considered to be major issues. The decision of when to formally document a deficiency is left to the Facility Representative's judgment. Surveillance observations are documented in the Facility Representative's log book and discussed with the Assistant Area Manager for Facility Operations. Findings, observations, and strengths are discussed with LANL management prior to issuing LAAO quarterly reports.
The Under Secretary established a pilot oversight program for line environment, safety, and health management in 1995.
On August 31, 1995, Charles Curtis, the Under Secretary of Energy, sent a memorandum that established the "Pilot Oversight Program for Line Environment, Safety, and Health Management" at DOE laboratories. The key features of this pilot program included:
The Curtis memorandum also provided a copy of the Albuquerque Operations Office (AL)/LANL proposed pilot program description, which defines the purpose, objective, process, guiding principles, and assumptions for the AL/LANL pilot oversight program. Statements in this document included:
The first ES&H annual appraisal was conducted by AL in late October. However, the report was not issued until January 31, 1996, because of difficulties in writing the report and reaching agreement with LANL management on a conduct of operations issue in the report.
Several conduct of operations issues were identified in appraisals related to this program.
A memo (9WB-008) prepared by two LAAO Facility Representatives on October 31, 1995, highlighted several conduct of operations problems at LANL, including lockout/tagout, lack of procedures, inadequate procedures, failure to follow procedures, maintenance, and work control. These issues were extracted from occurrences at LANL over the past year. The memo indicated that during the past year, there were 159 accidents at LANL resulting in 132 personnel injuries and 57 lost work days. The memo highlighted the lack of formality and discipline regarding these types of occurrences. One passage in the memo states: "I am concerned that continued poor performance in the area of conduct of operations may result in additional severe consequences to the health and safety of the public, the environment, and laboratory employees, as well as the potential for facility shutdowns with associated programmatic impacts. LANL's current level of performance in the area of conduct of operations is unacceptable. A need exists for additional formality and discipline in operations. Operations are occurring without procedures and when procedures do exist, they are often inadequate or employees are just not following them." The memo asked for an action plan and formal presentation that would institutionalize conduct of operations at LANL.
Management wished to handle the issues informally as part of a "teaming concept."
The October 31, 1995, memorandum from the LAAO Acting Area Manager was never sent. In lieu of sending the memo, the Acting Area Manager met with the LANL Deputy Director in early November of 1995 and informally discussed many of the issues. LANL management requested that the memorandum not be sent since the Facility Management Unit model was increasing ownership for conduct of operations issues, and the activities at Technical Area 55 had shown improvement in conduct of operations. The LAAO Acting Area Manager agreed to this, but directed that the memorandum be shared with the LANL Division directors.
A similar memorandum was prepared by AL and sent to LAAO on September 1, 1995. The AL letter presented a trend analysis of occurrence reports from January 1, 1995, through August 1995 and found that 43 percent (74 out of 174) of the occurrences had direct, contributing, or root causes related to conduct of operations deficiencies. In the memorandum, AL offered to work collectively as a "team" with LAAO and LANL management in reducing the number of conduct of operations related occurrences.
The Board was unable to find any acknowledgement from LAAO about the receipt of this memo. The Board was also unable to determine whether the conduct of operations issues cited in the memo were formally transmitted to LANL management by the LAAO Acting Area Manager.
There are concerns about the effectiveness of the teaming concept.
Although there has been no written guidance providing LAAO with AL's expectations for implementation of the "teaming concept," there have been discussions within LAAO encouraging a more cooperative approach in identifying ES&H findings/problems to LANL management. Recently, LAAO management also suggested changing the Facility Representative's quarterly report cover memorandum format to eliminate the standard 30 day response requirement. The explanation given for doing this was to foster a spirit of "teaming."
The Facility Representatives and their management expressed concerns about how the "teaming concept" is being implemented. They are unsure as to how they are expected to interact with the facility managers, document their findings, and take decisive actions, such as directing the contractor to stop work.
The Operations Office appraisal procedure is inconsistent with the pilot oversight program.
The Functional Area Appraisal Procedure developed by AL and approved by the Assistant Manager (Office of Technical Management and Operations) is not consistent with the definition of the Pilot Oversight Program contained in the memorandum from the Deputy Secretary of Energy dated August 31, 1995.
This procedure states that: "Potential findings become formal findings when agreed upon by the assessor, Area or Project Office, and contractor." The procedure further states that the Team Lead Assessor has the responsibility to: "Facilitate a discussion of any potential findings and risk categories that would not be agreed upon and determine if the discussion should be elevated through the Division Directors, Area or Project Office management and contractor management."
In 1995, the EH Resident at the Laboratory noted a trend of construction-related electrical exposures and reported it informally to the Area Office.
EH provides ES&H oversight of DOE facilities through the EH Site Resident program. Each DOE field office has a Senior Resident and several EH Residents, depending on the scope and location of the various facilities. The Senior EH Resident for AL, including Sandia National Laboratory and LANL, is located in Oak Ridge, TN. Only one EH Resident is located at Los Alamos.
The EH Resident performs scheduled surveillances and reviews a variety of management information pertinent to LANL operations. In late 1995, the EH Resident reviewed a series of Occurrence Reporting and Processing System reports and identified a trend of safety-related incidents involving concrete cutting and wall penetrations that resulted in electrical exposure to workers. These incidents were generally attributed to a failure to follow the principles of conduct of operations. A memorandum was prepared and discussed with LAAO personnel, but was not formally transmitted. The EH Resident has a background in health physics and approximately one year of oversight experience as an EH Resident. The EH Resident participates in a weekly conference with the Senior Resident and EH Headquarters to report concerns and share experiences. The EH Resident provides issues, concerns, and observations discovered through onsite surveillance to the LAAO Area Manager on a weekly basis.
Last Modified: Friday, 28-Feb-97 10:09:00