The building employees who first responded to the accident may not have fully understood the victim's condition.
Because the accident victim was having gasping respirations, lay rescuers assumed that he was not in cardiac arrest, even though they were never able to feel a pulse. Gasping respirations probably represented agonal respirations, which are respirations observed in a dying patient, and can continue to occur for several minutes after the heart has stopped.
These first responders also did not confirm that the power was off before removing the victim from the pit.
Although some lay rescuers considered the continued presence of electrical hazards, they did not ask for positive confirmation that power had been cut. Rescuers assumed that power was cut since the lights were out and there was no physical evidence that the accident victim or his jackhammer were still in contact with the energized cable (e.g., sparks). Although the rescuers should be commended for providing first aid, they should be adequately trained to ensure that all energy sources are removed prior to beginning emergency first aid/CPR. Some employees indicated that their Group leaders had discouraged them from receiving CPR training or had not encouraged such training.
The Laboratory's 911 service cannot always handle two simultaneous calls effectively.
The Assistant Director of Operations for Protective Technologies Los Alamos, the organization that administers the LANL 911 service, indicated that operators can handle up to four 911 calls at a time. When two or more calls are received at once, the 911 operator may have to operate both the telephone and the radio. This will necessitate an interruption in the 911 call. Because there are only two regular 911 operators (with two backups), the 911 operator had to interrupt one of the calls about the accident in order to alert Emergency Medical System responders by radio.
The victim's heart might have recovered sooner if the emergency medical technicians had been certified to administer cardiac drugs.
Los Alamos Fire Department personnel and Los Alamos Medical Center physicians involved in emergency response indicated that a significant proportion of emergency calls in Los Alamos are for cardiac problems, including heart attacks or cardiac arrests. Physicians who were interviewed estimated that a Los Alamos Fire Department emergency medical technician cardiac medication capability would potentially benefit only one to two patients per year. Emergency medical technicians/paramedics represent the highest level of emergency medical technician certification, and can administer cardiac medications under the supervision of a doctor. Los Alamos Fire Department currently has no emergency medical technicians certified at that level. The consensus of the physicians was that having an emergency medical technician/paramedic with this capability would be desirable, but could not be justified given the relatively small number of cardiac patients benefitting from it. However, emergency medical technicians can become additionally trained and certified in "special skills for cardiac drugs." According to one of the emergency medical technicians interviewed, this certification can be accomplished in six months. In this case, administration of cardiac medications on site or in transport might have converted the accident victim's heart to a normal sinus rhythm sooner, although this is uncertain.
The Department of Energy and the Occupational Safety and Health Administration have promulgated requirements to protect construction workers.
OSHA and DOE have promulgated rules, regulations, and orders designed to provide assurance that personnel will be protected from accidents, injuries, and illnesses. The rules and regulations applicable to the accident investigation, particularly as they apply to defining construction and maintenance activities and conducting safety-related surveys, are discussed below.
DOE Order 5480.4, Environment, Safety and Health Standards, invokes requirements of OSHA 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, dated 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, dated 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."
These definitions establish the boundaries for the activities that may be considered maintenance and those that may be considered construction. During the planning phases for the Waste Stream Corrections Project, activities were characterized as construction. The scope of work included elements normally associated with construction, including installation of new components and systems, modifications, and alterations. Following JCI's submission of a request for the Davis-Bacon determination to LAAO, the LAAO Determining Official evaluated the information contained in the request and determined that waste stream corrections work was "uncovered." However, information contained in the JCI submission did not adequately characterize the scope or cost of the various subtasks contained in the Waste Stream Corrections Project, and indicated that Waste Stream Corrections work would be accomplished under Standard Work Orders, which are normally used to conduct maintenance activities.
No preliminary hazard analyses were conducted.
As a result of the LAAO Davis-Bacon determination, Waste Stream Corrections activities were assigned to the JCI Maintenance Group. The Board determined that the level of JCI safety attention provided to maintenance activities is much lower than that provided for construction. For example, all construction activities must receive a preliminary hazard analysis/activity hazard analysis, whereas maintenance activities are required to receive only a preliminary hazard analysis. However, the Board determined that for the work in Building TA-21-209, a preliminary hazard analysis had not been conducted by the project supervisor, who was also unfamiliar with the requirement and form for conducting those analyses. In addition, construction work packages generally receive a review by the JCI ES&H Group, whereas maintenance packages do not always receive this review.
Compliance with 29 CFR 1926.651(b) required LANL and/or JCI personnel to determine the estimated location of utility installations prior to opening an excavation. This includes utilities such as sewer, telephone, fuel, electric, and water lines, or any other underground installations.
No utility location surveys were performed.
LANL and JCI personnel stated that neither organization conducted surveys or assessments in the basement of Building TA-21-209 to determine whether utility installations, such as high-pressure steam, natural gas, or electrical installations were around the locations marked for excavation. Both LANL and JCI organizations responsible for conducting such surveys stated reservations as to whether available survey equipment (e.g., utility locator tools) would be effective in locating underground installations, due to the amount of reinforcing steel and concrete in the floor slab, which would hinder accurate locator tool readings. At the request of the Board, and following re-energization of the electrical cable involved in the Building TA-21-209 accident, LANL and JCI personnel conducted surveys in the area surrounding the accident scene to determine whether routinely accepted industry methods for locating buried electrical cables would be effective. As witnessed by a Board member, the surveys were shown effective in identifying the location of the energized 13.2 kV electrical cable at the accident scene.
Various OSHA construction regulations, 29 CFR 1926, 55, 55(a), 55(b), and 57(a), require employers to take actions necessary to limit the exposures of their workers 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.
The hazards of crystalline silica dust in the work area were not evaluated even though the potential for overexposure was well known.
Following a June 1994 occurrence at Technical Area 54 involving the overexposure of four personnel to crystalline silica, the Laboratory transmitted information to the JCI ES&H Group regarding potential work activities that might involve similar exposures. JCI ES&H personnel had undertaken an evaluation of various jobs that could involve similar exposures, and had requested JCI Maintenance to notify them when dust-producing activities would be conducted so that onsite evaluations could be made. JCI ES&H personnel were never notified of the sump excavation work in Building TA-21-209. Consequently, air sampling was not conducted there to evaluate the potential for personnel exposures to crystalline silica, engineering controls such as local exhaust ventilation were not established, and respiratory protection devices were not used to limit the potential for personnel exposures.
DOE Order 5480.20 is not specific as to training requirements for maintenance personnel. However, Chapter I of that order states that training for operators and maintenance personnel should be based on a needs or job analysis. After a training need is identified, training is then developed, implemented, and evaluated.
Electrical safety training was not subject to a systematic process.
In the application of the graded approach to training by JCI, this process is sacrificed in favor of time and fiscal resource savings. Periodic safety meetings providing informational awareness are mistaken for training. The electrical safety training components for the use of personal protective equipment have definite skill and ability (psychomotor) components. No skills-based training on the use of insulated blankets and electrical protective gloves was provided to the workers involved in the Building TA-21-209 work prior to the accident. The JCI Personal Protective Equipment Training and Certification Program (Number 12-29-040) requires this training. In addition, this document requires that training be driven by a preliminary hazard analysis or hazard assessment worksheet for each work area or work task. The preliminary hazard analysis was not performed, and the hazard assessment worksheet for Building TA-21-209 work did not address any electrical hazard potentials.
Specific training is required for workers who face the risk of electrical shock.
The OSHA regulations, 29 CFR 1910.331 through 335, specify that unique training shall be given to employees who face the risk of electrical shock. Training for unqualified persons should be based on the specific construction and operational hazards or on the hazards associated with the equipment or tools they work with. Personnel involved in the accident at Building TA-21-209 had not received the specific training mandated by 29 CFR 1910.332 on hazards unique to their work.
DOE Order 4330.4B requires the implementation of a maintenance training and qualification program aimed at developing and maintaining the knowledge and skills required for effective maintenance. The JCI Training Manual, dated August 1992, addresses the DOE order requirements. However, lack of effort to institute the specific training measures at the craft level contributes to the ineffective implementation of the order. In particular, the training measures include the verification through specific measurements that training is producing measurable changes in work practices. Performance measures used in training evaluation are typically developed by training personnel in cooperation with first- and second-line supervisors, safety personnel, and human resource personnel. Additionally, the use of "trained-trainers" for the specific training at the craft level is required.
Training records for construction workers in the accident area did not indicate a need for required training in electrical safety, personal protective equipment, and excavation safety.
Training requirements are driven by orders, standards, regulations, and procedures. The ability to administer these requirements and manage the training process for each employee requires diligent recordkeeping. The records allow for the implementation of training on a defined and timely schedule. The training database used by JCI keeps the required general training records. However, it lacks the input for specific training needs, which may or may not have been identified by line management, the safety organization, or the workers' foreman/ supervisor. Training records for the employees involved at Building TA-21-209 did not indicate the specific training required by the OSHA standards and by JCI requirements, not only in electrical safety and personal protective equipment, but in excavation safety as well.
The effectiveness of post-accident training on the use of personal protective equipment cannot be determined.
The post-accident response to immediately "train" personnel on the use and application of personal protective equipment is commendable. However, this training was not conducted or facilitated by the Training Department, nor did it include the prescribed components to define it as training. This training was conducted by JCI Safety staff and JCI Maintenance supervision. There is no evidence that an evaluation step was incorporated into the training to allow feedback necessary for revision of the processes, procedures, and materials that are essential to more efficient and effective training. There is no evidence that the training measured the level of learning critical to evaluate the training quality and the employees' ability to apply what was learned. Transference of required skills and knowledge to the job setting requires a measurement both during the training process and during the work process.
The Support Services Subcontract 9-X86-Y7575-1 between LANL and JCI requires compliance with the applicable sections of the LANL Health and Safety Manual. LANL's Administrative Requirement 7-1, "Electrical Safety," identifies training requirements. Those requirements include workplace and employee task hazard analysis. They also specify the requirement for line managers to "ensure that their employees receive the electrical safety training appropriate to the work tasks..." LANL oversight regarding the JCI training program, procedures, processes, and implementation is done at a high programmatic level that does not provide for the measurement of training quality or satisfactory implementation at the craft level. Evaluation of training implementation at the craft level, particularly in safety requirements, would provide a significantly enhanced safety training program at JCI.
The JCI ES&H Manual addresses safety training in Section 12-21-030, "Safety Promotion and Training." The document assigns management the responsibility "to see that the appropriate safety training is made available to all its employees in a timely manner. This training should be, where necessary, job specific to cover the hazards involved in particular job tasks." The deficiencies that the Board sees in this requirement are:
Weaknesses were identified in the construction contractor's work control system.
The Board interviewed management at JCI in an attempt to understand the work control system and how perceived weaknesses in that system could have contributed to the accident. The Board focused on work control documentation, supervisory and management responsibilities, communications, and the design documentation used for construction projects such as the sump pit work.
Based on the personnel interviews and document reviews, the Board concluded that:
Contractual requirements for the design contractor were insufficient for safe task execution.
The Board reviewed the intent of the SFE contract as further defined by the task order developed by ESH-18 and concluded that:
Significant gaps between regulatory requirements and implementation were noted.
The waste stream characterization assessment found significant gaps between regulatory requirements and implementation at LANL. ESH-18 took aggressive actions to ensure that the Waste Stream Corrections actions (building modifications) were defined for the facility organizations. Some line division managers assessed the need to complete the actions, while others were selective in implementing corrective actions. Progress on the completion of corrective actions was tracked by the Waste Stream Corrections Project Team in ESH-18 to ensure that milestones were being met. The Waste Stream Corrections Project Team informed LANL organizational Group and Division level management that the facility organizations were not making adequate progress on completing the corrective actions. It appeared that LANL would not meet the EPA milestone dates. ESH Division management assessed this to be an institutional problem. When funding was allocated, ESH-18 was assigned to coordinate the project.
The project was assigned to an organization with limited experience in managing major, complex projects.
The assignment of the multi-million dollar Waste Stream Corrections Project to ESH-18 significantly changed that organization's role. The staff of ESH-18 were previously consultants to line division managers, providing recommendations on how to bring facilities into compliance. The recommendations were usually written descriptions but occasionally contained sketches. The Waste Stream Corrections Project Team had successfully managed smaller projects in the past, including the Waste Stream Characterization Project. When the fiscal year 1996 budget responsibility for the Waste Stream Corrections Project was assigned to ESH-18, the organization took on project lead responsibility for a project that was much larger and more complex than the characterization project. During the implementation phase of a project of this magnitude, a high degree of coordination is required between the facility organizations, engineering support groups, maintenance engineering, and the construction organizations. In addition, the Waste Stream Corrections Project Team Leader also needed to maintain communications with state and Federal environmental regulators, DOE, and LANL management concerning project status. The Waste Stream Corrections Project Team Leader did not recognize the complexity of the tasking and failed to develop a detailed project plan that defined interfaces and established roles, responsibilities, and schedules for accomplishing the work.
In addition to the administrative burden, there was constant pressure created by budget and time constraints, as well as the economic and political impact of not meeting regulatory commitments. It is the opinion of the Board that these factors influenced the decision to assign project responsibility to ESH-18. Further, these factors also drove the development of an ad hoc process that eliminated many of the engineering and safety reviews needed to assure worker safety.
When LANL Division level management transferred responsibility for correcting the waste stream outfall deficiencies to ESH-18, the result was that ownership for the work was transferred from the facility line management organizations to an environmental support organization. Although there were some communications between the Waste Stream Corrections Project Team and Building TA-21-209 facility management, that management organization was not in control of modifications to the facility. Consequently, it was not directly involved in reviewing the work packages or the physical performance of the work. If the facility management organization had been directly involved in the modification process, it might have questioned the design details and identified the hazards present at the work site. When LANL management allowed the facility line management to transfer responsibility for the Waste Stream Corrections facility modifications to the ESH-18 support organization, an administrative barrier for preventing the accident was eliminated.
During the formation of the #06006 Standard Work Order package, ESH-18 considered using FSS-6 or FSS-9 engineers to develop detailed construction packages but decided that ESH-18, in conjunction with SFE, could perform the work faster and cheaper. The decision to perform the work within ESH-18 was based on the belief that there were necessary and sufficient engineering and project management resources within ESH-18 and SFE to accomplish the assigned task. However, weaknesses in project administration, along with the time constraints, were more than the Waste Stream Corrections Project Team Leader could manage with the tools and processes available.
Complex design projects are normally managed from within FSS-6, which was originally designated the lead responsibility for managing such modifications as the piping, sump, and pump installation in Building TA-21-209. The redesignation of the design responsibilities to the ESH-18 engineers in the Waste Stream Corrections Project Team was made due to cost and schedule pressures felt by the Waste Stream Corrections Project Team Leader. ESH-18 did not have the internal procedures, the experience using codes and standards, or the field construction expertise needed to perform facility modification work. The ESH-18 Manager indicated that he did not fully comprehend the fact that his organization had accepted the responsibility for the construction packages. The ESH-18 Manager assumed that FSS-9 would prepare detailed work packages. He did not confirm this assumption. Both the managers and the staff involved overestimated the capability of the Waste Stream Corrections Project Team to engineer and manage a construction project.
The Waste Stream Corrections Project Team did not understand the complexity of the processes required to implement design changes. The Waste Stream Corrections Project Team, along with the FSS-9 work coordinator and the JCI Work Controller, implemented an undocumented modification process that did not (1) provide the guidance needed to assure adequate safety reviews, (2) adequately develop the designs, (3) require preparation of detailed work packages, (4) manage changes to the work packages during installation, (5) document the completed work, and (6) formally turn over the new and modified systems to the facility operations organization. The overall process met neither the LANL Quality Assurance Management Plan requirements (Section 4.6, "Design") nor those of DOE Order 6430.1a, General Design Criteria (Section 0140, "Quality Assurance").
The engineering drawings provided to the construction contractor were insufficient to ensure safe task execution.
JCI should have been given detailed civil, mechanical, and electrical engineering drawings that provide the specific information needed to locate the sumps, route and tie the new piping into the utility piping, and route and connect the electrical components into the existing electrical system. The process also should have required "as-built" drawings of the modifications to Building TA-21-209 so that future operation, maintenance, and engineering activities could be conducted safely with drawings that reflect the new configuration. The initial premise that these were minimal modifications was incorrect.
Detailed drawings might have prompted someone in the modification review cycle to ask about subterranean utilities. The individual preparing a detailed plan might have added a precaution about locating utilities prior to excavating, even if it was not recognized that an excavation permit was required. The work group supervisor, foreman, or craft workers for this job may have seen references to the 13.2 kV electrical cable located three feet below the floor.
As it was, the JCI craft workers assigned to construct sump pump additions to Building TA-21-209 were not given specific guidance on the location of the excavation or provided adequate instructions by their foremen or supervisors about the precautions to be taken during the work. Further, the ad hoc process developed in combination with the FSS-9 Work Coordinator and the JCI Work Controller did not define how the design, construction, changes to construction work packages, as-built drawings, and facility acceptance and turnover of the project would be developed and reviewed for ES&H engineering concerns.
Management has not emphasized adherence to procedures.
LANL management has established a culture that condones selective use of procedures. By not intervening, even when the desirable outcomes are being achieved, management has sent a message that bypassing existing requirements is acceptable. Although this section of the report has focused on the Waste Stream Corrections Project Team's actions, it is LANL senior management that has set the stage for the deficiencies found in this analysis by lack of direct involvement in decisions made at the Division level.
The Facility Management Unit model has not been effective in defining and communicating roles and responsibilities.
Because of a lack of direction from LANL senior management, the process for implementing the Facility Management Unit model has not been effective in ensuring that individuals understand their roles and responsibilities during the transition. The logical flow of responsibility as described in the Facility Managers' memorandum of understanding clearly assigns responsibility for facility operations and maintenance activities to the Facility Manager. However, actual implementation of this flow becomes unclear in Building TA-21-209, because there are other individuals involved in a process that is not clearly defined, namely, the Area Coordinator, Building Manager, Facility Manager Designee, and Facility Manager. Figure 3-10 illustrates the reporting relationships of these individuals.
From the structure indicated in Figure 3-10 it is clear that the Facility Manager does not exercise supervision over the "Facility Manager Designees." Interviews revealed confusion over facility responsibility, especially for individuals outside the Engineering Sciences and Applications Division. Internally, the responsibilities of the Facility Manager are not being implemented as described in Director Policy DP-124; the program's organizations do not accept the facility manager role as it relates to their operations. In addition, there is confusion about the requirement to notify the Facility Manager or Building Manager immediately prior to beginning work in their facility. As a result, the following occurred:
Because of the decision to have ESH-18 provide project management for the Waste Stream Corrections Project, the responsibilities defined
Figure 3-10
in Director's Policy 124 and the Laboratory Facility Management Program document were not assigned or assumed by anyone in the Engineering Sciences and Applications Division (Facility Manager, Building Manager, Area Coordinator, or Facility Manager Designee). This was contrary to the Facility Management Unit model in that the process did not ensure that the Engineering Sciences and Applications-Facility Management organization fulfilled its responsibilities for the Waste Stream Corrections work in Building TA-21-209.
Through interviews with the Engineering Sciences and Applications - Facility Management Facility Manager, Building Manager, and Area Coordinator, and the Engineering Sciences and Applications Division (LANL) Tritium Science and Engineering Facility Manager Designee, the Board concluded that verbal assignments of responsibility for facility operations within Engineering Sciences and Applications Division (LANL) have created confusion about facility management responsibilities.
Their responsibilities are inconsistent with the requirements of the memorandum of understanding, Director's Policy 124, and the Laboratory facility program documents. Further, there is a wide gap between the assignment of responsibility for facilities to a facility manager and having the actual authority, infrastructure, and facility-specific information needed to carry out that responsibility. In the case of Building TA-21-209, the Facility Manager is assigned the responsibility for safety at this facility and possibly many other facilities, and therefore does not necessarily reside in that facility. In addition, the Facility Manager does not have the processes needed to control as-built drawings of the facility, maintain control of modifications, or control the lockout/tagout status lists for each of the facilities under his cognizance.
The Laboratory Director has not aggressively endorsed the Facility Management Unit transition process. This support is needed to bring about the changes in roles, responsibilities, authorities and accountabilities necessary to effectively implement the facility management unit model at LANL.
The Board endorses LANL's Facility Management Program purpose and policy. The assignment of facility operations and facility safety responsibility to a facility management/operations organization will, as noted in Director's Policy 124, help to manage "resources for optimum efficiency and effectiveness" and help to define a "planning and change process to drive us [LANL] to improve the match between our facilities and evolving program needs." The success of this model will depend on the ability of LANL senior management to clearly and formally state expectations and hold individuals accountable for their actions.
Conduct of operations principles have not been effectively implemented with respect to worker safety.
The AL Assistant Manager for Management and Administration was quoted in a February 3, 1996, newspaper article as saying "DOE officials are particularly bothered by worker safety conditions at the Lab [LANL], particularly over the past year or so... Worker safety is being regarded gravely... We're really taking a closer look at that aspect." In the same article a LANL spokesman was quoted as saying "The three serious accidents in the past fourteen months is unacceptable by any standards... We need to renew our commitment to safety."
The Board agrees with the conclusions reached in the article quoted above. The Board also concluded that these conditions exist because the principles of conduct of operations have not been effectively implemented as they relate to worker safety at LANL. The ineffective implementation is directly correlated to the fact that there is no Laboratory-wide implementation plan for conduct of operations, as required by DOE Order 5480.19, dated July 1990.
The Laboratory's approach to determining the management level of an activity eliminated some process controls from the task.
FSS-3 determined that the appropriate management level for the #06006 work was Management Level 4, using the "Graded Approach to Maintenance Management," Laboratory Standard, LS121-01.0. The intent of this maintenance procedure is to define the level so that the level of safety specified for maintenance activities can be determined. This procedure does not provide guidance on the activity of constructing a new system. It was inappropriate to use this procedure in defining the management level for this work project. In addition, the organization making this determination was different than the organization responsible for the project. Neither the ESH-18 Group Manager nor the Waste Stream Corrections Project Team Leader Manager was aware that any management level designation was made. This is because the decision was made after the responsible manager (requester) approved the service request. Table 3-4 is a copy of the matrix criteria from Laboratory Standard LS121-01.0 which was used by FSS-3 to classify the Waste Stream Corrections service request. This matrix does not provide for a graded approach to regulatory compliance and, therefore, only considers maintenance impacts.
FSS-6 uses a different procedure, namely "1.01 Graded Approach to Project Management," to make the determination of management level. A copy of this matrix is provided in Table 3-5. Following the FSS-6 procedure, the Waste Stream Corrections Standing Work Order should have been classified as Management Level 2, because the sump systems and piping modifications were being installed to meet EPA
Table 3-4
Table 3-5
regulatory compliance requirements. The LANL management level determination process does not assure that decisions are made using the correct set of criteria, as occurred in this instance.
The use of the management level determination to implement LANL's graded approach is fundamental to the Laboratory's management system, because it ensures that LANL management expectations are being met with respect to assumed risk for all activities at the Laboratory. Laboratory Standard LS121-02.0, "Graded Approach to Conduct of Maintenance," references LS121-01.0 but provides a different description of management levels. These descriptions use such words and phrases as "inconvenience," "minor damage," "no probable impact," "serious mission impact," and "serious economic impact" without adequately defining them. These concepts are too vague to predict decision outcomes. Consequently, since management is not providing clear expectations to the workforce, there is no assurance that work such as that performed in Building TA-21-209 would be properly categorized.
Another problem with implementation of the "risk based" approach at LANL is that the controls established at the Group level do not receive Laboratory-wide management reviews and, therefore, may not be adequate. Assuming that the Building TA-21-209 modifications were not regulatory driven, the sump installation work would probably still have been classified as Management Level 4 using either the FSS-3 or the FSS-6 matrices, and the safety significance of the work would not have been realized.
The Facilities Project Delivery Group Configuration Management Plan and supporting procedures provide formal LANL guidance for managing design-related processes. However, in the FSS-6 system, projects classified as Management Level 4 do not require development of a technical baseline and configuration controls. The decision not to require a technical baseline was made at the FSS-6 Group level. Eliminating the technical baseline and configuration controls eliminates design review, change control, and turnover processes. This significantly reduces the safety of workers involved in the construction work, and of those individuals who will operate or maintain the system in the future. Consequently, every modification that changes the operation of the facility should be documented in the baseline for the facility as required by DOE Order 6430.1A to ensure that future operations and maintenance can be accomplished in a safe manner.
Design, configuration, construction work, and turnover control deficiencies occurred in the Waste Stream Corrections Project designs because there is no single Laboratory-wide program to properly implement a risk-based approach. These deficiencies contributed to the Building TA-21-209 accident of January 17, 1996.
Internal programmatic reviews were effective in identifying deficiencies, but corrective actions were not pursued aggressively.
Assessments by the Laboratory Assessment Office covering a period of approximately two years (1994-1996) were reviewed to evaluate the quality of the assessments being performed and LANL management's effectiveness in correcting adverse conditions found. The assessments were effective in analyzing and describing for the Laboratory Director the programmatic deficiencies that are at the root of many of the safety performance trends being experienced by LANL. Although these findings were not prioritized, they were performance oriented. The facts supported the findings, the causal factors were clearly stated, and the recommendations were generally appropriate for the findings. The assessments recognized issues that have general applicability to the Laboratory. Tables 3-6 through 3-9 provide a comparison of the findings, supporting facts, and causal factors identified by the LANL internal assessment program with the facts and probable causes identified by the Type A Accident Investigation Board.
It is evident from the tables that the specific programmatic deficiencies identified in internal LANL investigation were previously identified in the assessments made in 1994 and 1995. Although these programmatic deficiencies were communicated to LANL senior management, timely and effective corrective actions have not been implemented. The Board believes that corrective actions are not being implemented in a timely and effective manner, because LANL senior management has not aggressively promoted an atmosphere in which research and safety are equally emphasized and has not held Division and Group level managers responsible and accountable for safety.
Five major internal accident investigations were conducted between October 1992 and the present.
Accident reports covering the period of October 1992 to the present were reviewed. In all, there were five major accident investigations conducted during that period. Each had multiple findings and contributing causes that were similar to many of those identified in the January 17, 1996, accident. A summary of one of these accidents is presented below to provide a common basis for analysis. The October 15, 1992, accident investigation was conducted because a 20-ton shielding block was dropped at the Meson Physics Facility when a lifting fitting failed. The investigation was conducted due to the high property loss of $470,000. Table 3-10 provides a comparison of the findings, and Table 3-11 provides a comparison of the causes identified in the October 1992 accident and the January 1996 accident at Building TA-21-209.
Table 3-6
Table 3-6 cont
Table 3-7
Table 3-7 cont
Table 3-8
Table 3-9
Table 3-9 cont
Table 3-10
Table 3-11
Several judgments of need from those investigations are pertinent to the January 1996 accident.
The November 1992 accident investigation report indicated that the root cause was a lack of configuration control reviews. The investigation's analysis of standards and directives determined that "although the LANL Director has established centralized management guidance, through the issuance of the Director's Policies, the infrastructure and implementation of the responsibilities and authorities do not exist. The guidance and operating procedures at the division and Group level are developed independent of other LANL requirements and validation and are not necessarily consistent." The report summary indicated that policies and procedures at every level in the organization are open to interpretation, may be selectively followed, are not enforced by managers, or are not available.
The following judgments of need noted in the November 1992 accident report are common to the January 1996 accident:
The Laboratory's management systems are ineffective in resolving longstanding, well defined programmatic issues.
The cover memorandum that transmitted the report to LANL management stated that "This investigation indicates inadequate LANL line management accountability and ownership, as well as an inability to learn from previous incidents and prevent their recurrence. This accident investigation, as well as other recent incidents, indicate that LANL's formality of operations must be strengthened... Further implementation must begin without delay." This direction was not followed. It is clear from the number of serious accidents (three) that have occurred in the past 13 months and by the deficiencies identified in this investigation that LANL's management systems are ineffective at resolving longstanding, well defined programmatic issues or translating lessons learned into day-to-day operations at LANL.
Supervisors must be held accountable for assuring workers' right to raise safety concerns without fear of recrimination.
The ability to raise safety issues on any job by any employee of the contractor or the subcontractor is a right protected by the OSHA regulations as prescribed by the DOE orders. Workers must be trained to identify and assess hazards on the job and report them to their supervisor if they feel that the work place is not safe. Supervisors must be held accountable and must be disciplined if they try to subvert the craft workers' right to question safety. Workers and union stewards have expressed concern to the Board that this is not being done at LANL.
The Facility Representative for the facility where the accident occurred was assigned too many collateral duties to perform his job effectively.
The LAAO Facility Representative responsible for Building TA-21-209 was diverted from his normal duties for accident investigation, readiness assessments, and other duties including reassignment to Technical Area 55 in June 1995. These conditions left the Technical Area 21 Tritium Facilities without Facility Representative coverage for approximately 80 percent of the time during 1995. By the action taken, LAAO management judged that other activities had a higher priority than the oversight of the Tritium Facilities within Technical Area 21.
There are some concerns about the effectiveness of the "teaming" concept.
According to the August 31, 1995, Curtis Memo and its attachments, the pilot oversight program did not apply to the day-to-day operational monitoring of activities performed by DOE Facility Representatives or DOE program reviews. In Board interviews with LAAO Facility Representatives, they expressed concern that they were unable to formally document safety issues because of the "teaming" approach stressed by AL, LAAO, and LANL management. All Facility Representatives interviewed referenced the October 31, 1995, memorandum, which was not formally sent to the Director, LANL, as an example of the "teaming" concept.
Because of the lack of formal documentation on the October 31,1995, memo prepared for the LAAO Manager's signature, the Facility Representative program review of conduct of operations at LANL could not be formally included in the scope of the Annual ES&H Oversight Appraisal, as recommended by the August 31, 1995, Curtis memo and its attachments.
There continues to be some confusion among the LAAO Facility Representatives regarding their roles, responsibilities, and interfaces with LANL management as a result of the "teaming" concept trickling down from AL's pilot oversight program guidance.
The Operations Office's emphasis on contractor agreement with the findings, conclusions, and judgments of need of its appraisals limits the objectivity and effectiveness of the appraisals.
Although the August 31, 1995, Curtis Memo on the pilot oversight program indicated a degree of "teaming" with the Laboratories in terms of agreeing to the scope of the Annual ES&H Appraisal and the performance objectives, criteria, and measures to be used, there were no requirements in the memorandum or its attachments that indicated the Laboratory must agree to the findings, conclusions, or judgments of need of the appraisal prior to its issuance. In the Board's view, the need for agreement on the findings of the report jeopardizes the objectivity of the appraisal and removes DOE line management from its responsibility for the safety of the facilities/operations under its cognizance.
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 memorandum states that "The scope of assessments is agreed upon by DOE Operations Office and each University of California Laboratory." It does not assume or imply that a requirement exists for the contractor to agree on findings, as stated in the AL procedure and quoted in the following paragraphs.
This AL appraisal procedure, as applied to Team Assessors, 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 is responsible 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."
For preparing the appraisal report, the procedure says to "Cite findings that were approved during the appraisal and those that were approved by the appraisal team, the area or Project Office, and the contractor after being elevated to the appropriate management levels for resolution." The AL-developed procedure also contains a "Finding Record Form" that requires agreement by the contractor and DOE before a potential finding statement is accepted as a finding. The AL-developed Functional Area Appraisal Procedure is not consistent with the memorandum from the Deputy Secretary of Energy dated August 31, 1995. It is the judgment of the Board that this procedure significantly reduces the independent objectivity and effectiveness of the assessment team by requiring that the findings be accepted by the contractor.
The lack of EH Resident resources at the Laboratory is detrimental to effective day-to-day oversight.
The EH Resident Office at LAAO was originally established in 1992, with the plan to staff the office with four EH Residents to represent the range of ES&H skills required to have an overview of the broad range of activities conducted at LANL.
Because of staffing constraints within the EH organization, only one EH Resident position has been filled at LAAO. There is no Senior EH Resident at Los Alamos, and an acting Senior EH Resident periodically visits the site from Oak Ridge. The Board considers the lack of EH Resident resources at LANL to be detrimental to performance of day-to-day independent oversight of LANL activities. Furthermore, there is a lack of direction from EH regarding the priorities that the EH Resident at LANL is to assign to everyday EH Resident activities, such as facility surveillance, EH management of events/conditions, followup of EH assessments, and corrective actions resulting from maintaining site profile documents.
Last Modified: Friday, 28-Feb-97 10:09:00