5.0 JUDGMENTS OF NEED

Judgments of need are managerial controls and safety measures believed necessary to prevent or mitigate the probability or severity of a recurrence. They flow from the conclusions and probable causes and are directed at guiding managers in developing followup actions. The judgments of need are categorized according to the Guiding Principles of safety management established by the Secretary of Energy.

GUIDING PRINCIPLE 1: LINE MANAGERS ARE RESPONSIBLE AND ACCOUNTABLE FOR SAFETY

PROJECT MANAGEMENT SYSTEMS/ORGANIZATION

• LANL management needs to formally embrace and support the Facility Management Unit concept to assure that all levels of the LANL organization are committed to the program's purpose and policy, expedite its implementation, and prevent Division Director level decisions from circumventing the program's objectives.
• LANL management needs to reassess the structure of facility line management organizations to assure that definitive responsibility for all facility/building operations and safety is assigned to one individual or his/her designee. In keeping with the Facility Management Unit model, this individual should:

- Have detailed knowledge of the facility/building

• Preferably be housed in or very near the facility/building
• Maintain controlled copies of safety analysis, design, and operating documents, including drawings and procedures
• Control the lockout/tagout status list for the facility/building
• Be provided with sufficient resources to operate, modify, and maintain the facility/building in a safe condition
• Be responsible for initiating and having the project responsibility for all work to be performed in the facility/building.

· LANL management needs to develop and standardize Laboratory programs that crosscut all the Facility Management Units, including, but not limited to, maintenance, work planning, work control, configuration management, training, and quality assurance.

· LANL management needs to assure that Laboratory projects, such as the Waste Stream Corrections Project, that involve maintenance, construction, or modifications to facilities/buildings across the various Facility Management Units are structured so that all aspects of the project are under the control of the respective individual in the facility line management group or his/her designee and that work planning and control for these projects follow standardized, Laboratory-wide procedures and processes.

RESPONSIBILITY AND AUTHORITIES

• LANL management needs to ensure that Laboratory subcontractors are not requested, or allowed to, perform work outside the scope of their contract or beyond the capabilities and expertise of their personnel.
• LANL management needs to develop a process/procedure to confirm that Laboratory-wide actions, such as stop-work orders, are communicated, received, and verified to be in place.
• The AL Manager needs to reassess the extent of the "teaming" approach as it is applied in the AL-LANL pilot oversight program for ES&H to ensure that the objectivity and effectiveness of line management's safety oversight are not compromised.

GUIDING PRINCIPLE 2: COMPREHENSIVE REQUIREMENTS EXIST, ARE APPROPRIATE, AND ARE EXECUTED

WORK PLANNING AND CONTROL

• LANL management needs to assure that the Standing Work Order system is used only on routine, repetitive, and non-complex tasks where no significant risks or hazards have been identified or could reasonably be encountered.
• Based on other DOE site experience, the AL Manager and the LAAO Area Manager need to reevaluate the continued use of Standing Work Orders at LANL.
• LANL and JCI management need to develop and standardize Laboratory-wide work planning and control procedures and processes for construction and maintenance activities. These processes and procedures should include, but not be limited to, the following:

- A documented flow path for work requests

• ES&H reviews to be performed
• Determination of the adequacy of the technical/safety detail provided in the work package
• Assurance that all information pertaining to the work being performed is included in the work package (e.g., service requests, preliminary hazard/activity hazard analyses, drawings, permits)
• Requirements for ES&H field inspections
• Identification of personnel responsibility and accountability, particularly those authorized to accept, review, and assign work
• Provisions for maintaining configuration control.

In addition, these procedures should detail similar expectations for the control of LANL-generated work packages within subcontractor organizations performing the work.

• LANL management needs to ensure that the Laboratory develops, as part of the Laboratory-wide work control procedures, a well defined risk-based methodology (graded approach) for assignment of "Management Levels" or "quality levels" for work packages based on the hazards to which craft persons are expected to be exposed, the hazard level of the facility, and the consequences related to failure of the work to be performed correctly and safely.
• LANL and JCI management need to revise Laboratory procedures to emphasize the requirement for permits for penetrations or excavation outside or inside facilities/buildings whenever ground breaking or cutting into walls or floors is to be performed. The penetration or excavation permit process should include:

- A review of the applicable electrical, mechanical, civil, and utility drawings

• Walkdowns of the work site to physically observe piping and electrical penetrations
• Utility surveys (electronic measurements) as part of the permitting process.

ELECTRICAL SAFETY AND PERSONAL PROTECTIVE EQUIPMENT

• LANL management needs to assess the critical power requirements for Building TA-21-209 and other nuclear facilities to ensure that temporary emergency power requirements are known in the event of loss of external power. Temporary emergency power plans and procedures should be prepared to document the temporary power requirements, diesel generator capacities needed, cable routing, and electrical connection points for these facilities. These plans and procedures should be readily available to the individual assigned responsibility for facility safety.
• JCI management needs to ensure that appropriate personal protective equipment is available and utilized by all craft workers when hazards have been identified in the work they are to perform.
• JCI management needs to ensure that all personal protective equipment is tested in accordance with approved national consensus standards, Federal regulations, and procedures; tracked by date and personnel assignment; and retested within the periods specified in these standards.
• LANL management needs to develop and complete implementation of a formal electrical safety program for the Laboratory in a timely fashion utilizing the assistance and material developed by the Department's Electrical Safety Committee.

ASSESSMENTS AND LESSONS LEARNED

• LANL management needs to continue to perform internal assessments to improve the Laboratory's level of compliance with Director's Policies, to bring cases of noncompliance immediately to the Director's attention, and to assure the timely completion of corrective actions.
• LANL management needs to analyze data from occurrence reports on a monthly basis, assure implementation of corrective actions, and identify to the Director, LANL, adverse worker and programmatic safety trends to enable management to be proactive in requesting detailed investigations and/or stopping work prior to personnel injuries or fatalities.
• The LAAO Area Manager needs to review the assignments and activities of the Facility Representatives under his/her cognizance to ensure that objective and effective line management safety oversight is being performed through the day-to-day monitoring of LANL activities in accordance with the Facility Representative Program Manual.
• DOE EH management needs to reassess the Los Alamos EH Resident Office resources to ensure that appropriate numbers of trained staff are available to provide adequate EH independent oversight of LANL operations and activities. In addition, EH management's expectations of the Los Alamos EH Resident Office should clearly define assignment priorities for performing facility or programmatic surveillances, walkthroughs, and site profile maintenance.
• AL, LAAO, and the Los Alamos EH Residents Office need to track all corrective actions proposed in response to this Type A accident investigation to closure.

GUIDING PRINCIPLE 3: COMPETENCE IS COMMENSURATE WITH RESPONSIBILITIES

TRAINING AND RESOURCES

• JCI management needs to provide aggressive and structured monitoring, oversight, followup, and feedback to ensure effective integration of safety procedures and requirements into training courses and materials, which are then implemented in accordance with JCI training procedures.
• LANL management needs to evaluate the effectiveness of the implementation of the JCI training program by observing and measuring workplace performance.
• LANL management needs to implement effective work planning and control procedures and training in the assessment of hazards, identification and use of personal protective equipment required, and training in electrical and other stored energy systems safety-related work practices.
• The LAAO Area Manager needs to assure that LAAO personnel are trained in appropriate DOE accident investigation methods and procedures.
• LANL management needs to consider funding for training and certification of Los Alamos Fire Department emergency medical technicians in the administration of cardiac medication, or to contract for emergency medical technicians already trained and certified for this skill.
• LANL management needs to consider funding or contracting for modifications to Protective Technologies-Los Alamos procedures, equipment, and staffing to enable that organization's 911 operators to stay on the line with callers whenever continuity of communication is needed.

WORKER EMPOWERMENT AND NON-DISCRIMINATION

• LANL and JCI management need to develop and implement a process to ensure the acceptance of and individual accountability for safety, particularly occupational safety and health, through increasing management and supervisory presence in the field; a better understanding among employees for safety requirements through improved training; and reinforcement of safety, particularly occupational safety and health, through the proper application of graded incentives and disciplinary actions.
• LANL management needs to change the culture within the Laboratory and JCI by training and encouraging their employees to raise safety issues in the workplace and to provide accountability and disciplinary action to those supervisory employees (foreman and above) who in any way discriminate against such actions.

Last Modified: Friday, 28-Feb-97 10:09:00