Table 3-10. Similarities of October 1992 Type A Accident Investigation Findings to January 1996 Type A Accident Investigation Findings

October 1992 Type A Accident Investigation Findings

January 1996 Type A Accident Investigation Findings

The design specification, qualification testing, acceptance criteria and inspection documentation for the concrete shielding blocks were not available.

Design specification finding

There were no detailed drawings showing the piping or electrical installations. There was no intent to "as-build" the installation.

Configuration control was not maintained on either the eyebolts or the concrete shielding blocks.

Configuration control finding

Although there were sketches to work by, field direction changed sump locations without documenting the changes. There was no intent to "as-build" the installation.

The facility had neither an inspection nor a maintenance plan for the hardware that failed.

Lack of project plan

There were no provisions made for operating and maintaining the installed systems after the work was completed. There were no turnover provisions considered.

The infrastructure for implementation of the responsibilities of the Director's Policies did not exist nor were the management authorities delineated.

Unclear lines of responsibility

The Facility Management Unit Memorandum of Understanding and a Director Policy describe a transfer of responsibility to the facility manager but there is no implementation of procedures to do this. The facility manager should have been involved in the modification to Building TA-21-209 but was not.

LANL Director Policies are neither uniformly implemented nor enforced.

Policy implementation/enforcement

Within Facilities, Security, and Safeguards there are two processes for determining the management level of work. They have different criteria.

The LANL Administrative Requirements do not adequately implement the LANL Director's Policies and are not uniformly enforced.

Need for sitewide policies

Many procedures needed to assure consistent operations have not bene prepared. Where procedures do exist, procedure compliance is optional.

LANL Administrative policies and programs are decentralized and inhibit their effectiveness.

Design description

Work control, design, and conduct of operations procedures are not implemented in sitewide procedures.

LANL has not incorporated lessons learned from previous accidents and incidents into an overall loss prevention program.

Lessons learned from previous accidents are not incorporated

The findings of this accident and previous accidents at LANL demonstrate that LANL management has not been effective at implementing corrective actions from lessons learned.

LANL has not sufficiently incorporated DOE Order 5480.19, "Conduct of Operations."

The requirements of DOE Order 5480.19 are not fully implemented at the Laboratory.

LANL management has not ensured the timely implementation of DOE Order 5480.19, "Conduct of Operations".

Table 3-11. Similarities of October 1992 Type A Contributing Causes to January 1996 Type A Contributing Causes

October 1992 Type A Accident Investigation Findings

January 1996 Type A Accident Investigation Findings

Contributing Causes

Contributing Causes

Design description

Design description

Change review process

Change review process

Policies

Policies

Management responsibilities and authorities

Management responsibilities and authorities

Procedures

Procedures