Table 3-6. Past Occurrence Report Findings, Supporting Facts, and Causal Factors Identified by LANL Internal Assessments Versus Those Identified by the Board in the Building TA-21-209 Accident: Report AA-2-94-60

Source Document

Environmental, Safety and Health; Quality; and Safeguards and Security Review of the Business Operations Division (BUS), AA-2-94-60, not signed out.

Type A Accident Investigation of Electrical Accident

Finding

The program for construction and modification of the Laboratory facilities has not consistently ensured sufficient quality of cost effectiveness.

Supporting Facts

BUS employees with no construction management experience performed the functions of project manager

ESH-18 Project Team assumed responsibilities for project design and development of construction work packages. ESH-18 does not have the infrastructure, tools or project management experience needed to perform this work.

Supporting Facts

The project involved several organizations: FSS, Johnson Controls World Services, Inc. (JCI), Industrial Hygiene and Safety Group (ESH-5) and the Environmental Science and Waste Technology Group (Formally CST-7).

The project involved several organizations, FSS, Johnson Controls World Services, Inc., ESH-3, EH-5, ESH-18, ESH-20, ESA, Santa Fe Engineering, and others.

Supporting Facts

Lack of communication and coordination between these entities led to the problems cited.

Lack of communication and coordination between these entities led to the problems cited.

Supporting Facts

Early in the renovation of SM-142, BUS personnel had questioned FSS on the requirement for a fire wall, but did not receive a response until a formal memorandum was written by BUS to FSS.

Early in the process ESH-5 personnel commented that Safety Reviews could not be completed due to the broad description of the work in the standing work order. This concern was not resolved.

Supporting Facts

The electrical upgrade for SM-142 had to be redesigned because the trench from SM-30 to SM-142 for the electrical conduit passed through a solid waste management unit (SWMU). Designers had not been informed of the existence of the SWMU.

The sump location had to be relocated because the placement would interfere with Building TA-21-209 ingress and egress.

Supporting Facts

Two years after a high-priority X-urgent work order was issued, roof repairs had not been satisfactorily completed for SM-142.

The need to perform the NPDES modification was identified before the end of 1994 but the line organization had not completed action.

Supporting Facts

Design reviews were not performed on changes and modifications to designs for Building 142. The lack of design reviews contributed to omissions in requirements and lack of coordination of installations.

Design reviews were not performed on the changes to the design. The lack of design development and review contributed to the omission in noting the buried 13.2 kV electrical cable.

Supporting Facts

The deficiencies noted in the construction activities for Building 142 are similar to those documented for the PF-4 facility addition at Building TA-55, ventilation modifications at CMR Building, the WETF addition, and the new construction of the DAHRT Facility.

Deficiencies noted in this activity are similar to deficiencies noted two years ago in the assessment.

Causal Factor/

Probable Cause

The Laboratory does not have an effective management system.

The Laboratory does not have an effective project management system.

Table 3-7. Past Occurrence Report Findings, Supporting Facts, and Causal Factors Identified by LANL Internal Assessments Versus Those Identified by the Board in the Building TA-21-209 Accident: Report LAO-2-94-02

Source Document

LAO-2 Assessment of Johnson Controls World Services, Inc., LAO-2-94-02, dated March 18, 1994

Type A Accident Investigation of Electrical Accident

Finding

Processes had not been formally established and implemented to detect and prevent quality problems and to ensure quality improvement.

Supporting Facts

A lack of definitive direction from Laboratory.

The process being used to complete the Waste Stream Corrections modifications was not documented. Project expectations were unclear.

Supporting Facts

Problems were not being documented by employees and elevated to senior management for resolution.

The Building TA-21-209 Waste Stream Corrections modification work package did not provide sump locations, plumbing tie-ins or electrical connections. These deficiencies were accepted by the workers.

Supporting Facts

Verbal direction from Laboratory personnel to proceed with work even though requirements were not being met.

Sump location was moved to a location over 13.2 kV electrical cable based on a telephone call to Waste Stream Corrections engineer.

Supporting Facts

There was no follow-up system for recommendations resulting from accident investigations and recordable employee injuries and vehicle accidents.

The contributing causes for Building TA-21-209 electrical safety incident are the same as for other serious accidents that have occurred at LANL over the past 40 months.

Supporting Facts

Recommend actions were sometimes not completed.

The programmatic deficiencies that contributed to this accident were all previously identified in past assessments and occurrence reports, also LAO-2-94-02, dated March 19, 1994.

Causal Factor/

Probable Cause

Managers are reluctant to bring problems to another manager's attention because it may be perceived as a failure to carry out the job responsibilities. Some Laboratory work coordinators operate under personal preferences rather than following procedures.

Finding

JCI work request system did not ensure that work was performed according to standards, procedures, and instructions, as required by DOE Orders 5700.6C, 4330.4A, 4700.1, and 6430.1A.

Supporting Facts

Senior management was not actively establishing principles and encouraging behaviors that ensured the integration of quality requirements into daily work.

Corrective actions are not being implemented in a timely and effective manner because senior management has not aggressively promoted an atmosphere in which research and safety are equally emphasized.

Supporting Facts

Work orders did not always thoroughly describe the work done and the codes and standards followed.

The work package provided to JCI for the Building TA-21-209 building modifications did not provide sump locations, nor the plumbing tie-ins, nor the electrical connections for the pumps, nor did it require an excavation permit.

Supporting Facts

Procedures for configuration control in progress did not exist nor was configuration control being implemented.

There were no procedures established in the Waste Stream Correction project to manage changes or to require preparation of as-built drawings.

Supporting Facts

There were no procedures for management review of audits, reviews, and self-assessments; such reviews were not routinely conducted.

JCI Safety conducts job-site safety reviews but no JCI organization has performed a safety program review of the work control processes or compliance with procedures.

Causal Factor/

Probable Cause

Line managers failed to recognize the importance of implementing and enforcing Quality Assurance program requirements.

Finding

There was no published Laboratory maintenance plan; therefore, there was no auditable method of communicating maintenance requirements to JCI.

There still is no published (final) LANL maintenance plan.

Supporting Facts

FSS and ESH Groups communicated many Laboratory work requirements, safety requirements, and job tasks verbally or by memorandum.

The changes to the location of the sump were conveyed over the telephone without any documentation.

Causal Factor/

Probable Cause

The Laboratory management did not assign a high priority to the implementation of DOE Order 4330.4A.

Table 3-8. Past Occurrence Report Findings, Supporting Facts, and Causal Factors Identified by LANL Internal Assessments Versus Those Identified by the Board in the Building TA-21-209 Accident: Report AA-2-94-31

Source Document

AA-2 Assessment of the Los Alamos National Laboratory Quality Assurance Management Plan (Director's Policies and Program Requirements Document 110-01.0) AA-2-94-31, dated August 29, 1994.

Type A Accident Investigation of Electrical Accident

Finding

The Laboratory Quality Assurance program was not organized and implemented in a manner that promoted an integrated program in accordance with Director Policy 110 and Program Requirements Document 110-01.0.

Conduct of operations, work control, and design processes were not integrated into the activities involved with the modifications at Building TA-21-209.

Causal Factor/

Probable Cause

Laboratory management had not mandated implementation and had not held themselves accountable for an integrated Quality Assurance program that is consistent with Program Requirements Document 110-0.01.

Finding

FSS Division had discontinued its Quality Assurance program and activities, contrary to requirements of PRD 110-01.0.

Procedures such as Administration Requirements 1-10, 1-11, 1-12, and 1-14 were not followed by ESH-18 in this project.

Finding Cause

ESH-9, ESH-4, and FSS/OS-2 were not coordinating their efforts to avoid duplication of effort and ensure consistency in implementation of requirements.

The coordination of the WSC project did not assure adequate safety reviews of the design and work packages. Neither the facility manager nor the building manager were involved in the process.

Causal Factor/

Probable Cause

Line management was not sufficiently involved in QA program planning, monitoring, and verification to ensure interfaces and functional relationships were defined and documented.

Table 3-9. Past Occurrence Report Findings, Supporting Facts, and Causal Factors Identified by LANL Internal Assessments Versus Those Identified by the Board in the Building TA-21-209 Accident: Report AA-2-94-73

Source Document

AA-2 Assessment of the Construction Safety Program, AA-2-94-73, dated November 18, 1994.

Type A Accident Investigation of Electrical Accident

Finding

There was inadequate oversight of the construction safety program.

Causal Factor/

Probable Cause

Responsibilities for oversight of the construction safety program were divided, and the various organizations had not fulfilled their oversight roles. The draft Program Requirements Document 110-01.0 had never been approved and distributed.

Responsibility for performing a safety review was eliminated by use of an ad hoc form; Facilities Operations, Maintenance, and Modification Groups coordinator did not submit work packages for internal safety review; JCI supervision was bypassed for on its review.

Finding

The process for ensuring contractor compliance with safety standards was ineffective.

Project Team Leader assumed JCI would perform a safety review but did not verify. The work packages did not conform to electric code, plumbing code or building code.

Causal Factor/

Probable Cause

The Laboratory had not been aggressive in implementing existing procedures that could be used to ensure contractor complied with safety standards.

Source

Document

AA-2 Assessment of the Tritium Systems Test Assembly and the Tritium Sciences and Fabrication Facility AA-2-94-49, dated March 28, 1995.

Finding

The quality assurance program had not been fully implemented (Program Requirements Document 110-01.0, Par. 5.3 and Section 4.5.

Supporting Facts

Timely resolution of quality assurance issues had decreased over the past year, and no initiation of corrective action was evident.

Engineering Sciences and Application Division did not complete assigned actions to correct National Pollutant Discharge Elimination System deficiencies between March 1994 and October 1995.

Supporting Facts

There was inadequate documentation to demonstrate that the quality assurance program had been applied before tritium and facility work began.

Tritium Science and Fabrication Facility or building management did not participate in the design or construction decisions effecting the facility as required in Director's Policy DP-124 and in the Memorandum of Agreement signed by the Facility Management Council.

Causal Factor/

Probable Cause

The implementation of quality assurance program had not received a high priority.

Supporting Facts

A review of the Standard Operating Procedures revealed that many had not been updated since 1991.

Many of the Administrative Requirements Documents have not been updated in over 3 years and consequently do not integrate with the restructuring of LANL organizations.

Supporting Facts

This lack of updating/reviewing of Standard Operating Procedures was identified in a pervious assessment (93-40), and no action had been taken to meet the time lines of the action plan.

Procedures at all levels of LANL have not been revised to reflect work practices and organizational structures.

Causal Factor/

Probable Cause

Management had not established a system that ensured the timely review and approval of Standard Operating Procedures.