The Honorable Spencer Abraham
Secretary of Energy
1000 Independence Avenue, SW
Dear Secretary Abraham:
On May 6, 2003, due to the accumulation of combustible
material, a fire occurred in the basement of Building 371 at the Rocky Flats
Environmental Technology Site (RFETS) as workers were preparing to remove Glovebox 8 from the facility. The fire broke out after operators began
cutting a hole near the top of Glovebox 8 to
establish a ventilation path for the glovebox. A significant firefighting effort ensued,
including the discharge of more than a dozen fire extinguishers and eventual
use of a fire hose. No workers were
harmed, but the potential for severe injury existed, four firefighters received
skin contamination, and a significant cleanup effort was required.
Because of the urgency of the matter, the
Defense Nuclear Facilities Safety Board (Board) issued a letter on July
31, 2003, imposing
a 15-day reporting requirement to ensure that the Department of Energy (DOE)
would take appropriate immediate actions to verify that the conditions
contributing to the fire did not exist elsewhere at RFETS. DOE provided an action plan to the Board in a
letter dated August 15, 2003.
In parallel to the July
31, 2003, letter,
the Board and its staff continued to review the causes and implications of the
May 6 fire at RFETS. The enclosed
reports prepared by the Board’s staff documents the results of this review and
the results of the staffs review of documentation and practices related to
activity-level work planning at RFETS. These reviews identified problems in all five
core functions of Integrated Safety Management (ISM)―defining the
scope of work, analyzing the hazards, developing and implementing hazard
controls, performing work within those controls, and providing feedback and
continuous improvement. Furthermore, the
Board’s staff observed ineffective oversight by DOE’s Rocky Flats Field Office (RFFO)
of the events leading up to the fire, of the RFETS contractor’s actions in
response to the fire, and of the subsequent resumption of work. Each of these areas and a number of specific issues
are discussed in the enclosed reports. The following examples illustrate some of the principal
deficiencies detailed in these reports.
- Despite previous correspondence from the Board regarding the need
for improvements in work planning at RFETS and actions committed to by
DOE, the RFETS contractor approached the removal of Glovebox
8 using a generic work package that failed to address the unique design of
the glovebox and a Job Hazards Analysis that
failed to address the uncharacterized combustible contents of the glovebox or other unique hazards associated with its
design. As a result, the contractor
failed to implement effective safety controls for this task.
- The RFETS contractor inadequately implemented other key safety
controls that had been specified for decommissioning work in Building 371,
including the combustible control program and the procedure for reducing
and neutralizing chemicals used to decontaminate gloveboxes.
(Improvements in these areas have
been noted subsequent to the Board’s letter of July 31, 2003.)
- The materials found in Glovebox 8 after
the fire included combustible wastes from chemical decontamination of
another glovebox, a condition which violated
safety procedures and which was not acknowledged by the site until the
Board’s staff obtained photographs showing the material amid the debris
from the fire.
- The concerted firefighting effort undertaken by the decommissioning
workers violated site procedures in which they had been trained and
exposed them to severe hazards.
- Despite the ever-changing facility conditions and hazards
associated with decommissioning work, RFFO did not perform oversight of
decommissioning activities in Building 371 prior to the fire.
- Despite the commitment provided to the Board by DOE’s Assistant
Secretary for Environmental Management in the letter of August
15, 2003, the
Board’s staff determined that chemical decontamination of gloveboxes at RFETS had resumed prior to review of the
procedure by RFFO and without RFFO oversight.
On October 20–23, 2003, a review team from the Board’s staff that
included a former Board Site Representative for RFETS conducted an in-depth
review of conduct of operations, work control, and safety oversight at RFETS. A summary of the staff’s observations from
this review is provided in Enclosure 3 to this letter. This review concluded that, although the RFETS
contractor has implemented a number of positive practices, its recent safety
performance is unsatisfactory, as evidenced by continued lapses in work
planning and execution. This review also
reinforced the Board’s conclusion that the oversight capability of RFFO has
degraded considerably in recent years. Improvements are needed to remedy the loss of
technical competence within RFFO and to refocus RFFO on performing safety
oversight of decommissioning work at RFETS.
Given the scope and significance of the
lapses in the implementation of the core functions of ISM at RFETS and the
deficiencies in safety oversight by RFFO, the Board concludes that the ISM
System at RFETS, including safety management within both the RFFO and its
contractor, needs improvement. The Board
believes that an independent review is needed to thoroughly evaluate the state
of ISM at the site, including an assessment of the effectiveness of RFFO’s health and safety oversight of decommissioning
activities, and that comprehensive corrective actions are needed to correct the
root causes of the specific issues identified in the enclosed reports prepared
by the Board’s staff and highlighted above.
Therefore, pursuant to 42 U.S.C. § 2286b(d), the Board requests that DOE
provide a corrective action plan to the Board within 60 days of receipt of this
letter regarding how DOE and its contractor at RFETS will address the findings
documented in this letter and the enclosed reports.
John T. Conway
Honorable Jessie Hill Roberson
Mr. Frazer R. Lockhart
Mr. Mark B. Whitaker, Jr.
(1) Staff Report Re: Glovebox Fire at
(2) Staff Report Re: Documentation & Practices Related to
Activity-Level Work Planning at RFETS
(3) DNFSB Review of Conduct of Operations,
and Safety Oversight at RFETS