[DNFSB LETTERHEAD]
August 7, 2003
The Honorable Jessie Hill Roberson
Assistant Secretary for Environmental
Management
U.S. Department of Energy
1000 Independence Avenue, SW
Washington, DC 20585-0113
Dear Ms. Roberson:
The staff of the Defense Nuclear Facilities
Safety Board (Board) recently visited the Fernald Closure Project site near
Cincinnati, Ohio, to review issues related to worker safety. The Fernald site is currently involved in
the demolition of former uranium processing plant buildings, removal of
radioactive waste, and environmental remediation of the site. Under the new contract with Fluor Fernald
(Fluor), all work at the site is scheduled to be completed by the end of 2006. The results of the staff’s review are
documented in the enclosed report.
Although significant progress is being made
toward cleaning up and remediating the site, there was an increase in the
number of worker injuries and near misses in 2002. The site has attributed this rise in the accident rate to an
increase in the number of new workers on site and the greater amount of work
being performed on most site projects.
While Fluor’s upper management places a strong emphasis on safety,
information from project safety and quality personnel in the field indicates
that many project and field managers believe safety is adequate, and meeting
the schedule is the top priority.
Similar conclusions were reached by an independent review of Fernald
sponsored by the Department of Energy’s (DOE) Ohio Field Office in May 2003.
The Board believes the safety culture of the
contractor’s project and field management needs to be improved to increase
operational safety at the site. The
Board is aware of attempts by DOE and Fluor to reaffirm a commitment to safety
by holding meetings and engaging in other communications, but such activities
do not appear to have achieved the desired improvements in safety. For example, in an attempt to reduce the
number of worker injuries, Fluor is implementing a Safety Recovery Plan that
includes additional safety training, safety performance reviews, improvements
in training of new employees, and attempts to develop leading safety
performance indicators. The plan is too
new for its effectiveness to be fully evaluated. However, the plan has many of the same elements as previous plans
that have not resulted in the desired improvements in safety.
The Board suggests that other actions―such as additional training that clearly
identifies the safety responsibilities and activities of all levels of
management, and the development of performance-based safety incentives for the
contractor’s project and field management-may need to be considered to produce
a measurable improvement in safety at the site. Also, in view of the fact that Fluor has concluded that new
workers are involved in a disproportionate share of the site’s injuries, a more
thorough screening of the qualifications of new workers may be necessary.
Therefore, pursuant to 42 U.S.C. § 2286b(d), the Board requests the
responsible DOE and Fluor personnel to brief the Board within 90 days of
receipt of this letter regarding further actions that may be undertaken to
improve operational safety at the Fernald site.
Sincerely,
John T. Conway
Chairman
c:
Mr. Robert Warther
Mr. Glenn Griffiths
Mr. Mark B. Whitaker, Jr.
Enclosure
DEFENSE
NUCLEAR FACILITIES SAFETY BOARD
July 11,
2003
MEMORANDUM FOR: J. K.
Fortenberry, Technical Director
COPIES: Board Members
FROM: L. Zull
The staff of the Defense Nuclear Facilities
Safety Board (Board) visited the Fernald Closure Project on June 2-5,2003, to review
issues related to worker safety. The
staff also toured the site and conducted a walk-down of the Waste Pits Remedial
Action Project (WPRAP) and the Silos project.
Background.
Fernald produced high-quality uranium metal products for defense nuclear
applications between 1951 and 1989.
Production operations were suspended in 1989 and ended formally in 1991
with the Department of Energy’s (DOE) decision to close the site. Current work involves six major projects to
decontaminate and demolish site structures, remove and dispose of nuclear
waste, and remediate the site. Four
projects (Silos, Waste Management, Soil Disposition, and Aquifer Restoration)
are self-managed by the lead contractor, Fluor Fernald (Fluor). The two remaining projects, WPRAP and the
Decontamination and Demolition project, are managed by subcontractors―Shaw E&I, Inc. and MACTEC Inc.,
respectively.
New Contract and DOE Organization. A
new cost plus incentive fee contract was signed with Fluor on April 30,
2003. The new contract places emphasis
on DOE’s monitoring of the contractor’s schedule. DOE’s review and approval of the contractor’s work plans have
been significantly reduced. The effect
of these changes on safety remains to be seen.
The target date for completion of the cleanup and remediation work at
the site is December 31, 2006. The pace
of work is accelerating, but experienced DOE and contractor personnel are
gradually leaving as the site moves toward closure. There is currently no plan to retain key DOE or contractor
personnel until the site work is completed.
The new manager of DOE’s Ohio Field Office,
who was appointed earlier this year, has relocated the office from the Mound
site in Miamisburg to a commercial office building in the Cincinnati suburb of
Springdale, Ohio. The Ohio Field Office
has been reorganized, and many personnel from the Mound and Fernald sites have
been relocated to the Springdale office.
Support and subject matter personnel have been transferred to
Springdale, while only associate directors, project managers, and facility
representatives remain on site. The Board’s
staff plans to monitor the impact of these changes on the effectiveness of
DOE’s safety oversight at the Mound and Fernald sites.
Current Activities. The
last of more than 200,000 drums of legacy uranium and thorium waste is
scheduled to be repackaged and shipped off site by September 2003. The demolition of most former production
buildings was scheduled to be completed by September 2003, but is behind
schedule and is not estimated to be completed before December 2003. The low-level demolition debris and
contaminated soil are being placed in 8 engineered on-site disposal cells. WPRAP has removed and shipped almost 70
percent of the 790,000 tons of uranium and thorium processing wastes and
contaminated soils from 6 in-ground waste pits and other locations. The WPRAP waste is placed in gondola cars
and shipped in 65-car trains to Envirocare in Utah. All of the WPRAP waste material is scheduled to be shipped off
site by September 30, 2004. A
nationwide problem with defective railcar bolsters (the castings that connect
wheel carriages to the railcars) manufactured in Mexico during 1998–1999 may require that WPRAP replace bolsters
on its railcars, which could delay completion of the project.
The Silos project has completed design work
for the structures and equipment required to retrieve uranium processing wastes
stored in three on-site silos (Silos 1, 2, and 3), treat it, and ship it off
site. The Silos project, which is now
in the construction phase, is on the critical path to site closure. Silo 3 operations are scheduled between
April 2004 and December 2004, while Silo 1 and 2 operations are scheduled
between February 2005 and February 2006.
The silos and the waste treatment plants will be demolished after waste
treatment has been completed. Fluor
would like to ship the packaged silos waste to Envirocare in Utah via railcar,
rather than to the Nevada Test Site via truck, but must obtain state approvals
and congressional legislative changes to do so.
Worker Safety. The
staff reviewed information on various worker safety programs and DOE and
contractor oversight programs. The
staff’s principal observations are
summarized below.
Accidents and Injuries―During 2002, the number of accidents,
injuries, and near misses at the site increased. Injury statistics indicate that injuries among subcontractor
personnel are trending higher than those among Fluor employees. During this period, the number of employees
and the amount of work being performed at the site have both increased. While Fluor’s upper management places a
strong emphasis on safety, information from project safety and quality
personnel in the field indicates that many project and field managers believe
safety is adequate, and meeting the schedule is the top priority. Also, it did not appear to the Board’s staff
that the identification and resolution of safety and quality problems is
treated consistently as the responsibility of project personnel, rather than
safety and quality oversight personnel.
To address the increase in the accident rate,
Fluor implemented a Safety Recovery Plan in May 2003 that identifies actions
designed to improve worker safety at the site.
This plan, which includes additional safety training, safety performance
reviews, improvements in new employee training, and attempts to develop leading
safety performance indicators, is too new for its effectiveness to be
evaluated. However, the staff noted
that the plan has many of the same elements as previous plans that have not
resulted in the desired improvements in safety. The staff believes the safety culture of the contractor’s project
and field management personnel needs to be improved to increase operational
safety at the site. Other actions―such as additional training that clearly
identifies the safety responsibilities and activities of all levels of
management, and the development of performance-based safety incentives for the
contractor’s project and field management-may be necessary to produce a
measurable improvement in safety at the site.
In an attempt to improve safety on the
Decontamination and Demolition project, Fluor recently gave formal notice to
the demolition project contractor, MACTEC, of the need to develop a corrective
action plan to reduce the number of reportable occurrences. MACTEC is also 6 months behind the September
30, 2003, schedule date for the completion of demolition of the former
production area buildings and structures.
New Employees―The site is in the process of adding more
than 850 new employees to the workforce this year. The new workers are primarily equipment operators, trades
personnel, and general laborers. As
part of the Safety Recovery Plan, Fluor is implementing a Fluor Corporate New
Employee Development Safety Orientation program, in addition to a Safety Mentor
Program. These programs are being
implemented because Fluor has determined that new employees are involved in a
disproportionate number of injuries.
The Safety Mentor Program uses mentors to serve as positive role models
to influence the behaviors and work practices of new workers. Through this program, the work practices of
new workers are observed over a 6-month period. In addition to the Safety Mentor Program, however, more thorough
screening of prospective employees may be necessary to ensure that new workers
are qualified for the work they are to perform.
Safety Performance Indicators―Part of the Safety Recovery Plan involves an
attempt to develop meaningful safety performance indicators for early
identification of those projects or program areas that need additional
attention. The staff commented that
predictive, rather than reactive, indicators are more useful, but more
difficult to identify. One source of
predictive information is input from first-line managers. In the past, first-line management has tried
to fix problems, but has not always informed upper levels of management of the
problems. Precursor information is
often not recognized and reported. The
staff believes it is important to develop a plan for encouraging first-line
managers to report trends promptly and request assistance from upper-level
management when necessary. Currently,
the best predictive safety information appears to be feedback from the various
project safety and quality personnel in the field.
Respiratory
Protection Programs―An average of 2,000 respirators are used
weekly in the respiratory protection programs (RPPs) operated by Fluor, Shaw,
and MACTEC at the site. The site uses
19 different models of respirators.
Fluor operates the RPP for the Silos and Soil Disposition projects, Shaw
for WPRAP, and MACTEC for the Decontamination and Demolition project. Fluor administers the site RPP and uses
MACTEC’s laundering facilities for some respirators, but the contractors supply
their own equipment and support services.
Shaw has its own RPP and procedures, whereas MACTEC follows the RPP and
procedures of Fluor.
A discussion with Fluor personnel
administering the RPP indicated a lack of familiarity with some of the details
of the implementing procedures. Fluor
personnel conduct scheduled quality assurance/quality control assessments of
the RPPs of all site contractors. In
reviewing the assessment reports, the staff noted that the reviews were mainly
reactive (verifying completion of corrective actions) during 2000-2001, but
have been more proactive in identifying problems since 2002.
Recent contaminations and uptakes due to
chemical and radiological exposures indicate the need for increased attention
to the condition of personal protective equipment, including respirators. The staff was told that lessons-learned
information has been fed back into the respirator training program, and that
the lessons learned will be formally documented. However, recent feedback from project safety and quality
personnel has called into question the adequacy of pre-use inspections by
workers. Although respirators are
inspected by trained personnel after cleaning, recent occurrences indicate the
need for increased worker attention to personal inspections of personal
protective equipment, including respirators.
The staff toured the respirator and worker dress-out facilities at
WPRAP, which appeared to be operating in compliance with procedures.
DOE and Contractor Oversight―Both DOE and Fluor conduct various types of
safety oversight reviews. Fluor has
quality assurance/quality control programs that perform programmatic and field
audits, inspections, and surveillances.
Fluor also has a Safety and Health Program that conducts reviews of
safety and health programs and project operations. Approximately 17 percent of Fluor personnel are involved in
performing safety reviews, Although Fluor conducts numerous safety reviews, it
has apparently been slow to react to safety problems with its
subcontractors. DOE has also been slow
to request officially that Fluor pay more attention to working with
subcontractors to improve safety. DOE
conducts a much smaller number of quality and safety audits than does Fluor.
DOE and Fluor have conducted some joint
reviews (not joint readiness assessments or Operational Readiness
Reviews). Fluor representatives told
the Board’s staff that more findings tend to be identified in the joint
reviews, and DOE said that findings of joint reviews are written up by Fluor as
nonconformances and corrected more quickly than findings of separate Fluor
reviews. However, the staff is
concerned that some independence may be lost, and that the contractor may not
be as willing to discuss potential problem areas or concerns openly with DOE
present. The joint reviews have both
advantages and disadvantages. DOE and
Fluor plan to continue such reviews in the future as projects work toward
completion; the staff plans to monitor the effectiveness of such joint reviews.
The DOE Ohio Field Office manager chartered
an independent team to conduct a safety review of the Fernald Closure Project
in May 2003. The report of this review,
issued on June 6, 2003, reaches conclusions similar to those reached by the
Board’s staff. The DOE Fernald Site
Office issued a corrective action plan on June 24, 2003, that includes
commitments to conduct further meetings and communications on safety, increase
oversight of the Decontamination and Demolition project, evaluate the manner in
which operational events are analyzed and reported, improve the distribution of
lessons learned, and develop a staffing plan that shows how DOE will support
closure of the site by 2006. The
Board’s staff believes that these actions should improve safety at Fernald;
however, the additional actions identified by the staff―training all levels of management on their
safety responsibilities, defining performance-based incentives related to
safety performance, and ensuring new workers are appropriately qualified―may be needed to address the observed
weaknesses in safety culture and safety performance.