Yucca Mountain
DOE's Planned Nuclear Waste Repository Faces Quality Assurance and Management Challenges Gao ID: GAO-06-550T April 25, 2006The Department of Energy (DOE) is working to obtain a license from the Nuclear Regulatory Commission (NRC) to construct a nuclear waste repository at Yucca Mountain in Nevada. The project, which began in the 1980s, has been beset by delays. In 2004, GAO raised concerns that persistent quality assurance problems could further delay the project. Then, in 2005, DOE announced discovery of employee e-mails suggesting quality assurance problems. Quality assurance, which establishes requirements for work to be performed under controlled conditions that ensure quality, is critical to making sure the project meets standards for protecting public health and the environment. This testimony, which summarizes GAO's March 2006 report (GAO-06-313), provides information on (1) the history of the project's quality assurance problems, (2) DOE's tracking of these problems and efforts to address them since GAO's 2004 report, and (3) challenges facing DOE as it continues to address quality assurance issues within the project.
DOE has had a long history of quality assurance problems at the Yucca Mountain project. In the 1980s and 1990s, DOE had problems assuring NRC that it had developed adequate plans and procedures related to quality assurance. More recently, as it prepares to submit a license application for the repository to NRC, DOE has been relying on costly and time-consuming rework to resolve lingering quality assurance problems uncovered during audits and after-the-fact evaluations. DOE announced, in 2004, that it was making a commitment to continuous quality assurance improvement and that its efforts would be tracked by performance indicators that would enable it to assess progress and direct management attention as needed. However, GAO found that the project's performance indicators and other key management tools were not effective for this purpose. For example, the management tools did not target existing areas of concern and did not track progress in addressing them. The tools also had weaknesses in detecting and highlighting significant problems for management attention. DOE continues to face quality assurance and other challenges. First, DOE is engaged in extensive efforts to restore confidence in scientific documents because of the quality assurance problems suggested in the discovered e-mails between project employees, and it has about 14 million more project e-mails to review. Second, DOE faces quality assurance challenges in resolving design control problems associated with its requirements management process--the process for ensuring that high-level plans and regulatory requirements are incorporated into specific engineering details. Problems with the process led to the December 2005 suspension of certain project work. Third, DOE continues to be challenged to manage a complex program and organization. Significant personnel and project changes initiated in October 2005 create the potential for earlier problem areas, such as confusion over roles and responsibilities, to reoccur.
GAO-06-550T, Yucca Mountain: DOE's Planned Nuclear Waste Repository Faces Quality Assurance and Management Challenges
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United States Government Accountability Office:
GAO:
Testimony:
Before the Subcommittee on the Federal Workforce and Agency
Organization, Committee on Government Reform, House of Representatives:
Tuesday, April 25, 2006:
Yucca Mountain:
DOE's Planned Nuclear Waste Repository Faces Quality Assurance and
Management Challenges:
Statement of Jim Wells, Director Natural Resources and Environment:
GAO-06-550T:
GAO Highlights:
Highlights of GAO-06-550T, a testimony before the Subcommittee on the
Federal Workforce and Agency Organization, Committee on Government
Reform, House of Representatives.
Why GAO Did This Study:
The Department of Energy (DOE) is working to obtain a license from the
Nuclear Regulatory Commission (NRC) to construct a nuclear waste
repository at Yucca Mountain in Nevada. The project, which began in the
1980s, has been beset by delays. In 2004, GAO raised concerns that
persistent quality assurance problems could further delay the project.
Then, in 2005, DOE announced discovery of employee e-mails suggesting
quality assurance problems. Quality assurance, which establishes
requirements for work to be performed under controlled conditions that
ensure quality, is critical to making sure the project meets standards
for protecting public health and the environment.
This testimony, which summarizes GAO‘s March 2006 report (GAO-06-313),
provides information on (1) the history of the project‘s quality
assurance problems, (2) DOE‘s tracking of these problems and efforts to
address them since GAO‘s 2004 report, and (3) challenges facing DOE as
it continues to address quality assurance issues within the project
What GAO Found:
DOE has had a long history of quality assurance problems at the Yucca
Mountain project. In the 1980s and 1990s, DOE had problems assuring NRC
that it had developed adequate plans and procedures related to quality
assurance. More recently, as it prepares to submit a license
application for the repository to NRC, DOE has been relying on costly
and time-consuming rework to resolve lingering quality assurance
problems uncovered during audits and after-the-fact evaluations.
DOE announced, in 2004, that it was making a commitment to continuous
quality assurance improvement and that its efforts would be tracked by
performance indicators that would enable it to assess progress and
direct management attention as needed. However, GAO found that the
project‘s performance indicators and other key management tools were
not effective for this purpose. For example, the management tools did
not target existing areas of concern and did not track progress in
addressing them. The tools also had weaknesses in detecting and
highlighting significant problems for management attention.
DOE continues to face quality assurance and other challenges. First,
DOE is engaged in extensive efforts to restore confidence in scientific
documents because of the quality assurance problems suggested in the
discovered e-mails between project employees, and it has about 14
million more project e-mails to review. Second, DOE faces quality
assurance challenges in resolving design control problems associated
with its requirements management process”the process for ensuring that
high-level plans and regulatory requirements are incorporated into
specific engineering details. Problems with the process led to the
December 2005 suspension of certain project work. Third, DOE continues
to be challenged to manage a complex program and organization.
Significant personnel and project changes initiated in October 2005
create the potential for earlier problem areas, such as confusion over
roles and responsibilities, to reoccur.
View of Yucca Mountain and the Exploratory Tunnel for the Repository:
[See PDF for Image]
Source: DOE:
[End of Image]
What GAO Recommends:
In its March 2006 report, GAO recommended actions DOE can take to
improve the project‘s management tools and their use in identifying and
addressing quality assurance and other problems. In commenting on a
draft of the report, DOE agreed with GAO‘s recommendations.
To view the full product, including the scope and methodology, click on
the link above.
For more information, contact Jim Wells at (202) 512-3841 or
wellsj@gao.gov.
[End of Section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss our work concerning quality
assurance and other management challenges facing the Department of
Energy (DOE) as it prepares to construct a deep geological repository
at Yucca Mountain in Nevada for the nation's nuclear wastes. My
testimony is based on our March 2006 report entitled Yucca Mountain:
Quality Assurance at DOE's Planned Nuclear Waste Repository Needs
Increased Management Attention.[Footnote 1]
DOE is preparing an application for a license from the Nuclear
Regulatory Commission (NRC) to construct an underground geological
repository at Yucca Mountain for the permanent storage of highly
radioactive nuclear waste. Nuclear waste is a by-product of the
production of nuclear power, which provides about 20 percent of U.S.
electricity. About 50,000 metric tons of nuclear waste are stored at 72
sites around the country, principally at commercial nuclear power
plants. These wastes have been accumulating for several decades in
surface storage designed to be temporary. The Nuclear Waste Policy Act
of 1982 required DOE to construct a repository for permanent storage
and to begin accepting these wastes by January 31, 1998. In 2002, after
more than 15 years of scientific study, the President recommended and
the Congress approved Yucca Mountain as a suitable location for the
repository. However, DOE continues to encounter delays, and it is not
certain when it will apply for the license to construct the repository.
The licensing process requires DOE to demonstrate to NRC that its plans
for the repository will meet Environmental Protection Agency standards
for protecting public health and the environment from harmful exposure
to the radioactive waste. To show that it can meet these standards, DOE
has been conducting scientific and technical studies at the Yucca
Mountain site that will provide supporting documentation for its
planned license application. DOE has also established a quality
assurance program to meet NRC requirements and ensure that its work and
the technical information it produces are accurate and defensible. To
accomplish this goal, the program established procedures that require
scientific, design, engineering, procurement, records keeping, and
other work to be performed under controlled conditions that ensure
quality and enable the work to be verified by others. However,
persistent problems implementing these procedures and resulting
questions about the quality of the work are significantly contributing
to delays in DOE's submission of the license application. Resolving
these quality assurance issues is essential to proceeding with
construction.
In April 2004, we reported that recurring quality assurance problems at
the Yucca Mountain project could delay the licensing and operation of
the repository. At that time, we also reported that DOE had completed
efforts--known as Management Improvement Initiatives (Initiatives)--to
better manage quality assurance problems, but could not assess their
effectiveness because its performance goals lacked objective measures
and time frames for determining success.[Footnote 2] Then, in early
2005, DOE reported that it had discovered a series of e-mail messages
written in the late 1990s by U.S. Geological Survey (USGS) employees
working on the Yucca Mountain project under a contract with DOE that
appeared to imply that workers had falsified records for scientific
work. Several of these messages appeared to show disdain for the
project's quality assurance program and its requirements. In October
2005, DOE began planning an aggressive series of changes--known as the
"new path forward"--to the facility design, organization, and
management of the Yucca Mountain project. These efforts are intended to
address quality assurance and other challenges, including those
associated with the USGS e-mails, and advance the license application
process. However, in December 2005 and again in February 2006, some
project work was stopped due to continuing quality assurance problems.
Our March 2006 report examined (1) the history of the project's quality
assurance problems since its start in the 1980s, (2) DOE's tracking of
quality problems and progress implementing quality assurance
requirements since our April 2004 report, and (3) challenges that DOE
faces as it continues to address quality assurance issues with the
project. To determine the history of quality assurance problems, we
reviewed previous GAO, DOE, and NRC documents, visited the Yucca
Mountain site, and interviewed officials from DOE, NRC, and Bechtel/
SAIC Company, LLC (BSC), which is DOE's management contractor for the
Yucca Mountain project. To assess DOE's tracking of quality-related
problems and progress in addressing them, we examined management tools
and associated documentation, and interviewed BSC and DOE officials
regarding those tools. To identify current quality assurance and other
challenges, we attended quarterly NRC management meetings, interviewed
the Acting Director and other senior managers of the DOE project, and
gathered information on management turnover. The work on our report was
conducted from July 2005 through January 2006 in accordance with
generally accepted government auditing standards.
In summary, we found the following:
* DOE has had a long history of quality assurance problems at the Yucca
Mountain project. In the late 1980s and early 1990s, DOE had problems
assuring NRC that it had developed adequate plans and procedures
related to quality assurance. As we reported in 1988, NRC had found
that DOE's quality assurance procedures were inadequate and its efforts
to independently identify and resolve weaknesses in the procedures were
ineffective. By the late 1990s, DOE had largely addressed NRC's
concerns about its plans and procedures, but its own audits identified
quality assurance problems with the data, software, and models used in
the scientific work supporting its potential license application. For
example, in 1998, a team of project personnel determined that 87
percent of the models used to simulate the site's natural and
environmental conditions, and to demonstrate the future repository's
performance over time, did not comply with requirements for
demonstrating their accuracy in predicting geologic events. More
recently, DOE has relied on costly and time-consuming rework to resolve
lingering quality assurance concerns. Specifically, in the spring of
2004, DOE implemented a roughly $20 million, 8-month project called the
Regulatory Integration Team to ensure that scientific work was
sufficiently documented and explained to support the license
application. This effort involved about 150 full-time employees from
DOE, USGS, and multiple national laboratories, such as Sandia and Los
Alamos, working to inspect technical documents to identify and resolve
quality problems.
* DOE cannot be certain that its efforts to improve quality assurance
have been effective because the management tools it adopted did not
target existing management concerns and did not track progress in
addressing significant and recurring problems. DOE announced in 2004
that it was making a commitment to continuous quality assurance
improvement and that its efforts would be tracked by performance
indicators that would enable it to assess progress and direct
management attention as needed; however, its management tools have not
been effective for this purpose. Specifically, its one-page summary, or
"panel," of selected performance indicators that project managers used
in monthly management meetings was not an effective tool for assessing
progress because the indicators poorly represented the major management
concerns and were changed frequently. For example, the panel did not
include an indicator to represent the management concern about unclear
roles and responsibilities--a problem that could undermine
accountability within the project. Use of the indicator panel was
discontinued in late 2005, and DOE is deciding on a tool to replace it.
Moreover, a second management tool--trend evaluation reports--also did
not track relevant concerns. The reports generally had technical
weaknesses for identifying recurrent and significant problems and
inconsistently tracked progress toward resolving the problems. For
example, lacking reliable data and an appropriate performance benchmark
for determining the significance of human errors as a cause of quality
problems, DOE's trend reports offered no clear basis for tracking
progress on such problems. In addition, under the trend reports' rating
categories, the rating assigned to convey the significance of a problem
was overly influenced by a judgment in the report that there were
already ongoing management actions to address the problem, rather than
solely assessing the problem's significance. For example, the trend
report's rating of one particular problem at the lowest level of
significance did not accurately describe the problem or sufficiently
draw management's attention to it.
* DOE's aggressive "new path forward" effort faces substantial quality
assurance and other challenges, as it prepares to submit the license
application to construct the repository at Yucca Mountain. First, the
March 2005 announcement of the discovery of USGS e-mails suggesting the
possible falsification of quality assurance records has resulted in
extensive efforts to restore confidence in scientific documents, and
DOE is conducting a wide-ranging review of approximately 14 million e-
mails to determine whether they raise additional quality assurance
issues. Such a review creates a challenge not just because of the sheer
volume of e-mails to be reviewed, but also because DOE will have to
decipher their meaning and determine their significance, sometimes
without clarification from authors who have left the project.
Furthermore, if any of the e-mails raise quality assurance concerns,
further review, inspection, or additional work may need to be
performed. Second, DOE faces quality assurance challenges associated
with an inadequate requirements management process--the process
responsible for ensuring that broad plans and regulatory requirements
affecting the project are tracked and incorporated into specific
engineering details. In December 2005, DOE issued a stop-work order on
some design and engineering work until it can determine whether the
requirements management process has been improved. Third, DOE continues
to be challenged by managing a changing and complex program and
organization. The significant project changes initiated under the new
path forward create the potential for confusion over accountability as
roles and responsibilities change--a situation DOE found to contribute
to quality assurance problems during an earlier transition period. For
example, one proposed reorganization--establishing a lead laboratory to
assist the project--would not only have to be effectively managed, but
also would introduce a new player whose accountability DOE would have
to ensure. DOE has also experienced turnover in 9 of 17 key management
positions since 2001--including positions related to quality assurance-
-that has created management continuity challenges. For example, three
individuals have directed the project since 1999, and the position is
currently occupied by an acting director. Since DOE is still
formulating its plans, it is too early to determine whether its new
path forward effort will resolve these challenges.
In our report, we recommend that DOE strengthen its management tools by
(1) improving the tools' coverage of the Initiatives' areas of concern,
(2) basing the tools on projectwide analysis of problems, (3)
establishing quality guidelines, (4) making indicators and analyses
more consistent over time, and (5) focusing rating categories on
problem significance rather than a judgment on the need for management
action. In commenting on the report, DOE agreed with our
recommendations.
Background:
The Congress enacted the Nuclear Waste Policy Act of 1982 to establish
a comprehensive policy and program for the safe, permanent disposal of
commercial spent nuclear fuel and other highly radioactive wastes in
one or more mined geologic repositories. The act charged DOE with (1)
establishing criteria for recommending sites for repositories; (2)
"characterizing" (investigating) three sites to determine each site's
suitability for a repository (1987 amendments to the act directed DOE
to investigate only the Yucca Mountain site); (3) recommending one
suitable site to the President, who would submit a recommendation of
such site to the Congress if he considered the site qualified for a
license application; and (4) upon approval of a recommended site,
seeking a license from NRC to construct and operate a repository at the
site. The Yucca Mountain project is currently focused on preparing an
application for a license from NRC to construct a repository. DOE is
compiling information and writing sections of the license application,
conducting technical exchanges with NRC staff, and addressing key
technical issues identified by NRC to ensure that sufficient supporting
information is provided.
In February 2005, DOE announced that it does not expect the repository
to open until 2012 at the earliest, which is more than 14 years later
than the 1998 goal specified by the Nuclear Waste Policy Act of 1982.
More recently, the conference report for DOE's fiscal year 2006
appropriations observed that additional significant delays to
submitting a license application are likely. In October 2005, the
project's Acting Director issued a memorandum calling for the
development of wide-ranging plans for the "new path forward" to
submitting the license application. The plans address the need to
review and replace USGS work products, establish a lead national
laboratory to assist the project, and develop a new simplified design
for the waste canisters and repository facilities, among other things.
In addition, DOE announced, in April 2006, that it was proposing
legislation intended to accelerate licensing and operations. For
example, the legislation provides that if NRC authorizes the
repository, subsequent licensing actions would be conducted using
expedited, simplified procedures.
Given the delays, the Congress has considered other options for
managing existing and future nuclear wastes, such as centralized
interim storage at one or more DOE sites. In addition, the conference
report for DOE's fiscal year 2006 appropriations directed DOE to
develop a spent nuclear fuel recycling plan to reuse the spent fuel.
However, according to the Nuclear Energy Institute, which represents
the nuclear energy industry, none of technological options being
considered will eliminate the need to ultimately dispose of nuclear
waste in a geologic repository.
DOE Has a Long History of Quality Assurance Problems at Yucca Mountain:
DOE has had a long history of quality assurance problems at the Yucca
Mountain project. In the project's early stages, DOE had problems
assuring NRC that it had developed adequate quality assurance plans and
procedures. By the late 1990s, DOE had largely addressed NRC's concerns
about its plans and procedures, but its own audits identified quality
assurance problems with the data, software, and models used in the
scientific work supporting its potential license application. While
recently resolving these quality problems, DOE is now relying on costly
and time-consuming rework to ensure the traceability and transparency
of several technical work products that are key components of the
license application.
As we reported in 1988, NRC reviewed DOE's quality assurance program
for the Yucca Mountain project and concluded that it did not meet NRC
requirements[Footnote 3] and that DOE's quality assurance audits were
ineffective. In 1989, NRC concluded that DOE and its key contractors
had yet to develop and implement an acceptable quality assurance
program. However, by March 1992, NRC determined that DOE had made
significant progress in improving its quality assurance program, noting
among other things, that all of the contractor organizations had
developed and were in the process of implementing quality assurance
programs that met NRC requirements, and that DOE had demonstrated its
ability to evaluate and correct deficiencies in the overall quality
assurance program.
By the late 1990s, however, the DOE quality assurance program began
detecting new quality problems in three areas critical to demonstrating
the repository's successful performance over time: data management,
software management, and scientific models.
* Data management. In 1998, DOE identified quality assurance problems
with the quality and traceability of data, specifically that some data
had not been properly collected or tested to ensure its accuracy and
that data used to support scientific analysis could not be properly
traced back to its source. DOE found similar problems in April and
September 2003.
* Software management. DOE quality assurance procedures require that
software used to support analysis and conclusions about the performance
and safety of the repository be tested or created in such a way to
ensure that it is reliable. From 1998 to 2003, multiple DOE audits
found recurring quality assurance problems that could affect confidence
in the adequacy of software.
* Model validation. In 1998, a team of project personnel evaluated the
mathematical models used to simulate natural and environmental
conditions and determined that 87 percent of them did not comply with
validation requirements to ensure they accurately predict geologic
events. In 2001, and again in 2003, DOE audits found that project
personnel were not properly following procedures, specifically in the
areas of model documentation, model validation, and checking and
review. Further, the 2003 audit concluded that previous corrective
actions designed to improve validation and reduce errors in model
reports were not fully implemented.
After many years of working to address these quality assurance problems
with data, software, and models, DOE had mostly resolved these problems
by February 2005.
As DOE prepares to submit the Yucca Mountain project license
application to NRC, it is relying on costly and time-consuming rework
to ensure that the documents supporting its license application are
accurate and complete. Although the department had known for years
about quality assurance problems with the traceability and transparency
of technical work products called Analysis and Model Reports (AMR)--a
key component of the license application---DOE did not initiate a major
effort to address these problems until 2004. AMRs contain the
scientific analysis and modeling data that demonstrate the safety and
performance of the planned repository and, among other quality
requirements, must be traceable to their original source material and
data and be transparent in justifying and explaining their underlying
assumptions, calculations, and conclusions. In 2003, based in part on
these problems, as well as DOE's long-standing problems with data,
software, and modeling, NRC conducted an independent evaluation of
three AMRs to determine if they met NRC requirements for being
traceable, transparent, and technically appropriate for their use in
the license application. In all three AMRs, NRC found significant
problems with both traceability and transparency.[Footnote 4] NRC
concluded that these findings suggested that other AMRs may have
similar problems and that such problems could delay NRC's review of the
license application, as it would need to conduct special inspections to
resolve any problems it found with the quality of technical information.
To address problems of traceability and transparency, DOE initiated an
effort in the spring of 2004 called the Regulatory Integration Team
(RIT) to perform a comprehensive inspection and rework of the AMRs and
ensure they met NRC requirements and expectations.[Footnote 5]
According to DOE officials, the RIT involved roughly 150 full-time
personnel from DOE, USGS, and multiple national laboratories such as
Sandia, Los Alamos, and Lawrence Livermore. The RIT decided that 89 of
the approximately 110 AMRs needed rework. According to DOE officials,
the RIT addressed or corrected over 3,700 problems, and was completed
approximately 8 months later at a cost of about $20 million. In a
February 2005 letter to DOE, the site contractor stated that the RIT
effort had successfully improved the AMRs' traceability and
transparency.
Subsequently, however, DOE identified additional problems with
traceability and transparency that required further inspections and
rework. DOE initiated a review of additional AMRs that were not
included in the scope of the 2004 RIT review after a March 2005
discovery of e-mails from USGS employees written between May 1998 and
March 2000 implying that employees had falsified documentation of their
work to avoid quality assurance standards. These additional AMRs
contained scientific work performed by the USGS employees and had been
assumed by the RIT to meet NRC requirements for traceability and
transparency. However, according to DOE officials, DOE's review
determined that these AMRs did not meet NRC's standards, and rework was
required. DOE identified similar problems as the focus of the project
shifted to the design and engineering work required for the license
application. In February 2005, the site contractor determined that, in
addition to problems with AMRs, similar traceability and transparency
problems existed in the design and engineering documents that
constitute the Safety Analysis Report--the report necessary to
demonstrate to NRC that the repository site will meet the project's
health, safety, and environmental goals and objectives. In an analysis
of this problem, the site contractor noted that additional resources
were needed to inspect and rework the documents to correct the problems.
DOE Cannot Be Certain Its Efforts to Improve Quality Assurance Have
Been Effective Because of Weaknesses in Tracking Progress and
Identifying Problems:
DOE's management tools for the Yucca Mountain project have not enabled
it to effectively identify and track progress in addressing significant
and recurring quality assurance problems. Specifically, its panel or
one-page summary of selected performance indicators did not highlight
the areas of management concern covered by its Management Improvement
Initiatives (Initiatives) and had weaknesses in assessing progress
because the indicators kept changing. Its trend reports also did not
focus on tracking these management concerns, had technical weaknesses
for identifying significant and recurrent problems, and has
inconsistently tracked progress with problems. Furthermore, the trend
reports have sometimes been misleading as to the significance of the
problems being presented because their significance ratings tend to be
lower if corrective actions were already being taken, without
considering the effectiveness of the actions or the problem's
importance to the project.
In April 2004, DOE told us it expected that the progress achieved with
its Initiatives for improving quality assurance would continue and that
its performance indicators would enable it to assess further progress
and direct management attention as needed. By that time, the actions
called for by the Initiatives had been completed and project management
had already developed a "panel" of indicators to use at monthly
management meetings to monitor project performance. The panel was a
single page composed of colored blocks representing selected
performance indicators and their rating or level of performance. For
example, a red block indicated degraded or adverse performance
warranting significant management attention, a yellow block indicated
performance warranting increased management attention or acceptable
performance that could change for the worse, and a green block
indicated good performance. The panel represented a hierarchy of
indicators where the highest-level indicators were visible, but many
lower-level indicators that determined the ratings of the visible
indicators were not shown. Our review analyzed a subset of these
indicators that DOE designated as the best predictors in areas
affecting quality.
We found that the panel was not effective for assessing continued
progress because its indicators poorly represented the management
concerns identified by the Initiatives. The Initiatives had raised
concerns about five key areas of management weakness as adversely
affecting the implementation of quality assurance requirements, and had
designated effectiveness indicators for these areas. (These areas of
concern are described in app. I.) However, two of the Initiatives' five
key areas of concern--roles and responsibilities as well as work
procedures--were not represented in the panel's visible or underlying
indicators. In other cases, the Initiatives' effectiveness indicators
were represented in underlying lower-level indicators that had very
little impact on the rating of the visible indicator. For example, the
Initiatives' indicator for timely completion of employee concerns was
represented by two lower-level indicators that together contributed 3
percent of the rating for an indicator visible in the panel.
Another shortcoming of the panel was that frequent changes to the
indicators hindered the ability to identify problems for management
attention and track progress in resolving them. The indicators could
change in many ways, such as how they were defined or calculated. Such
changes made it difficult to measure progress because changes in
indicator ratings could reflect only the changes in the indicators
rather than actual performance changes. Some of the indicators tracking
quality issues changed from one to five times during the 8-month period
from April 2004 through November 2004. Even after a major revision of
the panel in early 2005, most of the performance indicators tracking
quality issues continued to change over the next 6 months--that is,
from March 2005 through August 2005. Only one of these five indicators
did not change during this period. One indicator was changed four times
during the 6-month period, resulting in it being different in more
months than it remained the same. Moreover, the panel was not always
available to track problems. It was not created for December 2004
through February 2005, and it has not been created since August 2005.
In both cases, the panel was undergoing major revisions. In December
2005, a senior DOE official told us that the project would begin to
measure key activities, but without use of the panel.
According to DOE, a second management tool, the project's quarterly
trend evaluation reports, captured some aspects of the Initiatives'
areas of concern and their associated effectiveness indicators that
were not represented in the performance indicators. However, the trend
reports are designed more to identify emerging and unanticipated
problems than to monitor progress with already identified problems,
such as those addressed by the Initiatives. In developing these
reports, trend analysts seek to identify patterns and trends in
condition reports, which document problematic conditions through the
project's Corrective Action Program. For example, analysis might reveal
that most occurrences of a particular type of problem are associated
with a certain organization.
In practice, DOE missed opportunities to use trend reports to assess
progress in the Initiatives' areas of concern. For example, DOE missed
an opportunity to use trend reports to discuss the Initiatives' goal
that the project's work organizations become more accountable for self-
identifying significant problems. The August 2005 trend report briefly
cited an evaluation of a condition report highlighting the low rate of
self-identification of significant problems during the previous quarter
and reported the evaluation's conclusion that it was not a problem
warranting management attention. However, the trend report did not
mention that about 35 percent of significant problems were self-
identified during the previous quarter, while the Initiatives' goal was
that 80 percent of significant problems would be self-identified.
Beyond whether they effectively track the Initiatives' areas of
concern, trend reports generally face serious obstacles to adequately
identifying recurrent and significant problems. For example, trend
analysis tends to focus on the number of condition reports issued, but
the number of reports does not necessarily reflect the significance of
a problem. For example, the number of condition reports involving
requirements management decreased by over half from the first quarter
to the second quarter of fiscal year 2005. However, this decrease was
not a clear sign of progress. Not only did the number rise again in the
third quarter, but the May 2005 trend report also noted that the number
of all condition reports had dropped during the second quarter.
According to the report, the volume of condition reports had been high
in the first quarter because of reviews of various areas, including
requirements management.
Due, in part, to these obstacles, trend reports have not consistently
determined the significance of problems or performed well in tracking
progress in resolving them. For example, trend reports have
questionably identified human performance as a significant problem for
resolution and ineffectively tracked progress in resolving it because
there was (1) no clearly appropriate or precise benchmark for
performance, (2) a changing focus on the problem, and (3) unreliable
data on cause codes. The February 2004 trend report identified a human
performance problem based on Yucca Mountain project data showing the
project's proportion of skill-based errors to all human performance
errors was two times higher than benchmark data from the Institute of
Nuclear Power Operations (INPO).[Footnote 6] Interestingly, the report
cautioned that other comparisons with these INPO data may not be
appropriate because of differences in the nature, complexity, and scope
of work performed, but did not explain why this caution did not apply
to the report's own comparison. While this comparison has not appeared
in trend reports since May 2004, a November 2004 trend report changed
the focus of the problem to the predominance of human performance
errors in general, rather than the skill-based component of these
errors. (Later reports reinterpreted this predominance as not a
problem.) The report cited an adverse trend based on the fact that the
human performance cause category accounted for over half of the total
number of causes for condition reports prepared during the quarter.
Nevertheless, by February 2005, trend reports began interpreting this
predominance as generally appropriate, given the type of work done by
the project. That is, the project's work involves mainly human efforts
and little equipment, while work at nuclear power plants involves more
opportunities for errors caused by equipment. In our view, this
interpretation that a predominance of human performance errors would be
expected implies an imprecise benchmark for appropriate performance.
Further, although trend reports continued to draw conclusions about
human performance problems, the February 2005 report indicated that any
conclusions were hard to justify because of data reliability problems
with cause coding. For example, the majority of problems attributed to
human performance causes are minor problems, such as not completing a
form, that receive less-rigorous cause analysis. This less-rigorous
analysis tends to reveal only individual human errors--that is, human
performance problems--whereas more-rigorous analysis tends to reveal
less-obvious problems with management and procedures.
Another shortcoming of the trend reports was that their rating
categories made it difficult to adequately determine the significance
of some problems. Specifically, trend reports sometimes assigned a
problem a lower significance than justified because corrective actions
were already being taken. The rating categories for a problem's
significance also involve an assessment of the need for management
action. In their current formulation, DOE's rating categories cannot
accurately represent both these assessments, and the designated rating
category can distort one or the other assessment. For instance, a
November 2005 trend report rated certain requirements management issues
as a "monitoring trend"--defined as a small perturbation in numbers
that does not warrant action but needs to be monitored closely.
However, this rating did not accurately capture the report's
simultaneous recognition that significant process problems spanned both
BSC and DOE and the fact that the numbers and types of problems were
consistently identified over the previous three quarters. A more
understandable explanation for why the problem received a low rating is
that designating the problem at any higher level of significance would
have triggered guidelines involving the issuance of a condition report,
which, according to the judgment expressed in the report, was not
needed. Specifically, the report indicated that existing condition
reports have already identified and were evaluating and resolving the
problem, thereby eliminating the need to issue a new condition report.
However, by rating the problem at the lowest level of significance, the
trend report did not sufficiently draw management's attention to the
problem. At about the same time the trend report judged no new
condition reports were necessary, a separate DOE investigation of
requirements management resulted in 14 new condition reports--3 at the
highest level of significance and 8 at the second-highest level of
significance. These condition reports requested, for instance, an
analysis of the collective significance of the numerous existing
condition reports and an assessment of whether the quality assurance
requirement for complete and prompt remedial action had been met. As a
result of the investigation and a concurrent DOE root cause
analysis,[Footnote 7] DOE stated during the December 2005 quarterly
management meeting with NRC that strong actions were required to
address the problems with its requirements management system and any
resulting uncertainty about the adequacy of its design products.
I would now like to update you on the project's February 2006 stop-work
order, which occurred too late to be included in our report. We believe
this incident is an example of how the project's management tools have
not been effective in bringing quality assurance problems to top
management's attention. After observing a DOE quality assurance audit
at the Lawrence Livermore National Laboratory in August 2005, NRC
expressed concern that humidity gauges used in scientific experiments
at the project were not properly calibrated--an apparent violation of
quality assurance requirements. According to an NRC official, NRC
communicated these findings to BSC and DOE project officials on six
occasions between August and December 2005, and issued a formal report
and letter to DOE on January 9, 2006. However, despite these
communications and the potentially serious quality assurance problems
involved, the project's acting director did not become aware of the
issue until January 2006, after reading about it in a news article. Due
to concerns that quality assurance requirements had not been followed
and the length of time it took top management to become aware of the
issue, BSC issued a February 7, 2006, stop-work order affecting this
scientific work. Project officials have begun a review of the issue.
DOE's New Path Forward to Submitting a License Application Faces
Substantial Quality Assurance and Other Challenges:
In pursuing its new path forward, DOE faces significant quality
assurance and other challenges, including (1) determining the extent of
problems and restoring confidence in the documents supporting the
license application after the discovery of e-mails raising the
potential of falsified records, (2) settling the design issues and the
associated problems with requirements management, and (3) replacing key
personnel and managing the transition of new managers and other
organizational challenges.
The early 2005 discovery of USGS e-mails suggesting possible
noncompliance with the project's quality assurance requirements has
left lingering concerns about the adequacy of USGS's scientific work
related to the infiltration or flow of water into the repository and
whether other work on the project has similar quality assurance
problems. As part of its new path forward, DOE has taken steps to
address these concerns. It is reworking technical documents created by
USGS personnel to ensure that the science underlying the conclusions on
water infiltration is correct and supportable. In addition, DOE is
conducting an extensive review of approximately 14 million e-mails to
determine whether they raise additional quality assurance concerns.
According to NRC on-site representatives, screening these millions of e-
mails to ensure that records were not falsified will be challenging.
Further, many of the e-mails were written by employees who no longer
work at the project or may be deceased, making it difficult to learn
their true meaning and context. Moreover, if additional e-mails raise
quality assurance concerns, DOE may have to initiate further review,
inspections, or rework.
DOE officials have stated that it will need to resolve long-standing
quality assurance problems involving requirements management before it
can perform the design and engineering work needed to support the
revised project plans called for by its new path forward. According to
a 2005 DOE root cause analysis report, low-level documents were
appropriately updated and revised to reflect high-level design changes
through fiscal year 1995. However, from 1995 through 2002, many of
these design documents were not adequately maintained and updated to
reflect current designs and requirements. Further, a document that is a
major component of the project's requirements management process was
revised in July 2002, but has never been finalized or approved.
Instead, the project envisioned a transition to a new requirements
management system after the submission of the license application,
which at that time was planned for December 2004. However, for various
reasons, the license application was not submitted, and the transition
to a new requirements management system was never implemented. The DOE
report described this situation as "completely dysfunctional" and
identified the root cause of these conditions as DOE's failure to fund,
maintain, and rigidly apply a requirements management system. According
to an NRC on-site representative, repetitive and uncorrected issues
associated with the requirements management process could have direct
implications for the quality of DOE's license application.
In December 2005, DOE issued a stop-work order on design and
engineering for the project's surface facility and certain other
technical work. DOE stated that a root cause analysis and an
investigation into employee concerns had revealed that the project had
not maintained or properly implemented its requirements management
system, resulting in inadequacies in the design control process. The
stop-work order will be in effect until, among other things, the lead
contractor improves the requirements management system, validates that
processes exist and are being followed, and requirements are
appropriately traced to implementing mechanisms and products. Further,
DOE will establish a team to take other actions necessary to prevent
inadequacies in requirements management and other management systems
from recurring.
Finally, DOE continues to be challenged to effectively manage a
changing and complex program and organization. The significant project
changes initiated under the new path forward create the potential for
confusion over accountability as roles and responsibilities change--a
situation DOE found to contribute to quality assurance problems during
an earlier transition period. An important part of this challenge is
ensuring that accountability for quality and results are effectively
managed during the transition to the new path forward. For example,
DOE's plan to establish a lead laboratory to assist the project would
not only have to be effectively managed, but also would introduce a new
player whose accountability DOE would have to ensure. According to one
DOE manager, transitioning project work to a lead laboratory under a
direct contract with DOE could pose a significant challenge for quality
assurance because the various laboratories assisting with the project
are currently working under BSC quality assurance procedures and will
now have to develop their own procedures.
In addition, the project faces management challenges related to
ensuring management continuity at the project. DOE has experienced
turnover in 9 of 17 key management positions since 2001. For example,
in the past year, the project has lost key managers through the
departures of the Director of Project Management and Engineering, the
Director of the License Application and Strategy, the Director of
Quality Assurance, and the contractor's General Manager. To ensure the
right managers move the project forward to licensing, the project has a
recruitment effort for replacing key departing managers. Further, the
director position for the project has been occupied by three
individuals since 1999 and is currently filled by an acting director.
The current Acting Director took his position in summer 2005, and
initiated the new path forward in October 2005. DOE is currently
awaiting congressional confirmation of a nominee to take the director
position. However, the current Acting Director told us he expects that
the new path forward will be sustained after the new director assumes
the position because it has been endorsed by the Secretary of Energy.
Conclusions:
DOE has a long history of trying to resolve quality assurance problems
at its Yucca Mountain project. Now, after more than 20 years of work,
DOE once again faces serious quality assurance and other challenges
while seeking a new path forward to a fully defensible license
application. Even as DOE faces new quality assurance challenges, it
cannot be certain that it has resolved past problems. It is clear that
DOE has not been well served by management tools that have not
effectively identified and tracked progress on significant and
recurring problems. As a result, DOE has not had a strong basis to
assess progress in addressing management weaknesses or to direct
management attention to significant and recurrent problems as needed.
Unless these quality assurance problems are addressed, further delays
on the project are likely.
Mr. Chairman, this concludes my prepared statement, I would be happy to
respond to any questions that you or other Members of the Subcommittee
may have at this time.
GAO Contact and Staff Acknowledgments:
For further information about this testimony, please contact Jim Wells
at (202) 512-3841 or wellsj@gao.gov. Casey Brown, John Delicath, Terry
Hanford, and Raymond Smith also made key contributions to this
statement.
[End of section]
Appendix I: The Management Improvement Initiatives' Key Areas of
Concern:
The Department of Energy's Management Improvement Initiatives
(Initiatives) perceived five key areas of management weakness as
adversely affecting the implementation of quality assurance
requirements at the Yucca Mountain project:
1. Roles and responsibilities were becoming confused as the project
transitioned from scientific studies to activities supporting
licensing. The confusion over roles and responsibilities was
undermining managers' accountability for results. The Initiatives'
objective was to realign DOE's project organization to give a single
point of responsibility for project functions, such as quality
assurance and the Corrective Action Program, and hold the project
contractor more accountable for performing the necessary work in
accordance with quality, schedule, and cost requirements.
2. Product quality was sometimes being achieved through inspections by
the project's Office of Quality Assurance rather than being routinely
implemented by the project's work organizations. As a result, the
Initiatives sought to increase work organizations' responsibility for
being the principle means for achieving quality.
3. Work procedures were typically too burdensome and inefficient, which
impeded work. The Initiatives sought to provide new user-friendly and
effective procedures, when necessary, to allow routine compliance with
safety and quality requirements.
4. Multiple corrective action programs existed, processes were
burdensome and did not yield useful management reports, and corrective
actions were not completed in a timely manner. The Initiatives sought
to implement a single program to ensure that problems were identified,
prioritized, and documented and that timely and effective corrective
actions were taken to preclude recurrence of problems.
5.The importance of a safety-conscious work environment that fosters
open communication about concerns was not understood by all managers
and staff, and they had not been held accountable when inappropriately
overemphasizing the work schedule, inadequately attending to work
quality, and acting inconsistently in practicing the desired openness
about concerns. Through issuing a work environment policy, providing
training on the policy, and improving the Employee Concerns Program,
the Initiatives sought to create an environment in which employees felt
free to raise concerns without fear of reprisal and with confidence
that issues would be addressed promptly and appropriately.
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FOOTNOTES
[1] GAO-06-313 (Washington, D.C.: Mar. 17, 2006).
[2] GAO, Yucca Mountain: Persistent Quality Assurance Problems Could
Delay Repository Licensing and Operation, GAO-04-460 (Washington, D.C.:
Apr. 30, 2004).
[3] GAO, Nuclear Waste: Repository Work Should Not Proceed Until
Quality Assurance Is Adequate, GAO/RCED-88-159 (Washington, D.C.: Sept.
29, 1988).
[4] U.S. Nuclear Regulatory Commission, U.S. Nuclear Regulatory
Commission Staff Evaluation of U.S. Department of Energy Analysis Model
Reports, Process Controls, and Corrective Actions (Washington, D.C.,
Apr. 7, 2004).
[5] In addition, the RIT edited the AMRs to assure consistency and ease
of technical and regulatory reviews.
[6] Skill-based errors are defined in trend reports as unintentional
errors resulting from people not paying attention to the task at hand.
[7] A root cause analysis seeks to determine the root cause of a
problem, which is the underlying cause that must change in order to
prevent the problem from reoccurring.
