Nuclear and Worker Safety
Actions Needed to Determine the Effectiveness of Safety Improvement Efforts at NNSA's Weapons Laboratories Gao ID: GAO-08-73 October 31, 2007Federal officials, Congress, and the public have long voiced concerns about safety at the nation's nuclear weapons laboratories: Lawrence Livermore, Los Alamos, and Sandia. The laboratories are overseen by the National Nuclear Security Administration (NNSA), while contractors carry out the majority of the work. A recent change to oversight policy would result in NNSA's relying more on contractors' own management controls, including those for assuring safety. This report discusses (1) the recent history of safety problems at the laboratories and contributing factors, (2) steps taken to improve safety, and (3) challenges that remain to effective management and oversight of safety. To address these objectives, GAO reviewed almost 100 reports and investigations and interviewed key federal and laboratory officials.
The nuclear weapons laboratories have experienced persistent safety problems, stemming largely from long-standing management weaknesses. Since 2000, nearly 60 serious accidents or near misses have occurred, including worker exposure to radiation, inhalation of toxic vapors, and electrical shocks. Although no one was killed, many of the accidents caused serious harm to workers or damage to facilities. Accidents and nuclear safety violations also contributed to the temporary shutdown of facilities at both Los Alamos and Lawrence Livermore in 2004 and 2005. Yet safety problems persist. GAO's review of nearly 100 reports issued since 2000 found that the contributing factors to these safety problems generally fall into three key areas: relatively lax laboratory attitudes toward safety procedures, laboratory inadequacies in identifying and addressing safety problems with appropriate corrective actions, and inadequate oversight by NNSA site offices. NNSA and its contractors have been taking some steps to address safety weaknesses at the laboratories. Partly in response to continuing safety concerns, NNSA has begun taking steps to reinvigorate a key safety effort--integrated safety management--originally started in 1996. This initiative was intended to raise safety awareness and provide a formal process for employees to integrate safety into every work activity by identifying potential safety hazards and taking appropriate steps to mitigate these hazards. NNSA and its contractors have also begun taking steps to develop or improve systems for identifying and tracking safety problems and the corrective actions taken in response. Finally, NNSA has initiated efforts to strengthen federal oversight at the laboratories by improving hiring and training of federal site office personnel. NNSA has also taken steps to strengthen contractor accountability through new contract mechanisms. Many of these efforts are still under way, however, and their effect on safety performance is not clear. NNSA faces two principal challenges in its continuing efforts to improve safety at the weapons laboratories. First, the agency has no way to determine the effectiveness of its safety improvement efforts, in part because those efforts rarely incorporate outcome-based performance measures. The department issued a directive in 2003 requiring use of a disciplined approach for managing improvement initiatives, often used by high-performing organizations, including results-oriented outcome measures and a system to evaluate the effectiveness of the initiative. Yet GAO found little indication that NNSA or its contractors have been managing safety improvement efforts using this approach. Second, in light of the long-standing safety problems at the laboratories, GAO and others have expressed concerns about the recent shift in NNSA's oversight approach to rely more heavily on contractors' own safety management controls. Continuing safety problems, coupled with the inability to clearly demonstrate progress in remedying weaknesses, make it unclear how this revised system will enable NNSA to maintain an appropriate level of oversight of safety performance at the weapons laboratories.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-08-73, Nuclear and Worker Safety: Actions Needed to Determine the Effectiveness of Safety Improvement Efforts at NNSA's Weapons Laboratories
This is the accessible text file for GAO report number GAO-08-73
entitled 'Nuclear And Worker Safety: Actions Needed to Determine the
Effectiveness of Safety Improvement Efforts at NNSA's Weapons
Laboratories' which was released on November 28, 2007.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
October 2007:
Nuclear And Worker Safety:
Actions Needed to Determine with Effectiveness of Safety Improvement
Efforts at NNSA's Weapons Laboratories:
GAO-08-73:
GAO Highlights:
Highlights of GAO-08-73, a report to congressional committees.
Why GAO Did This Study:
Federal officials, Congress, and the public have long voiced concerns
about safety at the nation‘s nuclear weapons laboratories: Lawrence
Livermore, Los Alamos, and Sandia. The laboratories are overseen by the
National Nuclear Security Administration (NNSA), while contractors
carry out the majority of the work. A recent change to oversight policy
would result in NNSA‘s relying more on contractors‘ own management
controls, including those for assuring safety.
This report discusses (1) the recent history of safety problems at the
laboratories and contributing factors, (2) steps taken to improve
safety, and (3) challenges that remain to effective management and
oversight of safety. To address these objectives, GAO reviewed almost
100 reports and investigations and interviewed key federal and
laboratory officials.
What GAO Found:
The nuclear weapons laboratories have experienced persistent safety
problems, stemming largely from long-standing management weaknesses.
Since 2000, nearly 60 serious accidents or near misses have occurred,
including worker exposure to radiation, inhalation of toxic vapors, and
electrical shocks. Although no one was killed, many of the accidents
caused serious harm to workers or damage to facilities. Accidents and
nuclear safety violations also contributed to the temporary shutdown of
facilities at both Los Alamos and Lawrence Livermore in 2004 and 2005.
Yet safety problems persist. GAO‘s review of nearly 100 reports issued
since 2000 found that the contributing factors to these safety problems
generally fall into three key areas: relatively lax laboratory
attitudes toward safety procedures, laboratory inadequacies in
identifying and addressing safety problems with appropriate corrective
actions, and inadequate oversight by NNSA site offices.
NNSA and its contractors have been taking some steps to address safety
weaknesses at the laboratories. Partly in response to continuing safety
concerns, NNSA has begun taking steps to reinvigorate a key safety
effort”integrated safety management”originally started in 1996. This
initiative was intended to raise safety awareness and provide a formal
process for employees to integrate safety into every work activity by
identifying potential safety hazards and taking appropriate steps to
mitigate these hazards. NNSA and its contractors have also begun taking
steps to develop or improve systems for identifying and tracking safety
problems and the corrective actions taken in response. Finally, NNSA
has initiated efforts to strengthen federal oversight at the
laboratories by improving hiring and training of federal site office
personnel. NNSA has also taken steps to strengthen contractor
accountability through new contract mechanisms. Many of these efforts
are still under way, however, and their effect on safety performance is
not clear.
NNSA faces two principal challenges in its continuing efforts to
improve safety at the weapons laboratories. First, the agency has no
way to determine the effectiveness of its safety improvement efforts,
in part because those efforts rarely incorporate outcome-based
performance measures. The department issued a directive in 2003
requiring use of a disciplined approach for managing improvement
initiatives, often used by high-performing organizations, including
results-oriented outcome measures and a system to evaluate the
effectiveness of the initiative. Yet GAO found little indication that
NNSA or its contractors have been managing safety improvement efforts
using this approach. Second, in light of the long-standing safety
problems at the laboratories, GAO and others have expressed concerns
about the recent shift in NNSA‘s oversight approach to rely more
heavily on contractors‘ own safety management controls. Continuing
safety problems, coupled with the inability to clearly demonstrate
progress in remedying weaknesses, make it unclear how this revised
system will enable NNSA to maintain an appropriate level of oversight
of safety performance at the weapons laboratories.
What GAO Recommends:
GAO recommends that NNSA strengthen management and oversight of
laboratory safety by ensuring that safety improvement initiatives be
carried out in a systematic manner, with effective performance measures
based on outcomes, not process; retaining sufficient independent
federal oversight; and reporting annually to Congress on progress
toward making the weapons laboratories safer. In commenting on a draft
of this report, NNSA generally agreed with the report and
recommendations.
To view the full product, including the scope and methodology, click on
GAO-08-73. For more information, contact Gene Aloise, 202-512-3841,
AloiseE@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Long-standing Management Weaknesses Contribute to the Laboratories'
Persistent Safety Problems:
NNSA and Contractors Have Been Taking Some Steps to Address Management
Weaknesses:
NNSA Faces Fundamental Challenges to Effective Management and Oversight
of Safety at Weapons Laboratories:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: List of Key Safety Evaluations:
Appendix III: Enforcement Actions at NNSA Weapons:
Appendix IV: Comments from the Department of Energy:
Appendix V: GAO Contact and Staff Acknowledgments:
[End of section]
October 31, 2007:
The Honorable Joe Barton:
Ranking Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Ed Whitfield:
Ranking Member:
Subcommittee on Oversight and Investigations:
Committee on Energy and Commerce:
House of Representatives:
The National Nuclear Security Administration[Footnote 1] (NNSA)
oversees three weapons laboratories--Lawrence Livermore, Los Alamos,
and Sandia national laboratories[Footnote 2]--to help carry out its
missions of nuclear weapons stewardship, environmental cleanup, and
scientific and technical research. The sensitive research conducted at
these laboratories involves the handling of radioactive and hazardous
materials, such as plutonium, and radioactive wastes that, if not
handled safely, could cause nuclear accidents or expose the public and
the environment to heavy doses of radiation. The weapons laboratories
also conduct a wide range of other activities, including construction
and routine maintenance and operation of equipment and facilities, that
also run the risk of accidents. Although the consequences of such
accidents could be less severe than one involving nuclear materials,
they could also lead to long-term illness, injury, or even deaths among
workers or the public.
NNSA relies on contractors and subcontractors to perform day-to-day
operations at each site. To promote laboratory and worker safety,
NNSA's primary approach has been to require its contractors to follow
federal safety laws and Department of Energy (DOE) requirements,
including policies, orders, and standards, by incorporating these
requirements into the contracts. DOE requirements address safety both
in nuclear operations (nuclear safety) and in maintaining health and
safety of laboratory workers (worker safety). NNSA site offices located
at the laboratories are responsible for direct oversight of the
contractors, including monitoring contractor-generated data on safety-
related incidents and observing daily work activities in the facility.
A recent change in DOE policy places more responsibility on the
contractor for having a reliable system of management controls,
including those addressing safety, and focuses NNSA oversight efforts
on high-hazard activities.
Over the years, federal officials, Congress, and members of the public
have expressed concerns about safety problems and weaknesses at the
weapons laboratories. The Defense Nuclear Facilities Safety Board
(Safety Board), which was created by Congress to provide an independent
assessment of safety conditions and operations at defense nuclear
facilities, held a series of eight public hearings starting in 2002 to
address concerns with DOE's approach to ensuring safety--including at
NNSA's weapons laboratories--and in 2004 recommended that the
department take a number of steps, such as strengthening the federal
oversight role, in an effort to improve safety at these facilities. In
addition, more than a dozen congressional hearings have addressed
management problems at Los Alamos National Laboratory, including a May
2005 hearing that raised questions about the laboratory's ability to
manage safety issues.[Footnote 3]
In this context, you asked us to examine NNSA's safety performance at
the three weapons laboratories. This report discusses (1) the recent
history of safety problems that have occurred at the weapons
laboratories and contributing factors, (2) steps NNSA and its
contractors have taken to improve safety management, and (3) challenges
that remain to effective management and oversight of safety performance
at the weapons laboratories.
To address these issues, we reviewed federal laws and regulations
describing safety requirements for nuclear safety and for worker safety
and health. We also reviewed DOE policies and procedures regarding
safety management. We reviewed relevant reports issued since 2000
evaluating safety issues at the three weapons laboratories, including
accident investigations, inspections by DOE's Office of Independent
Oversight and Performance Assurance,[Footnote 4] reviews by NNSA's
Chief of Defense Nuclear Safety, and reviews by the Safety Board. We
also discussed the safety problems and contributing factors with
representatives from these organizations, as well as with DOE and NNSA
headquarters officials. In addition, we visited the three weapons
laboratories and met with NNSA officials and contractors to discuss
safety management and safety problems at the laboratories and to
determine what steps NNSA and contractors were taking to address these
issues. Appendix I describes our scope and methodology in more detail.
We performed our work in accordance with generally accepted government
auditing standards, which included an assessment of data reliability,
from September 2006 through September 2007.
Results in Brief:
The three NNSA weapons laboratories have experienced persistent safety
problems--including accidents and violations of nuclear safety rules
designed to protect workers and the public--stemming largely from long-
standing management weaknesses. Since 2000, nearly 60 serious accidents
or near misses have occurred at the laboratories, including worker
exposure to radiation, inhalation of toxic vapors, and electrical
shocks. Although no one was killed, many of the accidents caused
serious harm to workers or damage to facilities. For example, in an
accident at Los Alamos in 2000, seven workers received significant
doses of radiation--four requiring immediate medical attention--
because, the accident investigation concluded, the laboratory had
failed to take appropriate corrective action after similar previous
accidents. In addition, since 2000, two of the laboratories (Los Alamos
and Lawrence Livermore) have been found in violation of nuclear safety
rules on a total of eight separate occasions--violations that signal
safety vulnerabilities. Accidents and nuclear safety violations also
contributed to the temporary shutdown of facilities at both Los Alamos
and Lawrence Livermore in 2004 and 2005, respectively, costing
taxpayers hundreds of millions of dollars in lost productivity.
Nevertheless, safety problems persist. We reviewed nearly 100 reports
issued since 2000 that address safety at the three weapons
laboratories--including accident investigations and independent
assessments of safety--and found that factors contributing to these
safety problems generally fall into three key areas:
* A relatively lax attitude toward safety procedures. Lax safety
attitudes at the three laboratories have created an environment where
workers can become complacent about following safety requirements, and
managers about enforcing them, raising the potential for accidents.
* Weaknesses in identifying safety problems and taking appropriate
corrective actions. Fundamental weaknesses in the laboratories' ability
to accurately identify and fully understand safety problems and
implement appropriate corrective actions have hampered the
laboratories' ability to improve safety performance.
* Inadequate oversight by NNSA site offices. Shortcomings in federal
oversight of safety at the laboratories have included insufficient
technical and safety expertise at the site offices to perform adequate
and timely on-site reviews.
NNSA and its contractors have been taking some steps to address
weaknesses in these three key areas. NNSA's key safety effort--
integrated safety management--was originally launched in 1996 in
response to concerns raised by the Safety Board about safety culture
and safety management issues DOE-wide. This effort was intended to
raise safety awareness and provide a formal process for employees to
integrate safety into every work activity by identifying potential
safety hazards and taking appropriate steps to mitigate these hazards.
In response to continuing Safety Board concerns about safety at NNSA
nuclear facilities, NNSA began taking steps to reinvigorate this
program. To address weaknesses in how safety problems are identified
and corrected, NNSA and its contractors have also begun taking steps to
develop or improve systems for identifying and tracking safety problems
and the corrective actions taken in response. Further, NNSA has
initiated efforts to strengthen federal oversight at the laboratories
by improving hiring and training of federal site office personnel. In
addition, NNSA has been taking steps to hold contractors more
accountable for safety, including using new contract mechanisms that
provide for additional fee or contract extensions for meeting annual
safety and other goals. It also implemented a new regulation in
February 2007, which allows the agency to either impose fines on
contractors or reduce contractors' fees or profit for failing to follow
existing worker safety requirements. Many of these efforts are still
under way, however, and their effect on safety performance is not
clear.
NNSA faces two principal challenges in its continuing efforts to
improve safety at the laboratories. First, the agency lacks a way to
determine the effectiveness of its safety improvement efforts, in part
because those efforts rarely incorporate outcome-based performance
measures. We have found that high-performing organizations often use a
systematic approach to managing improvement efforts that includes,
among other things, clear goals and results-oriented outcome measures.
Despite a DOE directive calling for a disciplined, systematic approach
to implementing improvement initiatives--one including results-
oriented outcome measures and a system to evaluate effectiveness--NNSA
has not adopted such an approach with regard to safety at the weapons
laboratories. Rather, safety performance measures are often process-
oriented, with no indication of how they might be used to gauge the
effectiveness of safety improvement efforts. Second, because of the
long-standing safety problems at the laboratories, we and others have
raised concerns over the agency's shift in its oversight approach to
rely more heavily on contractors' own safety management controls. Given
the persistent safety problems at the laboratories, coupled with NNSA's
and contractors' continued inability to clearly demonstrate progress in
remedying weaknesses, it is unclear how this revised system will enable
NNSA to maintain an appropriate level of oversight of safety
performance at the weapons laboratories.
To strengthen safety management and oversight at the nation's weapons
laboratories, we recommend that the Secretary of Energy direct the
Administrator of NNSA to ensure that safety improvement initiatives
comply with DOE requirements, in particular, that they be carried out
in a systematic manner, with effective performance measures based on
outcomes, not process; retain sufficient independent federal oversight
of safety to fulfill its responsibilities associated with protecting
workers, the public, and the environment; and report annually to
Congress on progress toward making the weapons laboratories safer.
In commenting on a draft of this report, NNSA generally agreed with the
report and recommendations.
Background:
NNSA carries out the department's nuclear weapons research missions at
three weapons laboratories--Lawrence Livermore, Los Alamos, and Sandia
national laboratories. These three laboratories have primarily a
science and technology mission, which focuses on maintaining the
nation's nuclear weapons stockpile; preventing nuclear proliferation;
and furthering basic scientific knowledge in chemistry, structural
biology, and mathematics. In addition to their primary mission, the
three laboratories perform work for other federal agencies, such as
supporting homeland security efforts, and they coordinate research
efforts with DOE's Office of Science national laboratories in areas
such as climate change and nanotechnology. In support of these various
missions, contractors at the laboratories may carry out major
construction projects, as well as projects to clean up radioactive and
hazardous wastes from decades of producing materials or components for
nuclear weapons.
NNSA relies heavily on contractors to carry out its work, making
effective federal oversight crucial to accomplishing its missions. At
each of the laboratories, about 100 NNSA staff at the site office have
responsibility for overseeing the work performed under contract by
thousands of contractor employees. The contractors, in turn, may
subcontract out major portions of their work, especially in mission-
support areas such as constructing and maintaining facilities. Although
NNSA has no direct relationship with these subcontractors, it is
ultimately responsible for ensuring that all work, whether done by the
prime contractor or its subcontractors, is performed in a manner
consistent with the contract, including with all requirements for
nuclear and worker safety.
NNSA's contracts for the three laboratories generally provide for
reimbursing contractors for allowable costs plus an additional fee. The
total fee available to the contractors may include a base, or fixed,
amount that is guaranteed and an "at-risk" amount that is tied to
performance measures in the contract. To help strengthen
accountability, the department established a new contract provision in
1999 that allows it to reduce the fee otherwise earned if a contractor
does not meet certain environmental, safety, and health performance
standards.[Footnote 5]
DOE regulations and directives set forth requirements for ensuring that
nuclear facilities are operated safely to protect workers and the
public.[Footnote 6] NNSA's primary approach to ensuring nuclear and
worker safety is to incorporate these regulations and directives into
contracts. These rules require contractors to develop and maintain
documentation that (1) describes the work to be performed; (2)
evaluates all potential hazards and accident conditions; (3) contains
appropriate controls, including technical requirements, that will
eliminate or minimize the risk of hazards; and (4) delineates
procedures and practices for operating the facilities safely. This
documentation is commonly referred to as the facility's documented
safety basis. In addition, DOE regulations require that radiation doses
to workers at DOE facilities be maintained within prescribed limits.
NNSA's laboratories and facilities, with few exceptions, are not
regulated by the Nuclear Regulatory Commission or by the Occupational
Safety and Health Administration. Instead, DOE and NNSA provide
internal oversight of the three weapons laboratories at several
different levels. NNSA provides direct oversight of the laboratories
and the contracts through its site offices. In addition, NNSA
headquarters staff offices, such as the offices of Defense Programs and
Nuclear Nonproliferation, provide funding and program direction to the
site offices. DOE's Office of Enforcement[Footnote 7] and Office of
Independent Oversight and Performance Assurance (now called the Office
of Environment, Safety and Health Evaluations) and NNSA's Chief of
Defense Nuclear Safety and Senior Advisor for Environmental Safety and
Health also provide oversight of laboratory activities to ensure
nuclear and worker safety. Finally, the Safety Board, an independent
oversight organization created by Congress in 1988, provides advice and
recommendations to the Secretary of Energy to help ensure adequate
protection of public health and safety at all of the department's
defense nuclear facilities, including those at the three weapons
laboratories. As part of its independent oversight, the Safety Board
has full-time representatives at the Los Alamos and Lawrence Livermore
laboratories to work with the NNSA site offices and to observe
contractor work activities at the site's nuclear facilities.
Long-standing Management Weaknesses Contribute to the Laboratories'
Persistent Safety Problems:
From 2000 through 2007, the three NNSA weapons laboratories have been
troubled by persistent safety problems, including accidents and
violations of nuclear safety rules designed to protect laboratory
employees and the public. Our review of nearly 100 internal and
external safety reviews since 2000 found that factors contributing to
safety problems stemmed largely from weaknesses in NNSA's management of
safety issues at the weapons laboratories--weaknesses that leave the
laboratories vulnerable to continued, and potentially serious, safety
problems.
Accidents and Violations of Nuclear Safety Rules Persist at All Three
Weapons Laboratories:
From 2000 through 2007, nearly 60 accidents or near misses--each
serious enough to be investigated--have occurred at the three NNSA
weapons laboratories.[Footnote 8] The accidents have included radiation
exposures, inhalation of toxic vapors, electrical shocks, and injuries
during construction projects or maintenance activities. Fortunately, no
one has been killed, but many of these accidents have resulted in
serious worker injuries or facility damage. (Appendix II lists the
major accident investigations at the three weapons laboratories since
2000.) For example:
* In 2000, seven workers at a Los Alamos plutonium-processing and -
handling facility received significant doses of radiation from
plutonium released into the air from a faulty unit, known as a
glovebox, that shields people working with radioactive materials. When
plutonium is inhaled, it can damage cells or raise a person's risk of
getting cancer. In this incident, a technician was trying to determine
why the glovebox system was not operating properly; seven other workers
were in the room at the time. As the technician was working, a fitting
in the system leaked plutonium into the air, setting off alarms.
Although the eight workers left the room at once, at least four of them
were exposed to radiological releases much higher than the allowable
annual exposure limits set in regulation, raising their cancer risk.
(The workers were provided immediate treatment).
An internal DOE accident investigation found a number of factors behind
this accident--which, because of the number of workers involved and the
potential radiological doses, ranked among the top 10 worst
radiological intake accidents in 41 years of data gathering by DOE and
its predecessor agencies. These contributing factors included
inadequate design and configuration of the glovebox and its auxiliary
systems, lack of communication between workgroups tasked with
maintaining different parts of interconnected systems, weaknesses in
the technician's training, and informal operations in the plutonium-
handling facility. Moreover, according to the investigation report, the
Los Alamos Laboratory had apparently failed to apply lessons learned
from previous contamination releases in the same facility--including a
similar event 2 years before, involving the same glovebox and some of
the same people.
* In 2002, at another Los Alamos unit, liquid chlorine dioxide formed
unexpectedly during an experiment and then exploded, sending debris
into the air with enough force to destroy the fume hood where the
experiment was taking place and to knock out pieces of wall, ceiling,
and concrete. One of the two researchers present during the experiment
noticed a rapid rise in temperature in the experimental apparatus, and
both researchers fled the room seconds before the explosion, thus
averting serious injury or death. According to an independent
investigation of this accident, the experiment was changed to use 100
percent chlorine gas instead of 4 percent chlorine gas, a change that
warranted a formally changed hazard control plan; yet only informal
evaluations, without adequate analyses, review, or authorization, were
done. As a result, the researchers failed to recognize the potential
for formation of liquid chlorine dioxide and carried out the altered
experiment inside a vessel that could not withstand the high pressure
of the unanticipated liquid chlorine dioxide. According to the
investigation report, this accident represents a case in which division
management, line management, and workers had not adequately evaluated
or ensured implementation of existing safety requirements.
* In 2003, an accident at a construction site on the New Mexico campus
of Sandia National Laboratories seriously injured two ironworkers who
were part of a crew of three installing a steel stairway in one
building's open stairwell. As the crew was hoisting and positioning a
stair section near the top of the stairwell, a temporary hoisting beam
slipped and fell; it struck the first worker's hardhat on its way down
and crushed his foot before hitting the ground. Other parts of the
hoisting apparatus also collapsed, cutting another worker's shin and
knocking over a third worker. The first worker was hospitalized for a
week; the second worker required six stitches to close the wound on his
leg; the third worker escaped injury. The accident investigation report
stated that neither the installation of the temporary hoisting beam nor
the lifting of the stair section conformed to safety requirements. The
report further noted that lack of clarity in safety requirements and
poor communication between NNSA's Sandia site office, project
management, and subcontractors contributed to this preventable
accident.
Since 2000, Los Alamos and Lawrence Livermore have also been cited a
total of eight times for violating nuclear safety rules.[Footnote 9]
These rules are intended to protect workers and the public from nuclear
hazards, including unintended nuclear explosions and radiation
exposure, and under federal law,[Footnote 10] DOE has the authority to
impose fines, or civil penalties, on contractors that violate them. In
general, the rules (1) require analyses of work to be performed in a
nuclear facility so as to identify potential hazards and operate the
facility at an acceptably low level of risk and (2) spell out controls
needed to ensure the safety of workers and the public. The eight
citations levied since 2000 against Los Alamos and Lawrence Livermore
laboratories have carried total penalties of nearly $4 million[Footnote
11] for violations of a number of nuclear safety requirements by, for
example:
* failing to test safety equipment, such as fire-alarm systems, before
beginning work to ensure proper operation;
* failing to follow protective procedures for handling radioactive
materials;
* failing to label areas that contained high levels of radiation;
* illegally storing radioactive waste in a facility that lacked proper
operating documentation; and:
* failing to maintain proper documentation for the safe operation of
nuclear facilities.
In addition to accidents serious enough to warrant formal investigation
and violations of nuclear safety rules, the three laboratories have
experienced a number of less serious accidents and near misses. For
example, from 2004 to mid-2007,[Footnote 12] the three laboratories
have reported 97 worker injuries serious enough to require off-site
medical attention[Footnote 13] and more than 150 electrical and
mechanical near-miss incidents where serious injury could have
occurred. Other reviews have also raised concerns about safety at the
laboratories. In 2004, for instance, DOE's Office of Independent
Oversight and Performance Assurance and the Safety Board both raised
concerns about safety management at Lawrence Livermore Laboratory's
plutonium-handling facility, including concerns over the adequacy of
fire-suppression and ventilation systems in case of an accident.
At both Los Alamos and Lawrence Livermore laboratories, such persistent
safety problems (combined with concerns about security at Los Alamos)
ultimately resulted in the temporary closure, or stand- down, of
certain of the laboratories' facilities. On July 16, 2004, the director
of Los Alamos Laboratory suspended all laboratory operations, except
those specifically designated as critical, to address safety and
security concerns. The ensuing 10-month shutdown cost taxpayers an
estimated $121 million to $370 million in lost productivity. Similarly,
on January 15, 2005, the director of Lawrence Livermore Laboratory
suspended all programmatic work at the site's plutonium-handling
facility, largely because of numerous unresolved safety issues and
failure to address these issues adequately. The facility did not return
to full operation for 16 months. During the stand-downs, both
laboratories conducted comprehensive investigations into the causes of
the numerous safety and security problems and found hundreds of
deficiencies in both areas, which ranged from muddled lines of
authority to overly complex and unclear safety policies and procedures
to inadequate documentation and training.
Despite the stand-downs, however, all three laboratories have continued
to experience accidents warranting formal investigation, as well as
violations of nuclear safety rules. For example, of the nearly 60
accidents investigated at the three weapons laboratories since 2000, 15
of them have occurred since the stand-downs. In addition, Los Alamos
and Lawrence Livermore have both been cited for nuclear safety
violations since the stand-downs were declared. Accidents included the
following:
* In 2005, a worker at Los Alamos received and opened a package
containing radioactive material delivered from another Los Alamos site
and unknowingly contaminated himself, his clothing, and things he later
touched; the contamination was not detected for 11 days. The shippers
assumed the receiver would know that radiological contamination was
possible and would act accordingly, and they did not test the package
for contamination before shipping. The receiver, in contrast, assumed
the package was uncontaminated because he had not been alerted
otherwise. When the worker left that day, he was not screened for
potential contamination because the room he was working in was not
designated as a radiological control area. Over the next days and
weeks, the worker unwittingly spread contamination to his home, to
relatives' homes in Kansas and Colorado, and to other locales at Los
Alamos. In addition, he handled some otherwise nonradioactive parts,
which also became contaminated and were shipped to Pennsylvania. The
officials investigating this accident found a number of failures to
follow safety procedures, unverified assumptions, and undocumented
requirements; according to their report, "all of the accident's causal
factors were well established" before the accident.
* In 2006, an electrician working alone on a project to replace rooftop
air conditioners at Lawrence Livermore missed a step while climbing a
ladder mounted on the building. The worker fell and sustained multiple
fractures of his wrist, shoulder, and pelvis, along with other
injuries; he was hospitalized for nearly a month. The officials
investigating this accident explicitly stressed the "significance of
this seemingly simple accident--a worker slipped and fell from a
ladder" because workers frequently climb similar ladders, the potential
consequences of a fall are serious, and remedies--from ladder design to
worker training--are straightforward and easy to put in place.
Other safety problems have also occurred since the stand-downs. For
example, the three laboratories have reported 33 electrical shock
incidents since 2005. In one case at Los Alamos, two employees
operating a generator-powered winch received electrical shocks on
multiple occasions over a 4-day period without stopping work to report
the shocks; the winch then malfunctioned, and the employees reported
the shocks. At Sandia, a subcontractor employee received an electrical
shock requiring the attention of paramedics after touching a "hot"
screw on a 120-volt receptacle he was testing.
Long-standing Management Weaknesses Leave Sites Vulnerable to Continued
Safety Problems:
In our review of nearly 100 safety studies--including accident
investigations and independent assessments by the Safety Board and
others since 2000--we found that factors contributing to safety
problems stemmed largely from weaknesses in how NNSA manages safety at
the weapons laboratories. These contributing factors generally fall
into three key areas:
* A relatively lax attitude toward safety procedures. Accident
investigations and other reviews of the weapons laboratories have
repeatedly found an informal or lax attitude toward safety.
Specifically, reviews have cited weaknesses such as (1) laboratory
management that does not consistently and effectively emphasize the
importance of working safely and following prescribed safety
procedures, (2) employees who rely on their own expertise and knowledge
of work hazards rather than following safety procedures, and (3)
subcontractors who understand and implement safety procedures
inadequately. The Safety Board and others have cautioned that such lax
safety attitudes--including employees' reluctance to question potential
safety problems or inadequate leadership insistence on safety--create
an environment where workers become complacent, and accidents occur. At
the Los Alamos plutonium-handling facility, multiple accidental
releases of airborne plutonium since 1996-- including the 2000 incident
involving seven workers and another one in 2003 involving the same
group of employees in the same facility--led the investigators of the
2003 accident to conclude that "the organizational safety culture has
evolved to one of complacency towards safety such that workers and
managers fail to respect the hazards present in the workplace, and
risks to workers are accepted without understanding the magnitude of
those risks." Study after study has highlighted the informality of
laboratory operations and the lack of emphasis on safety throughout,
from division management levels to individual worker levels. As a
result of lax attitudes over the years, the laboratories have
repeatedly failed to prevent what many reports and reviews regard as
preventable accidents and near misses.
* Weaknesses in identifying safety problems and taking appropriate
corrective actions. Fundamental weaknesses in the laboratories' ability
to accurately identify and fully understand safety problems and take
appropriate corrective actions have hindered safety performance. Many
reviews have cited (1) an inability to learn from past incidents, (2) a
lack of rigorous self-assessments by the laboratories to identify
problems, and (3) a failure to develop appropriate or timely corrective
actions to mitigate these problems as factors contributing to recurring
accidents. Several investigations stressed that accidents could have
been prevented had lessons from previous accidents been learned and
properly applied.
* Inadequate oversight by NNSA site offices. Many reviews have pointed
out continuing deficiencies in federal oversight of the laboratories,
including that oversight was insufficiently formal or documented (for
example, that roles and responsibilities for safety were not clearly
and consistently delineated). Such weaknesses have been exacerbated by
staff shortages at the site offices, specifically, (1) unfilled
positions resulting in too few staff available to serve as NNSA's eyes
and ears at the laboratories and (2) shortages in staff with adequate
technical expertise. For example, positions for critical senior nuclear
safety officials at both the Lawrence Livermore and Los Alamos site
offices went unfilled for more than a year.
These safety evaluations have repeatedly indicated that key management
weaknesses have contributed to the laboratories' continuing safety
problems and that accidents could have been prevented had weaknesses
been properly addressed. Together, these safety evaluations indicate
that unless corrected, the weaknesses create conditions that leave the
laboratories vulnerable to continued--and potentially more serious--
safety problems.
NNSA and Contractors Have Been Taking Some Steps to Address Management
Weaknesses:
Steps taken by NNSA and its contractors include on-site efforts to
address weaknesses in three key areas, as well as mechanisms to hold
contractors more accountable for safety.
Steps Taken at the Laboratories Include Efforts in Three Key Areas:
NNSA and its contractors have been taking steps intended to address
weaknesses in three key areas: safety culture, systems for identifying
and correcting safety problems, and federal oversight:
* Safety culture. Since at least 2006, NNSA and its contractors have
been taking steps to reinvigorate NNSA's key safety improvement effort,
called integrated safety management. Launched in 1996, integrated
safety management was designed to respond to concerns raised by the
Safety Board about the lack of formal, standardized procedures
throughout DOE for ensuring that hazardous activities were carried out
safely. The effort was intended to raise safety awareness and provide a
formal process for employees to integrate safety into work activities
by requiring employees to (1) define the scope of work, (2) analyze the
hazards associated with that scope of work, (3) develop and implement
hazard controls to address possible safety issues, (4) perform work
within those controls, and (5) provide a feedback system for continuing
to improve safety. This program aims to instill in every individual at
the laboratories a sense of responsibility for working safely.
Despite the program's longevity and the soundness of the concepts
behind integrated safety management, many safety reviews have stated
that the program has not been fully or successfully implemented. In the
decade since it began, NNSA and laboratory contractors have developed
policies and procedures under program guidelines, but the laboratories
have been unable to ensure that managers and employees consistently
follow these policies and procedures in their work. Many of the
accident and other reports we examined specifically cited ineffective
implementation of integrated safety management at NNSA's laboratories
as a key factor contributing to the accidents.
To remedy these recognized shortcomings, NNSA is revising its guidance
to clarify integrated safety management requirements, and the
laboratories have been taking various steps to reemphasize the
principles of integrated safety management. First, according to
laboratory officials, the laboratory directors have publicly stressed
safety by, for example, at Sandia making unannounced monthly visits to
different laboratory units to observe operations firsthand. At Lawrence
Livermore, the laboratory director holds monthly performance reviews
requiring his associate directors to report on specific safety metrics
for their division. Second, several hundred managers and employees at
all three laboratories have undergone training on why accidents happen
and how to prevent them, in part through better communication and
teamwork. In addition, Los Alamos and Sandia site office officials told
us, the laboratories have been hiring staff from contractors at other
DOE sites or from other programs where adherence to safety procedures
has been more consistent, a move they believe will help shift the
safety culture at the laboratories.
* Identifying safety problems and taking corrective actions. NNSA and
its contractors at the laboratories have been taking steps to better
identify safety problems and appropriate corrective actions. For
example, Lawrence Livermore has created a new process in which teams of
workers and managers annually review and assess implementation of work
practices to identify deficiencies in safety procedures or other
opportunities to improve safety. Sandia has also begun to standardize
its annual self-assessment process for identifying safety and other
problems, although officials told us that the new approach cannot yet
provide consistent and useful information across laboratory divisions.
Two laboratories (Los Alamos and Sandia) have also created new
processes and computer systems for managing safety issues. Previously,
reviews found deficiencies in processes for assigning and tracing
accountability for safety problems. Both laboratories now have
management boards that review identified safety issues and assign
responsibility for those issues to individual managers, who must
analyze and address the identified problems. To complete the process,
individual managers must sign off on the fixes they have directed and
either have the issue re-reviewed by the assigning board or have
independent verification that the corrective action was completed.
Further, the laboratories and site offices have begun using new
software systems to help them track safety issues. Specifically, Los
Alamos and Sandia have been improving their electronic management
systems for tracking safety deficiencies and associated corrective
actions, and two of the site offices, at Sandia and Lawrence Livermore,
are using new integrated software systems intended to help the site
offices track safety issues at the labs and document oversight efforts.
Previously, this information was stored in multiple systems across the
labs and site offices, which made it more difficult to track overall
safety efforts.
* NNSA site office oversight. The site offices have initiated efforts
to address concerns about inadequate federal oversight by instituting
more-formal oversight procedures, seeking to fill vacant positions, and
providing additional training. The site offices at Lawrence Livermore
and Sandia have revised their operating procedures and documentation on
staff responsibilities, qualifications of technical staff, and
schedules for evaluating laboratory operations. Los Alamos and Lawrence
Livermore site officials told us they have begun to fill vacant
positions, including hiring a senior nuclear safety expert at Lawrence
Livermore who directly advises the site office manager.[Footnote 14]
The site offices told us that they have also been formalizing their
process to provide training related to general scientific and technical
expertise, applicable regulations, contract administration, and safety
management.
Many of these efforts are still under way, however, and their effect on
safety performance is not clear.
Additional Steps Target Contractor Accountability for Safety
Performance:
To hold its contractors more accountable for safety performance, NNSA
has incorporated into its contracts at Los Alamos and Sandia new
contract mechanisms that provide for additional fee or contract
extensions for meeting annual safety and other goals.[Footnote 15]
Under the new contract incentives, contractors can earn substantially
larger fees--or, in the case of Sandia, a one-year contract extension
as well--if they improve safety performance. At Los Alamos, incentive
fees are offered for improving safety documentation and decreasing
rates of illness and injury, for example.[Footnote 16] In 2005, Sandia
had the opportunity to earn the 1-year extension but could not do so,
primarily because of safety problems. NNSA officials we spoke with were
hopeful that these contract incentives would foster greater
accountability but said that improvements could take years to achieve.
Moreover, officials expressed concern that incentives to reduce
accidents could actually lead to underreporting, rather than actual
reductions in the number of accidents.
NNSA also is expecting to hold contractors more accountable through a
newly implemented regulation--referred to as the "851 rule"--that
requires contractors to follow worker safety requirements and imposes
penalties for violations.[Footnote 17] Promulgated in response to a
2002 congressional requirement, and similar to nuclear safety
regulations, the worker safety regulation (effective as of February
2007) encourages contractors to report violations of worker safety
requirements and provides for DOE's Office of Enforcement to levy civil
penalties carrying monetary fines up to $70,000 per day. As of
September 2007, DOE had not yet levied any fines against its
contractors.
NNSA Faces Fundamental Challenges to Effective Management and Oversight
of Safety at Weapons Laboratories:
NNSA faces two principal challenges in its continuing efforts to
improve safety at the nation's weapons laboratories. First, the agency
has no way to determine the effectiveness of its safety improvement
efforts, in part because those efforts rarely incorporate outcome-based
performance measures. Second, concerns have arisen over the agency's
shift in its oversight approach to rely more heavily on contractors'
own safety management controls.
NNSA Has No Way of Determining the Effectiveness of Its Safety
Improvement Efforts:
NNSA does not have effective outcome-based performance measures that
would enable it to evaluate the impact of individual improvement
initiatives on safety performance. When asked what impact integrated
safety management has had on safety performance, for example, NNSA and
contractor officials at the laboratories described positive trends in
measures such as illness and injury rates. However, in a December 2005
report reviewing NNSA's implementation of integrated safety management
at seven of its sites, including the weapons laboratories, the Safety
Board noted that, although the illness and injury rates had been
declining, the number of serious accidents, nuclear safety enforcement
actions, and other safety occurrences had not declined. According to
the Safety Board, this evidence indicated that the integrated safety
management program had not reduced the number of serious safety
problems, and the Safety Board suggested that NNSA develop a way to
evaluate the effectiveness of integrated safety management. Yet
effective performance measures were not included in the action plan to
revitalize integrated safety management; rather, the planned actions
were primarily process-oriented, such as developing new policies or
manuals or providing additional training. The few measures that were
included in the plan focused on, for example, defining annual
performance measures in contracts or increasing the use of measures
related to repeated incidents, with no indication of how these measures
might help gauge effectiveness.
We have found that NNSA and its contractors have not consistently
managed safety improvement efforts using a disciplined approach
incorporating substantive outcome measures and a system to evaluate its
efforts' effectiveness.[Footnote 18] Such an approach, often taken by
high-performing organizations, generally includes four key elements:
(1) defining clear goals, (2) developing an implementation strategy
that sets milestones and establishes responsibility, (3) establishing
results-oriented outcome measures to gauge progress toward the goals,
and (4) using results-oriented data to evaluate the effectiveness of
the effort and making additional changes where warranted. We have
previously recommended that DOE develop and use this systematic
approach in future improvement efforts. In response to this
recommendation, the department issued a directive (DOE Notice 125.1) in
October 2003 that adopted these principles.[Footnote 19] In February
2004, we reported on challenges at Los Alamos and Lawrence Livermore
national laboratories, including problems with ensuring the safe
operations of nuclear facilities[Footnote 20] and recommended that NNSA
include in its contracts for the two laboratories a requirement that
the contractors manage future improvement efforts in accordance with
the October 2003 directive, to better ensure that its efforts are
effective.[Footnote 21] Nevertheless, we found little indication that
either NNSA or the contractors have been using the systematic approach
specified by the October 2003 directive, and the approach in the
directive has not been incorporated into the laboratory contracts.
Rather than following the recommended systematic approach, the safety
improvement efforts described by NNSA and its contractors echo previous
attempts while continuing to lack useful measures of effectiveness.
Specifically, the laboratory contractors have been providing managers
and workers with additional safety training, but the contractors have
not instituted any systems to evaluate whether the trainees have put
into practice what they have been taught. In another example, the
laboratories have changed their systems for tracking identified safety
problems and the corrective actions taken to address those problems.
But these systems still measure whether corrective actions were
completed and completed on time, rather than how effective the actions
were in addressing underlying weaknesses. What outcome-based measures
do exist to evaluate safety performance--specifically, accident,
illness, and injury rates--consider just part of the safety situation
and do not address underlying management weaknesses that allow these
incidents to recur. In short, NNSA has no objective way of determining
whether improvement efforts are effective, whether these efforts will
correct long-standing safety problems, or whether reduced accident
rates are merely coincidental. Without stronger performance measures,
NNSA and its contractors have no way of knowing whether the time and
money invested in their improvement initiatives have actually resulted
in safer laboratories.
Given the persistent nature of safety problems at the laboratories, it
appears that either the identification of the underlying causes or the
corrective actions taken have been inadequate. A crucial step in the
October 2003 directive is to fully understand problems and their
underlying causes so that corrective actions will be effective. Yet
over the past decade, NNSA and laboratory contractors have developed
corrective action plans that were essentially reactive--responding to
findings and recommendations from one or another internal or external
report--without consistently taking the next step of identifying
deeper, systemic weaknesses and taking steps to mitigate these
weaknesses. Moreover, for at least two of the weapons laboratories,
neither the safety problems nor the efforts to correct them are new. As
we reported in February 2004, NNSA had put into place contract
mechanisms and requirements to address known problems in areas
including nuclear safety.[Footnote 22] Although this effort was
intended to strengthen management and federal oversight of nuclear
safety at Los Alamos and Lawrence Livermore, most of the measures
included in the contracts were aimed at establishing processes or
developing plans. In reports issued as recently as 2007, the Safety
Board and others have again raised similar concerns about safety
management weaknesses and suggested that NNSA and its contractors have
not fully understood the safety problems or their underlying causes and
have not identified and implemented the appropriate corrective actions.
It thus appears likely that agency efforts will continue to be
disjointed, and incidents and vulnerabilities could continue.
Weaknesses in Federal Oversight Raise Concerns about NNSA's Decision to
Rely More Heavily on Contractors' Management Controls:
NNSA has revised its laboratory contractor oversight policy to rely
more on the contractors' own systems of management controls to identify
and correct safety problems. Nevertheless, we and others have expressed
concerns in the past, however, about these changes to its oversight
policy and the increased emphasis and reliance on the contractors'
systems of management controls. In its draft policy of August 2003,
NNSA proposed relying more on contractor assurance systems and self-
assessments to identify and correct problems in all areas of
operations, including safety. NNSA would then use a risk-based approach
to its oversight, tailoring the extent of federal oversight to the
quality and completeness of the contractor's assurance system and the
extent to which NNSA could rely on the contractor's system to identify
and correct problems effectively. In our February 2004 report, we
acknowledged the potential benefits of a risk-based approach to federal
oversight, but we also raised concerns about NNSA's ability to
effectively carry out this approach while successfully meeting its
responsibility for safety. Furthermore, we recommended that NNSA retain
sufficient independent federal oversight of contractors' activities to
fulfill its responsibilities for protecting workers, the public, and
the environment.[Footnote 23] In addition, the Safety Board, in a
series of public meetings in late 2003 and early 2004, expressed
concerns about NNSA's proposed oversight policy and stressed that NNSA
should not delegate responsibility for the inherently high-risk area of
operations at its nuclear facilities. The Safety Board was concerned
about both the adequacy and the quality of federal oversight; it was
also concerned that the contractors' systems of management controls had
yet to be proven effective.
In response to these concerns, NNSA revised its oversight policy to
outline how contractors' systems of management controls, federal line
management oversight, and independent reviews would work together to
ensure effective operations, including safety.[Footnote 24] To
specifically address the Safety Board's concerns about high-hazard
operations, the revised policy requires additional, and more rigorous,
federal oversight of nuclear facilities and other high-hazard
operations. The departmentwide oversight policy's stated objective is
to ensure that contractor assurance systems and federal oversight
programs are comprehensive and integrated for all aspects of operations
essential to mission success. According to the policy, contractor
assurance systems should identify and address program and performance
deficiencies and opportunities for improvement, provide the means and
requirements to report deficiencies, establish and effectively
implement corrective and preventive actions, and share lessons learned
across all aspects of operations.
Regardless, NNSA lacks a cohesive implementation strategy for how it
will maintain appropriate levels of oversight of its laboratory
contractors' safety performance under this revised policy. At the site
offices, oversight consists of a collection of activities, such as
observations of work activities and reviews of contractor data, but it
is not clear how these activities will fit into NNSA's overall
oversight structure. Furthermore, the NNSA site offices lack their own
clear goals for improving oversight but instead equate improved
oversight to ensuring that the contractors meet contract goals and
annual performance measures. For example, at the Lawrence Livermore
site office, the goals and outcomes for fiscal year 2007 included (1)
ensuring that the contractor completes all required nuclear facility
safety documentation, (2) ensuring that lessons learned from the 2005
plutonium facility stand-down are implemented at the laboratory's other
nuclear facilities, and (3) ensuring that the contractor implements the
new worker safety rule. Yet these three goals and outcomes are still
geared more toward process rather than safety improvements and are
generally activities that the contractor should already have completed.
Specifically, one of these goals--ensuring that the contractor
completes all required nuclear facility safety documentation to
identify the potential nuclear hazards and mitigation plans to protect
workers, the public, and the environment--has been part of Lawrence
Livermore's contract requirements since 2001. Yet the laboratory had
nuclear facilities that lacked completed safety documentation until
September 2007.
Furthermore, no clear criteria or results-oriented outcome measures
exist for determining when a contractor assurance system is mature and
reliable enough for NNSA to depend on the contractor for identifying
and correcting safety problems. Without such measures, NNSA has no
assurance that contractors can and will effectively identify and
correct safety problems. In line with what we reported 3 years
ago,[Footnote 25] we continue to believe it is premature for NNSA to
rely so heavily on the contractors to maintain laboratory safety. Given
the perennial safety problems at the laboratories, coupled with NNSA's
and contractors' continued inability to clearly demonstrate progress in
remedying weaknesses, it is unclear how this revised system will enable
NNSA to maintain an appropriate level of oversight of safety
performance at the weapons laboratories.
Conclusions:
The NNSA weapons laboratories, which conduct important but potentially
dangerous research, have experienced persistent safety problems despite
years of effort to make the laboratories safer. Although dozens of
reviews since 2000 have repeatedly highlighted significant safety
management problems at the laboratories, and NNSA and contractors have
been taking steps aimed at improving safety, many of the steps appear
to be revision or repackaging of earlier efforts, with few new
approaches to correcting underlying problems. A key shortcoming may be
that--despite a DOE-wide directive requiring that improvement
initiatives include results-oriented outcome measures--neither NNSA nor
its contractors have developed performance measures suitable for
assessing the effect, if any, of safety improvement efforts on
identified safety weaknesses. As a result, NNSA has no assurance that
the resources expended on safety improvement efforts will successfully
remedy fundamental weaknesses or strengthen laboratory safety.
Furthermore, we remain concerned about NNSA's recent shift to relying
more on contractors to police themselves at a time when the
laboratories remain vulnerable to safety problems, including accidents.
We and others have raised concerns that although effective oversight of
laboratory safety requires a strong, qualified federal presence,
federal oversight remains problematic. Until contractors at the weapons
laboratories can demonstrate improved safety performance, and until
their efforts to address underlying management weaknesses are
effective, our misgivings remain about NNSA's ability to maintain
effective independent oversight. As the responsible owner of these
weapons laboratories, NNSA must be able to demonstrate that it is
carrying out sufficient independent federal oversight of contractors'
activities to fulfill its responsibilities for protecting the health
and safety of workers, the public, and the environment. Unless NNSA
addresses these fundamental challenges and adopts a more structured and
disciplined approach to improvement efforts and federal oversight, the
weapons laboratories will continue to be vulnerable to safety problems
and potentially serious consequences.
Recommendations:
To strengthen safety management and oversight at the nation's weapons
laboratories, we recommend that the Secretary of Energy direct the
Administrator of NNSA to take the following four actions:
* Ensure that safety improvement initiatives comply with DOE Notice
125.1, which requires, in particular, that improvement initiatives be
carried out in a systematic manner, with effective performance measures
based on outcomes, not process.
* Negotiate with the weapons laboratories to include in their contracts
a requirement that safety improvement initiatives be managed in a
manner consistent with the best practices of high-performing
organizations, as defined in accordance with the framework established
in DOE Notice 125.1.
* Ensure that as NNSA implements its proposed oversight and contractor
assurance policy, it develops a clear plan and specific measures that
enable it to (1) determine when a contractor's assurance system is
sufficiently mature and reliable to identify and address safety
problems at the weapons laboratories effectively and (2) retain
sufficient independent federal oversight of safety to fulfill its
responsibilities associated with protecting workers, the public, and
the environment.
* Report annually to Congress on progress toward making the weapons
laboratories safer, including the status and effectiveness of safety
improvement initiatives, using outcome-based performance measures.
Agency Comments:
We provided a draft of this report to NNSA for its review and comment.
In written comments, NNSA's Associate Administrator for Management and
Administration stated that NNSA generally agreed with the report and
its recommendations. NNSA's written comments on our draft report are
included in appendix IV.
While generally agreeing with the facts in our report and its
corresponding recommendations, NNSA sought to provide additional
context in which our findings could be viewed. Specifically, NNSA
stated that it believes that, given the numbers of employees, the
period of years covered, and the high-hazard work that is performed at
these laboratories, safety at the laboratories has been impressive.
NNSA suggests that the ladder incident we describe does not exemplify
lax safety. Yet this view overlooks the fact that even an accident as
simple as a ladder fall can result in serious personal injuries. NNSA‘s
own accident investigation report stressed the ’significance of this
seemingly simple accident“ because the consequences can be serious, and
the remedies are relatively easy to put into place. Furthermore, we
cited a number of examples illustrating the range and severity of
accidents at the laboratories, including major radiation exposures. We
remain concerned that such safety incidents are symptoms of more
pervasive problems.
NNSA also stated that, contrary to our criticism of its oversight of
the weapons laboratories, it believes that oversight of safety at the
laboratories is excellent. NNSA offers as evidence the existence of
safety evaluations performed by its offices and other DOE offices.
While we agree that reports by NNSA‘s offices and other DOE offices are
useful, our report focused on oversight at the NNSA site office level.
In fact, NNSA‘s safety evaluations themselves point out the same long-
standing concerns about the adequacy of NNSA site office oversight. In
addition, NNSA pointed to a decrease in its illness and injury rates at
the weapons laboratories as evidence of the effectiveness of federal
oversight of safety at the weapons laboratories. We acknowledge in the
report that NNSA and its contractors described recent positive trends
in safety measures such as illness and injury rates. We remain
concerned about relying solely on this measure as evidence of improved
safety performance because a number of factors could affect these
rates, including instances of underreporting. In addition, illness and
injury rates are not useful in indicating performance in nuclear
safety, where a single accident can carry serious consequences not only
for workers but for the public at large. Finally, as we stated in our
report, a December 2005 Safety Board report noted that, although
illness and injury rates had declined, the number of serious accidents
and nuclear safety enforcement actions had not declined. We continue to
believe that until NNSA adopts a more disciplined approach to
improvement efforts and federal oversight--an approach that
incorporates meaningful performance indicators--the laboratories cannot
assure that safety improvement efforts have been effective or will be
sustained.
As agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the date of this letter. At that time, we will send copies of this
report to the Secretary of Energy; the Administrator, NNSA; and
appropriate congressional committees. We will also make copies
available to others on request. In addition, the report will be
available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions on this report, please contact
me at (202) 512-3841 or AloiseE@gao.gov. Contact points for our Office
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this
report are listed in appendix V.
Signed by:
Gene Aloise:
Director, Natural Resources and Environment:
Appendix I: Scope and Methodology:
To determine the safety problems that have occurred at the weapons
laboratories and contributing factors, we reviewed documents, including
federal laws and regulations describing safety requirements for nuclear
safety and for worker safety and health, Department of Energy (DOE)
policies and procedures regarding safety management, and about 100
relevant reports issued since 2000 evaluating safety issues at the
three weapons laboratories: Lawrence Livermore, Los Alamos, and Sandia
national laboratories. Reports included inspections or reviews of the
weapons laboratories by DOE's Office of Independent Oversight and
Performance Assurance, the National Nuclear Safety Administration's
(NNSA) Chief of Defense Nuclear Safety, the Defense Nuclear Facilities
Safety Board (Safety Board), and our past reports. Reports also
included all type A and type B accident investigation reports for the
three weapons laboratories and, when possible, any contractor-led
accident investigations. We also reviewed all enforcement actions for
violations of nuclear safety rules taken against the laboratories by
DOE's Office of Enforcement. We reviewed the factors these reports
identified as contributing to safety problems and categorized them into
three key areas, using an analytical tool developed in consultation
with our methodologist. We also analyzed safety performance data
provided by DOE, specifically, safety incident data contained in DOE's
Occurrence Reporting and Processing System and Computerized Accident/
Incident Reporting System. We determined that these data were
sufficiently reliable for the purposes of this report. We discussed the
safety problems and contributing factors, as well as our categorization
of them, with representatives from DOE's Office of Independent
Oversight and Performance Assurance, NNSA's Chief of Defense Nuclear
Safety and Senior Advisor for Environmental Safety and Health, and the
Safety Board, as well as with DOE and NNSA headquarters officials. In
addition, we visited the three weapons laboratories and met with NNSA
officials and contractors to discuss the factors we identified as
contributing to safety problems at the laboratories.
To identify the steps NNSA and its contractors have taken to improve
safety management and address underlying management weaknesses, we
reviewed agency documents, including implementation plans; laboratory
contracts; and, to the extent it was available, documentation on safety
improvement initiatives. We also interviewed officials at the three
laboratories and NNSA site offices to discuss efforts taken by NNSA and
the laboratories to improve safety and to more specifically address the
areas of concern we identified. We also discussed efforts to improve
safety performance with independent experts, including officials from
DOE's Office of Enforcement and representatives from the Safety Board.
To determine the challenges that remain to effective management and
oversight of safety performance at the weapons laboratories, we
reviewed and analyzed relevant GAO reports on safety issues at the
laboratories; recommendations made, if any; steps taken in response, if
any; and issues remaining. We reviewed relevant DOE, NNSA, and
contractor documents, including DOE policies and orders, site office
strategies and plans, laboratory contracts, and annual evaluations of
contractor performance. We also discussed challenges with DOE and NNSA
officials; contractor officials; and independent experts, including
officials from the Safety Board.
We performed our work in accordance with generally accepted government
auditing standards, which included an assessment of data reliability,
from September 2006 through September 2007.
[End of section]
Appendix II: List of Key Safety Evaluations:
Los Alamos National Laboratory:
Department of Energy, National Nuclear Safety Administration. Type B
Accident Investigation of the Americium Contamination Accident at the
Sigma Facility, Los Alamos National Laboratory, New Mexico, July 14,
2005. Washington, D.C.: January 2006.
Department of Energy, Office of Security and Safety Performance
Assurance. Inspection of Environment, Safety, and Health Programs at
the Los Alamos National Laboratory. Washington, D.C.: November 2005.
Department of Energy, National Nuclear Safety Administration. Type B
Accident Investigation of the Acid Vapor Inhalation on June 7, 2005, in
Technical Area 48, Building RC-1, Room 402, Los Alamos National
Laboratory. Washington, D.C.: June 2005.
Tarantino, Frederick A., et al. LANL Investigation of a Laser Eye
Injury. LA-UR-04-6229. Los Alamos, New Mexico: Los Alamos National
Laboratory, 2004.
Department of Energy, National Nuclear Safety Administration. Type B
Accident Investigation of the August 5, 2003, Plutonium-238 Multiple
Uptake Event at the Plutonium Facility, Los Alamos National Laboratory,
New Mexico. Washington, D.C.: December 2003.
Hargis, Barbara, et al. Unanticipated Formation and Explosion of Liquid
Chlorine Dioxide in a Parr Reaction. LA-CP-02-206. Los Alamos, New
Mexico: Los Alamos National Laboratory, 2002.
Department of Energy, Office of Security and Safety Performance
Assurance. Inspection of Environment, Safety, and Health Programs at
the Los Alamos National Laboratory. Washington, D.C.: 2002.
Department of Energy, National Nuclear Safety Administration. Type B
Accident Investigation of the Mineral Oil Leak Resulting in Property
Damage at the Atlas Facility, Los Alamos National Laboratory, New
Mexico. Washington, D.C.: March 2001.
Department of Energy, National Nuclear Safety Administration. Type A
Accident Investigation of the March 16, 2000, Plutonium-238 Multiple
Intake Event at the Plutonium Facility, Los Alamos National Laboratory,
New Mexico. Washington, D.C.: July 2000.
Lawrence Livermore National Laboratory:
Department of Energy, Office of Health, Safety and Security. Inspection
of Environment, Safety, and Health Programs at the Lawrence Livermore
National Laboratory. Washington, D.C.: May 2007.
Department of Energy, National Nuclear Safety Administration. Type B
Accident Investigation of the July 31, 2006, Fall from Ladder Accident
at the Lawrence Livermore National Laboratory, Livermore, California.
Washington, D.C.: October 2006.
Department of Energy, Office of Security and Safety Performance
Assurance. Inspection of Environment, Safety, and Health Programs at
the Lawrence Livermore National Laboratory. Washington, D.C.: December
2004.
Department of Energy, National Nuclear Safety Administration. Type B
Accident Investigation Board Report of the June 2002 High Radiation
Dose to Extremities in Building 151, Lawrence Livermore National
Laboratory, Livermore, California. Washington, D.C.: Department of
Energy, October 2002.
Department of Energy, Office of Security and Safety Performance
Assurance. Inspection of Environment, Safety, and Health Programs at
the Lawrence Livermore National Laboratory. Washington, D.C.: July
2002.
Sandia National Laboratories:
Department of Energy, Office of Security and Safety Performance
Assurance. Inspection of Environment, Safety, and Health Programs at
the Sandia National Laboratories. Washington, D.C.: 2005.
Department of Energy, National Nuclear Safety Administration, Type B
Accident Investigation of the March 20, 2003, Building 752 Stair
Installation Accident at the Sandia National Laboratories, New Mexico.
Washington, D.C.: Department of Energy, April 2003.
Department of Energy, Office of Security and Safety Performance
Assurance, Inspection of Environment, Safety, and Health Programs at
the Sandia National Laboratories, New Mexico. Washington, D.C.: 2003.
Other Key Safety Reports:
Defense Nuclear Facilities Safety Board, Safety Management of Complex,
High-Hazard Organizations. DNFSB/TECH-35. Washington, D.C.: December
2004.
Defense Nuclear Facilities Safety Board, Integrated Safety Management:
The Foundation for a Successful Safety Culture. DNFSB/TECH-36.
Washington, D.C.: December 2005.
[End of section]
Appendix III: Enforcement Actions at NNSA Weapons Laboratories, 2000
through September 2007:
Office of Enforcement citation number: Los Alamos National Laboratory:
EA 2000-13;
Date of enforcement action: Los Alamos National Laboratory: Jan. 19,
2001;
Penalty assessed: Los Alamos National Laboratory: $605,000;
Severity level[A]: Los Alamos National Laboratory: I, II;
Description of violation: Los Alamos National Laboratory: Significant
multiple deficiencies in work control, quality improvement, and
radiation protection resulting in exposure of eight employees to
airborne radioactive material (estimated to be 1 of 10 worst
radiological exposures over past 41 years). Failure to address long-
standing deficiencies at an additional nuclear facility, which should
have been identified and corrected during routine assessments and
reviews.
Office of Enforcement citation number: Los Alamos National Laboratory:
EA 2002-05;
Date of enforcement action: Los Alamos National Laboratory: Dec. 17,
2002;
Penalty assessed: Los Alamos National Laboratory: $220,000;
Security level [A]: Los Alamos National Laboratory: II;
Description of violation: Los Alamos National Laboratory: Management
failures leading to establishing and operating an unauthorized nuclear
facility for 5 years by storing radioactive waste in a facility without
a safety evaluation and necessary controls. Failure of management
processes, including oversight and assessments to identify inventory of
nuclear materials that required analysis and controls.
Office of Enforcement citation number: Los Alamos National Laboratory:
EA 2003-02;
Date of enforcement action: Los Alamos National Laboratory: Apr. 10,
2003;
Penalty assessed: Los Alamos National Laboratory: $385,000;
Security level [A]: Los Alamos National Laboratory: II, III;
Description of violation: Los Alamos National Laboratory: Numerous work
process and radiological control violations resulting in exposure of
workers to radioactive material and contamination of facility. Numerous
failures to follow nuclear safety requirements and repeated work and
radiological control deficiencies. Long-standing weaknesses in
recognizing and addressing nuclear safety deficiencies.
Office of Enforcement citation number: Los Alamos National Laboratory:
EA 2004-05;
Date of enforcement action: Los Alamos National Laboratory: June 21,
2004;
Penalty assessed: Los Alamos National Laboratory: $770,000;
Security level [A]: Los Alamos National Laboratory: I;
Description of violation: Los Alamos National Laboratory: Significant
work control deficiencies resulting in two workers receiving greater
than annual allowed doses of radioactive material and exposure of five
workers to toxic vapors. Severity levels increased because of long-
standing nature of underlying problems and failure of management
assessments and controls to identify or correct such problems.
Office of Enforcement citation number: Los Alamos National Laboratory:
EA 2006-05;
Date of enforcement action: Los Alamos National Laboratory: Feb. 16,
2007;
Penalty assessed: Los Alamos National Laboratory: $1,100,000;
Security level [A]: Los Alamos National Laboratory: I, II;
Description of violation: Los Alamos National Laboratory: Fifteen
separate violations of nuclear safety rules, which reflect continuing
safety performance deficiencies over past several years. Deficiencies
in work controls and quality improvement. Lack of fundamental
improvements noted since stand-down of facilities.
Total for Los Alamos;
Office of Enforcement citation number: [Empty];
Date of enforcement action: Los Alamos National Laboratory: [Empty];
Penalty assessed: Los Alamos National Laboratory: $3,080,000;
Security level [A]: Los Alamos National Laboratory: [Empty];
Description of violation: Los Alamos National Laboratory: [Empty].
Office of Enforcement citation number: Lawrence Livermore National
Laboratory: EA 2000-12;
Date of enforcement action: Lawrence Livermore National Laboratory:
Sept. 27, 2000;
Penalty Assessed: Lawrence Livermore National Laboratory: $82,500;
Security level [A]: Lawrence Livermore National Laboratory: II;
Description: Lawrence Livermore National Laboratory: Failure to
adequately address or take steps to correct programmatic weaknesses
previously identified in maintaining and adhering to documents that
form the safety basis for nuclear facilities. Failure to perform work
using established controls over work processes.
Office of Enforcement citation number: Lawrence Livermore National
Laboratory: EA 2003-04;
Date of enforcement action: Lawrence Livermore National Laboratory:
Sept. 3, 2003;
Penalty Assessed: Lawrence Livermore National Laboratory: $137,500;
Security level [A]: Lawrence Livermore National Laboratory: II;
Description: Lawrence Livermore National Laboratory: Radiation
protection deficiencies resulting in significant radiological
overexposure to one worker. Inadequate radiological controls and
failure to implement a required hazard assessment.
Office of Enforcement citation number: Lawrence Livermore National Date
of enforcement action: EA 2006-01;
Date of enforcement action: Lawrence Livermore National Laboratory:
Feb. 23, 2006;
Penalty Assessed: Lawrence Livermore National Laboratory: $588,500;
Security level [A]: Lawrence Livermore National Laboratory: I, II, III;
Description: Lawrence Livermore National Laboratory: Long-standing and
repeated failures to effectively track and correct radiological program
deficiencies. Significant failure of management to properly oversee the
correction of repeated problems. Weaknesses in determining underlying
causes and corrective action plans.
Total for Lawrence Livermore;
Office of Enforcement citation number: Lawrence Livermore National Date
of enforcement action: [Empty];
Date of enforcement action: Lawrence Livermore National Laboratory:
[Empty];
Penalty Assessed: Lawrence Livermore National Laboratory: $808,500;
Security level [A]: Lawrence Livermore National Laboratory: [Empty];
Description: Lawrence Livermore National Laboratory: [Empty].
Total for both laboratories;
Office of Enforcement citation number: Lawrence Livermore National Date
of enforcement action: [Empty]
Date of enforcement action: Lawrence Livermore National Laboratory:
[Empty];
Penalty Assessed: Lawrence Livermore National Laboratory: $3,888,500;
Security level [A]: Lawrence Livermore National Laboratory: [Empty];
Description: Lawrence Livermore National Laboratory: [Empty].
Source: DOE Office of Enforcement.
Notes: The contractors were exempt from paying these penalties under
the provisions of the Price-Anderson Amendments Act of 1988. The Energy
Policy Act of 2005 removed this exemption after a new contract went
into effect. From 2000 through September 2007, no enforcement actions
were taken at Sandia National Laboratories.
[A] Severity level I violations, the most significant, are those that
involve actual or high potential for an adverse impact on the safety of
the public or workers at DOE or NNSA facilities. Level II violations
are those that show a significant lack of attention or carelessness
toward the contractors' responsibilities for protecting the public or
worker safety and that could, if uncorrected, potentially lead to an
adverse impact on public or worker safety. Level III violations are
less serious but of more than minor concern and, if left uncorrected,
could lead to a more serious condition.
[End of table]
Appendix IV: Comments from the Department of Energy:
Department of Energy:
National Nuclear Security Administration:
Washington, DC 20585:
October 3, 2007:
Mr. Gene Aloise:
Director:
Natural Resources and Environment Government Accountability Office:
Washington, D.C. 20548:
Dear Mr. Aloise:
The National Nuclear Security Administration (NNSA) appreciates the
opportunity to review the Government Accountability Office's (GAO)
report, GAO-08-73, "Nuclear And Worker Safety: Actions Needed to
Determine the Effectiveness of Safety Improvement Efforts at NNSA's
Weapons Laboratories." We understand that this work was requested by
the House's Subcommittee on Oversight and Investigations, Committee on
Energy and Commerce to review safety records at NNSA's major
laboratories.
NNSA generally agrees with the facts in the draft report and its
corresponding recommendations. The facts reported in the report, if put
in the context of the numbers of employees, the period of years covered
and the cutting-edge, high hazard work that is being performed at the
laboratories, are favorably impressive. However, the reader would not
have that impression because of the manner used to describe the status
of safety at our Laboratories. The fact that GAO mentions a fall from a
ladder as an example that safety is lax does not support the facts that
are, in fact, presented in their own report.
Contrary to the criticism of the report, the oversight/review by NNSA
is excellent, as is demonstrated by the very reports the GAO
references. The existence of the reported deficiencies and penalties
demonstrates that NNSA and the rest of the Department's safety
infrastructure are doing their job. The absence of reports would
actually be cause for concern. Safety is a discipline that must always
be managed and reinforced to affect the human element of our work, and
the very data that GAO dismisses (lowered illness and injury rates) is
proof that our oversight/management model is working to improve safety
in a general sense.
Should you have any questions about this response, please contact
Richard Speidel, Director, Policy and Internal Controls Management at
202-586-5009.
Sincerely:
Signed by:
Michael C. Kane:
Associate Administrator for Management and Administration:
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Gene Aloise, (202) 512-3841 or AloiseE@gao.gov:
Staff Acknowledgments:
In addition to the individual named above, Janet E. Frisch, Assistant
Director; Carole Blackwell; Timothy Bober; Candace Carpenter; Ellen W.
Chu; Doreen Eng; Daniel Feehan; Nancy Kintner-Meyer; Thomas Laetz;
Mehrzad Nadji; Omari Norman; Keith Rhodes; Rebecca Shea; and William R.
Swick made contributions to this report.
[End of section]
Related GAO Products:
Department of Energy: Consistent Application of Requirements Needed to
Improve Project Management. GAO-07-518. Washington, D.C.: May 11, 2007.
National Nuclear Security Administration: Security and Management
Improvements Can Enhance Implementation of the NNSA Act. GAO-07-428T.
Washington, D.C.: January 31, 2007.
National Nuclear Security Administration: Additional Actions Needed to
Improve Management of the Nation's Nuclear Programs. GAO-07-36.
Washington, D.C.: January 19, 2007.
DOE Contracting: Better Performance Measures and Management Needed to
Address Delays in Awarding Contracts. GAO-06-722. Washington, D.C.:
June 30, 2006.
Stand-down of Los Alamos National Laboratory: Total Costs Uncertain;
Almost All Mission-Critical Programs Were Affected but Have Recovered.
GAO-06-83. Washington, D.C.: November 18, 2005.
Department of Energy: Further Actions Are Needed to Strengthen Contract
Management for Major Projects. GAO-05-123. Washington, D.C.: March 18,
2005.
National Nuclear Security Administration: Key Management Structure and
Workforce Planning Issues Remain As NNSA Conducts Downsizing. GAO-04-
545. Washington, D.C.: June 25, 2004.
Department of Energy: Mission Support Challenges Remain at Los Alamos
and Lawrence Livermore National Laboratories. GAO-04-370. Washington,
D.C.: February 27, 2004.
Contract Reform: DOE's Policies and Practices in Competing Research
Laboratory Contracts. GAO-03-932T. Washington, D.C.: July 10, 2003.
Nuclear Security: NNSA Needs to Better Manage Its Safeguards and
Security Program. GAO-03-471. Washington, D.C.: May 30, 2003.
Department of Energy: Status of Contract and Project Management
Reforms.GAO-03-570T. Washington, D.C.: March 20, 2003.
Contract Reform: DOE Has Made Progress, but Actions Needed to Ensure
Initiatives Have Improved Results. GAO-02-798. Washington, D.C.:
September 13, 2002.
Nonproliferation R&D: NNSA's Program Develops Successful Technologies,
but Project Management Can Be Strengthened. GAO-02-904. Washington,
D.C.: August 23, 2002.
Nuclear Security: Lessons to Be Learned from Implementing NNSA's
Security Enhancements. GAO-02-358. Washington, D.C.: March 29, 2002.
Department of Energy: NNSA Restructuring and Progress in Implementing
Title 32. GAO-02-451T. Washington, D.C.: February 26, 2002.
Department of Energy: Fundamental Reassessment Needed to Address Major
Mission, Structure, and Accountability Problems. GAO-02-51. Washington,
D.C.: December 21, 2001.
National Laboratories: Better Performance Reporting Could Aid Oversight
of Laboratory-Directed R&D Program. GAO-01-927. Washington, D.C.:
September 28, 2001.
Nuclear Security: DOE Needs to Improve Control Over Classified
Information. GAO-01-806. Washington, D.C.: August 24, 2001.
Department of Energy: Follow-Up Review of the National Ignition
Facility. GAO-01-677R. Washington, D.C.: June 1, 2001.
Department of Energy: Views on Proposed Legislation on Civil Penalties
for Nuclear Safety Violations by Nonprofit Contractors. GAO-01-548T.
Washington, D.C.: March 22, 2001.
Nuclear Weapons: Improved Management Needed to Implement Stockpile
Stewardship Program Effectively. GAO-01-48. Washington, D.C.: December
14, 2000.
National Ignition Facility: Management and Oversight Failures Caused
Major Cost Overruns and Schedule Delays. GAO/RCED-00-141. Washington,
D.C.: August 8, 2000.
Department of Energy: Views on Proposed Civil Penalties, Security
Oversight, and External Safety Regulation Legislation. GAO/T-RCED-00-
135. Washington, D.C.: March 22, 2000.
Nuclear Security: Security Issues at DOE and Its Newly Created National
Nuclear Security Administration. GAO/T-RCED-00-123. Washington, D.C.:
March 14, 2000.
Department of Energy: Views on DOE's Plan to Establish the National
Nuclear Security Administration. GAO/T-RCED-00-113. Washington, D.C.:
March 2, 2000.
Nuclear Security: Improvements Needed in DOE's Safeguards and Security
Oversight. GAO/RCED-00-62. Washington, D.C.: February 24, 2000.
Department of Energy: Need to Address Longstanding Management
Weaknesses. GAO/T-RCED-99-255. Washington, D.C.: July 13, 1999.
Nuclear Weapons: DOE Needs to Improve Oversight of the $5 Billion
Strategic Computing Initiative. GAO/RCED-99-195. Washington, D.C.: June
28, 1999.
Department of Energy: DOE's Nuclear Safety Enforcement Program Should
Be Strengthened. GAO/RCED-99-146. Washington, D.C.: June 10, 1999.
National Laboratories: DOE Needs to Assess the Impact of Using
Performance-Based Contracts. GAO/RCED-99-141. Washington, D.C.: May 7,
1999.
Department of Energy: Key Factors Underlying Security Problems at DOE
Facilities. GAO/T-RCED-99-159. Washington, D.C.: April 20, 1999.
[End of section]
Footnotes:
[1] NNSA, a semiautonomous agency within the Department of Energy, was
established under Title 32 of the National Defense Authorization Act
for Fiscal Year 2000 as a separately organized agency within the
Department of Energy; it is responsible for the management and security
of the nation's nuclear weapons, nuclear nonproliferation, and naval
reactor programs.
[2] Lawrence Livermore National Laboratory is located in California;
Los Alamos National Laboratory is located in New Mexico; and Sandia
National Laboratories has two campuses--the main campus in Albuquerque,
New Mexico, and a smaller California campus near Lawrence Livermore
National Laboratory.
[3] A Review of Ongoing Management Concerns at Los Alamos National
Laboratory, Hearing before the Subcommittee on Oversight and
Investigations of the Committee on Energy and Commerce, House of
Representatives, serial no. 109-45 (May 5, 2005).
[4] As of October 1, 2006, the Office of Independent Oversight and
Performance Assurance was renamed the Office of Environment, Safety and
Health Evaluations.
[5] This provision is often referred to as the conditional-payment-of-
fee clause.
[6] Nuclear Safety Management, 10 C.F.R., part 830; Occupational
Radiation Protection, 10 C.F.R., part 835; Worker Safety and Health
Program, 10 C.F.R., part 851; and Procedural Rules for DOE Nuclear
Activities, 10 C.F.R., part 820.
[7] DOE's Office of Enforcement is responsible for identifying
violations of the nuclear safety rules and assessing civil penalties
against contractors. This enforcement program, originally established
in 1996, now also includes enforcement of rules that have been issued
for security and safeguarding of classified information and for worker
or industrial health and safety.
[8] The severity of an accident determines which category of safety
investigation is carried out. Type A investigations are for the most
serious accidents; the investigation team is appointed by DOE's Chief
Health, Safety and Security Officer. Threshold criteria for type A
investigations include a fatality, high-dose radiation exposure, or
property damage of $2.5 million or more. Type B investigations are
managed by the NNSA site office. Threshold criteria for type B
investigations include one or more people injured and requiring
hospitalization for 5 days or more, radiation exposure exceeding
certain thresholds, or property damage of $1.0 million to less than
$2.5 million. Serious accidents not meeting the type A or type B
criteria are investigated by the contractor.
The 60 accidents at the laboratories from 2000 to 2007 include all type
A and type B accident investigations conducted by DOE, as well as the
most serious incidents investigated by the contractors. We included all
investigations of events resulting in injury or property damage as well
as those considered near misses. If one investigation included more
than one incident, we counted each incident separately.
[9] Sandia National Laboratories has not been cited for a nuclear
safety violation since 2000, although it was cited on four occasions
from 1996 through 1999, with total assessed penalties of $61,250.
[10] Under section 234A of the Atomic Energy Act of 1954, as amended,
42 U.S.C. 2282a, DOE has the authority to impose civil penalties on
contractors for violations of nuclear safety requirements. However,
under section 234A(d), certain nonprofit contractors (including the
University of California, which operated the Los Alamos laboratory
until June 2006 and the Lawrence Livermore laboratory until October
2007) were specifically exempted from paying such penalties. In 2005,
Congress passed the Energy Policy Act of 2005, which removed this
exemption for contracts becoming effective after passage of the act.
Because a new Los Alamos contract became effective on June 1, 2006, and
a new Lawrence Livermore contract took effect on October 1, 2007, the
new contractors are required to pay any penalties levied.
[11] Because of the exemption under section 234A(d) of the Atomic
Energy Act of 1954, as amended, 42 U.S.C. 2282a, under the contractors
at the time, neither of the laboratories paid the penalties associated
with the enforcement actions levied against them.
[12] According to DOE, because of a change in the system for reporting
incidents, consistent data were available only from 2004 and later.
[13] Many of these injuries resulted from slips, trips, and falls.
[14] Initially proposed by the Safety Board in 2005, this position was
filled in August 2007.
[15] Specific performance criteria, including criteria for safety, were
incorporated into the contract for Sandia National Laboratories in
fiscal year 2004, into the contract for Los Alamos National Laboratory
in fiscal year 2006, and for Lawrence Livermore National Laboratory in
fiscal year 2008.
[16] The Los Alamos contractor can earn about $3 million in fiscal year
2007 for improving the safety documentation at its nuclear facilities
and another $2 million for completing and implementing required safety
manuals and other requirements for nuclear facilities. The contractor
can also earn about $600,000 for decreasing illness and injury rates by
20 percent during fiscal year 2007.
[17] Worker Safety and Health Program, 10 C.F.R., part 851.
[18] GAO, Contract Reform: DOE Has Made Progress, but Actions Needed to
Ensure Initiatives Have Improved Results, GAO-02-798 (Washington, D.C.:
Sept. 13, 2002).
[19] DOE Notice 125.1, "Managing Critical Management Improvement
Initiatives," Oct. 1, 2003. The objectives of this directive were to
establish a systematic, results-oriented approach for managing critical
improvement initiatives. Among other things, the directive requires
that improvement initiatives must identify the nature and source of
current problems; analyze theories about the causes; consider
alternative solutions; and provide measures for assessing outputs and
outcomes, which will permit an assessment of the effectiveness and
identification of any needed changes.
[20] GAO, Department of Energy: Mission Support Challenges Remain at
Los Alamos and Lawrence Livermore National Laboratories, GAO-04-370
(Washington, D.C.: Feb. 27, 2004).
[21] In commenting on a draft of the report, NNSA was silent on the
usefulness of this recommendation, instead stating that the contractors
were committed to ensuring that their improvement efforts continued to
achieve the desired results. However, we pointed out that although the
contractors had made progress in implementing corrective actions and
new requirements, the extent to which those actions had resulted in
improved performance in mission support activities was unclear.
[22] GAO-04-370.
[23] GAO-04-370.
[24] DOE Order 226.1, ’Implementation of Department of Energy Oversight
Policy“, Sept. 15, 2005. The contractor assurance systems cover areas
beyond safety, including security and business operations, which have
also been problematic at the laboratories.
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "Subscribe to Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office:
441 G Street NW, Room LM:
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngC1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
