Nuclear Safety
DOE's Investigation of Phosgene Gas Contamination Was Inadequate, but Experts Conclude That Worker Safety and Facilities Are Not Threatened Gao ID: GAO-07-712 May 31, 2007More than 700,000 tons of uranium are stored at two Department of Energy (DOE) sites where uranium enrichment took place and where two facilities are being constructed to treat depleted uranium. Some of the storage cylinders for uranium came from the Army more than 50 years ago and may originally have contained phosgene, a toxic gas used as a chemical weapon in World War I. In September 2005, DOE's Inspector General issued an alert warning that residual phosgene, if present, could threaten the safety of people and the treatment facilities. GAO was directed to review DOE's investigation of possible phosgene contamination of uranium storage cylinders. GAO consulted a panel of experts to assess the adequacy of DOE's investigation and whether possible phosgene contamination could threaten the new treatment facilities under construction.
According to members of GAO's expert panel, although DOE adequately demonstrated that the public would not be harmed if small amounts of phosgene escaped from the storage cylinders, it neglected to explicitly document its analysis of worker safety in its investigation of possible phosgene contamination. DOE's regulations and guidance call for thorough safety analyses of newly identified hazards, such as possible phosgene contamination, to protect workers and the public. Yet DOE assumed, without explicitly documenting, that existing worker safety procedures were adequate to protect workers from the possible presence of phosgene. After GAO identified the need for DOE to support this key assumption, DOE provided supplemental information on worker safety; GAO's panel agreed that this supplement sufficiently supported DOE's position. In addition, although DOE's guidance calls for independent review of investigation results, DOE officials supervising the phosgene investigation also served as reviewers. This lack of independent review may have contributed to weaknesses in the investigation. The experts GAO consulted agreed that, for two reasons, the facilities under construction in Ohio and Kentucky would not be threatened by possible phosgene contamination of uranium storage cylinders. First, at the start of treatment operations, cylinders containing depleted uranium will be placed inside pressure vessels designed to withstand and contain any leak from a cylinder. If phosgene were present, it would not affect either the pressure vessels or the treatment facilities. Second, during subsequent steps, any phosgene that may be processed with the depleted uranium would be destroyed by the extreme heat and water vapor applied during the treatment process.
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-07-712, Nuclear Safety: DOE's Investigation of Phosgene Gas Contamination Was Inadequate, but Experts Conclude That Worker Safety and Facilities Are Not Threatened
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Contamination Was Inadequate, but Experts Conclude That Worker Safety
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Report to Congressional Addressees:
United States Government Accountability Office:
GAO:
May 2007:
Nuclear Safety:
DOE's Investigation of Phosgene Gas Contamination Was Inadequate, but
Experts Conclude That Worker Safety and Facilities Are Not Threatened:
GAO-07-712:
GAO Highlights:
Highlights of GAO-07-712, a report to congressional addressees
Why GAO Did This Study:
More than 700,000 tons of uranium are stored at two Department of
Energy (DOE) sites where uranium enrichment took place and where two
facilities are being constructed to treat depleted uranium. Some of the
storage cylinders for uranium came from the Army more than 50 years ago
and may originally have contained phosgene, a toxic gas used as a
chemical weapon in World War I. In September 2005, DOE‘s Inspector
General issued an alert warning that residual phosgene, if present,
could threaten the safety of people and the treatment facilities.
GAO was directed to review DOE‘s investigation of possible phosgene
contamination of uranium storage cylinders. GAO consulted a panel of
experts to assess the adequacy of DOE‘s investigation and whether
possible phosgene contamination could threaten the new treatment
facilities under construction.
What GAO Found:
According to members of GAO‘s expert panel, although DOE adequately
demonstrated that the public would not be harmed if small amounts of
phosgene escaped from the storage cylinders, it neglected to explicitly
document its analysis of worker safety in its investigation of possible
phosgene contamination. DOE‘s regulations and guidance call for
thorough safety analyses of newly identified hazards, such as possible
phosgene contamination, to protect workers and the public. Yet DOE
assumed, without explicitly documenting, that existing worker safety
procedures were adequate to protect workers from the possible presence
of phosgene. After GAO identified the need for DOE to support this key
assumption, DOE provided supplemental information on worker safety;
GAO‘s panel agreed that this supplement sufficiently supported DOE‘s
position. In addition, although DOE‘s guidance calls for independent
review of investigation results, DOE officials supervising the phosgene
investigation also served as reviewers. This lack of independent review
may have contributed to weaknesses in the investigation.
The experts GAO consulted agreed that, for two reasons, the facilities
under construction in Ohio and Kentucky would not be threatened by
possible phosgene contamination of uranium storage cylinders. First, at
the start of treatment operations, cylinders containing depleted
uranium will be placed inside pressure vessels designed to withstand
and contain any leak from a cylinder. If phosgene were present, it
would not affect either the pressure vessels or the treatment
facilities. Second, during subsequent steps, any phosgene that may be
processed with the depleted uranium would be destroyed by the extreme
heat and water vapor applied during the treatment process.
Figure: Uranium Storage Cylinders at Paducah, Kentucky:
[See PDF for Image]
Source: Uranium Disposition Services.
[End of figure]
What GAO Recommends:
GAO recommends that the Secretary of Energy strengthen DOE‘s review
process for safety investigations to include reviewers who are
independent of the investigations being done and can provide objective
evaluations of the methods used and the findings and conclusions
reached.
DOE agreed that workers and the public were not at risk but did not
believe that its investigation had flaws. DOE did not comment on our
recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-712].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Gene Aloise at (202) 512-
3841 or AloiseE@gao.gov.
[End of section]
Contents:
Letter:
Scope and Methodology:
Results in Brief:
Background:
DOE's Investigation of Possible Phosgene Contamination Did Not
Adequately Document Analysis of Worker Safety:
Possible Phosgene Contamination of Uranium Storage Cylinders Does Not
Threaten Depleted Uranium Conversion Facilities:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Comments from the Department of Energy:
Appendix II: GAO Contact and Staff Acknowledgments:
Table:
Table 1: GAO's Expert Panelists, Titles, and Affiliations:
Figures:
Figure 1: Uranium Storage Cylinders at DOE's Paducah Site:
Figure 2: Cylinder with an Open Hole:
Figure 3: Steps to Convert Depleted Uranium Hexafluoride to Uranium
Oxide, with Impact on Phosgene, If Present:
Abbreviations:
DOE: Department of Energy:
UDS: Uranium Disposition Services:
USEC: U.S. Enrichment Corporation:
United States Government Accountability Office:
Washington, DC 20548:
May 31, 2007:
The Honorable Byron L. Dorgan:
Chairman:
The Honorable Pete V. Domenici:
Ranking Minority Member:
Subcommittee on Energy and Water:
Committee on Appropriations:
United States Senate:
The Honorable Peter J. Visclosky:
Chairman:
The Honorable David L. Hobson:
Ranking Minority Member:
Subcommittee on Energy and Water Development:
Committee on Appropriations:
House of Representatives:
The Honorable Mitch McConnell:
United States Senate:
From the 1940s, one of the missions of the Department of Energy (DOE)
and its predecessors was to enrich uranium as a source of nuclear
material for defense and commercial purposes. Before it can be
enriched, uranium is combined with fluorine to form uranium
hexafluoride, a substance dangerous to human health and the environment
because it is radioactive and forms potentially lethal compounds if it
comes in contact with water. The enrichment process results in two
principal products: (1) enriched uranium hexafluoride, which can be
further processed for specific uses, such as nuclear fuel or weapons,
and (2) depleted uranium hexafluoride, a material that can be converted
into a more stable form for storage and other applications. Both
processes--uranium enrichment and depleted uranium conversion--involve
hazardous materials and processes that can harm the public, workers,
and the environment. DOE therefore requires specific safety procedures
to be in place at uranium-processing sites. Uranium-processing
activities took place at three sites near Paducah, Kentucky;
Portsmouth, Ohio; and Oak Ridge, Tennessee,[Footnote 1] where over
700,000 tons of uranium hexafluoride is currently stored. At the
Paducah and Portsmouth sites, DOE is constructing two new facilities to
convert depleted uranium hexafluoride into a more stable compound,
uranium oxide, for long-term storage.
Between 1945 and the mid-1950s, the Atomic Energy Commission, a DOE
predecessor, acquired from the U.S. Army Chemical Warfare Service more
than 2,500 of the approximately 63,000 steel cylinders in which it now
stores uranium hexafluoride. The Army previously stored other chemicals
in these 2,500 cylinders, including a toxic gas called phosgene, which
was used as a chemical weapon during World Wars I and II. Phosgene can
immediately endanger health or life, even in quantities as small as 2
parts per million. If inhaled, the gas damages the lungs, causing them
to fill with fluid and potentially leading to death by suffocation or
heart failure. DOE's records from 1946 indicate that some of the
storage cylinders it received from the Army tested positive for
phosgene; the records do not indicate, however, which cylinders tested
positive, how much phosgene was present, or whether DOE removed the
phosgene before using the cylinders to store uranium hexafluoride.
In September 2005, DOE's Inspector General issued an urgent letter,
called a management alert, to DOE regarding the possible presence of
phosgene in the cylinders received from the Army. The alert warned that
the possible presence of phosgene in uranium storage cylinders had
significant implications for the safety and health of workers and the
public. In response to the Inspector General's alert, DOE identified
2,509[Footnote 2] cylinders suspected of containing phosgene,
immediately suspended regular maintenance activities around these
cylinders, implemented precautions to protect workers from the
potential phosgene hazard, and began an investigation of phosgene
contamination of the 2,509 cylinders. This investigation was conducted
collaboratively by DOE and a contractor, Uranium Disposition Services
(UDS), which was tasked with analyzing and reporting on possible
phosgene contamination and also with maintaining the storage cylinders
and constructing the facilities to convert depleted uranium.[Footnote
3] In April 2006, DOE completed its investigation,[Footnote 4]
concluding that phosgene, if present, would not react with uranium
hexafluoride and that the uranium storage cylinders would not contain
enough residual phosgene to harm the public outside site boundaries,
that is, no closer than 200 meters from the cylinders.[Footnote 5] DOE
also concluded that the small quantity of residual phosgene it deemed
safe for the public would also pose no harm to workers, who would be
protected under existing safety procedures, and not threaten the
depleted uranium conversion facilities at Portsmouth, Ohio, and
Paducah, Kentucky.
Given the potential safety risks, the Conference Report accompanying
the Fiscal Year 2006 Energy and Water Development Appropriations
Act[Footnote 6] directed us to provide an independent review of
possible phosgene contamination of DOE's uranium storage cylinders.
This report discusses (1) the adequacy of DOE's investigation of
potential harm to workers and the public from phosgene contamination of
the storage cylinders and (2) whether possible phosgene contamination
of storage cylinders could threaten the depleted uranium treatment
facilities after conversion operations begin at the Portsmouth and
Paducah sites.
Scope and Methodology:
To determine the adequacy of DOE and UDS's investigation of potential
harm to workers and the public from possible phosgene contamination of
uranium storage cylinders, we reviewed the DOE Inspector General's
workpapers and interviewed officials to understand their preliminary
findings. We also interviewed officials at the Defense Nuclear
Facilities Safety Board and U.S. Enrichment Corporation (USEC). To
identify what actions DOE and UDS were required to take to address
worker and public safety in light of the possible presence of phosgene,
we reviewed federal safety requirements set out in the Code of Federal
Regulations[Footnote 7] and DOE guidance.[Footnote 8] In addition, we
spoke with senior DOE safety officers to clarify the requirements and
expectations of DOE safety investigations. To learn what actions DOE
and UDS took to address the potential presence of phosgene, we reviewed
DOE's Phosgene Characterization Study and supporting documents and
interviewed DOE and UDS officials who conducted the investigation. To
determine the reliability of the data DOE and UDS used in determining
whether cylinders posed harm to workers or the public, we reviewed a
stratified random sample of 250 cylinders from the 2,509 cylinders in
question and reviewed all the available records for each cylinder. We
visited the cylinder storage yards at the Paducah and Portsmouth sites
to view some of the cylinders in our sample and to examine cylinder
records. We found that DOE and UDS had generally interpreted the
cylinder record information correctly and consistently and that their
data were sufficiently reliable.
To assess DOE and UDS's scientific assumptions and conclusions in their
investigation of possible phosgene contamination, we assembled a panel
of experts from outside DOE to review DOE's final report and supporting
documents. To select experts, we used an iterative process (often
referred to as the "snowball sampling" technique) to identify
scientists outside DOE who had experience or expertise in phosgene,
nuclear material, or both. Through recommendations by knowledgeable
government agency officials, we first identified a small number of
experts. We asked these experts to participate in the panel and to
provide names of other experts with knowledge of phosgene or nuclear
material. We continued soliciting names until we determined that we had
appropriate coverage of the topic areas. We did not limit our search to
government agencies but solicited recommendations for experts from
government, private, academic, and international organizations. The
scientists we identified with the necessary expertise were all
government scientists. Table 1 lists the resulting panel of seven
experts.
Table 1: GAO's Expert Panelists, Titles, and Affiliations:
Name: Dr. Frederic Berg;
Title: Supervisory Research Chemist;
Affiliation: U.S. Army Edgewood Chemical and Biological Center.
Name: Dr. John F. Kalinich;
Title: Principal Investigator, Research Biochemist;
Affiliation: Armed Forces Radiobiology Research Institute.
Name: Dr. Tadeusz Kleindienst;
Title: Research Physical Scientist;
Affiliation: U.S. Environmental Protection Agency, National Exposure
Research Laboratory.
Name: Dr. Urmila Kodavanti;
Title: Research Biologist;
Affiliation: U.S. Environmental Protection Agency, Experimental
Toxicology Division, Pulmonary Toxicology Branch.
Name: Dr. David McClain;
Title: Research Biochemist;
Affiliation: Armed Forces Radiobiology Research Institute.
Name: Dr. Alfred Sciuto;
Title: Research Physiologist, Branch Chief;
Affiliation: U.S. Army Medical Research Institute of Chemical Defense.
Name: Mr. William Troskoski;
Title: Senior Chemical Engineer;
Affiliation: Nuclear Regulatory Commission, Office of Nuclear Materials
Safety and Safeguards.
Source: GAO.
[End of table]
Panelists were given DOE and UDS's final report on the investigation
and the report's attached supporting documents, in addition to
information we collected on uranium enrichment from scientists at USEC
who work directly with the uranium enrichment process. DOE and UDS
officials reviewed these documents for completeness and accuracy. The
panelists met to discuss their own analyses and conclusions and
continued discussions via e-mail and telephone calls.
To determine whether possible phosgene contamination of uranium storage
cylinders could threaten the depleted uranium treatment facilities, we
assessed documentation on the facilities' operations and interviewed
officials at UDS and the Nuclear Regulatory Commission. The expert
panel we assembled reviewed the conversion process and discussed
whether the facilities would be threatened by phosgene and how the
conversion process would affect phosgene. Finally, to corroborate the
information we gathered, we interviewed officials at UDS and the
Nuclear Regulatory Commission who are familiar with the conversion
facilities and the equipment used to process the uranium storage
cylinders. We performed our work in accordance with generally accepted
government auditing standards from March 2006 through April 2007.
Results in Brief:
The experts we consulted confirmed that DOE and UDS's investigation of
possible phosgene contamination was flawed because, among other things,
it did not explicitly document that phosgene would not harm workers
near the storage cylinders. It was not until February 2007, after we
brought this weakness to DOE and UDS's attention that they provided
supplemental information that addressed worker safety. Until then, DOE
and UDS believed, but did not explicitly document, that existing worker
safety procedures were adequate to protect workers from the possible
presence of phosgene. Regulations governing how DOE and its contractors
should conduct operations involving hazardous materials explicitly call
for the contractor to prepare documented safety analyses that establish
hazard controls necessary to ensure adequate protection of workers, the
public, and the environment. The regulations require DOE to take
appropriate action to address a newly identified hazard, such as
possible phosgene contamination. Our panelists agreed that DOE and
UDS's investigation demonstrated that phosgene would not be present in
quantities that could harm members of the public passing by or living
near the DOE sites--at a distance of 200 meters or more from the
cylinders--where uranium is stored or treated.
The experts also agreed, however, that DOE and UDS failed to document
that the same quantities of phosgene that would not harm the public
would also not harm workers directly involved in handling and
maintaining the cylinders. Although DOE and UDS officials stated that
they systematically analyzed the potential consequences to workers of
phosgene in uranium storage cylinders, they did not explicitly document
their analysis or conclusions, creating a weakness in their
investigation. In particular, we found no record of their assumptions,
analysis, or results. DOE and UDS officials reasoned that because the
uranium hexafluoride in the cylinders was more dangerous than the
possible presence of phosgene, the existing safety procedure--known as
"see and flee"--was adequate to protect workers from phosgene.
Specifically, "see and flee" directs workers to evacuate the area when
they see any sign of a cylinder rupture. DOE guidance instructs DOE and
its contractors to document all support for safety investigations to
allow independent reviewers to assess the adequacy of analyses and
conclusions. DOE's guidance also calls for independent review of
investigation results by officials who are not directly involved in the
investigation. In this case, however, reviewers may have been too
familiar with the investigation to provide a review that was
sufficiently independent to identify and correct this weakness. In
February 2007, DOE and UDS issued a supplement to the original
investigation report, which supported their earlier assertion that
existing safety procedures would protect workers near the uranium
storage cylinders from residual phosgene, and our expert panel
concurred. In our view, DOE and UDS were fortunate that their
undocumented assumptions proved correct and existing safety procedures
had been sufficient to protect workers throughout the investigation.
The experts with whom we spoke agreed that any phosgene present in
uranium storage cylinders would not threaten the depleted uranium
conversion facilities under construction at Portsmouth and Paducah, for
two reasons. First, at the start of the conversion process, cylinders
containing depleted uranium hexafluoride will be placed inside pressure
vessels, where their contents will be heated and liquefied. According
to our expert panel and officials from DOE and UDS, the pressure
vessels are designed to withstand and contain any leak from a cylinder,
so that if phosgene were present, it would not affect either the
pressure vessels or the facilities. Second, during subsequent steps in
the conversion process, any phosgene that was processed with the
depleted uranium hexafluoride would be destroyed. Specifically, our
expert panel and DOE and UDS officials all agreed that the extreme heat
would destroy phosgene. In addition, the water vapor added during the
process would react with any phosgene present to form compounds,
including carbon dioxide, that would not threaten the facilities.
We recommend that DOE better ensure that its safety investigations
follow agency guidelines and are technically adequate, in particular,
by making use of reviewers who are independent of the investigations
being done and who will provide objective evaluations of the
investigations' methods and resulting findings and conclusions.
DOE commented on a draft of this report and generally agreed with our
conclusions that neither workers nor the public would have been at risk
from potential phosgene contamination. DOE did not comment on our
recommendations. DOE took exception to our findings that its
assessments of worker safety and of the fate of phosgene in the
enrichment process were inadequately documented, stating that explicit
documentation was unnecessary. Our panel of technical experts, however,
concluded that without explicit documentation of these critically
important analyses, DOE could not adequately demonstrate that workers
would not be harmed by the potential presence of phosgene. DOE also
took issue with our finding that its review of the investigation was
not sufficiently independent, stating that its investigation was
reviewed by four officials who had no direct connection to the
investigation. Nevertheless, according to documents previously provided
to us by DOE, we believe that two of these officials, who had approved
investigation plans and provided direction to the investigation, were
not sufficiently independent to provide an objective review of the
quality or results of that investigation.
Background:
Created in 1977 from diverse agencies, DOE manages the nation's nuclear
weapons production complex, cleans up the environmental legacy of
nuclear weapons development, and conducts research in both energy and
basic science. DOE carries out its work at numerous sites and
facilities around the country, primarily through organizations that
manage the facilities and implement program and project activities
under contract to DOE. The department has established an extensive
network of field offices to directly oversee the work of these
contractors. DOE's Portsmouth/Paducah Project Office, under the Office
of Environmental Management, is responsible for cleanup and depleted
uranium conversion at the Portsmouth and Paducah sites.
The United States began processing uranium--a radioactive heavy metal
that is mined and extracted from ore--before the Manhattan Project gave
rise to the first atomic bomb in the 1940s. Subsequently, DOE and its
predecessor agencies continued to process uranium as fuel for
commercial nuclear reactors. A key step in this process is uranium
enrichment, which increases the concentration of uranium-235, the form
of uranium that undergoes fission to release enormous amounts of
energy.[Footnote 9] Uranium enrichment involves combining uranium with
the chemical fluorine to form uranium hexafluoride. Radioactive and
extremely corrosive, uranium hexafluoride reacts with water and can
burn the skin, eyes, and internal organs.
Uranium hexafluoride and depleted uranium hexafluoride (the material
left over after uranium enrichment) are currently stored in steel
cylinders. In all, approximately 700,000 tons of uranium hexafluoride
is stored in about 63,000 cylinders at storage yards on the Paducah and
Portsmouth sites (see fig. 1). A cylinder surveillance and maintenance
program includes regular inspections to check the integrity of cylinder
walls, valves, and plugs; replacement or reattachment of nameplates
(which are vital for cylinder identification and tracking); and repair
of any defective valves or plugs.
Figure 1: Uranium Storage Cylinders at DOE's Paducah Site:
[See PDF for image]
Source: DOE Inspector General.
[End of figure]
Ultimately, DOE plans to convert the stored depleted uranium
hexafluoride into uranium oxide, a more stable chemical form for long-
term storage. UDS is constructing two depleted uranium hexafluoride
conversion facilities, one each at Paducah and Portsmouth. Scheduled to
begin operating in 2008, the facilities together will be able to
process a total of about eight cylinders of depleted uranium
hexafluoride per day. DOE estimates that once the conversion facilities
begin operating, it will take approximately 25 years to convert its
existing stockpile of depleted uranium hexafluoride.
Historically, because of national security concerns, DOE and its
predecessors have not been externally regulated for worker or nuclear
facility safety; rather, DOE relies on its own internal system of
oversight and controls to hold its contractors accountable. DOE's
primary approach to regulating its contractors to ensure public health
and safety and the safety of workers at nuclear facilities is to
incorporate the requirements of DOE regulations and directives,
including policies, orders, and standards, into contracts. Among other
requirements, DOE regulations require nuclear facilities to maintain a
master document, called a documented safety analysis, that analyzes
hazards and describes the controls necessary to ensure that workers,
the public, and the environment are adequately protected. The
documented safety analysis and hazard controls are referred to as a
safety basis. The contractor must submit a safety basis to DOE for
review and approval; update the safety basis to keep it current and
reflect changes in the facility itself, its work, or the hazards
present; and submit the updated document (or a letter stating that
there have been no changes) to DOE once a year thereafter. If a new
hazard is discovered, the regulations direct contractors to take
immediate steps to ensure the facility's safety and to notify DOE. In
addition, the contractor must conduct and submit to DOE a safety
evaluation of the new hazard.
An October 2000 report by DOE's Office of Environment, Safety, and
Health informed DOE that some 30-inch diameter cylinders acquired from
the Army, now used to store uranium hexafluoride, previously contained
phosgene. A chemical not found in nature, phosgene, or carbonyl
chloride (COCl2), was used as a chemical weapon in World War I and
stockpiled by the U.S. Army Chemical Warfare Service in World War II;
at present, it is used to make plastics, pesticides, and even
pharmaceuticals. At room temperature, phosgene is a colorless gas
heavier than air, with an odor of musty hay; in the presence of
moisture, it may form a white cloud. According to the National
Institute for Occupational Safety and Health, phosgene presents an
immediate threat to life and health at a concentration of about 2 parts
per million. When the chemical comes in contact with moisture on the
skin or in the respiratory tract, it reacts to form hydrochloric acid,
which, like uranium hexafluoride, burns human tissues.[Footnote 10]
With uranium storage cylinders used in the conversion process, DOE's
Inspector General raised a concern that some 30-inch cylinders could
possibly contain phosgene and could enter the depleted uranium
conversion facilities for processing.
After DOE's Inspector General issued its warning about possible
cylinder contamination from phosgene, DOE and UDS conducted an
investigation to determine the extent to which the cylinders received
from the Army were contaminated. For each cylinder, they applied one of
three criteria to establish that the cylinder could contain no more
than a trace amount of phosgene. First, they found that if past
practices to prepare storage cylinders for use in the uranium
enrichment process had been consistently followed, these practices
should have eliminated any phosgene that might have been present. These
practices included cleaning the cylinders--washing their interiors with
corrosive chemicals and rinsing them with water--and pressure testing
them to ensure they were structurally sound. DOE had documents
demonstrating that 176 of the 2,509 cylinders had been cleaned or
pressure tested after DOE received them from the Army. DOE was
therefore able to clear these 176 cylinders of suspicion on the basis
of this first criterion. Second, DOE and UDS calculated that if the
storage cylinders had been filled with and emptied of uranium
hexafluoride at least once, any residual phosgene in the cylinders
should have been reduced to quantities too small to harm the public.
DOE cleared 2,296 cylinders on the basis of this second
criterion.[Footnote 11] Third, DOE and UDS determined that if a
cylinder had a hole in it--for example, where a valve was removed from
the cylinder and the resulting hole was left uncovered--residual
phosgene would have dissipated completely from the cylinder. DOE
cleared another 12 cylinders with open holes, on the basis of this
third criterion. Finally, DOE and UDS sampled and analyzed the contents
of the last 25 cylinders and did not detect phosgene at or above the
residual quantity they deemed safe for the public.
DOE's Investigation of Possible Phosgene Contamination Did Not
Adequately Document Analysis of Worker Safety:
DOE and UDS's investigation of possible phosgene contamination was
flawed because, among other things, it did not explicitly document that
phosgene would not harm workers near the uranium storage cylinders.
Under federal regulations and DOE guidance, DOE and its contractors are
to assess safety risks to workers and the public. Although DOE
considered worker safety, it did not explicitly document its analysis
or conclusions. It did adequately assess and document its conclusions
for public safety. In response to our review, DOE and UDS provided
supplemental information that the experts we consulted found sufficient
to support DOE's initial assertion that existing safety procedures had
protected workers from harm throughout the investigation.
DOE Did Not Explicitly Document Its Analysis of the Safety Risk to
Workers from Possible Exposure to Phosgene:
According to the experts we consulted, the original investigation was
flawed because DOE and UDS did not explicitly document that workers
would face no harm from small quantities of phosgene that could be
present in uranium storage cylinders. Federal regulations and DOE
guidance direct DOE and its contractors to analyze safety risks to
workers, the public, and the environment to ensure that they are
adequately protected from hazardous materials and conditions. To do so,
each DOE facility must maintain a comprehensive documented safety
analysis that details potential hazards and appropriate safety
procedures to mitigate those hazards. If a new hazard is discovered
that is not addressed in the existing documented safety analysis,
federal regulations direct DOE and its contractors to take action to
place or maintain the facility in a safe condition until a safety
analysis is completed and submitted to DOE for approval.
According to DOE guidance and senior regulatory officials, a safety
analysis conducted in response to a new hazard must analyze appropriate
accident conditions, derive or identify procedures sufficient to ensure
the safety of workers, and demonstrate the adequacy of those procedures
to maintain the work environment at an acceptably low level of risk. In
addition, guidance specifies that safety analyses should be well
documented to allow independent reviewers to assess the adequacy of the
analysis and its conclusions. The officials stated that the analysis
should be rigorous, include quantitative and qualitative reasoning, and
identify and defend assumptions.
In this case, DOE and UDS conducted an investigation of the possible
presence of phosgene contamination in uranium storage cylinders because
they recognized the possibility that workers and the public might be in
danger if phosgene were present in the cylinders. For example, if an
accident occurred in the uranium storage cylinder yard and a cylinder
containing phosgene ruptured, workers and the public could suffer
serious harm if they inhaled phosgene gas.[Footnote 12] Through their
investigation, DOE and UDS demonstrated that only small amounts of
phosgene could be present in the uranium storage cylinders. All members
of our expert panel reviewed and concurred with this finding.
Nevertheless, the expert panel raised concerns that DOE did not specify
whether or how workers conducting operations directly adjacent to the
cylinders would be protected from harm if phosgene accidentally escaped
from a cylinder.
When we related our expert panelists' concerns about the possible
effects of phosgene on workers, DOE and UDS officials stated that they
had assessed worker safety during the investigation and decided that
workers would not be harmed by the possible presence of small amounts
of phosgene. DOE and UDS officials stated that the first- response
safety procedure to protect workers from uranium stored in the
cylinders--termed "see and flee"--calls for immediate evacuation of the
area around a ruptured cylinder. They reasoned that since this
procedure was sufficient to protect workers against large quantities of
uranium hexafluoride if a cylinder ruptured and the contents escaped,
it would also be sufficient to protect workers from small amounts of
phosgene.
DOE and UDS did not, however, explicitly document or support their
inference that workers would be protected by the "see and flee" safety
procedure. During their investigation, DOE and UDS considered worker
safety and inferred that "see and flee" would protect workers from the
possible presence of phosgene. Contrary to guidelines, however, they
did not document a thorough analysis demonstrating that "see and flee"
was adequate to protect workers until we brought the matter to their
attention. Although DOE and UDS officials stated that they had
systematically analyzed the potential consequences of the presence of
phosgene in uranium storage cylinders to worker safety, they were
unable to provide any documentation of their analysis, such as
assumptions, reasoning, or results. The phosgene investigation did
undergo review, but the lack of documentation of DOE and UDS's
consideration of worker safety made it impossible for reviewers to
assess the adequacy of this consideration and thus allowed a key
element of the investigation to pass without inspection.
In addition, DOE's review of the phosgene investigation may not have
been sufficiently independent. Senior DOE regulatory officials stated
that reviewers should not be involved in the investigation under
review; in this case, however, officials involved in the investigation
also served as reviewers. DOE reviewers may have been too familiar with
the project to provide a sufficiently independent assessment of the
investigation. DOE's review allowed a weakness--the unsupported
inference that existing safety procedures would protect workers--to
persist in DOE's investigation of possible phosgene contamination. Thus
DOE and UDS believed, without explicitly documenting, that existing
worker safety procedures were adequate to protect workers from the
possible presence of phosgene.
Ultimately, in February 2007, DOE and UDS issued a supplement to the
original investigation report, which documented the assumptions,
reasoning, and calculations used to reach the conclusion that existing
safety procedures would protect workers from the possible presence of
phosgene. All members of our expert panel agreed with the conclusions
presented in the supplement. Therefore, the supplemental information
showed that, throughout the investigation, workers were protected from
harmful phosgene exposure by existing safety procedures.
In addition, we identified two other weaknesses in DOE and UDS's
investigation of possible phosgene contamination, which they addressed
during our review. Specifically:
² DOE and UDS assumed, but did not explicitly document, that any
phosgene introduced into the uranium enrichment process would be
destroyed. DOE and UDS did not identify this assumption or support it
with evidence or analysis during the investigation. This is a key
assumption because if the uranium enrichment process did not destroy
phosgene, the gas could have passed through the process and into
hundreds of thousands of cylinders containing enriched uranium
hexafluoride and could still be present today. Scientists knowledgeable
about the uranium enrichment process and the experts we consulted all
confirmed that DOE and UDS's undocumented assumption was correct--
phosgene, if introduced into the uranium enrichment process, would have
reacted with other chemicals in the process and been destroyed, or it
would have been purged from the process with other waste gases. After
we discussed this weakness with DOE and UDS, they provided supplemental
information demonstrating that phosgene would not survive the uranium
enrichment process. We reviewed the supplemental information and found
that it adequately supports DOE and UDS's assumption.
² DOE and UDS used records to determine that 181 cylinders had been
pressure tested, which would have eliminated any phosgene that may have
been present, but records for 6 cylinders lacked sufficient information
to meet this criterion. According to DOE and UDS's definition of the
pressure-test criterion, a cylinder must have information showing that
(1) it underwent a pressure test and (2) the cylinder was under DOE's
control at the time of the test. If a test had been performed while the
cylinder was still in the Army's possession, it could have subsequently
been used to store phosgene. During our review, we identified one
cylinder that did not have sufficient information to prove that DOE had
performed the pressure test. After discussing this weakness with DOE
and UDS officials, UDS conducted its own review of all 181 cylinders
and found 5 additional cylinders that also had insufficient information
to meet the pressure-test criterion. The available information for all
6 cylinders, however, did meet the definition of another criterion, and
as a result, DOE and UDS concluded that the cylinders posed no harm.
These two weaknesses created potential vulnerabilities in DOE and UDS's
investigation of possible phosgene contamination because if phosgene
had survived the enrichment process, or if the six cylinders could not
have passed a different criterion, many cylinders could still contain
unknown amounts of phosgene today.
DOE Did Document Its Analysis of the Safety Risk to the Public:
According to the experts we consulted, DOE and UDS conclusively
demonstrated that the presence of small amounts of phosgene in storage
cylinders would not harm the public. DOE and UDS followed federal
regulations and agency guidelines by identifying possible accident
conditions and applying and documenting a qualitative and quantitative
analysis consisting of three main steps. First, DOE and UDS determined
that the closest the public would be to cylinders possibly containing
phosgene was 200 meters--the shortest distance between the storage site
boundary and the cylinders. Second, DOE and UDS calculated the maximum
amount of phosgene that could be released from a cylinder without
harming a person standing 200 meters away. To do this, DOE and UDS used
emergency-response planning guidelines that specify the maximum
airborne concentration of phosgene that nearly all individuals could be
exposed to for up to 1 hour without experiencing more than mild,
transient health effects (such as coughing and eye irritation) and
perceiving only an objectionable odor.[Footnote 13] They then applied a
computer model to predict the dispersion of phosgene gas from a
ruptured cylinder and determined that 1.2 grams was the maximum amount
of phosgene that could be present in a cylinder without harming a
member of the public 200 meters away. Third, DOE and UDS determined
that none of the cylinders could contain phosgene in excess of this 1.2
gram amount. Specifically, DOE and UDS reviewed cylinder records to
document that the cylinders:
² had been washed or pressure tested after DOE acquired them;
² had been filled and emptied of uranium hexafluoride at least once,
which would have removed enough phosgene that only a residual amount
(less than 1.2 grams) could remain; or:
² had open holes (for example, where a valve had been removed; see fig.
2), which would have allowed any phosgene to diffuse harmlessly over
time.
DOE and UDS determined that if any one of these criteria were met, the
amount of phosgene that could remain in a cylinder was 1.2 grams or
less. For cylinders that did not meet these criteria, DOE and UDS
sampled the contents to test for phosgene. On the basis of these
procedures, DOE and UDS determined that phosgene could not be present
in quantities that would harm the public.
Figure 2: Cylinder with an Open Hole:
[See PDF for Image]
Source: Uranium Disposition Services.
[End of figure]
DOE and UDS documented their assumptions, reasoning, calculations, and
results from this analysis and reported them in their April 2006
investigation report. According to the experts we consulted, DOE and
UDS's analysis conclusively demonstrated that the public would not be
harmed from any phosgene that could be present in uranium storage
cylinders.
Possible Phosgene Contamination of Uranium Storage Cylinders Does Not
Threaten Depleted Uranium Conversion Facilities:
In September 2005, DOE's Inspector General warned that the introduction
of phosgene into the conversion process could possibly have
catastrophic safety consequences. At that time, neither the Inspector
General nor DOE and UDS knew how much phosgene could be in a cylinder.
In the investigation prompted by the warning, however, DOE and UDS
demonstrated that no more than 1.2 grams of phosgene could be present
in a cylinder. DOE and UDS determined that this small quantity of
phosgene, if introduced into the conversion facilities, would not cause
a safety concern, and the experts we consulted concurred.
The experts, as well as DOE and UDS officials, cited two main reasons
for concluding that the conversion facilities would not be threatened
if 1.2 grams or less of phosgene were present in the uranium storage
cylinders. First, during the conversion process, the cylinders will be
placed in pressure vessels (called autoclaves) that will heat their
contents to approximately 200 degrees Fahrenheit. (Fig. 3 summarizes
the conversion process and what would happen to any phosgene present.)
According to UDS officials and experts we consulted, these autoclaves
are designed to withstand any cylinder ruptures and to contain the
contents of the cylinders, regardless of whether phosgene is present.
Specifically, the autoclaves are designed to withstand pressures up to
200 pounds per square inch and temperatures exceeding 200 degrees
Fahrenheit, and their interiors are treated with a protective coating
that resists heat and corrosive chemicals. They would therefore
withstand any depleted uranium hexafluoride or phosgene that might leak
from a ruptured cylinder into the interior of the autoclave.
Furthermore, if a cylinder did rupture, according to UDS officials,
sensors in the autoclave would detect any depleted uranium hexafluoride
released. These sensors would alert workers, who could then shut down
the autoclave and follow safety procedures for cleaning it out.
Second, once the gaseous depleted uranium hexafluoride and phosgene, if
present, left the autoclave and entered the conversion unit, high
temperatures and water vapor applied during conversion would destroy
any phosgene, in addition to converting the uranium hexafluoride to
uranium oxide and hydrofluoric acid. According to UDS officials, the
conversion unit will heat the depleted uranium hexafluoride and
phosgene to temperatures exceeding 800 degrees Fahrenheit as water
vapor is added. Because phosgene reacts with water and begins to
dissociate into carbon monoxide and chlorine gases below 800 degrees
Fahrenheit, any phosgene would separate and react with the water vapor,
forming carbon dioxide and hydrochloric acid, neither of which would
threaten the conversion equipment. According to UDS officials, the
carbon dioxide would be vented from the conversion system with other
gases through exhaust stacks. The hydrochloric acid would also react
with the water vapor and be purged from the system. Thus, any residual
amounts of phosgene that may be introduced into the depleted uranium
conversion process would be destroyed and would not threaten any part
of the conversion facilities.
Figure : Steps to Convert Depleted Uranium Hexafluoride to Uranium
Oxide, with Impact on Phosgene, If Present:
[See PDF for image]
Sources: GAO and DOE.
[End of figure]
Conclusions:
In view of DOE's long history of processing highly radioactive and
other dangerous materials for use in defense and civilian endeavors,
protecting workers, the public, and the environment is an integral part
of accomplishing DOE's missions. In doing so, DOE has guidelines for
addressing potential hazards to workers and the public, which include
an independent review of safety analyses. Nevertheless, DOE and UDS's
investigation of possible phosgene contamination of uranium storage
cylinders did not follow guidelines for adequately documenting a safety
analysis of the potential harm to workers that phosgene contamination
might present. Furthermore, we do not believe that DOE had an adequate
internal review process for assessing this investigation, a process
that should have but did not identify weaknesses. Specifically, the
review should have been conducted by reviewers who were independent of
the investigation and who could have provided an objective evaluation
of the investigation's methodology, findings, and conclusions. Although
the assumptions DOE used in reaching its judgment on possible phosgene
contamination turned out to be reasonable in this case, DOE may not be
so fortunate the next time. The same process weaknesses, if undetected
in other situations, could have dangerous consequences. The discovery
of the possible presence of a potentially hazardous or lethal safety
condition, such as phosgene contamination, demands a better planned and
managed review process and assurance that guidelines are followed.
Recommendations for Executive Action:
To ensure the comprehensiveness and technical adequacy of
investigations of potentially unsafe situations at DOE's nuclear
facilities, we recommend that the Secretary of Energy ensure that
safety investigations benefit from a review process that (1) includes
reviewers who are sufficiently independent of the investigations being
done and (2) provides objective evaluations of the methodologies being
used and the findings and conclusions reached.
Agency Comments and Our Evaluation:
We provided a draft of this report to DOE for review and comment. In a
written response, DOE's Chief Operating Officer for Environmental
Management agreed with our conclusion that neither workers nor the
public would have been at risk from potential phosgene contamination of
depleted uranium cylinders but took exception to our findings of
inadequacies in DOE's investigation. DOE did not comment on our
recommendations. DOE's comments on our draft report are included in
appendix I. DOE also provided the February 2007 supplement to its
investigation that was previously provided to us. We did not, however,
reproduce the supplement because our draft report already discussed its
contents.
In its written comments, DOE expressed the view that three basic
assertions in our draft report were incorrect, inaccurate, or
misleading. Specifically, DOE took issue with our findings that DOE's
assessment of worker safety was flawed, DOE's reviewers of the
investigation were not sufficiently independent, and explicit
information on the fate of phosgene in the enrichment process was not
included in the investigation.
Regarding worker safety, DOE agreed that its investigation did not
specifically document that potential phosgene contamination would not
increase health consequences to workers. Nevertheless, DOE argued that
explicit documentation was unwarranted because it was so obvious to
those involved in the investigation that the existing safety management
plan fully protected workers, and the investigation was written by
technical experts for review and approval by technical experts. We
disagree. Our expert panel, which consisted of nationally recognized
technical experts on phosgene or nuclear material, was unable to
independently draw the same conclusions as DOE because of the lack of
explicit documentation in DOE's investigation regarding the effects on
worker safety of potential phosgene contamination. In our view, this
fact calls into question DOE's contention that it was "obvious" that
the existing safety management plan fully protected workers.
Furthermore, we are concerned about the seemingly lax attitude
portrayed in DOE's comments about the need for adequate documentation
of important safety analyses. DOE asserted that the absence of explicit
documentation of the analysis and results of its investigation does not
jeopardize worker safety, just as the presence of explicit
documentation would not ensure worker safety. Nevertheless, DOE's own
standard for reviewing and approving safety documents states that
hazards analyses should be both "clearly characterized" and
"understandable."[Footnote 14] Our expert panel found DOE's analyses to
be neither clearly characterized nor understandable until DOE issued a
February 2007 supplement to its original report. DOE stated in its
comments that such a supplement would have been unnecessary had DOE
officials been allowed to communicate directly with our expert panel.
GAO's standards of evidence, however, require that the experts we rely
on be independent and objective. To help ensure their independence and
objectivity, the experts on our panel did not interact directly with
DOE or UDS officials, but the experts did review information provided
by those officials about the investigation's details. We worked closely
with DOE and UDS officials to ensure that the information provided to
the expert panel fairly, accurately, and sufficiently described the
steps DOE and UDS had taken. We also disagree with DOE's
characterization of the February 2007 supplement as "simple." In fact,
without it--that is, on the sole basis of the documentation from DOE
and UDS's original investigation--our expert panel was not convinced of
the adequacy of DOE and UDS's worker safety analyses. Thus we maintain
that the information and analyses included in the February 2007
supplement should have been included in the original investigation
report.
As our draft report noted, we and our expert panel agree that the
assumptions DOE used in reaching its judgment on possible phosgene
contamination turned out to be reasonable in this case. Nevertheless,
the fact that DOE was fortunate this time does not reduce the need for
future DOE hazards analyses to be adequately documented to sufficiently
demonstrate that workers and the public will not be harmed by potential
risks to their safety. In our view, by questioning the need for
explicit documentation of its analyses, DOE is contending that those
outside the department should believe DOE's conclusions on the basis of
trust rather than on the basis of rigorous, scrupulously documented
analyses. We feel that, given the potentially deadly results of a
phosgene release, workers, the public, and Congress deserve better than
simply being asked to take DOE's conclusions on faith.
Regarding DOE's independent review of the investigation, DOE stated in
its comments that four high-level, technically qualified officials who
had no direct connection to the investigation provided an independent
review of its findings. DOE's argument, however, is misleading because
two of these reviewers were also named on a list provided to us by DOE
during our review as staff who provided input on the direction of the
investigation and who were involved in reviewing and approving
investigation plans. In our view, staff who have provided direction to
an investigation are not sufficiently independent to provide an
objective review of the quality or the results of that investigation.
Finally, regarding our finding that explicit information on the fate of
phosgene in the uranium enrichment process was not included in DOE and
UDS's investigation, DOE noted that uranium enrichment facilities are
operated by USEC, which analyzed the fate of phosgene in the enrichment
process and concluded that the gas would not survive. DOE stated that
it was neither necessary nor appropriate for DOE to repeat USEC's
assessment. Contrary to DOE's assertion, our draft report did not argue
that DOE should duplicate USEC's analysis of the fate of phosgene in
the enrichment process. Instead, we believe that DOE should have, at a
minimum, noted in its investigation that USEC had performed such an
analysis and summarized its results. We agree, and our draft report
noted, that the February 2007 supplement sufficiently documents the
conclusion that phosgene would be destroyed in the enrichment process.
Nonetheless, as with DOE's analysis of worker safety, we continue to
believe that a supplement should not have been necessary at all,
because the information and analyses explained in the February 2007
supplement should have been included in the original investigation
report.
We are sending copies of this report to the Secretary of Energy. We
will also make copies available to others upon request. In addition,
the report will be available at no charge on the GAO Web site at
http://www.gao.gov.
If you or your staff have any questions about this report, please
contact me at (202) 512-3841 or AloiseE@gao.gov. Contact points for our
Offices 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 II.
Signed by:
Gene Aloise:
Director, Natural Resources and Environment:
[End of section]
Appendix I: Comments from the Department of Energy:
Department of Energy:
Washington, DC 20585:
May 10 2007:
Mr. Ryan Coles:
Assistant Director:
Government Accountability Office:
441 G Street, NW:
Washington, D. C. 20548:
GAO Report Entitled "DOE'S Investigation Of Phosgene Gas Contamination
Was Inadequate, But Experts Conclude That Worker Safety And Facilities
Are Not Threatened" - (Report GAO-07-712):
Dear Mr. Coles:
The Department of Energy (DOE) agrees with the Government
Accountability Office's (GAO) conclusions that neither workers nor the
public would have been at risk by the possibility of small amounts of
phosgene remaining in 30 inch cylinders that were previously used in
Chemical Warfare Service. DOE takes exception to GAO's allegations of
inadequacies and/or flaws in the DOE investigation. We are disappointed
that you were not able to include more of our significant comments in
the draft report.
There are three basic assertions in the Government Accountability
Office draft report on the Department of Energy investigation of
potentially contaminated storage cylinders that are incorrect,
inaccurate, or misleading. The issues are summarized below and are
addressed in greater detail in Sections 1 through 3 of Attachment 1.
Assessment of Worker Safety:
In the initial sections of the draft report, GAO stated that DOE simply
assumed that existing worker safety procedures were adequate to protect
workers from any potential contamination. In fact, long before GAO
began their review of this issue, DOE explicitly assessed the potential
risk to workers using widely accepted chemical hazard measures and
initial determinations of the maximum possible phosgene contamination.
DOE concluded the possibility of phosgene in the absence of uranium
hexafluoride increased the risk to workers and imposed additional
administrative controls. These controls included the immediate measures
taken to isolate the suspect cylinders, restrict cylinder movements,
minimize the operational events that have the potential to breach a
suspect cylinder, minimize the number of personnel in the vicinity of a
suspect cylinder and other administrative controls documented in the
investigation report.
A timeline detailing the various analyses supporting the worker safety
is provided as Attachment 2 of this response.
In the safety document "Justification for Continued Operations while
Resolving the Potential Presence of Phosgene in Selected 30-inch
Cylinders" (DUF6-G-JCO-001, November 30, 2005), DOE specified that
"Personnel working in the cylinder storage yards containing the suspect
cylinders will be trained to recognize actual or suspected off-nominal
conditions and on evacuation and emergency notification procedures."
This action was carried out. Workers were briefed when the initial
concern was raised and provided routine status of the investigation.
The JCO states that the UDS Safety Management Programs provide the
necessary controls to safely address the potential phosgene issue, a
conclusion based on an expert understanding of the relative risks of a
small amount of phosgene (if present) in a large amount of uranium
hexafluoride. For additional protection beyond the existing protection
provided by the standard safety measures developed for activities
around uranium hexafluoride, interim compensatory measures were
implemented to further minimize the risks associated with the suspect
cylinders. The appropriate response practices required were those
already in place for existing hazards and this was understood by the
workers. When cylinder sampling occurred, specific activities required
by workers were reviewed with them (to obtain their input) and the
final instructions were signed by all workers involved in the
activities. These documents are part of the Phosgene Characterization
Study reviewed by GAO.
The absence of explicit documentation of the calculations and reasoning
leading to the DOE worker safety assessment in the Phosgene
Characterization Study does not jeopardize worker safety just as the
presence of explicit documentation of the assessment would not ensure
worker safety. The GAO continues to assert that the DOE study did not
explicitly address worker safety in spite of DOE providing a supplement
to the study (see Attachment 3) that convinced the GAO expert panel
that workers were not at risk.
The worker safety assessment, documented in supporting information
provided to GAO, clearly demonstrated that the exceedingly low risk
from potential phosgene contamination was overwhelmed by the risk of
the much larger quantities of uranium hexafluoride. This early worker
safety determination allowed DOE to focus its subsequent investigations
on assessing the potential risk to the public in the event phosgene
contamination actually existed. The GAO report states:
"...DOE and UDS issued a supplement to the original investigation
report, which documented the assumptions, reasoning, and calculations
used to reach the conclusion that existing safety procedures would
protect workers from the possible presence of phosgene. All members of
our expert panel agreed with the conclusions presented in the
supplement."
Independent Review:
The GAO stated that the independent reviewers of the DOE study also
supervised the investigation and thus were too familiar with the
investigation to identify the alleged weaknesses identified by GAO. In
fact, the DOE report was reviewed by at least four, high level,
technically qualified DOE officials who had absolutely no role in
supervision of the investigation.
The development and implementation of the investigation was strictly
the responsibility of the DOE Portsmouth-Paducah Project Office and was
supported by their contractors and DOE Oak Ridge where some of the
suspect cylinders were located. The independent reviewers did not
supervise or otherwise direct any aspects of the investigation. The GAO
report states that:
"...DOE and UDS's analysis conclusively demonstrated that the public
would not be harmed from any phosgene that could be present in uranium
storage cylinders."
Also, in the previous quotation above, the GAO report states that their
expert panel agrees that the small amounts of possible phosgene
contamination represent no increased risk to the health and safety of
the workers under any circumstances. These conclusions of the GAO
expert panel suggest that independent review of the Phosgene
Characterization Study did not fail to identify significant flaws.
Phosgene Fate in Enrichment Facilities:
GAO stated in their draft report that the DOE assumed but did not
explicitly document that any phosgene introduced into the uranium
enrichment process would be destroyed. In fact, the enrichment
facilities are operated by a commercial firm, the United States
Enrichment Corporation (USEC). The management alert on potential
phosgene contamination was promptly forwarded to USEC. They conducted
an analysis of the potential consequences for their operations and
concluded that there are none. In response to the GAO assertion that
explicit information on the fate of phosgene should be included in the
Phosgene Characterization Study for the convenience of their expert
panel, DOE provided a supplement addressing the topic. The supplement
is provided as Attachment 3 of this response.
DOE, based on the experience and knowledge of their own experts, agreed
with the USEC determination and that it was neither necessary nor
appropriate to repeat the USEC assessment of the fate of hypothetical
phosgene in enrichment facilities. The GAO and their expert panel also
agreed with the USEC conclusions and the GAO report states that:
"...phosgene, if introduced into the uranium enrichment process, would
have reacted with other chemicals in the process and been destroyed, or
it would have been purged from the process with other waste gases."
Please be assured, our first commitment is to the health and safety of
our workers and the public.
Sincerely,
Signed by;
Ines R. Triay, Ph.D.
Chief Operating Officer for Environmental Management:
Attachments:
cc:
W. Murphie, PPPO/LEX:
J. Zimmerman, PPPO/LEX:
R. Holland, EM CBC:
J. Craig, EM CBC:
T. Brown, MA-62:
Response to the GAO Review of the DOE Investigation of Potential
Phosgene Contamination:
1. Assessment of Worker Safety:
In its report, the GAO stated that "DOE and UDS assumed, without
explicitly documenting, that existing worker safety procedures were
adequate to protect workers from the possible presence of phosgene"
(emphasis added). This is not correct. DOE and UDS declared, in the
positive Unresolved Safety Question (USQ) issued on November 8. 2005,
that the presence of phosgene could increase risk of health
consequences to both workers and the public. This was stated again in
the Justification for Continued Operations (JCO), dated January 5, 2006
in which additional controls were established on cylinder yard
operations to further reduce the risk to workers and the public. Both
of these documents were provided to GAO during their review.
These controls retrained in place until:
* DOE and UDS demonstrated that 1.2 grams of phosgene would not result
in increased health consequences to a member of the public.
* DOE and UDS determined that the existing safety management program
was sufficient to protect workers if no more than 1.2 grams of phosgene
were present in individual 30 inch cylinders.
* Criteria were developed for demonstrating that cylinders could
contain no more than 1.2 grams of phosgene.
* The characterization of all 30 inch cylinders was completed in
accordance with the criteria established above.
* CYlinders that could not be cleared based on cylinder records were
sampled to verify that phosgene was not present at a level above 1.2
grams.
Although the final report did not specifically document that 1.2 grams
would not increase health consequences to workers. the data contained
in the calculations provided to GAO on April 19, 2006 show that the
ratio of phosgene to uranium hexafluoride vapor in the cylinder head
space is almost two orders of magnitude below the ratio required to
cause increased health consequences to workers.
The GAO report repeatedly makes the assertion that undocumented
conclusions are assumptions. This is not correct. GAO concluded that it
was not until February 2007, after the matter was brought to the
attention of DOE by the GAO, that DOE adequately demonstrated that
there would be no increased health consequences for workers. In
reality, the fact that the existing safety management plan fully
protected workers from small quantities of phosgene was so obvious to
those involved in the investigation, including the independent
technical reviewers, that explicit documentation in the Phosgene
Characterization Study was unwarranted.
The GAO asserted that because the DOE did not explicitly document its
analysis of safety risk to workers in the Phosgene Characterization
Study that the investigation was flawed. In fact, explicit
documentation in the study was not deemed necessary by the authors or
reviewers that approved the report. DOE repeatedly reminded GAO during
their investigation that the study in response to the DOE Inspector
General management alert was written by technical experts for review
and approval by technical experts.
The GAO report makes statements such as "DOE and UDS officials. decided
that workers would not be harmed by the possible presence of small
amounts of phosgene. " or "they reasoned that since this procedure was
sufficient. " In point of fact, the ERPG levels for phosgene, hydrogen
fluoride, and uranium hexafluoride that were used to "decide or reason"
are established by the American Industrial Hygiene Association and are
considered consensus standards throughout the country. DOE takes
exception to the implication that DOE's conclusions were based on
anything less than valid data and quantitative analyses.
The GAO investigation process prohibited direct communication between
their panel of experts and the personnel performing the DOE phosgene
investigation. DOE and UDS believe that the questions related to
assessment of worker safety could have been resolved with GAO's panel
of experts if direct communication had been allowed. Evidence to
support this belief is presented by the fact that a simple supplement
to the original report was all that was necessary to convince GAO's
expert panel that workers would not be affected by the presence of 1.2
grams of phosgene in a 30 inch cylinder containing uranium
hexafluoride.
2. Independent Review:
GAO asserts in their report that the DOE review of the phosgene
investigation may not have been sufficiently independent. DOE considers
this claim is without merit and reflects a misunderstanding of the DOE
review process.
The DOE study was authored by UDS, a DOE prime contractor. Before
submitting the report to DOE it was reviewed by UDS management as well
as a technical expert from Areva (a UDS member company). This technical
expert was not affiliated with the project in any way. When the final
draft study was submitted to DOE it was first reviewed by the DOE
Federal project director and DOE Portsmouth-Paducah Project Office
staff. Following local review, the report was reviewed by the EM Chief
Operating Officer, Deputy Assistant Secretary for Safety Management and
Operations and the Chief of Nuclear Safety (Office of the
Undersecretary of Energy). In total, at least 3 different reviews were
conducted by persons who had no direct connection to the DUF6 project.
None of the reviewers beyond the local level supervised the phosgene
investigation as stated by GAO.
3. Phosgene Fate in Enrichment Facilities:
The GAO asserted that, "DOE and UDS assumed but did not explicitly
document that any phosgene introduced into the uranium enrichment
process would be destroyed". Uranium enrichment activities in the US
are carried out by the United States Enrichment Corporation (USEC), a
publicly traded company. Both UDS and DOE notified USEC management of
the IG Alert when it was received. U SEC officials conducted their own
internal investigation into possible consequences of phosgene in UF6
cylinders and concluded (correctly) that there were no consequences to
their operations or potential health consequences to their workers or
the public. UDS and DOE personnel are familiar with the operating
principles of the enrichment plants including, in some cases, the
classified aspects of the process and with that knowledge agreed with
the USEC conclusions. DOE and UDS disagree that it was necessary or
appropriate for DOE to repeat the assessment of USEC to validate a
conclusion that they find entirely consistent with their knowledge of
the enrichment process.
Timeline for DOE Activities Performed to Assess and Effect Worker
Safety due to the Potential Presence of Unknown Quantities of Phosgene
in UF6 Storage Cylinders:
Documentation of the activities described in the following timeline was
provided to the GAO investigators during their site visit or as part of
DUF6-G-RGN-008, Phosgene Characterization Study.
September 30, 2005:
Department of Energy Office of the Inspector General issued the
management alert that identified the potential for the presence of
phosgene in 30-inch UF6 Cylinders, This report was received on October
3, 2005.
October 5, 2005:
Cylinder Yard crew was briefed.
The daily order and end-of-day briefing in the narrative logbooks for
cylinder yard supervisors dated October 5, 2005 document that the
phosgene issue was discussed with the cylinder yard crews.
Per procedure, UDS-GFP-001, Portsmouth Cylinder Yard Management, and
UDS-GFP-002, Paducah Cylinder Yard Management, the cylinder yard
supervisor maintains a narrative logbook for the purpose of process
control and event reconstruction. At a minimum, the narrative logbook
contains entries for the following:
* Changes in cylinder storage area operating mode or condition
(shutdown due to weather, equipment failure, etc.)
* Force report (personnel reporting for work each shift).
* Record of general UF6 cylinder related activities such as number of
cylinder inspections, relocations, as-found and as-left conditions, and
maintenance activities performed. This record supplements the cylinder
information database (CID) record but does not replace any CID entry
requirements.
* Yard maintenance performed.
* Status changes in safety-related or important equipment.
* Occurrences of reportable events.
* Actions that breach operational safety limits.
* Security incidents.
* Out-of-specification process results.
* Shift relief.
* Personnel changes.
* Illness or injuries occurring during the shift.
* Training activities.
The logbooks provide a documented record of the phosgene issue and
implementation of immediate actions. These forms of communication are
required by DOE Order 5480.19, Conduct of Operations Requirements for
DOE Facilities. Documentation of the daily orders was provided in
Attachment F of DUF6-G-RGN-008, Phosgene Characterization Study.
October 6, 2005:
UDS issued an Occurrence Reporting and Processing System (ORPS) report
and notifications were made.
The ORPS report EM-PPPO-UDS-PORTDUCON-2005-0003, Management concern
involving storage of Uranium Hexafluoride (UF6) Cylinders, was issued
to inform management of the issue and to track progress on resolution
of the issue. The ORPS report noted that all work on the 30A cylinders
was suspended and that ETTP (Bechtel-Jacobs Corporation) and UDS had
initiated the Unreviewed Safety Question (USQ) process with a Potential
Inadequacy in the Safety Analysis (PISA).
October 7, 2005,
As part of Daily Order 06-0004, the cylinder yard manager provided a
briefing that included a presentation consisting of the following:
* photographs of the UF6 service modification performed on the
cylinders, obtained from the U.S. Army Chemical Warfare Service t6
allow workers to identify the potential variations,
* data indicating the presence of phosgene,
* immediate actions which included suspending work on 30A cylinders,
* future actions,
* preliminary findings in the investigation, and:
* Material Safety Data Sheets for phosgene.
In addition, the daily orders noted the development of a phosgene
binder. The binder was located in the break room used by the cylinder
yard crew. Any existing information and all updates to the
investigation were placed in the binder for any of the workers to read.
Documentation of the daily orders was provided in Attachment F of DUF6-
G-RGN-008, Phosgene Characterization Study.
November 8, 2005:
UDS issued a positive Unreviewed Safety Question Determination (USQD)
identifying a PISA in both the Paducah and Portsmouth cylinder yards.
At the time of preparation of the USQD, cylinder records and other
information had not yet been collected and fully reviewed to
demonstrate that the maximum quantity of theoretical phosgene in the
cleared cylinders did not exceed the 1.2 grams found to present no
significant hazard to the public or workers.
The USQD was positive for three determination questions.
1) The potential presence of phosgene increased the consequences of an
accident previously evaluated in the existing safety basis.
The basis as revised to account for the phosgene USQD notes that during
a cold cylinder breach:
"The site facility worker is protected by SMPs [Safety Management
Programs] and the risk is not evaluated against ERPG [Emergency
Response Planning Guidelines] limits. The credited control for the site
worker is `see and flee'. This control is based on the `white smoke'
produced by the reaction of UF6 and moisture in the air to produce HF
and UO2F2. While in a cold cylinder breach, the quantity of white smoke
is much less than that of a liquid cylinder breach, nevertheless, the
reaction can be visibly seen. The odor threshold for HF is 0.04 ppm
while that of phosgene ranges from 0.4 to l. S ppm depending upon the
sensitivity of the worker. Phosgene has a distinctive odor similar to
that of fresh mown hay or moldy hay. In the event where phosgene and
UF6 are both present in the cylinder, 'see and flee' is still a viable
control since the worker will see the white smoke.
In the case of the seven [sic] unmodified cylinders at Portsmouth,
workers can be trained to recognize the smell of phosgene, however,
since the odor threshold is above the permissible exposure limit,
training the workers to recognize the smell of phosgene is not
adequate. Based on current industry practices, it is likely that the
worker will smell the phosgene and be able to fee, and it is probable
that the worker will fee and have health damage due to the exposure
prior to odor threshold; however, the exposure does not necessarily
result in a fatality. Therefore, the presence of phosgene does not
change the '.see and fee' control, however, additional training is
required for the worker to identify the odor of phosgene as an
additional measure to the visible white smoke and HF odor and
additional protective measures such as alarms are required to
adequately protect the worker and allow for emergency response, thus,
protecting the public."
Therefore, the effect of phosgene on the cylinder yard workers and the
hypothetical on-site worker was evaluated and additional controls and
training were deemed necessary to protect the workers when performing
work associated with the 30A cylinders.
2) The PISA concluded there were higher consequences from a malfunction
of the cylinder wall.
The basis as revised to account for the phosgene USQD notes the
following:
"The cylinder wall is [a] designated design feature in both the
Portsmouth and Paducah cylinder yard DSAs [Documented Safety Analyses].
If the cylinder wall were to malfunction and jail, the resulting breach
would be equivalent to a cold breached cylinder event. By applying the
air modeling data provided in the attachment, the ERPG-3 limit is
exceeded.for both the hypothetical on-site worker and the public.
If the cylinder wall were breached as a malfunction, the consequences
to the facility worker, on-site worker, and public would increase due
to the effects of phosgene in the air."
Therefore, the effect of phosgene during a cylinder wall failure was
evaluated for the facility worker and determined that additional
controls would be required to protect the facility worker, on-site
worker, and public. Again, this determination was made prior to
collecting and reviewing cylinder records and other information to
demonstrate that the maximum quantity of theoretical phosgene in the
cleared cylinders did not exceed the 1.2 grams found to present no
significant hazard to the public or workers.
3) The potential presence of phosgene reduced the margin of safety.
The basis as revised to account for the phosgene USQ notes the
following:
"The Paducah and Portsmouth cylinder yard DSAs do not have specific
measured parameters that can be associated with the effect due to
phosgene in the cylinders. However, the potential presence of phosgene
increases the consequences to the worker during a majority of the event
scenarios listed in the site DSAs. Due to the significant impact to the
worker, on-site worker and the public, the margin of safety has been
reduced due to the potential presence of phosgene."
Therefore, the effect of phosgene was evaluated for the facility worker
and determined to increase the consequences to the facility worker
during the accident scenarios deemed possible in the approved
documented safety analysis and hazard analysis for the cylinder yards.
(Subsequent analyses demonstrated that cleared cylinders would not
exceed the 1.2 grams of theoretical phosgene found to present no
significant hazard to the public or workers. The small number of
cylinders that did not satisfy the clearing criteria were sampled and
found to contain no detectible phosgene.)
Overall, the USQD documented the results of the investigation and
clearly shows that UDS and DOE considered the facility worker, on-site
worker, and the public during the evaluation. Since the USQD was
positive, UDS and DOE determined that additional controls were
necessary to provide sufficient protection to the facility worker if
phosgene was found in a cylinder. A record of the approved USQ-019,
Potential Presence of phosgene in 30-inch UF6 Cylinders, was provided
to the GAO for inclusion in their investigation.
November 28, 2005:
The cylinder yard manager issued a standing order, FY 06-02,
documenting the following items relative to the 30A cylinders:
* No vehicles are permitted on the cylinder yard.
* No maintenance or movement of 30A model cylinders is permitted unless
directed by facility manager.
* No radiological surveys of 30A model cylinders are permitted unless
directed by the facility manager.
* Entrance into the cylinder yard or any activities is with the
explicit permission of the facility manager.
The standing order was initialed by the cylinder yard crew documenting
that they had been provided this information.
Documentation of the standing orders was provided in Attachment F of
DUF6-G-RGN-008, Phosgene Characterization Study.
December 19, 2005:
DOE approved DUF6-G-JCO-001, Justification for Continued Operations in
the Paducah and Portsmouth UF6 Cylinder Storage Yards While Resolving
the Potential Presence of Phosgene in Selected 30-inch Cylinders. This
Justification for Continued Operations (JCO) documents the hazard
analysis results from the DOE and UDS analysis of the postulated
accidents scenarios.
The JCO states the following:
"The existing UDS SMPs provide the necessary controls to safely address
the potential phosgene issue. Additional administrative controls have
been implemented based on the specific cylinder surveillance and
maintenance program activity to be performed and the potential cold
breach accidents."
The potential presence of phosgene did not result in any new design
basis accidents from those in the Documented Safety Analysis. It was
determined that the procedures supporting the existing Safety
Management Program were adequate for safely managing the potential
presence of phosgene. However, based on the hazard analysis of the
design basis accidents, additional compensatory measures were
implemented to provide protection beyond the current procedures.
All facility workers were briefed to the JCO and the interim
compensatory measures. Documentation of the briefings was provided in
Attachment F and G of DUF6-G-RGN-008, Phosgene Characterization Study.
January 11, 2006:
DOE approved the revised JCO which was updated to include sampling
activities. All facility workers were briefed on the changes. The final
JCO was provided as Attachment E of DUF6-G-RGN-008, Phosgene
Characterization Study.
UDS approved the work package to begin sampling the suspect cylinders
at Portsmouth. Facility workers were briefed on the work flow and
instructions, activity hazard analysis, radiological work permits,
implementation of the JCO, and equipment to be used. In addition,
facility workers were provided with Material Safety Data Sheets for all
chemicals used in the sampling activity. The complete work package was
provided as Attachment F of DUF6-G-RGN-008, Phosgene Characterization
Study.
January 12, 2006:
Sampling activities were started and completed at the Portsmouth
facility. No phosgene was detected in the cylinders. Activities are
noted in the Portsmouth sampling work package number WA-PO-06-0001,
Perform Sampling of 10 Cylinders (2.5-ton 30 inch) Suspected of
containing Phosgene, which was provided as Attachment F of DUF6-G- RGN-
008, Phosgene Characterization Study.
January 26, 2006:
UDS approved the work package to begin sampling the suspect cylinders
at Paducah. Facility workers were briefed on work flow and
instructions, operation of the equipment to be used, implementation of
the JCO, activity hazard analysis, and radiological work permit.
Documentation of the facility worker briefing was provided in
Attachment G of DUF6-G-RGN-008, Phosgene Characterization Study.
Sampling activities were initiated.
February 6, 2006:
Paducah cylinder yard operations completed sampling activities. No
phosgene was detected in the cylinders. Activities are noted in the
Paducah sampling work package number WA-PA-06-0001, Sampling of Suspect
30-inch Diameter Cylinders for Phosgene at Paducah, which was provided
as Attachment G of DUF6-G-RGN-008, Phosgene Characterization Study.
[End of section]
Appendix II: 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, William R. Swick, Assistant
Director; James Ashley; Ellen W. Chu; Ryan T. Coles; Doreen Feldman;
Cindy Gilbert; Cynthia Grant; George Hinman; Wyatt R. Hundrup; Alison
O'Neill; Laina Poon; Keith Rhodes; Sushil Sharma; and John Stradling
made key contributions to this report. Also contributing to the report
was Jena Sinkfield.
(360673):
FOOTNOTES
[1] DOE processed uranium at the site near Oak Ridge, Tennessee until
1985. This site is now being decontaminated and decommissioned, and
storage cylinders have been moved to other sites, such as Portsmouth.
Since 1992, uranium enrichment activities have been performed by U.S.
Enrichment Corporation (USEC), a private company that was created in
1992 as a wholly owned government corporation and then privatized in
1998.
[2] DOE's Phosgene Characterization Study reported 2,544 cylinders that
were suspected of containing phosgene. Thirty-five of those cylinders
were removed from consideration because they were not relevant; for
example, some were not the type of cylinder in question. We chose not
to report on these 35 cylinders, reporting instead on the 2,509
relevant cylinders.
[3] In addition to DOE and UDS officials, officials from Bechtel Jacobs
Corporation were involved in investigating possible phosgene
contamination of uranium storage cylinders formerly stored at DOE's Oak
Ridge site.
[4] Department of Energy, Depleted Uranium Conversion Project, Phosgene
Characterization Study, DUF6-G-RGN-008, rev. 1 (Washington, D.C.: April
2006).
[5] DOE and UDS determined that, should a cylinder rupture, 1.2 grams
or less of residual phosgene present in a cylinder would not harm
people standing 200 meters or more from the ruptured cylinder.
[6] H.R. Rep. No. 109-275, at 150 (2005).
[7] 10 C.F.R. part 830, subpart B: Safety Basis Requirements.
[8] Department of Energy, DOE Standard: Review and Approval of Nuclear
Facility Safety Basis Documents (Documented Safety Analyses and
Technical Safety Requirements), DOE-STD-1104-96, Change Notice No. 1,
May 2002; Implementation Guide for Use in Addressing Unreviewed Safety
Question Requirements, DOE G 424.1-1, October 2001; and Implementation
Guide for Use in Developing Documented Safety Analyses to Meet Subpart
B of 10 C.F.R. 830, DOE G 421.1-2, October 2001.
[9] Natural uranium, the raw material required for the uranium
enrichment process, comprises several isotopes--forms of the same
element with different atomic weights. Uranium ore consists mostly of
uranium-238 and less than 1 percent uranium-235, the fissile isotope
used in nuclear reactors and nuclear weapons. To be usable as reactor
fuel, uranium must be enriched so that the proportion of uranium-235
exceeds 1 percent; commercial nuclear fuel is typically enriched to 3
to 5 percent.
[10] The severity of a chemical's toxic effect depends on a person's
total exposure to that chemical, that is, the concentration of the
chemical multiplied by the duration of exposure. For phosgene, exposure
to a concentration of 30 parts per million for 1 minute (or 3 parts per
million for 10 minutes) damages the lungs, exposure to 150 parts per
million for 1 minute causes the lungs to fill with fluid, and exposure
to 300 parts per million for 1 minute or more can kill.
[11] DOE and UDS originally identified 182 cylinders that met the first
criterion and 2,290 cylinders that met the second criterion. During our
review, however, 6 cylinders were found to not meet the first
criterion; they were subsequently cleared of suspicion by DOE under the
second criterion. As a result, 176 cylinders met the first criterion,
and 2,296 met the second. The next section discusses this difference in
more detail.
[12] The uranium hexafluoride stored in the cylinders is also very
dangerous to workers, but safety procedures are in place to protect
workers from uranium hexafluoride if a cylinder were to rupture.
[13] These emergency response planning guidelines were developed by the
American Industrial Hygiene Association, a nonprofit organization
founded in 1939 that serves the needs of environmental health
professionals practicing industrial hygiene in industry, government,
labor, academic institutions, and independent organizations.
[14] Department of Energy, DOE Standard: Review and Approval of Nuclear
Facility Safety Basis Documents, DOE-STD-1104-96, May 2002.
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