Kenneth Fletcher
WC Monitor
4/25/2014
The “preventable” Feb. 14 radiation release at the Waste Isolation Pilot Plant was preceded by poor maintenance, safety culture issues by contractor Nuclear Waste Partnership and lax oversight by Department of Energy headquarters and the Carlsbad Field Office, according to a DOE Accident Investigation Board report released this week. While an inadequate filtration system is what actually allowed radiation to be released into the environment aboveground, a host of major issues led up to the release, the investigation found. In total, 21 workers suffered low levels of internal contamination as a result, with at least 10 of those workers arriving on site hours after the event was detected. “The Board concludes that a thorough and conservatively considered hazard analysis, coupled with a robust, tested and well maintained HEPA filter capable exhaust ventilation system could have prevented the unfiltered above ground release,” the report states.
The radiation released came from a transuranic waste drum underground, the Department has said, though the exact cause of the incident is still unknown. This week a team entered the room underground where it is believed the release originated and did not see any visible damage to the drums, which makes unlikely the leading theory of a roof collapse or falling bolt puncturing a drum. This first phase of the accident investigation will be followed by a second report once the contamination source is pinpointed.
WIPP, an Environmental Protection Agency-regulated transuranic waste repository, was in many aspects held up to mine standards rather than nuclear safety standards. “We at WIPP have a world-class mining operation, but we are going to need a world-class nuclear operation as we go forward,” NWP Project Manager Bob McQuinn, who was brought in after the incidents, said this week at a Carlsbad, N.M., town hall meeting. “Much more improvement will be needed before we resume nuclear operations.”
Safety Requirements Not Up to Nuclear Standards…
The report listed numerous issues with safety requirements. “The Technical Safety Requirement documentation is not being controlled with the rigor normally associated with a Hazard Category 2 nuclear facility,” it states, also noting an “observed lack of robustness” in CBFO’s review of safety documents. In the safety basis, a roof fall accident would have been prevented by ground controls, meaning that only smaller releases such as waste handling accidents were considered possible. “As a result, the HEPA ventilation system and its associated bypass isolation dampers were not designated as credited safety related equipment. Because the isolation dampers were not nuclear safety system credited, the damper design was not required to meet requirements in the nuclear industry ventilation code,” the report states.
…Leading to Inadequate Ventilation System
The ventilation system is what ultimately allowed radiation to be released aboveground. In the event of an incident mine exhaust is routed through two High Efficiency Particulate Air filters. “However, in order to align for filtration, two bypass isolation dampers that represent a pathway of unfiltered exhaust into the environment must be closed. These isolation dampers have a design leak rate of up to 1000 cfm,” the report states, noting that the release likely escaped through these dampers. The technical basis for the monitoring systems was also inadequate, including reliance on a single continuous air monitor to “initiate an automatic shift to filtration, acceptability of leakage past the bypass dampers and automatic shift to filtration that now requires manual operation of 860 fan vortex dampers,” the report found.
The radiation alarm first sounded at 11:14 p.m. on Feb. 14, when only 11 workers were at the site, all on the surface. Notably, shelter-in-place instructions were not given until 9:34 a.m. the next morning, more than 10 hours after the alarm and after a shift change and the arrival of 153 workers to the site’s aboveground. Because radioactive control technicians are not on site 24 hours, a technician was not reached for several hours and air sample filters could not be pulled until the next morning to confirm the release, delaying action. “The emergency management program was not adequately structured and implemented such that personnel did not recognize, categorize, or classify the emergency and implement protective actions in a timely manner,” the report states.
Safety Culture Problems Include ‘Perceived Fear of Reprisals’
Numerous safety culture issues at WIPP revolved around a fear of reporting problems, which created a “chilled work environment” that contributed to conditions leading up to the event, the report found. “The Board heard from numerous workers, both NWP and CBFO employees, that there were perceived repercussions and reprisals for identifying issues on WIPP Forms, [Occurrence Reporting and Processing System] reports, nonconformance reports, and oversight reports from CBFO,” the report states. “Workers from both NWP and CBFO expressed a reluctance to report issues due to observation of or perceived fear of reprisals. In addition, several workers complained of a lack of management action to address the observed issues or deficiencies.”
The safety culture at WIPP does not implement all the principles in DOE’s Integrated Safety Management Guide, according to the report. “NWP and CBFO have allowed the safety culture at the WIPP project to deteriorate as evidenced by the workers feedback that they do not feel comfortable identifying issues that may adversely affect management direction, delay mission related objectives, or otherwise affect cost or schedule,” the report states. “Questioning attitudes are not welcomed by management and many issues and hazards do not appear to be readily recognized by site personnel.” There was also a general acceptance of degraded equipment and conditions, the investigation found
The report also notes that “DOE has exacerbated the safety culture problem by referring to numbers of ORPS reports and other deficiency reporting documents, rather than the significance of the events, as a measure of performance by Source Evaluation Boards during contract bid evaluations, and poor scoring on award fee determinations. Directly tying performance to the number of occurrence reports drives the contractor to non-disclosure of events in order to avoid the poor score.” The AIB recommended that DOE headquarters provide safety culture training and mentoring to NWP and DOE-Carlsbad management.
Maintenance Inadequate as Waste Processing Took Precedence
Last month, a separate investigation found that a lack of proper maintenance contributed to a Feb. 5 truck fire at WIPP, and this week’s report found that putting waste into the ground was prioritized over than maintenance. “The current culture at NWP is such that due consideration for prioritization of maintenance of equipment is not given unless there is an immediate impact on the waste emplacement processes,” the report states. Fee earned for NWP hinges on waste processed, not performance of maintenance. The report pinpoints issues with ventilation system maintenance and the buildup of salt on bypass dampers. “The condition of critical equipment and components, including continuous air monitors, ventilation dampers, fans, sensors, and the primary system status display were degraded to the point where the cumulative impact on overall operational readiness and safety was not recognized or understood,” the report states.
DOE HQ Failed to Provide Adequate Resources
The investigation also found that responsibility for the issues at WIPP traveled up the management chain to DOE’s Carlsbad office and headquarters, which didn’t give the site enough resources. “DOE HQ management has failed to ensure that adequate resources, full time employees, technical expertise, travel money, adequate budget, etc., are provided to support the WIPP project,” the report says. Subsequently, DOE Carlsbad “is lacking adequate qualified staffing in numerous areas related to line management, technical disciplines and oversight functions,” the report states. That includes a lack of sufficient Nuclear Safety Specialist staff and an Authorization Basis Senior Technical Advisor since 2010.
Weak oversight by headquarters and DOE Carlsbad missed opportunities to identify safety and maintenance issues in the report. “DOE HQ failed to ensure that CBFO was held accountable for correcting repeated identified issues involving radiological protection, nuclear safety, Integrated Safety Management System, maintenance, emergency management, work planning and control and oversight,” the report states. Meanwhile, both NWP and DOE Carlsbad “failed to identify weaknesses in conduct of operations, maintenance, radiological protection, nuclear safety, emergency management, and safety culture,” and “failed to adequately complete corrective actions from prior assessments to prevent or minimize recurrence,” the report says.
DOE Declines Interview, Is ‘Evaluating Impacts’
DOE declined requests for an interview on the report’s findings this week. When sent a list of questions including how headquarters would hold CBFO and NWP accountable and how the report’s findings would impact other sites, a DOE spokesperson said: “The Department remains focused on the ongoing recovery efforts at WIPP. We will continue to evaluate the impacts and performance implications raised in the recent accident investigation reports. Federal employees from across the complex have provided support and guidance to the Carlsbad Field Office, and DOE continues to evaluate additional permanent staffing needs and will continue to support the CBFO leadership team. EM Headquarters, working together with our sites, has already initiated extent of condition reviews on some of these key areas.”
NWP Taking Corrective Actions
NWP has already started taking corrective actions, contractor officials emphasized this week. NWP’s incumbent management “was not very experienced when it comes to nuclear operations,” McQuinn said, stating that it has since added more experienced managers such as new Recovery Manager Jim Blankenhorn. Additionally, there wasn’t a contractor assurance system. “There were pieces of the program that were distributed around the organization. I’ve gathered up all those pieces” and created a contractor assurance position, McQuinn said. The contractor has also created a “senior supervisory watch” to provide more rigorous oversight. “Each one of our line managers at least once a week has to go out in the field and watch the workers to see what the barriers are to being able to follow the procedures,” McQuinn said.
Together with DOE Carlsbad, NWP is developing a recovery plan with two phases. The first, to be completed by the end of May, will stabilize, identify the cause of the release and develop a resumption plan. The second phase will restore mine safety, increase ventilation capacity, decontaminate, address the inadequate safety basis and complete corrective actions. “Nuclear Waste Partnership (NWP) is committed to safe operations at WIPP, a one-of-a-kind facility which had a 15 year safety record without incident. We already have taken significant steps to strengthen WIPP’s leadership team and enhance safety and emergency response procedures since the February incident, and we will be reviewing the report in detail and working diligently with the DOE to address all areas of concern,” NWP spokesman Donavan Mager said in a written response.
Senators Say Findings ‘Deeply Troubling’
Members of New Mexico’s Congressional delegation called for improvements following the report’s release. “The report on the response to the radiation release at WIPP includes many of the same deeply troubling findings as the report after the fire, including concerns about a lack of oversight and an erosion of the safety culture,” Sens. Tom Udall (D) and Martin Heinrich (D) said in a statement. “WIPP is our nation’s only deep geological repository for transuranic waste and must be held to the highest standards. The workers and the surrounding community demand that level of attention, and anything less is unacceptable. As we move forward to clean up and reopen WIPP, we—and the community of Carlsbad—expect that all levels of management at the Department of Energy and at WIPP will take all necessary corrective action to ensure key safety management programs are in place and reinstate a culture in which safety is the top priority.”
Rep. Steve Pearce (R-N.M.) called the report “a major step in the recovery and reopening of the site.” He said in a statement: “The report clearly shows that immediate work needs to be done to improve safety at the plant. This is a vital step in the process of recovery for the community and plant workers. The report depicts a site, a contractor and a DOE that was ill-prepared for any hazardous or emergency situation—let alone a radiological event. The contractor and DOE must make the recommended corrective actions before operations can or should continue at the site. I expect the DOE and the contractor to work diligently, to update, revise, and add safety and management policies that dictate daily operations at the site.”
