Todd Jacobson
NS&D Monitor
1/9/2015
Officials with the National Nuclear Security Administration’s Production Office in November voiced concerns about an “operational excellence plan” developed by Y-12/Pantex contractor Consolidated Nuclear Security to respond to a series of incidents over the last few years, the Defense Nuclear Facilities Safety Board said in a recently released report. The CNS plan was developed after NPO Manager Steve Erhart ordered CNS to dig deeper into abnormal operational events at the Y-12 National Security Complex, many of which occurred before CNS took over management of Y-12 and Pantex in July. According to the Nov. 28 DNFSB memo, NPO senior managers “expressed concern that the plan had not resulted in more immediate improvements in CNS operational performance. They cited the number and significance of recent events, and an observation that CNS line management had not responded to certain events with the appropriate urgency or self-critical tone.”
According to the DNFSB, CNS’ “very high level” plan included five phases: “develop a detailed understanding of work environments and previous issues, establish a vision of excellence, communicate and train at all levels, improve processes and develop metrics to drive performance excellence, and implement continuous learning and improvement.” A systems review of recent incidents had begun, the DNFSB said, as had the development of an employee communications strategy, leadership development training, and the development of line organization standards. CNS and NPO did not respond to a request for comment.
Has Recent Uncertainty Led to Incidents?
Y-12’s Feedback and Improvement Working Group suggested that recent changes at the site could have contributed to an uptick in recent incidents, the DNFSB said. “The FIWG noted that the magnitude of change instituted in the last six months coupled with a significant number of experienced plant workers and supervisors retiring may have introduced unintended consequences impacting floor level performance,” the DNFSB said. “The FIWG also noted that the independent nuclear safety oversight function of the CNS organization is not fully functional, which may also be impacting desired improvements in operational performance.”
Erhart Sought Broader Look into Issues
In his original letter, Erhart acknowledged that some of the incidents occurred before CNS took over responsibility for management of Y-12 and Pantex on July 1. “However,” he wrote, “it is now our collective responsibility to assure that both Plants safely and securely execute mission deliverables/requirements while meeting our customers’ expectations and desires.” Erhart said he wanted CNS to take a broader look than previous studies, not just focusing on the problems listed in the letter, but including an evaluation of plant performance that goes beyond the “typical statistics,” rates, and metrics.
Erhart noted that since the July 2013 accidental weapon discharge by a security police officer at the site “a series of abnormal events have occurred at Y-12 that indicate a cultural undercurrent of complacency with regards to disciplined operations.” Erhart’s original letter identified a number of security and safety events that had not previously been disclosed publicly. Among the security issues raised in Erhart letter was a June 9 incident in which a bag containing an enriched uranium metal plate was found in an unauthorized storage area at Y-12. Less than a month later, two pellets of highly enriched uranium were found misplaced in an area of the 9212 complex, the uranium production hub for the Oak Ridge plant.
On July 21, production workers also identified classified parts that were being prepared for disposal as unclassified waste. In another, separate incident that month, classified and unclassified wastes were co-mingled at the site, and investigations determined that it was not an isolated incident. The result was a temporary suspension of all off-site waste shipments. Other events included failure to secure an area and closing a security portal without setting the alarm system; an unauthorized personal weapon inside the high-security Protected Area at Y-12; and an “inventory discrepancy.”
