Saturday, September 13, 2014
DNFSB Cites NNSA Safety Lapses
The following is excerpted from that letter:
September 2, 2014
RECOMMENDATION 2014-1 TO THE SECRETARY OF ENERGY from DNFSB
Emergency Preparedness and Response
The need for a strong emergency preparedness and response program to protect the public and workers at the DOE's defense nuclear facilities is self-evident. Design basis accidents resulting from natural hazards and operational events do occur and must be addressed.
Consequently, emergency preparedness and response is a key component of the safety bases for defense nuclear facilities. It is the last line of defense to prevent public and worker exposure to hazardous materials.
One of the objectives of DOE’s order on emergency preparedness and response is to “ensure that the DOE Emergency Management System is ready to respond promptly, efficiently, and effectively to any emergency involving DOE/NNSA facilities, activities, or operations, or requiring DOE/NNSA assistance.”
The Defense Nuclear Facilities Safety Board (Board) believes that the requirements in this order that establish the basis for emergency preparedness and response at DOE sites with defense nuclear facilities, as well as the current implementation of these requirements, must be strengthened to ensure the continued protection of workers and the public.
Problems with emergency preparedness and response have been discussed at Board public hearings and meetings over the past three years, as well as in Board weekly reports and other reviews by members of the Board’s technical staff. At its hearings, Board members have stressed the need for DOE to conduct meaningful training and exercises to demonstrate site-wide and regional coordination in response to emergencies.
Board members have also encouraged DOE to demonstrate its ability to respond to events that involve multiple facilities at a site and the potential for several “connected” events, e.g., an earthquake and a wildland fire at Los Alamos.
On March 21, 2014, and March 28, 2014, the Board communicated to the Secretary of Energy its concerns regarding shortcomings in the responses to a truck fire and radioactive material release event at the Waste Isolation Pilot Plant (WIPP) in Carlsbad, New Mexico. The DOE Accident Investigation Board explored and documented these shortcomings in its reports. Many of the site-specific issues noted at WIPP are prevalent at other sites with defense nuclear facilities.
The Board has observed that these problems can be attributed to the inability of sites with defense nuclear facilities to consistently demonstrate fundamental attributes of a sound emergency preparedness and response program, e.g., adequately resourced emergency preparedness and response programs and proper planning and training for emergencies.
The Board is concerned that these problems stem from DOE’s failure to implement existing emergency
management requirements and to periodically update these requirements.
DOE has not effectively overseen and enforced compliance with these requirements, which establish the baseline for emergency preparedness and response at its sites with defense nuclear facilities.
These requirements need to be revised periodically to address lessons learned, needed improvements to site programs, new information from accidents such as those at the Deepwater Horizon drilling rig and the Fukushima Dai-ichi Nuclear Power Plant, and inconsistent interpretation and implementation of the requirements.
Through its participation in DOE nuclear safety workshops in response to the events at the Fukushima Dai-ichi Nuclear Power Plant and its lines of inquiry regarding emergency preparedness and response at recent public hearings and meetings, Board members have been supportive of DOE’s efforts to improve its response to both design basis and beyond design basis events.
However, the Board believes DOE’s efforts to adequately address emergency preparedness and response at its sites with defense nuclear facilities have fallen short as clearly evidenced by the truck fire and radioactive material release events at WIPP.
Technical planning establishes the basis for emergency preparedness and response at DOE sites with defense nuclear facilities. Technical planning includes the development of emergency preparedness hazards assessments, identification of conditions to recognize and categorize an emergency, and identification of needed protective actions. This basis is used to develop emergency response procedures, training, and drills for emergency response personnel.
Hazards assessments form the foundation of the technical planning basis for emergency preparedness and response and provide the basis for the preparation of the procedures and resources used as personnel respond to emergencies.
The Board has observed that hazards assessments at many DOE sites with defense nuclear facilities do not:
(1) address all the hazards and potential accident scenarios,
(2) contain complete consequence analyses,
(3) develop the emergency action levels for recognizing indicators and the severity of an emergency,
(4) contain sufficiently descriptive protective actions.
One example of incomplete hazards analysis that is endemic to the complex is the lack of consideration of severe events that could impact multiple facilities, overwhelm emergency response capabilities, and/or have regional impacts.
This was a topic of discussion at the Board’s public meeting and hearing on the Pantex Plant in Amarillo, Texas, on March 14, 2013, and on the Y-12 National Security Complex in Knoxville, Tennessee, on December 10, 2013.
At many DOE sites with defense nuclear facilities, the Board has observed that training on the use of emergency response procedures, facilities, and equipment is not adequate to fully prepare facility personnel and members of the emergency response organization. Similarly, drill programs are not adequately developed and implemented to augment this training.
As part of their preparedness for emergencies, DOE sites with defense nuclear facilities have emergency response facilities such as Emergency Operations Centers and firehouses, and associated support equipment. The Board has observed that some emergency response facilities at DOE sites with defense nuclear facilities will not survive all potential accidents and natural phenomena events and, consequently, will be unable to perform their vital function of coordinating emergency response.
Many of these facilities will not be habitable during radiological or hazardous material releases. Equipment that is used to support operations of these facilities is frequently poorly maintained and may not be reliable during an emergency.
The Board has also observed problems with DOE efforts to demonstrate the effectiveness of its planning and preparation for emergencies and its response capabilities. Exercises are used to demonstrate a site’s capability to respond, and assessments are used to verify adequacy of planning and preparedness.
Exercises conducted at many DOE sites with defense nuclear facilities do not adequately encompass the scope of potential scenarios (i.e., various hazards and accidents) that responders may encounter. Some sites do not conduct exercises frequently enough or do not develop challenging scenarios. Many sites are not effective at critiquing their performance, developing corrective actions that address identified problems, and measuring the effectiveness of these corrective actions.
DOE oversight is a mechanism for continuous improvement and is used to verify the adequacy of
emergency preparedness and response capabilities at its sites with defense nuclear facilities.
The Board has observed that many DOE line oversight assessments are incomplete and ineffective, and do not address the effectiveness of contractor corrective actions. In addition, the Board has noted that the current scope of DOE independent oversight is not adequate to identify needed improvements and to ensure effectiveness of federal and contractor corrective actions.
As observed recently with the emergency responses to the truck fire and radioactive material release events at WIPP, there can be fundamental problems with a site’s emergency preparedness and response capability that will only be identified by more comprehensive assessments that address the overall effectiveness of a site’s emergency management program. For example, emergencies can occur during off-shift hours, such as the radioactive material release event at WIPP that happened at approximately 11:00 p.m. on Friday, February 14, 2014. Overall effectiveness was the scope of DOE’s independent assessments conducted prior to 2010.
These assessments consistently identified problems with site emergency preparedness and response, and also sought continuous improvement of these programs. In 2010, DOE independent oversight transitioned to assist visits and did not conduct independent assessments. In 2012, DOE independent oversight returned to conducting independent assessments. However, these assessments are targeted reviews, currently only focused on the ability of the sites to prepare and respond to severe events. As a result, these independent assessments do not encompass all elements of emergency management programs and will not identify many fundamental problems.
Causes of Problems
Based on an evaluation of the problems observed with emergency preparedness and response at DOE
sites with defense nuclear facilities, the most important underlying root causes of these problems are ineffective implementation of existing requirements, inadequate revision of requirements to address lessons learned and needed improvements to site programs, and weaknesses in DOE verification and validation of readiness of its sites with defense nuclear facilities.
The Board has observed at various DOE sites with defense nuclear facilities that implementation of DOE’s requirements for emergency preparedness and response programs varies widely. Therefore, the Board concluded that some requirements do not have the specificity to ensure effective implementation. For example, existing requirements for hazards assessments lack detail on addressing severe events. Requirements do not address the reliability of emergency response facilities and equipment. Requirements for training and drills do not address expectations for the objectives, scope, frequency, and reviews of effectiveness of these programs. Requirements for exercises do not include expectations for the complexity of scenarios, scope of participation, and corrective actions.
Guidance and direction that address many of the deficiencies in these requirements are included in the Emergency Management Guides; however, many sites with defense nuclear facilities do not implement the practices described in these guides. DOE has not updated its directive to address the problem with inconsistent implementation. In addition, DOE has not incorporated the lessons learned from the March 11, 2011, earthquake and tsunami at the Fukushima Dai-ichi Nuclear Power Plant in its directive. These lessons learned need to be more effectively integrated into DOE’s directive and guidance on emergency preparedness and response.
The Board also observed that DOE has not effectively conducted oversight and enforcement of its existing requirements. DOE oversight does not consistently identify the needed improvements to site emergency preparedness and response called for in its directive. When problems are identified, their resolution often lacks adequate causal analysis and appropriate corrective actions. When corrective actions are developed and implemented, contractors and federal entities frequently do not measure the effectiveness of these actions.
The Board and DOE oversight entities have identified problems with implementation of emergency preparedness and response requirements at various DOE sites with defense nuclear facilities. The Board has also identified problems with specific emergency preparedness and response requirements. These deficiencies lead to failures to identify and prepare for the suite of plausible emergency scenarios and to demonstrate proficiency in emergency preparedness and response. Such deficiencies can ultimately result in the failure to recognize and respond appropriately to indications of an emergency, as was seen in the recent radioactive material release event at WIPP. Therefore, the Board believes that DOE has not comprehensively and consistently demonstrated its ability to adequately protect workers and the public in the event of an emergency.
Read the entire letter at www.dnfsb.org.
Although it may seem a bit of a stretch for DNFSB to ask DOE/NNSA to plan for accidents that "go beyond the design basis," the consequences of containment failure at a defense nuclear facility can be estimated, and could be horrific.
Of course, much depends upon the type of facility and its location but, in this regard, LANL's PF-4 is probably among the most sensitive of the existing sites. It would behoove DOE/NNSA to pay close attention.