Inspection of Environment, Safety, and Health Management and Emergency Managementat the

Nevada Test Site

Summary Report

Office of Independent Oversight and Performance AssuranceOffice of the Secretary of Energy

October 2002

OV

ER

SIG

HTTable of Contents

1.0 INTRODUCTION .................................................................... 1

2.0 RESULTS ................................................................................. 4

2.1 Positive Attributes .............................................................4

2.2 Program Weaknesses ........................................................6

3.0 CONCLUSIONS ..................................................................... 11

4.0 RATINGS ................................................................................14

APPENDIX A – SUPPLEMENTAL INFORMATION ................... 15

APPENDIX B – SITE-SPECIFIC FINDINGS ................................ 16

Abbreviations Used in This Report

BN Bechtel NevadaCBD Chronic Beryllium DiseaseCY Calendar YearDAF Device Assembly FacilityDOE U.S. Department of EnergyDTRA Defense Threat Reduction AgencyEAL Emergency Action LevelEMC Emergency Management CenterEMOT Emergency Management Operations TeamEMHA Emergency Management Hazards AssessmentEOC Emergency Operations CenterERO Emergency Response OrganizationES&H Environment, Safety, and HealthHAZMAT Hazardous MaterialsHSC HAZMAT Spill CenterISM Integrated Safety ManagementLANL Los Alamos National LaboratoryLLNL Lawrence Livermore National LaboratoryM&O Management and OperatingMSDS Material Safety Data SheetNNSA National Nuclear Security AdministrationNTS Nevada Test SiteNV Nevada Operations OfficeOA Office of Independent Oversight and Performance AssuranceREOP Real Estate/Operations PermitRMAD Reactor Maintenance Assembly and DisassemblyRWP Radiation Work Permit

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Introduction1.0

The Secretary of Energy’s Office ofIndependent Oversight and PerformanceAssurance (OA) conducted an inspection ofenvironment, safety, and health (ES&H) andemergency management programs at the NationalNuclear Security Administration (NNSA) NevadaTest Site (NTS) in September and October 2002.The inspection was performed as a joint effort bythe OA Office of Environment, Safety and HealthEvaluations and the Office of EmergencyManagement Oversight.

Background

NTS is located approximately 65 miles northof Las Vegas, Nevada, and encompassesapproximately 1,375 square miles. The site is

located in a high desert basin and is surrounded bywildlife ranges and the Nellis Air Force Basemilitary gunnery range. Nuclear weapons testswere conducted at NTS from 1951 until the 1992nuclear weapons testing moratorium.

The current mission of NTS includessupporting the NNSA stockpile stewardshipprogram, which encompasses performingsubcritical experiments in support of nuclearweapons stockpile verification efforts andmaintaining NTS facilities and infrastructure. NTSalso performs activities in the areas ofenvironmental management (e.g., decontaminationand decommissioning, waste management, andenvironmental technology development); nationalsecurity response (e.g., emergency response toweapons of mass destruction); and defense andcivil technologies (e.g., conventional explosivetesting, characterization of hazardous material spills,and emergency response training). NTS activitiesinvolve significant quantities of hazardous materialsin various forms, including radiological materials,explosive materials, and chemicals. The variouspotential hazards at NTS that need to be effectivelycontrolled include exposure to external radiation,radiological contamination, explosive materials,chemicals, and various industrial physical hazardsassociated with testing activities and facilityoperations (e.g., machine operations, high-voltageelectrical equipment, pressurized systems, andnoise).

The NNSA Office of the Deputy Administratorfor Defense Programs is the cognizant secretarialoffice for NTS. As such, the Office has overallHeadquarters line management responsibility forprogrammatic direction, funding of activities,ES&H, and emergency management at the site.The U. S. Department of Energy (DOE)Headquarters Office of EnvironmentalManagement is responsible for directing andfunding certain activities at NTS (including certainwaste management activities). At the site level,the NNSA Nevada Operations Office (NV) hasline management responsibility for NTS operationsand safety.

Aerial View of the Nevada Test Site

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NTS is operated by Bechtel Nevada (BN), undercontract to NNSA. NNSA national laboratories,including Los Alamos National Laboratory (LANL) andLawrence Livermore National Laboratory (LLNL),perform experiments at NTS and are responsible foroperations of the U1a Facility and the Device AssemblyFacility (DAF), which are used to support nuclearweapons stockpile stewardship.

Throughout the evaluation of ES&H andemergency management programs, OA reviewed therole of NNSA organizations in providing direction tocontractors and conducting line management oversightof contractor activities. OA is placing more emphasison the review of contractor self-assessments andNNSA line management oversight in ensuring effectiveES&H and emergency management programs. Inreviewing NNSA line management oversight, OAfocused on the effectiveness of NNSA and NV inmanaging NTS contractors, including such managementfunctions as setting expectations, providingimplementation guidance, allocating resources,monitoring and assessing contractor performance, andmonitoring/evaluating contractor self-assessments.Similarly, OA focuses on the effectiveness of thecontractor self-assessment programs. DOE ordersrequire contractors to establish self-assessmentprograms that review all aspects of ES&H andemergency management performance.

ES&H Review Scope and Overview

The purpose of the ES&H portion of this inspectionwas to assess the effectiveness of selected aspects ofES&H management as implemented by NTS underthe direction of NV. The ES&H portion of the inspectionwas organized to evaluate three related aspects of theintegrated safety management (ISM) program:implementation of selected guiding principles of ISMby NV and NTS contractors, NV and NTS contractorfeedback and continuous improvement systems, andNTS implementation of the core functions of safetymanagement for various work activities.

The OA inspection team used a selective samplingapproach to determine the effectiveness of NV andNTS in implementing DOE requirements. Theapproach involved examining selected institutionalprograms that support the ISM program, such as NVand BN assessment programs. To determine theeffectiveness of the institutional programs, the OA teamexamined implementation of requirements at selectedNTS organizations and facilities. Specifically, OA

reviewed work at DAF in support of subcritical nuclearexperiments at the U1a Facility; decontamination anddecommissioning work at the Reactor MaintenanceAssembly and Disassembly (RMAD) building;hazardous chemical tests and operations at theHazardous Materials Spill Center (HSC) as part of theDOE work-for-others program; construction activities;facility and utility maintenance; and environmentalmonitoring.

In March 2002, NV was notified that a sub-contract employee stationed in the North Las Vegas“B” complex was diagnosed with Chronic BerylliumDisease (CBD). This individual had been working inthe B-1 building since 1998. The building was convertedinto office space in 1994 and had been a machine shopthat processed beryllium copper alloys from the 1970sto 1994. As a result of the CBD case, Bechtel Nevadainstituted an Industrial Hygiene sampling and voluntarymedical testing (LPT blood test) program to determinethe potential sources of beryllium contamination andthe number of sensitized individuals in the “A” and “B”building complexes. Throughout this series of events,NNSA, NV, and BN consulted with teams of expertsfrom both inside and outside DOE to help interpretsampling results, understand risks to current buildingtenants, and formulate actions to protect the health ofall workers. In July 2002, the NV site managerrequested that NNSA commission a formalinvestigation. On August 22, 2002, the NNSAAdministrator authorized an investigation andestablished an investigation team, comprised of DOEand National Institute of Occupational Safety andHealth (NIOSH) beryllium experts, to evaluate theberyllium issue at the North Las Vegas complex and toassess implications for other DOE sites within 90 days.The OA inspection team determined that it would notinterrupt or duplicate the efforts of the ongoingberyllium team investigation and therefore did notevaluate the beryllium issue at the North Las Vegasfacilities.

As discussed throughout this report, the NTS ISMprogram has improved significantly, and NV and NTScontractors have established an effective institutionalframework for the ISM program. The implementationof the ISM program is at various stages of maturityand effectiveness across NTS facilities and projects.Although improvements are warranted in some areas,NV and NTS contractors have an understanding ofthe current deficiencies and, in most cases, haveappropriate ongoing or planned initiatives to addressthem.

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Emergency Management Scope andOverview

The purpose of the emergency managementportion of this inspection was to assess the effectivenessof selected aspects of emergency managementprogram management as implemented at NTS underthe direction of NV. In addition to NV’s emergencymanagement oversight and operational awarenessactivities, OA evaluated selected institutional-levelemergency management program elements, such asplans and procedures; training, drills, and exercises;emergency public information; and self-assessmentprograms, the majority of which are managed andadministered by the BN Operations Centerorganization. Furthermore, the OA team examinedimplementation of requirements at selected NTSorganizations and facilities, specifically the U1a Facility,the DAF, and the HSC. Facility-level reviews includedan evaluation of hazards surveys and hazardsassessments. As part of the overall program evaluation,the inspection team also conducted tabletopperformance tests with a sample of the site’s keydecision-makers to evaluate their ability to employavailable tools and skills developed in training to respondto postulated emergency conditions.

As discussed throughout this report, the emergencymanagement program at NTS is generally well defined,emergency responders are trained and capable of

Exterior View of DAF

handling potential emergency events, and NV and BNfeedback and improvement programs are workingeffectively to self-identify and correct program andperformance weaknesses. The current programeffectiveness is attributed largely to the strongleadership and active involvement of the NV Manager,and the expertise and persistence of the NV emergencymanagement operations team (EMOT) in monitoringand overseeing this program. However, theeffectiveness of program implementation at the facilitylevel varies and is not consistent among or within thecontractor and national laboratory organizations at NTS.Serious weaknesses were identified in the area ofhazards surveys and hazards assessments. Theidentification and analysis of hazards in thesefundamental documents has not been established andmaintained to provide an accurate technical basis forthe other elements of the NTS emergency responseprogram. NV has documented and BN understandsthe current program deficiencies, and in most casesthey have established plans to address them.

Organization of the Report

Section 2 of this volume provides an overalldiscussion of the results of the review of the NTSES&H and emergency management programs,including positive aspects and weaknesses. Section 3provides OA’s conclusions regarding the overalleffectiveness of the NV, BN, LANL, and LLNLimplementation of the NTS ES&H and emergencymanagement programs. Section 4 presents the ratingsassigned during this review. Appendix A providessupplemental information, including team composition.Appendix B identifies specific findings that requirecorrective action and follow-up.

More detailed information on the inspection resultsis contained in two separate volumes of the report,which were provided to NV management and areavailable to other DOE sites on request. Volume Iprovides more detailed information on the results ofthe review of NTS ES&H programs, and Volume IIprovides more detailed information on the results ofthe review of the NTS emergency managementprogram.

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Results2.0

2.1 Positive Attributes

ES&H Positive Attributes

Several positive attributes were identified inthe institutional work control systems. Manyaspects of ISM implementation at the facility andactivity level were also particularly effective.

NV has demonstrated leadership andinitiative in improving ISM processes andperformance at NTS. NV has established clearexpectations and direction to NTS contractors andfacility users through published orders and policies,and performance-based contract incentives relatedto ISM. NV has led by example by establishingan NV lessons-learned program, conducting aninternal ISM performance survey, and partneringwith NTS contractors and facility users incontinuous improvement initiatives, such as theISM Council and the Lessons LearnedImplementation Team. NV has establishedrequirements for safety oversight by the NV staffin an Oversight Manual and Facility Representativeprogram procedures. NV senior managementdemonstrated a good understanding of the statusof NTS facilities and ES&H issues. NV’swillingness to perform self-critical evaluations,including the use of outside expertise, has resultedin NV self-identifying weaknesses and developingcorrective actions. The NV Manager, whoassumed that position in fiscal year 2000, has been

instrumental in providing leadership and directionthat have resulted in significant improvements inISM within the NV organization and at NTS. Forexample, the NV Manager has brought in externalexperts to perform program reviews and developrecommendations for improvement in many ES&Hareas.

The NTS ISM program has improvedsignificantly and is continuing to improve. TheNTS ISM program has improved significantly sincethe 1999 Headquarters independent oversight safetymanagement inspection, which identified a numberof systemic weaknesses in the ISM program. Withfew exceptions (e.g., issues management), NV andBN have appropriately addressed the deficienciesand weaknesses identified during that evaluation.Through the implementation of its ISM program,NTS has established a good framework ofinstitutional management systems (e.g., roles andresponsibilities) and work processes (e.g.,procedures and hazards analysis). Although stillmaturing, the implementation of the Real Estate/Operations Permit (REOP) process and associatedwork authorization controls provides for a majorimprovement in safety at NTS. In addition, BNdeveloped and implemented a well-documentedelectrical safety program, appointed aknowledgeable electrical Authority HavingJurisdiction to interpret code requirements andreview variances, and chartered a Senior ElectricalReview Board to oversee electrical safety at thesite. NV and BN have also made substantialprogress on resolving safety concerns associatedwith legacy high-voltage electric cable.Configuration control has been established throughwalkdowns, some energized sections have beende-energized, and cable locations have been markedwith warning signs, reducing the potential hazardsto workers. BN has upgraded all work controlprocedures and has implemented a sitewide workcontrol system to enhance work definition,planning, and execution. With support from NV,BN Site Services has been proactive in upgradingthe site electric power distribution system; as aresult, the hazards associated with unplanned lossof electrical power have been reduced. BN has

Hazardous Materials Equipment

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implemented a NTS performance-based safetyprogram facilitated by management and run by workersto improve job-related behavioral safety. NV and BNpersonnel displayed a good understanding of theremaining weaknesses and, in most cases, have ongoingor planned initiatives to address them. Senior NV andBN management demonstrated a willingness to be self-critical and a commitment to continuous improvement.

Subcritical experiments are performed inaccordance with rigorous safety processes. Mostaspects of the REOP process have been notablyeffective for subcritical experiments at the DAF. Theimplementation of the REOP process is effective andmature in these programs, and roles and responsibilitiesare clearly defined and understood. BN and the nationallaboratories have effectively coordinated their effortsand have established well-defined organizationalinterfaces. Experiments in these facilities are welldocumented, and involve a number of clearly identifiednotification and authorization steps by NV, NNSA, andthe national laboratories’ management chain. TheLANL subcritical experiment review process isextensive and includes hazard identification and reviewsby LANL, LLNL, and NV at various points in thedevelopment process. A comprehensive boundinghazard analysis is developed and reviewed by multipleES&H disciplines. The experiment plan, including thehazard analysis and the project execution plan, alsoreceives an extensive review prior to approval by themulti-disciplined Safety Evaluation Panel, which ischaired by NV. Checklists are used extensively to

implement facility operational safety requirements andto perform operational checks before allowing workwith special nuclear materials or high explosives. Thesechecklists are comprehensive, logically arranged, andensure that building-specific systems and equipment,such as cranes, ventilation, utilities, and safety systems,are operational and ready for use. Furthermore, facilitymanagers and technicians are experienced, well trained,and knowledgeable of facility hazards, and NV FacilityRepresentatives have a strong presence in the NTSDAF.

Pre-test review activities for tests conductedat HSC are rigorous and include facility workers,NV staff, independent reviewers, and test agencystaff. Pre-test reviews include a safety evaluation panel,numerous pre-start checklists, test briefings, and hazardstraining. For example, during the week before thecommencement of the Divine Invader tests, a varietyof pre-test reviews were conducted by NV, BN, andthe customer—the Defense Threat Reduction Agency(DTRA). BN staff at HSC conducted a pre-job briefingon the preparatory activities for staging the test. Aformal Safety Evaluation Panel meeting was held beforethe test, providing an opportunity for DTRA and itssubcontractors to present the details of the upcomingtests to a board of independent testing and ES&Hsubject matter experts, NV line managers, and othertest participants and observers. The NV FacilityRepresentative for HSC is actively involved in theplanning and conduct of testing and in the daily, routinework activities at HSC.

BN waste management practices are welldefined and effectively implemented at NTS. BNhas implemented rigorous controls to ensure that wastegoing either to the site’s disposal areas or off site fortreatment and/or disposal meets applicable wasteacceptance criteria. The BN Waste Generator Servicesorganization evaluates waste streams using acomprehensive set of procedures. Additional qualitycontrol is provided by the presence of a WasteCertification Official during waste packaging. Thisindividual is independent of the Waste Generator Serviceorganization and the generator, thus providing anotherlevel of review to verify that the generated waste meetsthe approved waste stream requirements.

Emergency Management PositiveAttributes

Many aspects of the NTS emergency managementprogram are effectively implemented, including thetraining, drill, and exercise program, emergency public

Device Assembly Facility Explosives Handling Room

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information program, and the BN self-assessment andNV oversight programs. Program requirements arewell defined, and the basic infrastructure of plans,procedures, and response tools is in place to supportemergency decision-making.

Through the strong leadership, direction, andactive involvement of the NV Manager, the NVemergency management operations team(EMOT) has implemented a comprehensive andextremely effective program for monitoring andoverseeing the BN emergency managementprogram. The NV oversight program that is beingimplemented by the EMOT includes a well-documentedand comprehensive assessment and corrective actionmanagement process, a formal and detailed task plandocumenting BN emergency management programdeliverables, and financial performance incentives. Allof these components have been used effectively to driveneeded improvements and to set appropriate prioritiesand expectations for upgrading the BN program. Forexample, during fiscal year 2002, EMOT has used theseprogram elements to direct much-needed improvementsin BN hazards assessments, and the NV Manager haswithheld fees from the contractor for failing to satisfyNV’s hazards assessment performance expectations.Senior NV managers, most notably the OperationsOffice Manager, are actively involved in the NTSemergency management and response programs, andprovide strong leadership to the EMOT in implementingtheir vigorous and effective oversight program.

NV and BN have established comprehensivetraining and qualification programs that effectivelyprepare emergency responders to perform theirassigned response duties. Both organizations havedeveloped position-specific qualification programs foreach emergency response organization (ERO) member.The qualification programs and supporting training

materials are well structured and routinely updated, andthe training status of each ERO member is meticulouslytracked. These qualification programs aresupplemented by an aggressive drill and exerciseprogram that has been highly effective in self-identifyingperformance weaknesses and facilitating continuousprogram improvement.

The performance of emergency respondersat all levels of the NV and BN EROs exhibitedmany significant positive attributes, asdemonstrated during tabletop performance tests.All of the responders clearly understood their assignedroles, responsibilities, and authorities; they demonstratedeffective command and control of the postulatedemergencies; and in most cases they took prompt andeffective actions to protect site workers from thepotential health and safety impacts of postulatedhazardous material emergencies. Most respondersadhered to proper emergency response protocols, andalmost all of the responders made effective use ofdecision-making aids and checklists to ensure that theirresponse duties were fully and correctly performed.

2.2 Program Weaknesses

ES&H Program Weaknesses

Although the framework for the NTS ISMprogram is sound, weaknesses were identified in someaspects of requirements implementation for certaintypes of work activities. In addition, certain aspects ofNV and BN feedback and improvement systems needadditional improvement.

NV and BN have not effectively implementedES&H roles, responsibilities, and interfaces forthe REOP process as applied to work-for-othersprograms, and have not ensured sufficientidentification and documentation of standards andrequirements for work-for-others programs. TheREOP process, as described in NV procedures,establishes an adequate mechanism for defining workscope, evaluating risk, establishing facility-level controlsand a safety envelope, and providing internal andexternal project reviews before work is authorized toproceed. However, the effectiveness of implementingthe REOP process has varied across NTS programsand facilities. The REOP process has been effectivelyimplemented for certain programs, but it lacks sufficientdefinition and guidance in some areas and was noteffectively implemented in the Divine Invader test serieswork-for-others program at HSC. The Divine Invader

An Emergency Management Exercise

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test series involves release of various chemicals(including explosive releases) and tracking of the plumesusing various technologies. This test series is typicalof tests being performed by work-for-others agencies,and presents challenges to NV in the oversight andcontrol of outside agencies and their subcontractors,who are less familiar with DOE’s regulations, practices,and safety culture than DOE laboratories. Deficienciesin ES&H roles and responsibilities identified throughthe review of this test program included ineffectivereview and approval of the REOP documents,insufficient involvement by the NV subject matterexperts in the review of test plans and procedures,unclear definition of responsibilities for personnel whohad key safety roles (e.g., the BN project manager),and insufficient definition of organization interfaces.These deficiencies in roles and responsibilitiescontributed to the deficiencies in implementing theREOP process for the Divine Invader tests and mighthave implications for other work-for-others programs.For example, the secondary REOP documentation wasinaccurate for the current test series (e.g., wrongchemicals were listed, and there was incorrectinformation about chemical storage), and requirementswere not clearly defined in some cases (e.g., whichexplosives safety standard governed operations).Although there are deficiencies in the implementationof the REOP process, many aspects of ISM programsare effectively implemented at HSC, and certainaspects of ES&H for the Divine Invader tests werenotably effective.

NV line managers have not performedsufficient planning and coordination to ensurecomprehensive oversight of NTS ES&H programsand effective implementation of somerequirements in the areas of tracking findings andperforming self-assessments. Although most of theframework for an effective program is in place andmany oversight activities are being performed, severalweaknesses are limiting the effectiveness of the NVoversight of ES&H performance at NTS. NV linemanagement oversight activities are not consistentlyplanned in a comprehensive, coordinated, and rigorousmanner that ensures comprehensive coverage offunctional and management system areas. Identifiedsafety deficiencies and issues are not being consistentlymanaged to ensure timely resolution and prevention ofrecurrence. NV organizations are not scheduling orperforming self-assessments as required by theOversight Manual. NV senior management recognizesthat some aspects of its line management oversightprogram need further improvement, and several actionsare underway.

BN and LANL issues management processeshave not ensured appropriate and timelyresolution of safety concerns, the BNmanagement assessment program has not beeneffectively implemented, and the frequency andscope of LANL assessments have not beensufficient to ensure comprehensive coverage ofES&H programs. Some frequently performedactivities, such as construction and maintenance, arenot subjected to a level of oversight consistent with thepotential for personnel injury and environmental impacts.The inconsistent conduct of self-assessments andinadequate capture and management of identified safetydeficiencies by BN hinders continuous safetyimprovement. Although BN and LANL conduct avariety of assessments, the scope, frequency, and rigorof these examinations vary significantly amongorganizations. BN and LANL have formal systemsfor tracking deficiency corrective actions andprocedures detailing the implementation requirements.However, the documentation, evaluation, and resolutionof ES&H deficiencies and issues at NTS are not beingmanaged in a structured, consistent, and effectivemanner that fully supports continuous improvement.Many deficiencies identified by BN and NV assessmentactivities are not being entered into the BN trackingsystem. For example, management assessmentsrelated to lessons-learned, environmental compliance,industrial hygiene, health physics, maintenance, and

DAF Hallway

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industrial safety/hygiene programs were not enteredinto the tracking system. In addition, performanceissues involving the failure to schedule and performmanagement assessments resulting from the June 2002independent assessment of corrective actions to thePrice Anderson Amendment Act concern in calendaryear 2000 were not documented in the BN trackingsystem. Furthermore, the resolutions of many BNdeficiencies do not address all aspects of the reportedissues, the extent of the condition (the potential forsimilar deficiencies in other areas), or recurrencecontrols to address the causes of the deficiencies. Insome cases, BN corrective actions addressed thespecific deficiencies without determining that they wereisolated cases or why the deficiency occurred. BNhas adequate directives in place for identifying andmanaging issues, but the applicable requirements havenot been effectively implemented by BN personnel and/or adequately monitored by NV. LANL has notadequately managed resolution of identifieddeficiencies. Over 20 open deficiencies identified in2001 and included in the LANL tracking system,including some identified as high priority, have not beenassigned to responsible parties or had planned actionsidentified. Weaknesses in issues management at NTSare longstanding and have been identified by previousinternal and external assessments, but they have notbeen adequately addressed.

NV and BN did not ensure that the controlsand storage configurations for bulk hazardouschemicals at the HSC were adequately analyzedand sufficient to ensure safe storage as requiredby BN procedures. While NTS has demonstratedeffective performance in many areas of hazard control,

some deficiencies were noted in the areas of chemicalstorage. A number of bulk hazardous chemicals at theHSC are stored in drums or compressed gas cylinders,in locations that are fully or partially open to theenvironment. Storage of hazardous chemicals in theseconditions, without a sufficient and documented reviewby BN and NV, presents two concerns. First, the OAteam identified four bulk chemicals at HSC that arestored under conditions that do not meet themanufacturer’s storage recommendations in thematerial safety data sheets (MSDSs), and an evaluationof this type of storage acceptability has not beendocumented in work packages or work documents.Improper storage increases the potential for containerrupture or inadvertent discharge of the chemical to theenvironment. For example, the MSDS for carbontetrachloride, which is stored in drums in the outsidestorage locations that are only partially protected fromthe environment, lists a number of handling and useprecautions, such as storing the containers in a cool,dark area and away from heat; not storing the chemicaloutdoors or in direct sunlight; and avoiding bulk storage.Second, some requirements in the applicable BNCompany Directive are either not followed or are notsufficiently described to be consistently implementedby HSC staff. For example, at least two of thechemicals stored at HSC are carcinogens or suspectedcarcinogens (i.e., benzene and carbon tetrachloride).For carcinogens, the company directive requiresestablishing regulated areas and posting warning signsat the entrance to regulated areas. However, adequatesigns are not present at the storage site. While NVwas aware of the chemical storage conditions, theydid not take action to ensure that the storage practicesand controls were adequate for safe storage.

BN has not applied sufficient rigor andformality in demonstrating that certainradiological control practices meet all DOErequirements and that all potential exposures arefully characterized and will be kept as low asreasonably achievable. A number of deficiencieswere identified in the application of radiological controls.First, the BN procedure for developing radiation workpermits (RWPs)—a principal means of identifyingnecessary controls and bounds for radiological work—does not adequately specify how to manage changesin RWPs. As a result, multiple versions of the sameRWP existed at the NTS RMAD facility, each withsomewhat different controls. Second, limiting conditionsand suspension limits were not clearly defined in someRWPs. Third, the manner in which respiratory

HAZMAT Drill

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protection requirements were being implemented atRMAD and DAF may not be fully effective incontrolling potential radiological or industrial hazardsand was not always specifically tailored to a knownradiological hazard. Fourth, BN health physics staff atRMAD did not appropriately post or mark fixed-contamination areas located outside of “radiologicalareas,” consistent with the requirements of the Radconmanual for “Fixed Contamination Areas.” Fifth, therewas insufficient evidence that BN as-low-as-reasonably-achievable reviews of radiological workwere being conducted in accordance with therequirements of the Radcon manual and companydirectives. Sixth, in one case, an expected radiologicalcontrol was not evident for work being performed atRMAD. Specifically, beta dose rate measurementswere not being taken to evaluate contact dose rates oncontaminated surfaces. In conjunction with this, hazardassessment information presented in work plans didnot discuss any potential for beta skin hazard fromhandling contaminated materials, although informaldiscussions determined extremity dose was notconsidered to be a concern. However, the site has nodocumented technical base or evidence that it isproperly accounting for extremity exposures orassociated monitoring requirements. The limitedassessment and oversight activity by NV at RMADdid not identify these or similar deficiencies in theradiological control program. Improvements in the levelof rigor and formality in radiological hazard analysisand controls and a sound technical basis for all decision-making is needed to ensure that NTS complies with itsdefined radiological requirements and ensures that allpotential radiological exposures are kept as low asreasonably achievable.

Emergency Management ProgramWeaknesses

Although the programmatic framework for NTSemergency management has been defined andestablished, some of the most fundamental elementsof the program have not been adequately developed,implemented, and maintained to ensure that respondershave the necessary tools and information to respondappropriately to an event, commensurate with thehazards.

BN and LLNL have not been completingrequired hazards surveys and/or hazardsassessments in accordance with DOE and NVOrder requirements before initiating facilityoperations or when there are significant changesin facility operations or hazardous materialinventories. Neither of the BN hazards assessmentsreviewed by the evaluation team complied with the long-standing requirements of DOE Order 151.1A,Comprehensive Emergency Management System, or,more importantly, is adequate to support effectiveresponse to mitigate the potential consequences of anaccidental hazardous material release. Significantweaknesses in these emergency management hazardsassessments (EMHAs) have lingered despite clear anddetailed feedback from NV. LLNL has not completedhazards surveys for the majority of NTS facilities undertheir cognizance to determine whether a facility oroperation requires an EMHA, based on the hazardspresent.

The requirements and expectations for theBN consequence assessment teams (CATs) in theemergency management center (EMC) andemergency operations center (EOC) have notbeen adequately defined and documented to assistthe CATs in fulfilling their assigned duties. A widevariety of consequence assessment deficiencies wereobserved during tabletop performance tests. Both CATswere unable to provide accurate and timelyconsequence assessment information to their respectiveEMC or EOC for at least one of the two scenariospresented to them. Weaknesses included failure torecognize that plume projections were not consistentwith the prevailing winds, difficulties in operating thecomputer-based dispersion models, and using incorrectprotective action criteria values when generatingdispersion plots. Further, NV and BN implementingprocedures do not clearly identify how the EOC CATis expected to perform its role of validating plumeprojections generated by the EMC CAT.Reactor Maintenance Assembly and Dissassembly

Facility

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The BN emergency plan and implementingprocedures do not reflect current emergencyresponse practices. Numerous BN emergencyresponse implementing procedures have not beenreviewed, updated, and maintained current, as requiredby DOE Order 151.1A. Many such procedures havenot been updated in over two years, even thoughsignificant changes affecting those procedures and the

BN response system have been implemented duringthat time. In addition, BN has not established a formaldocument control system to ensure that program andprocedure changes are communicated effectively tofacility owners, and that response aids and guidanceare updated in a timely manner to reflect changes thatcan affect emergency management decision-making.

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Conclusions3.0

ES&H Program

Safety management at NTS has significantlyimproved under the direction and leadership of theNV Manager. NV and NTS contractors haveworked cooperatively to establish an ISM programat NTS that is effective in most areas and isimproving. NV, BN, LANL, and LLNL managerswere actively involved in and supportive of ISMand continuous improvement. Workers areappropriately empowered to stop work to resolvesafety questions and have multiple avenues toexpress any safety concerns. Management hasnumerous programs to ensure that workers areinvolved in safety and to solicit ideas forimprovement, including the recent establishmentof a performance-based safety program.

The establishment of the REOP process andassociated work authorization processes aresignificant enhancements and are in most casesfunctioning effectively for nuclear defense programactivities. However, implementation of theseprocesses is not yet fully effective in ensuring thatwork-for-others programs are adequately reviewedand controlled. NV and BN recognize the needto further enhance the implementation of workauthorization processes for work-for-othersprograms as well as to continue to refine and bettercommunicate roles and responsibilities fororganizational interfaces.

For the most part, the existing ISM institutionalprograms and procedures are adequate. However,

the effectiveness of implementation varies and isless effective for work activities that historicallyhave received less attention and line managementoversight (work-for-others programs and someconstruction and maintenance activities).

The OA team’s observation of numerous workactivities conducted at NTS indicates that mostwork activities were conducted safely and, withfew exceptions, hazards were identified,appropriate controls were in place, and work wasproperly authorized. In most cases, NTScontractors have effectively translated theapplicable requirements to clear and concise workinstructions. Most aspects of environmentalprotection programs are effective and have beensuccessfully integrated into ISM. However,improvements are needed in a few areas, such asprocesses for evaluating and approving chemicalstorage practices, the rigor and formality ofradiation protection controls, and proceduraladherence in maintenance activities.

The NV and NTS contractor feedback andcontinuous improvement programs have identifiedand corrected numerous deficiencies. NV andNTS contractors conduct frequent assessments,and have improved the rigor of their assessmentprocesses and included more observations of work.NV has maintained good operational awarenessthrough its Facility Representatives and subjectmatter experts, particularly at the facilitiesassociated with subcritical experiments. BN andlaboratory managers also demonstrated detailedknowledge of ES&H programs and issues at NTS.Lessons-learned programs have been improved,and some aspects are notably effective.

However, longstanding weaknesses in issuesmanagement and some aspects of NV and NTScontractor assessments have not been fully andeffectively addressed. The various NV linemanagement oversight elements are notconsistently and effectively planned and integratedto ensure appropriate coverage of activities, ES&Hfunctional areas, and crosscutting managementsystems. Many deficiencies identified by self-assessments and external reviews have not beenrecorded in a tracking system, and thus have not

U1a Facility Exterior View

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been corrected or properly evaluated for the extent ofthe condition, recurrence controls, trend analysis, andperformance monitoring. In addition, BN has notperformed sufficient management assessments, and thefrequency and scope of LANL assessments have notbeen sufficient to provide coverage of LANL ES&Helements. Further, LANL has not adequately managedits backlog of identified deficiencies. NV and NTScontractors are working to implement new issuesmanagement systems that have the potential to addresssome of the longstanding weaknesses.

Overall, safety management at NTS hassubstantially improved in the past three years and iscontinuing to improve. The ISM institutional programsare effective, with only a few weaknesses, andimplementation of those programs is effective for mostactivities and facilities that were reviewed during thisOA inspection. However, implementation ofinstitutional requirements is not fully effective for certainactivities, such as work-for-others programs andmaintenance and construction activities. Theseactivities are perceived as lower hazard work andhistorically have received less management attentionand line management oversight. Improvements in issuesmanagement and planning for assessments is neededto ensure that NV and NTS contractors have theinformation needed to continue to make improvementsin ISM implementation.

Emergency Management Program

NV has clearly set forth the requirements andexpectations for the NTS emergency managementprogram through NV Order 151.1, ComprehensiveEmergency Management System, and an NVconsolidated emergency management plan. Therequirements therein apply to all contractors, national

laboratories, and other Federal agencies and users ofthe NTS. The NV Manager is actively involved in theNTS emergency management program and hasprovided strong and emphatic leadership in ensuringthat all NTS entities are fully prepared to respond to anemergency not only at the NTS but also nationwidethrough the deployment of NNSA assets and expertise.The NV Manager also has devoted significant resourcesto developing an emergency management operationsteam that is now comprised of a team leader with strongtechnical and managerial skills, and a highly competentand dedicated staff, supplemented by additionalexpertise where necessary, who work continuously toensure that the manager’s expectations areimplemented effectively across the NTS.

The NTS emergency preparedness and responseelements common to all parties at the site, which aremanaged and implemented by BN, have clearlyimproved since previous independent oversightevaluations conducted in 1998 and 1999. NV and BNhave established an adequate programmatic frameworkthat is supported by well-trained and practicedemergency responders. In the past year, NV and BNhave devoted significant resources to training andconducting drills and exercises for the primary decision-makers in their respective EROs. Training andqualification programs are comprehensive, welldocumented, and maintained up to date. Further, NTSresponders have participated in an aggressive scheduleof drills and exercises that have been effective in self-identifying performance weaknesses. Theeffectiveness of the training, drills, and exercises wasclearly reflected in the generally good performance ofthe emergency responders who were tested during theOA tabletop exercises conducted during this inspection.All of the responders clearly understood their roles,responsibilities, and authorities, and demonstratedexcellent command and control at their respectiveresponse venues; further, most respondersdemonstrated the appropriate decision-making skills andset appropriate priorities for protecting workers andthe public in the event of a hazardous materialemergency at NTS. To support these responseactivities and guide their decision-making, both NV andBN have established a set of implementing proceduresand other response aids, such as responder checklistsand packets of pertinent response information.Responders used these tools effectively to facilitatetheir decision-making and to prioritize response actions.

However, some of the NV procedures are no longerconsistent with the recently issued consolidatedemergency management plan, and there are some

U1a Facility Underground

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ambiguities in assigned decision-making authorities.Many of the BN procedures are outdated and do notreflect actual response practices. For both NV andBN, formal control of procedures and response aids isnot sufficient to ensure that all responders have themost current information available to support theirdecision-making. In addition, critical, fundamentaldecision-making elements, such as emergency actionlevels, do not have a consistent format and have notbeen assembled into a format that facilitates promptdecision-making.

The most significant weakness in the NTS-wideemergency management program is that the EMHAs,which form the foundation upon which all otheremergency management elements are based, have notbeen established and maintained in accordance withDOE Order 151.1A. LLNL has not completed hazardssurveys for most of the facilities they operate at theNTS and thus has not performed a hazards screeningto determine whether an EMHA is required. Both BNhazards assessments that were reviewed during thisinspection exhibited major weaknesses and did notcomply with DOE Order 151.1A. As a result,emergency action levels and predetermined protectiveactions have not been established for some knownhazards that could clearly impact not only site workersbut also personnel on adjacent land. In other cases,information about the type and magnitude of the hazardsat some facilities might not be readily available toemergency responders because neither a hazardssurvey nor hazard screening has been performed.However, NV managers and staff have demonstrateda strong and unwavering commitment to correct theseproblems. For example, they have denied contractor

incentive fees on three occasions this fiscal yearbecause inadequate EMHAs were submitted.

Despite these weaknesses, the remote location ofmost of the higher hazard facilities and the goodanticipatory decision-making skills that weredemonstrated during performance testing providereasonable assurance that workers and the public willbe adequately protected in the event of an accidentalhazardous material release at NTS. More importantly,the leadership, active involvement, and personalattention devoted to emergency management at NTSby the NV Manager guarantees that any remainingweaknesses will be addressed to the satisfaction ofNV. The NV EMOT has identified and documentedmost weaknesses identified in this report, is ensuringthat effective corrective actions are implemented, andhas set appropriate priorities for upgrading the BNemergency management program. The efforts of bothNV and BN demonstrate a positive trend in identifyingand addressing the challenges of implementing acomprehensive and integrated emergency managementprogram on a vast, multi-tenant, multi-user NNSA site.While the BN Operations Center organization is workingto address the weaknesses identified by NV and theirown self-assessments, the organization’s resources arecontinually being diverted to address unanticipated,time-urgent assignments. If this trend continues, seniorBN management intervention may be necessary toensure that appropriate emergency managementprogram priorities have been established commensuratewith hazards, risks, and available resources.Nevertheless, BN understands the current programdeficiencies and, in most cases, has established formalplans and schedules to address them.

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Ratings4.0

The ratings reflect the current status of the reviewed elements of the NTS program:

Safety Management System RatingsGuiding Principle #2 – Clear Roles and Responsibilities .........................EFFECTIVE PERFORMANCEGuiding Principle #5 – Identification of Standards and Requirements ......EFFECTIVE PERFORMANCE

Feedback and ImprovementCore Function #5 – Feedback and Continuous Improvement ........................ NEEDS IMPROVEMENT

NTS Implementation of Core Functions for Selected Work ActivitiesCore Function #1 – Define the Scope of Work .....................................EFFECTIVE PERFORMANCECore Function #2 – Analyze the Hazards .............................................EFFECTIVE PERFORMANCECore Function #3 – Develop and Implement Hazard Controls ....................... NEEDS IMPROVEMENTCore Function #4 – Perform Work Within Controls ...............................EFFECTIVE PERFORMANCE

Emergency PlanningHazards Survey and Hazards Assessments ............................................. SIGNIFICANT WEAKNESSProgram Plans and Procedures .................................................................. NEEDS IMPROVEMENT

Emergency PreparednessTraining, Drills, and Exercises ..............................................................EFFECTIVE PERFORMANCEEmergency Public Information ............................................................EFFECTIVE PERFORMANCE

Emergency ResponseEmergency Response Decision-Making ...............................................EFFECTIVE PERFORMANCEConsequence Assessment .......................................................................... NEEDS IMPROVEMENT

Readiness AssuranceNV Assessments and Performance Monitoring ....................................EFFECTIVE PERFORMANCEContractor Assessments and Issues Management .................................EFFECTIVE PERFORMANCE

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APPENDIX ASUPPLEMENTAL INFORMATION

A.1. Dates of Review

Scoping Visit July 16-18, 2002Onsite Inspection Visit September 9-19, 2002Report Validation and Closeout October 1-3, 2002

A.2 Review Team Composition

A.2.1 Management

Glenn S. Podonsky, Director, Office of Independent Oversight and Performance AssuranceMichael A. Kilpatrick, Deputy Director, Office of Independent Oversight and Performance AssurancePatricia Worthington, Director, Office of Environment, Safety and Health EvaluationsThomas Staker, Deputy Director, Office of Environment, Safety and Health EvaluationsCharles B. Lewis, Director, Office of Emergency Management OversightKathy McCarty, Deputy Director, Office of Emergency Management Oversight

A.2.2 Quality Review Board

Michael Kilpatrick Patricia WorthingtonCharles Lewis Dean HickmanRobert Nelson

A.2.3 Review Team

Charles Lewis, Team LeaderBrad Davy, ES&H Topic LeadKathy McCarty, Emergency Management Topic Lead

Safety Management Systems ES&H Technical TeamAli Ghovanlou Vic CrawfordBill Miller Marvin MielkeBob Compton (Feedback and Improvement) Mark Good

Jim LockridgeEmergency Management Team Edward StaffordJ. R. Dillenback Mario ViglianiMichael LloydJim O’BrienJeff RobertsonTom Rogers

A.2.4 Administrative Support

Mary Anne SirkBonnie BlakeTom Davis

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1. Nevada Operations Office (NV) and Bechtel Nevada (BN) have not effectively implemented environment, safety,and health (ES&H) roles, responsibilities, and interfaces for the Real Estate/Operations Permit process as appliedto work-for-others programs, and have not ensured sufficient identification and documentation of standards andrequirements for work-for-others programs.

2. NV line managers have not performed sufficient planning and coordination to ensure comprehensive oversight ofNevada Test Site (NTS) ES&H programs and effective implementation of some requirements in the areas oftracking findings and performing self-assessments.

3. BN and Los Alamos National Laboratory (LANL) issues management processes have not ensured appropriate andtimely resolution of safety concerns, the BN management assessment program has not been effectivelyimplemented, and the frequency and scope of LANL assessments have not been sufficient to ensurecomprehensive coverage of ES&H programs.

4. NV and BN did not ensure that the controls and storage configurations for bulk hazardous chemicals at theHazardous Materials Spill Center were adequately analylzed and sufficient to ensure safe storage as required byBN procedures.

5. BN has not applied sufficient rigor and formality in demonstrating that certain radiological control practices meetall U. S. Department of Energy (DOE) requirements and that all potential exposures are fully characterized andwill be kept as low as reasonably achievable.

1. BN has not developed and maintained emergency management hazards assessments (EMHAs) in accordance withDOE Order 151.1A and NV Order 151.1, and emergency action levels (EALs) and predetermined protectiveactions have not been established for many potential accidents that could result in a classifiable emergency at theNTS.

2. Lawrence Livermore National Laboratory has not maintained the Device Assembly Facility EMHA and has notprepared, completed, and/or maintained emergency management hazards surveys to determine whether any otherfacilities or operations under their cognizance that use or store hazardous materials at the NTS require quantitativeanalysis, as required by DOE Order 151.1A and NV Order 151.1.

3. BN’s emergency plan and implementing procedures have not been maintained up to date, as required by DOEOrder 151.1A, and do not accurately reflect current BN emergency response practices.

4. BN and NV have not established a set of EALs that support timely emergency event classification or a processfor prompt emergency event classification and notification when both the emergency management center (EMC)and emergency operations center (EOC) are operational, as required by DOE Order 151.1A.

5. The BN consequence assessment teams in the EMC and EOC did not demonstrate the ability to provide accurateand timely assessments of emergency event consequences, as required by DOE Order 151.1A.

APPENDIX BSITE-SPECIFIC FINDINGS

Table B-1. Site-Specific Findings Requiring Corrective Action Plans

EMERGENCY MANAGEMENT FINDING STATEMENTS

ES&H FINDING STATEMENTS