National Nuclear Security Administration FINAL REPORT for Criticality Safety Program Weaknesses Resulting in an Operational Pause at the Plutonium Facility (PF -4) A Root Cause Analysis of Federal Oversight A I .. 0033} 5? Washington, D.C. Apri12014 EXECUTIVE SUMMARY In June 2013. the Los Alamos National Laboratory (LANL) Director paused operations at the Plutonium Facility at Technical Area 55 (TA-55) to address concerns with weaknesses in the criticalin safety programs supporting the programmatic operations in this facility. The National Nuclear Security Administration (NNSA). as the owner and overseer ofoperations in PF 44. decided to evaluate the actions or inactions that may have contributed to this occurrence. A team ofsenior subject matter experts and managers in the organization with experience in root cause analysis. event and causal analysis. and accident investigations undertook this task. Detailed event. causal factor. and barrier analyses were conducted to analyse the timeline of events leading up to this pause. The results of this analysis are detailed in this report. The key root causes identified by the team are as follows: There was inadequate recognition on the part of the Field Of?ce that the programmatic criticality safety problems were signi?cant. For a variety of reasons. Field Of?ce management and staffdid not fully understand that the criticalin safety issues were serious enough to warrant Department of Energy involvement and assumed that these issues were being adequately managed by Los Alamos National Security. LLC (LANS), the LANL management and operating contractor. This assumption persisted even though there were prevalent indications to the contrary. such as the attrition of criticality safety staff. an increase in the number of criticality safety infractions that were not selilidentified. an increase in the backlog of criticality safety evaluations. and several other incidents indicating a fundamental breakdown in work control and conduct ofoperations. Recognition of the problems evolved somewhat over time. and some Field Of?ce staff eventually attempted to bring attention to the issues. However. the safety culture that existed within NNSA was to allow the contractor to manage the problem with minimal Federal intervention throughout most ofthe time period addressed during this review. There was a lack ofa questioning attitude on the part of senior of?cials at NNSA Headquarters (HQ) regarding the health of criticality safety program. Senior officials (both safety and line management) at NNSA HQ were made aware of concerns about the criticality safety and conduct ofoperations programs at LANL. (in this context. the Federal Criticality Safety Program Manager is considered to be ?staff? and not a ?senior There were sufficient signals to demonstrate that there were serious concerns. Examples of these include multiple reports from the Criticality Safety Support Group (CSSG) noting problems, letters to LANS from the Field Of?ce expressing concerns. verbiage in annual reports. and e- mails sent by the Federal Criticality Safety Program Manager and other federal criticality safety support staff. The team could find no evidence to indicate that NNSA HQ senior officials questioned the conflicting information to fully understand the concerns. lfsenior officials at NNSA HQ had exhibited more ofa questioning attitude towards these signals that were often mixed and inconsistently communicated through the line. they could have prevented the situation from deteriorating further. The structure of the MSLO contract and the performance-based incentives contributed to a perception among some personnel that production?not safety?was the most important measure of success. The LANL contract incentivized and prioritized production. and consequently in some cases. for: for safety performance was not reduced even though there were safety concerns. A number of contributing causes were also identi?ed. These contributing causes are discussed in detail in the report as well as the team?s basis for drawing these conclusions. A listing ofthese contributing causes follows: - There was inconsistent communication regarding the signi?cance ofcriticality safety issues throughout all levels of NNSA: from LANL, to the Field Office. to NNSA HQ. The process for correcting weaknesses in criticality safety performance via the fee determining award structure was ineffective. There was a prevalent culture ofdeference to the LANS criticality safety experts. both by LANL and the Field Office. Pressure to meet production schedules led to a lack of critical analysis and follow-up on previous commitments by both the Field Office and LANS. Senior management in the Field Office perceived that the problems with the LANS criticalin safety staff were simply human resource issues and therefore not within the Field Offices purview. - There was a false perception from some oversight elements that other LANL programs. such as work planning and control and conduct of operations, were adequate to offset weaknesses in the criticalin safety program. The team generated recommendations for consideration by management based on the root and contributing causes that were identified. It is recommended that NNSA HQ line management consider: - Sharing the results of this investigation in a timely manner across the entire NNSA Enterprise as a means to reinforce the commitment to improve the organization?s communication process: 4' Rte-evaluating the recommendations from the 2013 NNSA Safety Culture Report for common themes communication and engagement of staff. management of concerns): Developing additional paths to raise emergent issues up the chain ofcommand. {Examples might include an informal safety issues review board as a forum for the peer-to-peer discussion of potential issues); Continuing to aggressively pursue improvements in safety culture by improving communication ofissues via the most direct and effective channels; Recognizing that award fee for mission performance cannot be separated orjudged independently of safety performance. Final fee decisions and their bases should be shared broadly to enhance corporate learning; a Reviewing and clarifying the current safety and program nexus in the organization to ensure balanced priorities in effective decision-making. Reviewing and clarifying safety roles and responsibilities across the organization. as appropriate. to achieve this result: - Following up on and ensuring the efficacy ofclosure actions associated with the LANL Performance Improvement Plan for criticalin safety; Assessing the processes and procedures at the Los Alamos Field Of?ce for tracking. addressing. and closing corrective actions to determine if changes should be made in light of the ?ndings in this report; and - Conducting an extent-of?condition evaluation to determine if there are other potential safety issues that are developing in the NNSA organization at a particular site or sites). The team is grateful for the opportunity to undertake this task. it is our strong desire that the lessons learned and recommendations included in this report will serve to improve overall operations in the enterprise and to prevent the occurrence ofsimilar events in the future. While this report serves to identify errors and shortcomings in current processes. it is important to note that these actions were undertaken prior to any accident or serious casualty at the facility. Line management is improving safety culture through activities such as this. addressing trends. taking corrective actions. and learning lessons prior to the advent of signi?cant negative events. TABLE OF CONTENTS EXECUTIVE SUMMARY .. ii 1.0 INTRODUCTION AND BACKGROUND I 2.0 ANALYSIS PROCESS .. I 2.l. Accident Analysis .. I 3.0 DISCUSSION OF RESULTS .. 5 Detailed Analysis of Root Causes .. 5 4.0 EVENTS TIMELINE .. IE 5.0 RECOMMENDATIONS .. 24 APPENDIX A. EVENTS AND CAUSAL ANALYSIS DIAGRAM APPENDIX B. SUMMARY OF DOCUMENTS REVIEWED AND INTERVIEWS CONDUCTED .. APPENDIX C: TEAM MEMBER BIOGRAPHIES .. C-l SIGNATURE PAGE I, by signature below, concur with the recommendations of the Root Cause Analysis team of which I was a member. Mb ,?KJm?mc David George Anika Khanna Ce-Team leader [cam ember e?fwmw? ?La/Mm Kelii Markham gp?g?llace Team Member Team, Member Patrick Cahalane Senior Advisor Approvedweq ?1 - Leader vi 1.0 INTRODUCTION AND BACKGROUND In June 2013. the Los Alamos National Laboratory (LANL) Director paused operations in the Plutonium Facility (PF-4) at Technical Area 55 (TA-55). This pause in operations was to address concerns with weaknesses in the criticality safety programs supporting the programmatic operations in this facility. These weaknesses had existed for some time and were the subject of several corrective action plans and performance improvement plans over the course of several years preceding this pause in operations. LANL managing and operating contractor Los Alamos National Security. LLC (LAMS) has performed root cause analyses and other investigations to determine why corrective actions and formal improvement plans were not effective in eliminating these weaknesses and allowing to proceed with needed program operations. The National Nuclear Security Administration as both the owner and overseer of operations in PF-4. decided to evaluate the actions or inactions that may have contributed to this occurrence. This report documents a Federal review of the root and contributing causes related to the Federal and contractor actions or inactions that contributed to this pause in executing the program mission. This review was conducted by a team of senior subject matter experts and managers in the organization with experience in root cause analysis. event and causal analysis, and accident investigations. One ofthe experts was external to the NNSA to add an independent perspective to the report. Biographies ofthe participants in this analysis can be found in Appendix of this report. A detailed timeline of events is provided in Section 4. The team used the event and causal analysis method to analyze the data. An event tree and causal analysis diagram is also included in Appendix A. A brief description ofthis methodology follows to provide context for the results contained in this report. 2.0 ANALYSIS PROCESS Accident Analysis 2.1.1. Barrier Analysis The root cause analysis team collected data from various sources. including reports. interviews with knowledgeable staff. memoranda. and e?mails. The team used the data collected to develop a basic chronology of events. The team then performed a barrier analysis ofthe incident using the methodology for accident investigations. The team needed to select the target (the person or item to be protected) and the hazard (what the person or item is to be protected from). Unlike an accident investigation. where the terminal event is generally evident as the point ofthe injury. fatality. or excursion. the team had to decide the terminal event. In this instance. the team selected as the terminal event the degradation of the criticality safety capability at LANL to the point that it resulted in a shutdown. Therefore. the target was viewed as the health ofthe criticality safety program and the hazard was the degradation of the program. The team identi?ed and analyzed six barrier failures: - Healthy skepticism on the part ofthe Field Office and NNSA Headquarters (HQ) related to LANS's ability to recognize and address problems with the criticality safety program: a Open and accurate communications at all levels about the status of the criticality safety program; 0 Contract incentives that acted as tools to in?uence desired changes by the contractor: 0 Emphasis on safety in light of production pressure and pressure not to shut down operations: - Correct recognition of problems in the program and an accurate view of underlying causes: and The ability to hold the contractor accountable to address problems when they are identified. The team?s analysis indicated that the failure of barriers significantly degraded the criticality safety program. 2.1.2. Event and Causal Factors Chart The team developed a basic chronology ofevents and performed a barrier analysis ofthe incident. The team then assigned results from the root cause and barrier analyses to events on the chronology ofevents. This involved assigning analysis results as conditions that were related to. or initiated, the events within the chronology. Assigning these conditions with events resulted in the Events and Causal Factors (ECF) chart in Appendix A. Once conditions were assigned, the team examined the ECF chart to determine which events were signi?cant which events played a role in causing the accident}. The team then assessed the significant events (and the conditions of each) to determine the causal factors of the accident. The causal factors that resulted were: Root Cause (RC) causal factors that, if corrected. would prevent recurrence ofthe same or similar accidents. There was inadequate recognition on the part of the Field Of?ce that programmatic criticality safety problems were signi?cant. For a variety of reasons. Field Office management and staffdid not fully understand that the criticality safety issues were serious enough to warrant Department of Energy (DOEVNNSA involvement and assumed that these issues were being adequately managed by LANS. This assumption persisted even though there were prevalent indications to the contrary. such as the departure of criticality safety staff. an increase in the number of criticality safety infractions that were not self-identified, an increase in the backlog ofcriticality safety evaluations, and several other incidents indicating a fundamental breakdown in work control and conduct of operations (Conops). Recognition of the problem evolved somewhat over time. and some Field Of?ce staff eventually attempted to bring attention to the issues. However. the safety culture that existed within NNSA was to allow the contractor to manage the problem with minimal Federal intervention throughout most of the time period addressed during this review. There was a lack of a questioning attitude on the part of senior of?cials at NNSA HQ regarding the health of the LAN eriticality safety program. Senior of?cials (both safety and line management) at NNSA HQ were made aware of concerns about the eriticality safety and conduct of operations programs at LANL. In this context. the Federal Criticalin Safety Program Manager is considered to be "staff" and not a "senior of?cial.?) There were suf?cient signals to demonstrate that there were serious concerns. Examples ofthese include multiple reports from the Criticality Safety Support Group (CSSG) noting problems. letters to LANS from the Field Of?ce expressing concerns, verbiage in annual reports. and e-mails sent by the Federal Criticality Safety Program Manager and other federal eriticality safety support staff. The team could ?nd no evidence to indicate that NNSA HQ senior of?cials questioned the conflicting information to fully understand the concerns. If senior of?cials at NNSA HQ had exhibited more ofa questioning attitude towards these signals that were often mixed and inconsistently communicated through the line. they could have prevented the situation from deteriorating further. The structure of the contract and performance-based incentives contributed to a perception among some personnel that production?not safety?was the most important measure of success. The LANL contract was established to incentivize and prioritize production. and consequently in some cases. fee for safety performance was not reduced even though there were safety concerns. Contributing Cause (CC) event or condition that. collectively with other causes. increased the likelihood or severity ofan accident but that. individually. did not cause the accident. The team identi?ed six contributing causes to this accident: There was inconsistent communication regarding the signi?cance of eriticality safety issues throughout all levels of NNSA: from LANL. to the Field Office. to NNSA Headquarters. Inconsistent messages were being sent to LANL and to and from NNSA senior management. LANS continued to receive its fee even after signi?cant safety events in which eriticality safety control limits were exceeded. In addition. the annual reports that were sent to NNSA senior management from the Field Of?ce continued to use verbiage indicating that the situation was not signi?cant and no dramatic action or intervention was necessary. This situation was exacerbated by changing roles and responsibilities: speci?cally. in the reporting structure at NNSA Headquarters. numerous changes at the Field Of?ce Manager level. and inconsistent reporting through line management by the Federal Criticality Safety Program Manager. who had been assigned to various line support and staff suppth positions throughout this time period. The process for correcting weaknesses in eriticality safety performance via the fee determining award structure was ineffective. The Field Of?ce recommendation to reduce fee and not award an additional term to the contractor in response to weaknesses in eriticality safety performance was not accepted by the Fee Detetrnining Of?cial as a result. an opportunity was missed to drive the desired performance. In the December 2012 timeframe. the Field Of?ce concluded that the situation with the eriticality safety program had degraded to the point that that it should use the most punitive contractor oversight tool: withholding fee and award term. However. the FDO did not accept that recommendation and approved fee and award term for the contractor. While it is within the right to make the ?nal decision regarding fee and term. this particular decision essentially amounted to tacit approval of the contractor?s approach in addressing criticality safety issues. in addition. the Field Office lost an opportunity to drive the desired safety performance at a critical juncture. An additional Factor in this decision was that the FDO was also the Acting Administrator. Therefore. not only did the Senior Managers and staff at the Field Office perceive that they had lost the ability to effect change through contractual mechanisms. they felt they had lost the support of their senior leader in addressing the problems. There was a prevalent culture of deference to the criticality experts at LANL by both the contractor and the Field Of?ce. This situation led the Field Office to lack a questioning attitude. resulting in inadequate follow-up on issues. As a result, LANS was not held accountable for correcting deficiencies. LANS criticality safety staff were world-renowned experts in criticality safety. There was a beliefthat the criticality safety staff at LANL had the Situation under control. even when there was evidence to the contrary, such as events indicating criticality safety problems and infractions. This culture persisted even after evidence surfaced that there was friction between the operations and criticality safety personnel to the point that operations personnel did not seek criticality safety assistance when necessary. in a related matter. the effort to transition from an expert-based to a standards-based approach to criticality safety did not involve input from the current criticality safety staff. hindering the hiring of additional personnel. Pressure to meet production schedules led to a lack ofjudicious analysis and follow?up on previous commitments by both the Field Of?ce and LANS. Production pressures drove two significant areas: contract incentives and the reluctance of Field Of?ce staff to follow up on issues that may have delayed production. The Field Of?ce allowed subsequent events to supersede the closure of issues associated with criticality safety. Presumed higher-priority issues PF-4 seismic. Los Conchas wild?re. formality ofoperations. emergency management. lire protection. safety basis) diverted attention from the longer-term corrective actions needed to improve criticality safety functions at PF-4. Many ofthese de?ciencies remain open. as documented by own internal assessment in 20l3. Senior management in the Field Of?ce perceived that some of the problems with LANS criticality safety staff were simply human resource issues and therefore not within the purview of the Field Office. The Field Of?ce discounted the effects of staff attrition and low morale on criticality safety because it accepted explanation that the problem was not signi?cant or would be resolved by the attrition ofseasoned criticality safety experts who held differing safety philosophies. This belief persisted until the situation was so obvious that it could no longer be accepted. There was a false perception from some oversight elements that other LANL programs, such as work planning and control and conduct of operations, were adequate to offset weaknesses in the criticality safety program. Conops was cited by some ?eld personnel as a reason for the lack of concern about the criticality safety program. even after incidents occurred demonstrating weaknesses in the program. Federal oversight did not drive long?term improvement and corrective actions to closure or ensure the timeliness and effectiveness of improvement actions in some cases. 3.0 DISCUSSION OF RESULTS Detailed Analysis of Root Causes There was inadequate recognition on the part of the Field Of?ce that the programmatic criticality safety problems were signi?cant. For a variety of reasons, Field Office management and staffdid not fully understand that the criticality safety issues were serious enough to warrant involvement and assumed that these issues were being adequately managed by LANS. This sentiment was expressed in various communications. In a series ofannual reports submitted to the Defense Nuclear Facilities Safety Board throughout this timeframe. NNSA acknowledged that the criticalin safety program was understaffed. but verbiage repeatedly indicated that the Field Office did not consider the situation to be serious. For example. the report submitted in 2010 noted that the Los Alamos Site Of?ce (LASO) staff accessed the criticality safety program as understaffed: however. the report also noted that does not believe any dramatic changes in the current approach are needed." This conclusion was reached even though the 2009 report also indicated that LANL was understaffed, noting that. ?Ofthe six sites. currently only one. the Los Alamos National Laboratory. is understaffed." The assumption that the issues with the criticality safety program were not serious persisted even when there were prevalent indications to the contrary. such as the departure ofcriticality safety staff. an increase in the number of criticality safety infractions that were not self-identi?ed. an increase in the backlog of criticality safety evaluations. and several other incidents indicating a fundamental breakdown in work control and conduct of operations. Interviews were conducted with staff members and managers at the Field Office who were involved with the criticality program and providing input to the annual reports. Staffindicated that. in making their assessments of the health of the LANL criticality safety program. they gave greater weight to LANS's plans to hire more staff. This assessment shows that the Field Office continued to have confidence in ability to address the problems even though issues with the program continued to manifest themselves in production delays. potential inadequacies in the safety analysis (PISAs). and safety incidents. As noted elsewhere. some Field Of?ce personnel believed that other systems. such as ConOps. were adequate to offset any issues with criticality safety. However. in interviews with the root cause analysis team. Field Office staff members and support staff acknowledged that the Field Office staffdid not know the Conops program had significant problems until staff witnessed a criticality safety infraction that occurred in the April ?May 2013 timeframe in room 429. A robust hazard recognition program is critical for effective oversight. The ability ofthe overseeing entity to not only recognize that a hazard exists. but appreciate the magnitude ofthe hazard. is essential. Even with all the indications that the criticality safety program had significant problems. Field Of?ce management and staffdid not identify and recognize the depths of these problems. While the recognition of the problems evolved somewhat over time. and some Field Office staffeventually attempted to bring attention to the issues. the safety culture that existed within NNSA was to allow the contractor to manage the issues with minimal Federal intervention throughout most of the time period addressed during this review. That approach was exacerbated by the failure on the part of the Field Of?ce to recognize the true state of the program. Had the Field Of?ce management adequately understood the issues. they could have intervened sooner. thereby reducing the severity and longevity of the problems. 3.1.2 There was a lack ofa questioning attitude on the part of senior of?cials at NNSA Headquarters regarding the health of the LANL criticality safety program. Senior of?cials (both safety and line management) at NNSA HQ were made aware ofconcerns about the criticality safety and Conops programs at LANL. The Federal Criticality Safety Program Manager (CSPM) did not have line management responsibility for the oversight ofthe criticality safety program at LANL. and therefore raised awareness to other senior NNSA HQ of?cials in the line via e-mail. brie?ngs. and program reviews (In this context. the Federal Criticality Safety Program Manager is considered to be "staff" and not a ?senior The senior officials did not actively pursue resolution ofthese concerns. There were sufficient signals to demonstrate that there were serious concerns. Examples ofthese include multiple reports from the Criticalin Safety Support Group noting problems. letters to the Lab from the Field Of?ce expressing concerns. verbiage in annual reports. and e-mails sent by the Federal riticality Safety Program Manager and other federal criticality safety support staff. The team did not identify extensive evidence that HQ line management exhibited a questioning attitude to resolve the conflicting information. Instead. it was evident that a commonly used response was to recommend and conduct another criticalin safety review by either the riticality Safety Support Group (CSSG) or the NNSA Of?ce ofthe Chiefof Defense Nuclear Safety The other senior HQ of?cials did not follow up on concerns raised by the Federal CSPM and other subject matter experts. instead relying on the Field Of?ce to manage the issue; as a result, the situation further deteriorated. lfsenior of?cials at NNSA HQ had exhibited more ofa questioning attitude towards these signals that were often mixed and inconsistently communicated through the line. they could have prevented the situation from deteriorating further. The ongoing criticality safety issues at LANL eventually received the necessary attention and intervention from NNSA HQ as a result ofa meeting held on February 25. 20l3. between the acting NNSA Administrator. senior NNSA safety officials. and the Federal CSPM. During this meeting. con?icting perspectives were shared on the health of the LANL criticality safety program. As a result. the acting Administrator became actively engaged in addressing LANI.'s criticality saliety issues. This meeting was fortuitous as it served as the catalyst for bringing about direct and immediate NNSA HQ involvement in addressing the deteriorating criticality safety program at LANL. Problems with the LANL Criticality safety program were identified as a result ofmultiple criticality safety program assessments. In October 2005. the C856 performed a technical evaluation that identi?ed criticality safety staff shortages and noted that has an expert- based system that is highly dependent upon the knowiedge. experience. and diligence of staff that function largely without bene?t of complete documentation or formal processes." This report also challenged the basis for establishing and accepting the criticality risk of continued Operations. In addition. the 2005 Annual Criticalin Safety Report to the stated that 5-8 additional criticality safety engineers were needed at LANL. In October 2006. the CDNS sponsored a focused review of criticalin safety at LANL to look at progress made since the October 2005 CSSG review. The CDNS review concluded that. while the criticality safety program was not fully compliant with DOE Orders and ANSUANS-S standards. progress had been made and there was an established. documented. and auditable criticalin safety basis. Further. the CDNS team found that suf?cient documentation and operational controls existed to permit criticality safety experts to deduce that the risk ofa criticalin accident for operations ongoing at the time ofthe CDNS review was acceptably low. Given the ?ndings and verbiage in these three reports. this could have been an opportunity. in the late 2006 timeframe. for NNSA HQ senior leadership to question these conflicting reports and determine the health of LAN L?s criticality safety program. The root cause analysis team did not ?nd evidence of such queries by NNSA HQ senior leadership; rather. when assessments showed criticality safety de?ciencies. corrective actions were generated to address the findings. followed by additional CSP assessments to look into progress on previous ?ndings. The subsequent assessment identified some progress. albeit de?ciencies lingered. Still. the more recent assessment results were those that were accepted. and thus operations continued. lnjust over seven years. NNSA line management requested at least seven Special assessments: - October 2005 CSSG review; January 200? CDNS review; - April 2009 assessment by LASO: June 2009 CDNS biennial review: - January 20! LANL self?assessment of Area G: February CSSG limited-scope review; and the - March 20I3 CSSG limited review. The above-average frequency of additional CSP assessments should have raised awareness of underlying. lingering issues. instead. it seemed as though assessments were used as a tool to evaluate and accept some progress and thusjustify ?staying the course." This behavior allowed a situation to persist without adequate corrective actions or closure. There also appeared to be a clear trend by to rely on the Field Of?ce to manage the CSP de?ciencies at LANL. In general. allowing those closest to the work to manage their own issues is viewed as a positive trait exhibited by NNSA HQ and the Field Of?ce. However. it appears that both the Field and NNSA HQ relied on those under their purview to manage the safety de?ciencies LASO relied on LANS to manage the issues. and NNSA HQ relied on LASO). While this management strategy can be particularly effective to allow ef?cient resolution of issues. a healthy level of operational awareness needs to occur to ensure that overall risk is appropriately managed. The team observed that some officials at HQ felt that their involvement was not necessary unless they were alerted that LANL needed to be shut down. In addition. there was an admitted reluctance by all of those interviewed to recommend shutting LANL down. many indicating that the situation had not degraded to that level, or that unintended consequences would arise From a shutdown ofoperations. There is evidence that the Federal CSPM proposed a strategy to pause higher-risk operations. allowing some other operations to continue. However. this message was not carried Forward From ?eld line management and therefore was still not clear enough to gain the attention HQ senior of?cials. The culpability for the individual de?ciencies in CSP is not solely the responsibility of NNSA HQ. but the lack of questioning attitude allowed a problematic situation to linger. resulting in NNSA accepting risk that was not fully realized. These observations illustrate the need for senior of?cials at HQ to maintain a questioning attitude and are examples of missed opportunities to address a de?cient program where the de?ciencies could have had serious safety and health impacts. Had involvement been more prompt and balanced. this situation would not have been likely to linger. and operations that posed the greatest risk could have been appropriately curtailed to mitigate the risk of operating under a de?cient criticality safety program. 3.1.3 The structure of the contract and the performance-based incentives contributed to a perception among some personnel that production?not safety? was the most important measure of success. Performance management via the contract underwent numerous changes over the period ot?time covered by this review. There was a consistent theme throughout. however. that production outputs received signi?cant attention in most all of the incentive structures established by NNSA. While safety matters were addressed. the comparative value was signi?cantly smaller. Due to the more complicated nature ot'safety performance, as compared to an award for producing a speci?c number ofdiscrete products. it was more challenging to send a clear message in this area. The details are discussed below. In 2004. NNSA implemented a change in contract strategy whereby the LANL contract was rebid from the nonpro?t University of California (US) to consortiums of for-pro?t corporations. One ot'the intents ol'this revised contract strategy was to reward the contractor with fee for performing identi?ed activities important to the NNSA. Prior to this reward- type contracting system. NNSA. as LANL's owner and customer. had much less in?uence on activities and internal processes. The use of award fee signi?cantly enhanced ability to speci?cally direct LANL activities and processes and to reward LANL for work important to the agency. The consortium of UC. Bechtel International. Babcock and Wilcox. URS. and support subcontractors was awarded the contract in 2005. under the title of Los Alamos National Security. LLC. The initial contract was to operate LANL for 10 years. with additional years added to the contract based on performance. for up to 20 years. The annual operating budget for LANL was approximately $2 billion. Potential fee earned by LANS was in the area of$70 to $80 million per year. split between a base Fee and an earned performance fee. In 2006. only the base fee was paid. since performance objectives had not been developed. Earned fee was further divided up by LAMS. with shares going to each ofthe parent companies. These companies then paid performance bonuses to senior LANS employees. but not to lower-tiered workers. The ?scal year 2007 Performance Evaluation Plan (PEP) included 13 speci?c performance objectives, encompassing 170 specific milestones. The PEP covered the period October 2006 to September 2007. Fixed fee was approximately $22 million. while incentive fee was projected to be approximately $51 million. Award term incentives were not included in this PEP. Ofthe million ofincentive fee. approximately $7 million was for weapons deliverables. of which almost all was earned. Performance?Based incentive 4.2, entitled Safety Basis and Safary. was included in the PEP to address inadequacies in safety basis and criticality safety. A fee of$300K was assigned to this task. all of which was awarded. The 2008 PEP designated 30 percent of the available fee as ?xed fee and ?0 percent as performance incentive fee. The total fee available for the year was approximately $73 million. with approximately million at risk. Performance fee could be earned in 14 target sub- measures and was divided between base and stretch measures, divided (65 percent/35 percent). 0f the "at-risk fee.? 20 percent was also included as a subjective measure. An award term measure to operate LANL for an additional year was also included. based on the results ofthe performance in ?ve P815 (to include weapons work). Twenty percent of the incentive fee was also designated as "subjective" in 15. allowing LASO to measure performance on LANS's overall management of LANL. The weapons PBI was worth approximately $7.5 million in fee. 7.6. criticality safety performance, was worth with the requirement to maintain and accelerate the completion ofthe Nuclear Criticality Safety (NCS) Program Improvement Plan PIP). with demonstrated progress toward the out-year milestones. During that evaluation year. the signi?cant criticality safety de?ciency with the TA-SS vault was identi?ed which resulted in a pause in operations. However. due to the speci?c nature of the P315. LANE canted full fee in the criticality safety area for ?scal year 2008. Following the 2009 PEP. speci?c criticality safety elements were eliminated. This could also be perceived as a reduced emphasis on safety programs as compared to the production requirements levied on LANL. Options remained in the more subjective area to address safety performance. but zeroing in on the criticality safety issues at TA-SS would have been greatly diluted amid the broad set ofactivities taking place at LANL. Using the contract structure as a tool for managing contractor performance was dif?cult for safety matters. Much more clear and effective measures were available to drive production and delivery of specific products: therefore. the incentive process seemed to gravitate toward these production objectives. Even when safety objectives were used, dif?culties in de?ning the objective led to mixed signals related to safety performance being communicated to LANS. The structure of the M350 contract and the performance-based incentives reinforced the perception that production. not safety. was the most important measure of success. 3.2 Detailed Analysis of Contributing Causes There was inconsistent communication regarding the signi?cance of criticality safety issues throughout all levels of NNSA: from to the Field Of?ce. to NNSA HQ. A key deliverable to NNSA HQ management is the Annual Criticality Safety Report. in a letter dated August 7. 2003. closed Recommendation 97-2. and established an annual reporting requirement. The requires that DOE submit the Nuclear Criticality Safety Program (NCSP) report on contractor safety staf?ng as part of the annual report. Early reports in 2003 and 2004 provided staf?ng numbers of the Criticality Safety Engineers but did not indicate that the there was a staffing shortage. In 2005, LANL identified that it had a staft?ofcight quali?ed CSEs, with five to eight additional CSEs needed. thereby declaring that the LANL nuclear safety group was signi?cantly understaffed. in addition. the Executive Summary of the 2005 annual report stated that ?the Los Alamos National Laboratory was found to have significant weaknesses in its criticality safety program." In 2008. the need for extra staffing continued to be identi?ed; however. that year?s annual report indicated that LANS planned to two additional personnel with at least limited qualifications and experience. The number of new hires was limited by the availability of current staffto support and mentor new hires and the nationwide lack ofcriticality safety personnel- In 2008. the NCS program engaged criticality safety specialists from Pantex. LASO assessed the program as understaffed to address the emergent issues at the site. but approaching those needed to complete the Criticality Safety Improvement Plan. The report also stated that does not believe that any dramatic changes in the current approach are needed." The 2009 annual report stated that is pursuing internal hiring and has been adding staffslowly. The current increase of staf?ng is judged to be an appropriate balance between backlog work and training of new staff." In 201 l. with eight CSEs (including the manager and senior adviser plus two available consultants). LASO assessed the program to be understaffed. but did not provide an indication of significant concern. The 20l2 annual report indicated LANL CSE staffing levels as four engineers (two senior). one quali?ed in another group. and four in training. and remarked that ?Staff losses were catastrophic but do not appear market driven." Although the staffing losses were discussed. the report did not indicate any significant concern other than ?inadequate to support mission.? The annual reports discussed above seemed to indicate that the situation was not significant and that no major actions were necessary by NNSA. Communications from the Federal CSPM had a different tone. The Federal CSPM sent several e-mails to NNSA HQ senior officials indicating that there was a staffing problem at LANL that could result in potentially serious criticality incidents. In June 2012 and again on October 2012. the Federal CSPM voiced his concerns to senior HQ managers about the perilous stalling situation that LANL was in regarding NCS. The October communication was entitled Criticality Train Wreck Coating at At that point. there was indication that the last two quali?ed (33135 were leaving. The Federal CSPM expressed concern that the criticality safety program at LANL would collapse and become nonfunctional. identifying staffing as a leading 10 indicator of potentially serious. high-visibility criticality events that would show up in the coming year. Similar communications occurred in November 20 [2 where the Federal CSPM. by e-mail. stated to senior HQ leaders stated that it had been eight months since the C886 review of selected elements of the LANL NCS Program in February 2012. One ofthe ?ndings in the C886 review was that a major exodus of criticalin safety engineering staff was about to happen that would cripple the program. In sharp contrast to the noncommittal language in the annual reports. the e- mail from the Federal CSPM recommended that NNSA issue a show-cause letter to LANS requiring it to justify how it could continue managing nuclear operations safely while re- establishing an adequate criticality safety staff. The LASO criticality safety subject matter expert (SME) communicated on several occasions to his management that LANS had not aggressively pursued correction of signi?cant criticality safety program issues resulting from the loss of staff and provided other indicators that he had concerns with management ofthe program. such as: The LANL integrated assessment schedule did not include a single assessment of the criticality safety program for fiscal year 2013. This was an indicator that LANS was not actively managing the program. as it was speci?cally mentioned in the 836 assessment findings. - The corrective action plan for the CSSG assessment was not tasked until just before the due date (30 days). An extension to the due date was requested and approved {another 30 days); that final due date was September l4. 20l2. and had not been met at the time of the SM E?s communication. The communication from the Site Office Manager (80M) in October 201?. to the Federal CSPM stated that LASO felt that LANS had a Green program in implementation. operator awareness. management awareness. reporting, and was making etibn to correct the staffing issue. LASO stated that it had added several oversight items to watch the weak areas. LANS had four pending hires at the time. and LASO perceived this was an elevated risk program that still had the ability to recover. The SUM stated that don't see a stop work point yet. So let's give it about 4 weeks and see if the hires come through and several of the yellowlred factors have their trends reversed?- NNSA HQ continued to hear from LASO that the situation was being managed and that the risks were low. During the 2008-2012 timeframe. the LANL Dashboard Briefing Book was ?Green? for criticality safety. This led LANS. the Field Office. and NNSA HQ to believe that there were no immediate concerns with the criticality safety program at LANL. In October 2012, the LASO criticality safety SME suggested to Field Office management that there was an indication that the metrics used to track NCS Program performance were inadequate to identify significant reductions in group resources. In November 20I2. the metrics were changed to ?Yellow.? At the end of the 2012 ?scal year. the Field Of?ce recommended a significant reduction in the monetary fee awarded to LAN S. In addition. it also recommended that term be withheld. The weaknesses in the criticality safety program were a major contributor to this recommendation. This message was in stark contrast to the previous communications that had occurred from the Field Of?ce to HQ. and this further added to the inconsistent communication that had occurred between the NNSA leaders. The FDO did not accept the recommendation provided by the Field Of?ce and awarded term to LANS in addition to an increase in monetary fee. As a result. LANS received mixed messages from the Field Office and NNSA HQ. This situation was exacerbated by the changing roles and responsibilities. speci?cally in the reporting structure at NNSA Headquarters. numerous changes at the Field Office Manager level. and inconsistent reporting through line management by the Federal CSPM (also serving as the head ofthe CSSG). The Federal CSPM had been assigned to various line support and staff support positions throughout this time period. Had the message from the Field Of?ce not been diluted by transmission through non-line channels, and been more consistent with the messages that had been communicated by the Federal CSPM. senior of?cials at NN SA [It] would have had a clearer understanding of the situation. 3.2.2 The process for correcting weaknesses in criticality safety performance via the fee determining award structure was ineffective. At the close of the 2012 contract evaluation year for LANL. the Field Of?ce had come to the realization that the actions taken to date had not been effective in resolving the deficiencies in the LANL criticality safety program- The Field Of?ce chose to use one of the most powerful tools available via the contract: a reduction in the monetary fee awarded for the year. More signi?cantly. the Field Of?ce recommended that award term be withheld. This would reduce the overall contract period of performance awarded to LANS and constituted a signi?cant, negative reflection on performance. The systemic weakness in the criticality safety program was one ofthe major contributors to this recommendation. The Field Office sent these recommendations forward believing that an accurate assessment of weak performance was appropriately reflected. Interview with line personnel indicated that they felt this was a strong. necessary message that had the potential to get the appropriate attention of LANL line management to focus on correcting the continuing weaknesses. The made the decision to restore the award term to LANS and increase the monetary fee. While it was within the purview ofthe FDO to make the ?nal decision. a signi?cant opportunity was missed to drive the desired performance. This particular decision essentially amounted to tacit approval of approach in addressing criticality safety issues. An additional contributor to this decision could have been a lack of full awareness of the criticality safety de?ciencies at the FDO level due to the communications weaknesses identi?ed elsewhere in this report. Another factor in this decision was that the FDO was also the acting NNSA Administrator. Therefore. not only did the senior managers and staff at the Field Of?ce perceive that they had lost the ability to effect change through contractual mechanisms. they felt they had lost the support of their senior leader in addressing the problems. The Field Of?ce. in effect. lost an effective tool to drive safety performance- The basis for the decision was not communicated back to the Field Of?ce other than the statement that this decision was in the best interests of NNSA. The Field Office lost leverage in in?uencing LANS to take the signi?cant actions needed to arrest the decline in the criticality safety program. LANS concluded that its approach to issues. including criticality safety concems. had NNSA's tacit approval. The significant actions needed were not taken. Shortly thereafter. the last senior CSE left LANL for other employment. The general response during interviews with line managers at the Field Office indicated disappointment in the decision that their rationale was not accepted. Had a more detailed basis for the decision been communicated. the Field Of?ce may still have had some leverage to influence LANS in this area. 3.2.3 There was a prevalent culture of deference to the criticality experts at LANL. by both LANS and the Field Of?ce. Two events occurred that changed and criticality safety culture. With the loss of production and the subsequent closure of Rocky Flats starting in l989. there was no longer a capability to mass-produce weapons components. PF-4. although built for research. had the capacity to ?ll this role on a limited basis. The NNSA weapons program worked with LANL to implement the capability to produce various replacement components on a greater-than-rescarch scale. Research facilities were converted to production facilities. As this process progressed. work that was skills- or expert?based?to include the criticality safety program?was replaced by documented procedures. in October 2005. the CSSG completed a criticality safety program assessment at LANL. The report. Evataatton aftne Los Atamos National Laboratory Nae-tear Safer}? Program. stated that LANL criticality safety programs were expert-based and undocumented. and that. although no unsafe operations were observed. the program was not compliant with ANSIIANS requirements. LANI. responded to the C586 report with the submittal entitled Les Atom-os- National Nuclear Safety Program Improvement Plan (PIP). In October 2006. the CDNS completed a follow up criticality safety review at PF-4. The CDNS team concluded that criticality safety basis was auditable and documented and that the chances for a criticality accident were acceptably low. but noted that the program still did not comply with ANSIIANS 8 standards and appeared to be primarily implemented on an expert-based level. Also in 2006. NNSA explored two new interrelated initiatives: Governance and the Contractor Assurance System (GAS). Requirements for the CA3 were included in the initial NNSAILANS contract. CA3 requirements were included in the NNSA Policy Letter NAP-21. Transfer-mati?anat Gmernance and Oversight. which formally documented the NNSA's position in February 201 l. and was applicable to all sites. Tenets ofthe policy at the Field Of?ce level included the completion of scheduled assessments across all aspects of contractor operations. with speci?c oversight on operations using a risk-based. graded approach. Floor oversight was performed by Facility Representatives in the nuclear and high-hazard facilities with support from LASO safety SM Es. LASO Plan 00. l4. Integrated Management Sustain Description tnca'nding Functions, Responsibilities and Authorities (FRA). carried forward this approach through speci?c Site Of?ce implementing procedures covering DOE 226.1 requirements. Between 200? and 2009. LASO monitored criticality safety-related PIP closure progress. primarily through the newly assigned criticality safety SME. In 2007 and 2008. fee was awarded for progress. Following the discovery ofcriticality safety issues in the PF-4 vaults. no fee was awarded in 2009. Follow-up versions of the PIP attempted to address identi?ed criticality safety issues. but also extended the issue closure schedules and strained criticality safety staff. In the years 2010 to 2013. no speci?c criticality safety PBIs were included in the PEPs. Governance and the CAS. whereby, the contractor would police itself. reduced the need for NNSA oversight. Management direction to the NNSA oversight staff was "Eyes on. hands off." In ?scal year 2010. 23 criticality safety infractions were reported at PF-4. In August 201 1. an operator in PF-4 was observed violating three criticality safety limits. LANS had slipped the criticality safety PIP milestones at least three times. Given the results of the previous events and reports. on September 16. 201 l. the LASO Assistant Manager for Safety Operations directed LANS to review the criticality safety margins for various operations. This letter was followed by a letter to the LANL Director from the SOM questioning PF-4 criticality satiety. Conops. and con?guration management. The letter questioned CAS and nuclear safety culture. On March 19. 2013. due to insuf?cient criticality safety staf?ng. the Field Of?ce directed LANS to stand down critic-ality safety evaluations for operations at PF-4. unless speci?cally released by the Field Of?ce. resulting in the potential stoppage of?ssile material operations. In June 2013. LANL ceased all ?ssile material operations in PF-4. From December 2005 to February 2013. there was a continuous cycle of assessments. corrective action plans. plan extensions. and contract direction. Although documented progress has been made. key issues remained unresolved. Criticality infractions still occurred. conduct of operations issues remained. and con?guration management was still an issue. Roles and responsibilities issues were consistently identi?ed. as were issues with management interaction. This situation led the Field Of?ce to lack a questioning attitude. resulting in inadequate follow- up on issues. As a result. LANS was not held accountable for correcting de?ciencies. There was a sense that the LANL criticality safety staff had the situation under control. even when there was evidence to the contrary. such as events indicating criticality safety problems and additional delays closing out the criticality safety PIP. Only after operations at PF-4 were suspended in June 2013 were these issues actually being addressed and corrected. 3.2.4 Pressure to meet production schedules led to a lack of judicious analysis and follow- up on previous commitments by both the Field Of?ce and LANS. In 2004. the NNSA implemented a change in contract strategy at Los Alamos. whereby the Los Alamos National Laboratory (LANL) contract was re?compcted and opened up from the non- pro?t University of California to for pro?t corporations. The use of award fee signi?cantly enhanced ability to speci?cally direct Laboratory activities and processes. rewarding the Lab for speci?c work important to the agency. In early 2005. a consortium of UC. Bechtel International. Babcock and Wilcox. URS. and other specialty subcontractors was awarded the contract. under the title of Los Alamos National Security. LLC (LANS). The initial contract was to operate LANL for 10 years. with an additional 10 years added to the contract based on performance. Fee earned by the LANS was in the area of $60 $80 million per year. split between a base fee and an earned performance fee. Fee was further divided up by LANS. with shares going to each of the partners. These companies then paid performance bonuses to senior LANS employees. but generally not to lower tiered managers or employees. LANS took over operations of LANL in June. 2006. Under the revised contracting approach. LANS was able to earn fee of $452 million out of$579 million available over the past eight years. In addition to earned fee. an award term provision. initiated in 2008. could earn LANS up to 10 additional years onto the initial l0-year contract. The majority ofthe earned Fee was in the areas of Weapons Program; Threat Reduction; Multi- Site Complex Integration; Infrastructure Management; and Science. Technology. and Engineering; predominantly LANL Primary Fee work at PF-4 included pit production. plutonium stabilization. mixed oxide processing. uranium packaging. and plutonium-238 packaging and production. Fee was lost in areas ol'overall LANL operational management. health and safety. quality assurance. and construction management. traditionally weaknesses. Award term. although variable during the ?rst seven years ofthe contract. was primarily based on a combination ofWeapons Program; Threat Reduction; Multi-Site Complex Integration; Project Management: Operations: and Science. Technology. and Engineering. Besides pressure to produce to meet incentives. LANS also had to manage changes among presumed higher-priority issues. Following the 2005 C886 criticality assessment. which required significant revisions and enhancements to the criticality safety program. the issued Recommendation 2008-1. Srgf?ery Classi?cation off-Tire Protection Systems. which recommended that fire protection systems in nuclear facilities be upgraded to safety-class. requiring higher levels ol'maintenance. surveillance. and operability determinations. In October 2009. following discussions with LASO. LANL. and the the issued Recommendation 2009-2. Los Alomos Notional Laboratory Plutonium Fitch?in .S'eismic Sqfery. to address seismic stability and subsequent fire-related issues. Analyzing. responding to. and implementing corrective actions for these two recommendations drew valuable resources away from the criticality safety issues for both LANL and LASO. In June 201 l. the Las Conchas wildland fire threatened LANL property and the town of Los Alamos. Following on the heels ot?Cerro Grande Fire in May 2000. the Las Conchas wildland ?re burned over 155.000 acres. A new perspective on wildland fire and emergency response was initiated. The follow-up response to this event provided another requirement for resources and was a further distraction for LANL and LASO. In 20l2. a major radiological contamination event occurred at the Los Alamos Neutron Science Center (LANSCE). After a accident investigation. it was determined that poor Conops and radiological safety processes contributed to the event. Criticalin Safety Staff was further stressed with eriticality safety issues related to the move of the Criticality Experiments Facility to the Nevada Nuclear Security Site. and other criticality safety concerns involving operations at TA-35. the SIGMA project, CMR. Area G. and ISC. The response to these major issues. along with continuing problems related to safety basis and formality of operations (Conops. nuclear maintenance. engineering. configuration management and training and quali?cation}. relegated criticalin safety to just another safety management program. such that it no longer had specific in the PEPs. There were no CS-specific after 2009. CS was a subset under the Conops and nuclear safety PBis. also showing up in the subjective section. In the end. priority. management attention. staff attention. and incentives were diverted from ensuring that the longer-term actions needed to improve criticalin safety functions at were completed. Although LASO has had an assigned criticality safety SME since 2007. he has since been assigned additional duties such as the primary oversight ofthe LANL training and qualification program and is the Field Of?ce point of contact. 3.2.5 Senior management in the Field Of?ce perceived that the problems with the LANL criticalin safety staff were simply human resource issues and therefore not within the purview of the Field Of?ce. As a result. the safety effects of staff attrition and low morale were discounted. as the Field Office accepted LANL's explanation that the problem was not signi?cant. The C880 determined that there were concerns with the criticality safety staff and that the organization was in danger oflosing much?needed expertise and would be unable to replace it. The C386 felt that this situation was a significant risk to safety and proposed solutions designed to retain staff and avoid a shutdown of operations. The solutions proposed by the CSSG included providing bonuses and reorganizing the criticalin safety group. Senior managers at the Field Of?ce stated that they believed the problems within the criticality safety staff to be human resources problems and therefore not within the Field Office?s purview. However. this view confused the effects of the problems with the solutions proposed and resulted in a passive approach to staff attrition. While the solutions proposed had elements of human resources?such as bonusesuthe very real risks posed by the loss of criticality safety expertise was not a human resources issue. The ultimate potential consequence was not low staff morale; rather. it was the loss of criticality safety expertise. By viewing the problem through the lens ofa human resource issue rather than the solutions proposed. the Field Office misdiagnosed the risks and delayed intervening in any signi?cant way. 3.2.6 There was a false perception from some oversight elements that other LANL programs. such as work planning and control and Conops, were adequate to offset weaknesses in the criticality safety program. in NNSA conducted a review ofthe LANL criticality safety program in October 2005. The report. entitled Technical vol notion of the Los Alamos Norman! Laboratory Nuci?enr (?riticrtl?iry Safety Program, identi?ed 3 safety recommendations, 14 ?ndings, 16 recommendations, l3 opportunities for improvement, and 2 noteworthy practices. In response, LANL submitted an NCS PIP. Revision 1 ofthe PIP was submitted to NNSA for approval in August 2006. and Revision 2 in March 2008. Revision 2 was as a result ofthe Augmented Limited Review (ALR) that was performed due to a PISA and resulting positive unreviewed safety question, which identi?ed inadequacies in two separate nuclear criticality safety evaluations for storage of?ssile materials in the plutonium storage vault in TA-SS. Revisions to the PIP continued to occur; however, criticality safety infractions continued to occur at LAN L. In January 2007, the CDNS conducted a review ofthe CSP. This review concluded that while the CSP was not fully compliant with DOE Orders and standards, progress had been made, and that LANL had established a documented. auditable criticality safety basis. Further, the CDNS team found that suf?cient documentation and operational controls existed to permit critieality safety experts to deduce that the risk of a criticality accident for operations ongoing at the time ofthe CDNS review was acceptably low. On September 16. 20] a memorandum was issued to the LANL Principal Associate Director of Operations. Attachment 1 to the memorandum, Status of'Phrtonitrm Fociir'ijvCriticaiitvSafety and Conduct of?ipernrions. stated that in ?scal year 20l0. LANS self-identified 23 criticality safety infractions at PF-4, nearly all of which were due to incompletely implemented conduct of operations. On August l, 201 l. a major criticalin infraction occurred where three limits were violated, which was a major indicator that conduct of operations was of concern. One operator violated two interaction controls and created an overmass condition that was recognized by a second operator. However. the second operator incorrectly advised the ?rst operator to restore the material to its initial con?guration (?Photo~op Incident"). Although the above mentioned document stated that LANL had signi?cant weaknesses in its Conops program and that NN SA was concerned, interviews with key Federal criticality safety personnel indicated that, as a result of the AL-R extent of condition reviews that were conducted. LANL had a suf?cient Conops program in place that would not tax the limited resources ofthe safety The interviewees indicated that although incidents continued to be discovered and the situation may not have been good, it was not dire enough to result in a pause. The Federal technical staff believed that even if all of the LANS criticaiity safety staff left LANL and the facility had a good safety basis, operations could continue for a period oftime. One interviewee also mentioned that he didn?t think there was ?imminent danger,? as the entire community was discussing this concern weekly. Had he felt that the situation was serious, he would not have hesitated to raise that concern to management. Conops was continually cited as a reason for the apparent lack ofconcern about the criticality safety program, even after incidents occurred demonstrating weaknesses in these programs. Had the Federal oversight been more proactive in driving long-term improvement and corrective actions to closure and disregarding the false perception that good conduct of operations could sustain the CSP, there could have been an entirely different result, with LANL taking timely improvement actions. 4.0 EVENTS TIMELINE Year LASO Leadership Event Or Email 2005 2006 Ed Wilmot (from 2004 to Jan 2007) LANL TA-55 SST ORR Identified no LASO CS SMEiprogram manager. Support from HO and Albuquerque. New LANL Nuclear Criticality Safety Group Leader Move National Criticality Experiments Research Center from LANL TA- 18 to NTS DAF. October 2005 NNSA Technical Evaluation of the Los Alamos National Laboratory Nuclear Criticality Safety Program assessment performed. (Primarily TA-55, and CMR) December 8, 2005 - Above report transmitted from NNSA HO to LASO. Three safety recommendations. 14 findings, 16 recommendations. 13 OFls [Major issue expert-based vs standards-based. lack of formality and documentation]. CAP required in 3 months for LASO approval. 2006 LANL NCS PIP, Rev.0 submitted to LASO for approval. 2006 Annual Crit Safety report notes five open positions and that staff will be trained to an equivalent or better overall context December 11, 2005, LANL NCS PIP, Rev. ?l submitted to LASO. 2007 Dan Glenn, Acting Feb-Jul 2007 January 2007, NNSA Criticality Review at LANL by CDNS. April 1, 2007, LASO CS SMEIProgram Manager selected and assigned. Don Winchell (Jul 2007- 2010) September 24, 2007', Transmittal from LANL PISA of the CSE in the PF-4 Vault. October 18, 200?, Letter LASO to LANL Direction to Provide Evaluation of the Safety of the Situation and Describe the Plan to Resolve the PF 4 Vault Criticality Safety Issue (directed ESS be completed by October 22, 2007'). October 30, 200?, LANL Transmittal of ALR plan and release policy for TA-55 to LASO (ADNHHO 07-281.} ADNHHO 0??281-Transmittal of ALR and Operational Release November 19, 2007, AD-NHHO {Tr-285 - Transmittal of Justification for Continued Operation - November 23, 2007, TA-54 Area LASO FR identifies CS issues with drum storage. Discovery of drums potentially exceeding the TA-54 Area criticality limit December 13, 2007, 07-318?Transmittal of Justification for Continued Operation December 20, 200?, LASO transmittal "Approval of Justi?cation for Continued Operation to Remove the Criticality Safety Operational Restrictions Direction to Provide an Evaluation of the Safety of the Situation and Describe 2008 Don Winchell (Jul 2007+ 2010) April 9, 2008, LANL NCS PIP Rev. 2, transmittal to LASO for approval. {Phasel complete) includes ALR. AD-NHHO 08-038-Nuclear Criticality Safety Program Improvement Plan NCS PIP. April 17, 2008 NCS PIP for 2008, NNSA approval of LANL NCS PIP Rev. 2. 4PM-002 NCS PIP for FY 2008. May 12. 2008? T.C. Short-Announcement of a Quality Audit of Criticality Experiments Facility CEF Planet Ouality Audit Report: Audit of CEF Planet and Flat-Top Criticality Machines Prior to Delivery May 29, 2008, LANL 129} transmits TASS-JCO-DT-002 Revision 4 requesting removal of operational restrictions for Rooms 8 and of the PF-4 vault after reconfiguration to meet the controls in the new Criticality Safety Evaluations. Request to Remove Criticality Safety Operational Restrictions June 24, 2008, LANL (AS-NHHO 08?147} transmits revised JCO Rev 4.1 to LASO. AD-NHH0208-147 Request to Remove Criticality Safety Operational Restrictions July 3, 2008, SET: 4PM-T2037: Approval of Revision to Justification for Continued Operation to Remove Criticality Safety Operational Restrictions for Rooms and I of the Plutonium Facility 4 Vault August 21, 2008, LASO FR reports Crit Safety Limits Exceeded in Giovebox at TA-55 September 4. 2008, LASO Transmittal of Finding (55-DC-08-24F) in TA-SS, PF-4, Room 319. September 2008. Letter, Moss to McQuinn, Feedback on CS ALR at TA-55. Submittal of the NNSA Criticality Safety Review November 17, 2008, Bonita Eichorst-Criticality Experiments Facility CEF Project October 2008, PSI 116.1, FY08 PBI Completion Documentation, Criticality Safety Improvement October 28, 2008, PSI 7.8.1. FY08 PBI CSI completion certification, all actions closed, Award $176,000. November 18. 2008. 08-102-Ouality Audit Report Audit of Criticality Experiments Facility CEF December 18, 2008, SAFE-1 08-025-CLASSIFICATION ISSUES REGARDING CRITICALITY LIMIT POSTINGS AT TIA-55 2009 Don Winchell (Jul 2007- 2010) March 13, 2009, LANL Transmittal to NCS PIP Rev. 3 to LASO for approval. AD-NHHO 09-082-Nuclear Criticality Safety Program Improvement Plan NOS PIP April 6-9, 2009, LASO NCS Assessment at LANL. June 10, 2009, FOD-CMR 09-019-Status of the Nuclear Criticality Safety Program at CMR June 24. 2009, POM 08-348 Completion Package for PBI 7.8.1 Criticality Safety Improvement No date (2009), Letter from LASO to LANL Approval of NOS PIP for 2009, appears to be resubmittal for rev. 2. 4 COAs. July 29. 2009, Safety System Oversight Assessment Plan TA-55 Plutonium Facility Criticality August 3, 2009, Transmittal to Nuclear Criticality Safety Assessment of the Los Alamos National Laboratory conducted April 8 - 9, 2009. September 11, 2009, Report from June 2009 CDNS review of LASO. September 30, 2009, Transmittal of 50-130, R0 to LASO for approval. Submission of System Description (SD) 130, Nuclear Criticality Safety Program. October 6, 2009, PSI Criticality Safety Improvement Completion Document. No fee awarded {$100k}. October 13, 2009, Transmittal, LASO approval of 80-130. No comments. I9 October 28, 2009, Transmittal PCM 09-327 PBI 2.5.1 Criticality Safety Improvement November 2009, Transmittal of the Criticality Safety Evaluation for the Temporary (19.9) Fuel Plate Fabrication November 10, 2009. Approval of the Criticality Safety Evaluation for the Temporary W190) Fuel Plate Fabrication. November 25, 2009, Safety System Oversight Assessment PF-4 Criticality Alarm System. December 2009, LASO of the TA-55 Criticality Alarm System 2010 Kevin Smith (Aug 2010 Dec 2012) ?Eyes on hands off policy? instituted at NNSA January 2010, NCS rev 4 January 10, 2010, Annual crit safety report characterizing LANL (38 staff as "understaffed" February 9, 2010, Annual report stated that additional staff is necessary February 2010. NCS PIP rev 5 August 10, 2010, Assessment on Criticality Safety Staff Responsibilities and Emergency Response August 30, 2010, Approval of SD-130, "Nuclear Criticality Program?, Revision 0. September 2010, New and Updated SIGMA Facility Complex and BTF Criticaltty Safety Evaluations September 21. 2010, Concurrence with the New and Updated SIGMA Facility Complex and BTF Criticality Safety. 2011 Kevin Smith (Aug 2010 Dec 2012) January 19, 2011, Area Criticality Safety Program implementation; from LASO to LANL Area crit safety January 26, 2011, Instructions to Perform Criticality Safety Program Assessment of Area-G; (LANL to LASO Area crit safety assessment} February 1, 2011, NCS PIP for FY 2011 February 4, 2011, Area (3 Due Date Extension for Criticality Safety Program Review February 15, 2011, Nuclear Criticality Safety Assessment for Area February 18, 2011, Submittal of corrected Criticality Safety Effectiveness Evaluation Guidance checklist February 23, 2011, AD-NHH0111-050 Area - Criticality Safety Program Implementation Approved 4 new positions March 8, 2011, Nuclear Criticality Safety Program improvement Plan (NCS PIP) for FY11. March 20, 2011, Nuclear Criticality Safety Program Improvement Plan (NCS for FY11. May 16, 2011, ACTION: Criticality Experiments Facility (CEF) Project, Line Item 04-D-128, at the Nevada National Security Site June 2011, C886 assessment at TA-55 September 16, 2011, PF-4 Criticality Safety Program October 3, 2011, Transmittal of report - LA-UR-11-05363 Nuclear Criticality Safety Committee June 2011 Assessment of TA-55 December 12, 2011, Plutonium Facility (PF-4) Criticality Safety Program 2012 Kevin Smith (Aug 2010 Dec 2012} E-MAIL: Jan 2012, LASO Manager asks LANL if there is a shortage of criticaiity safety staff. LANL admits to a shortage of criticality resources but that they are working through mitigation actions? 20 LASO Mgr: will hold off engaging since you have it in work." NCERC at DAF (distractor) January 25, 2012, Coordination of Criticality Safety Program at the Nevada National Security Site February 1, 2012, Response to Criticality Safety Implementation issues at STO. February 28, 2012, Submittal of DOE Annual Report on Nuclear Criticality Safety for FY 2011 Mar 1 Jul 2012, SIGMA crit issues (distractor) Mar 1. 2012 Outbrief of 0836 review to LANS E-MAIL: Mar 6-7, 2012, ?Friday Meeting with [Deputy Lab Directed"; attachment described situation and urgency to be transmitted to the Deputy LD. March 8, 2012, Conduct a Federal Readiness Assessment for Processing of Hazard Category 3 at the Area G, 412 Big. March 8. 2012, Plutonium Facility - Approval of Evaluation of the Safety of the Situation March 8, 2012, Revised Schedule to LASO on Criticality Safety Programmatic Improvement Plan March 23, 2012, Approval of the Recovery Plan for Criticality Issue at SIGMA Slut?66) March 23, 2012, Request for LASO Approval of Recovery Plan for the Criticality Safety Infraction March 29. 2012, Request for LASO Approval of Recovery Plan for the Criticality Safety Infraction. April 2, 2012, Approval of the Recovery Plan for Infraction at SIGMA (TA-3, SM-GES) April El, 2012, TA-55 VSSA - report and ?eld work were done well. Management review and approval was unacceptable, May 1, 2012, Transmittal of the Criticality Safety Support Group Assessment E-MAIL: June 12, 2012, ?[Federal regarding confusion over upcoming visit and lack of coordination with ops office. E-MAIL: June 14, 2012, ?Any News?? Federal CSPM Manager ?sounded the alarms" to other Senior NNSA of?cials at possibility of 0 seniors: ?Sr ?nally paying attention, wish had been 3 mo before? E-MAIL: June 14, 2012, Crti [sic] Safety Staf?ng" e-mail to the CDNS from LASO Manager which stated that LASO was handiing things but ?without a smoking gun de?ciency or clear data that their folks are not cutting it. [they are} reluctant to get directly into personnel issues.? E-MAIL: June 18, 2012. ?After Action Report" Federal CSPM e?mailed LASCI Deputy Manager regarding recommendations to fix staf?ng July 2012, TA-35 Fuel Rod criticality safety evaluation Oct 2012, "Status of LANL discussion about the last 2 senior engineers leaving between the Senior Criticality Safety Program Manager and the LASO Mgr, asked about the state of the group and corrective actions; LASO provided status [see e~mail Oct 23 for follow on] E-MAIL: Oct 17, 2012, 2:03 PM "Criticality Train Wreck Coming at from Federal CSPM to Line Management Senior Official at last 2 qualified NCS staff are leaving. serious concerns about a collapsingnon-functional CSP E-MAIL: Oct 23-24, 2012, ?Status of LANL LASO to Federal CSPM CSP now a 'yeliow? program due to throughput issues, quality and trends, etc.; LASO thinks it's a ?green? program in the making. have 4 pending hires, but will need to be trained; added several LASO oversight items, give it about 4 more weeks to see if hires go through and whether tends are reversing; Federal CSPM provided additional for oversight Oct 28, 2012, Last senior quali?ed CS engineer departs LANL Oct 29-31, 2012, "Moving on?; LASO crit safety SME notified the Federal CSPM that the last senior crit engineer was leaving LASO reluctant to suspend ops since "we?re still good on the floor and don?t want to break the system by standing down;' LASO is active in pushing for enhanced oversight to drive awareness; overdue CAP so not sure how LANS is managing situation; detailed FR oversight efforts; Federal suggestions E-MAIL: Oct 31. 2012 "Moving on" between Federal CSPM and other senior NNSA HQ of?cials; Federal CSPM "exceedingly concerned;" others indicated that there have been reports on the crisis in staffing at LANL for a while but can see that the situation has gotten worse; asks for ideas of the root cause; Federal CSPM indicated they were documented in the Feb 2012 0388 review, LANS senior management inattention, lack of involvement, and still in denial: still no CAP Oct 31, 2012 6:28 PM. Federal CSPM alerted a senior NNSA line manager that one remaining junior CSE is leaving, NSC program is insolvent, recommend ?show?cause? letter; indicated LANL had ?ndings for 8 months and still no CAP E-MAIL: Nov 1, 2012 11:25 AM. ?Moving on LANL Federal CSPM passes on Oct 31, 2012 e?mail to LASO Manager and Deputy Manager and senior NNSA line manager and where he remains ?exceedingly concerned" and questions how LANS can fulfill 830 and ANSIIANS-S with two marginally quali?ed staff members (should be 10-15); gave predictions on how scenario could play out based on lessons learned. E-MAIL: Nov 1, 2012 12:39 PM, talking points on LANL NCS situation" Federal CSPM alerts senior NNSA line manager that all senior CSEs have left and only two CSEs remain; not meeting requirements for 'Mgmt Responsibilities?; recommend issue LANS ?show cause? letter to iustify continued ops; attached CSSG outbrief slides, 8 mo since outbrief. no CAP still from LANS E-MAIL: Nov 5, 2012, "Grit Safety Executive Risk Management Item" LASO Manager noti?es senior NNSA line manager and Federal CSPM that LANS crit safety and operational capability are 'red' on dashboard; tatked to URS re: resources and requirements Late 2012, Field Of?ce recommended no award term {crit safety performance as an indicator) Late 2012, N08 Committee letter to Director (risk) Late 2012, N08 Committee Chair asked to step down (new high-level comm.) Dec 13. 2012, ?My Comments on the LANL CAP in Response to the CSSG Assessment and the NCSP Staffing Shortage? Federal CSPM noti?es LASO Management and senior NNSA line manager that the CAP is not acceptable. not relying on (3886 report or STD-1158 (performing contractor self-assessments of NOS program}, no commitment for gap analysis on how to fulfill DSAIT SR commitments with limited staff; LASO Deputy reaponse: LANS completed ~a third of 29 commitments. listed 4 things being done to follow the situation. don't want to create more paper but rather want resources actively managing and solving the problem; Senior Criticality Safety Program Manager response: path forward was to require LASO approval of the deliverables under the outline [of the since there were no specifics mentioned, the Federal CSPM did not recommend approval of the submitted CAP, stating that LANS is not engaged and is having to be led to the 'correct' solution. a CAP will not fix that; key features missing and could be quickly added FDO awarded term to LANS (did not accept Field Office recommendation) 2013 Juan Griego "Acting" (Jan Mar 2013) E-MAIL: Jan 18. 2013. Status" Criticality safety SME (from support service center) detailed areas of some progress but also that LANL was not self-identifying infractions, a leading indicator for staff being able to stay within the current crit controls; ?rst hint at degrading Conops but neither SMEs feel it is in the 'red' yet. E-MAIL: Jan 22, 2013, NCS Program" Federal CSPM suggests to LASO that LANL justify nuclear ops with a degraded NCS program in upcoming revised NCS know that the existing limits and evaluations are adequate for current ops, but the system is living and organic and 'coasting' on the existing basis won't last long. The you will see from an inadequate NCS are described in the DOE 1999 N08 Self-Improvement Workshop Booklet? describes problems getting new staff up to speed and warns that history has shown that these conditions have lead to a shutdown of facilities in the past; burden should be on LANL to defend why they are safe to operate. Feb 25, 2013; meeting with acting Administrator and other senior NNSA officials; briefed the acting Administrator that LANL has two junior crit engineers; acting Administrator questioned why the facility is still operating; staffing justified based on a significant quantity of comp measures E-MAIL: Feb 25. 2013. ?Debrief from LANL NCS Discussion with [Acting Administrator]"; Federal CSPM to LASO Deputy Manager; summary of earlier meeting with Acting Administrator and actions stemming from that meeting E-MAIL: Feb 28, 2013 ?My Personal Crit Safety 'Watch' List As of Today" Federal CSPM details top 4 criticality safety concerns to senior NNSA of?cials and line managers; LANL criticality safety is listed at the top March 2013 DOE [3336 limited review and causal analysis ersistent lack of trust? March 25; 2013 2012 Annual Criticality Safety Report notes LANL will receive staff assistance form LLNL ?Staff losses are catastrophic but do not appear to be market driven.? Geoff Beausoleil Acting (Apr Sept 2013) June 2013 11 criticality safety staff have departed E-MAIL June 10. 2013, ?Path Forward on Criticality Safety at from Federal 08PM to LASO and senior NNSA line manager; 23 need de?nitive path forward on LANL crit safety to prep Acting Administrator for meeting with gave suggestions for a LAMS crit safety mgr. identify highest risk ops and pause. reduce mass limits, trainlqualify first-line supervisorsl'mgrs. 0305. and ?ssile material handlers June 2013. Operational pause at TA-SS E?l'lelL: June 21. 2013. "Crit Safety at Federal CSPM recommends the need to pause and review solution ops and reduce quantity limits to LASO and Sr NNSA Line Manager E-MAIL: Jun 26, 2013, ?Discussion with LANL Director About Potential Stand-down of Selected Nuclear Operations for Criticality Safety Concerns" from Federal CSPM to other senior NNSA officials and LASO Mgrs; described meeting with acting Administrator with discussions to stand down higher-risk operations. call later that day to discuss. July 2013 LANL Director commitment to Best in Class William (Ike) E-MAIL: Nov 2013, Federal CSPM noti?es HSSIOE that NNSA White Acting (Oct committed to a Federal analysis of NOS staf?ng collapse 2013 Jan 2014) 5.0 RECOMMENDATIONS Based on the result and analysis contained in this report, the team provides the following recommendations for consideration by line management in response to this report. These recommendations have been drawn from each ofthe root and contributing causes; in some cases. recommendations apply to more than one cause. Some broader recommendations are also included regarding the conclusions ofthis report as they relate to other enterprise initiatives. NNSA leadership should consider: - Sharing the results ofthis investigation in a timely manner across the entire NNSA Enterprise as a means to reinforce the commitment to improve the organization?s communications process. Developing additional paths to raise emergent issues up the chain ofcommand. (Examples might include an informal Safety Issues Review Board as a forum for the pcer?to-peer discussion ofpotential issues.) Rc~evaluating the recommendations the 2013 NNSA Safety Culture Report for common themes commonicationfengagement of staff. management of concerns). - Continuing to aggressively pursue improvements in safety culture to improve communication of issues via the most direct and effective channels. - Recognizing that award fee for mission performance cannot be separated orjudged independently of safety performance. Final fee decisions and their bases should be shared broadly to enhance corporate learning. Reviewing and clarifying the current safety and program nexus in the organization to ensure balanced priorities in effective decision-making. Reviewing and clarifying safety roles and responsibilities across the organization. as appropriate. Following up on. and ensuring the ef?cacy of. closure actions associated with the LANL PIP for criticality safety. Assessing the processes and procedures at the Field Of?ce for tracking. addressing, and closing corrective actions to determine ifchange-s should be made in light ofthe ?ndings in this report. Conducting an extent of condition evaluation to determine if there are other potential safety issues that are developing in the organization at a particular site or sites). APPENDIX A. EVENTS AND CAUSAL ANALYSIS DIAGRAM The team performed an events and causal factors analysis in accordance with the DOE Handbook 208?20 Accident Investigation and Prevention. The events and causal factors analysis requires deductive reasoning to determine those events or conditions that contributed to the undesired condition or event. Causal factors are the events or conditions that produced or contributed to the undesired condition or event. and they consist ot?direct. contributing. and root causes. The direct cause is the immediate event or condition that caused the undesired condition or event. The contributing causes are the events or conditions that. collectively with the other causes. increased the likelihood or severity ofthe undesired condition or event. but did not soler cause it. Root causes are the events or conditions that, if corrected. would prevent recurrence of this and similar incidents. Culture of del?ence to experts at the laborator?r Indications that were resistant to change perception that no SME ms needed Evaluation identi?ed safety staff shortages at EANL Site had historically been expert based LASO had no cm safety SME LANL crlticalitv grout: . C556 repdrt (2556 report 5 - changed from an tart A 18 move LANL Tit-$5 SST ORR C556 Techmca' transferred from HQ transferred from LASO . expert based 5v: em to DAF at Evaluation lo ?50 to LAM to standards based 2005 5 5 system 200 on ma Dec Early 2006 2005 Report notes there were '3 qualified and 3' in training Report noted there were 5 open positions and siaff will be trained Assessment of actual criticalitv safety pasture LTA Report stared risk of a {r?ticality accident was Sufficemiy low CDHS review sufficient operational controls existed In allow continued {in?ation - eview was wnducted based on request sum in response (2555' Significant potential crit safety issues were iaeniifer! LANL NCS Performance improvement Plan sent to LASO March 2006 LASD reviewed PIP and sent back 10 LANL for revisions 2005 2005 Annual Criticality Safety report finalized 2006 Incident involving NNSA Crizicaliw Sal?er nitric acid back?ew LANI. Revised PIP Rev: sent to LASO review by the CDNS J. Aug 2005 Jan 2007 A-Z Contract incentives focused on performance metrics, not safety Culture of deference to experts at the labor stow antic! that ConOps program was strong reinforced by lack of infractions Calculations wme not previoust questioned Discovered that documente? Ii its were not safe LASO crit safety SME selected and assigned April 2003" EANE. PISA an CSE in PF-4 Vault initiated Sent 2110? TA-SS vault shut down Sept 2307 LANL provldes E55 and plan to resolve vault cm saiety issue Oct 206? LANL sends ALR plan and policy to LASO Oct 2007 LANL sends JED to LASU NOV 2007 Contract incantives focused on performance metrics, not safety :elief that Con?ps program was strong reinforced by lack of infractions Eek-stations were not. previously questioned DiMavered that documented limits Were not sale Tilt-54 Area Facility Rep identifies a crit safety issue with drum storage LASO and found it lnaoequate LANE. submits revised Tit-55 was restarted LASO appmves the JEO far the vault NNSA sent letter of system to recognize pattern of poor performance LTA Quartet-tantra on production metric Nov 200?? Nov 200? .ICO to LASD Dec 200? commendation on crit safety Der: 2007 LANL PIP Rev 2. submitted to LASO {incorporated Mar 2008 LANE requests removal ot vault restrictions after new CSE implemented May 2003 Pressure to restart vault resulted in HA review of limits calculated limit: In fallow up (Ian LASO crit safety SME selected and assigned May 2003 QR audit addresses crit safety on. ?critiizalir.l machines May 2003 LAN submits revised 1C0 to LASO June 2005 U50 approves revised JCO, vault restriction lifted Jul EDGE Facility rep reports crit safety limits exceeded in gluuebo: Aug zone ?ndings regarding TA- 55 glovebait to LANL Sept 1008 Site SME sent feedback on safety b- ALR at TA-SS to LANL Sept 2008 Inconsistent communication regarding true state of operations Situational awareness by M50 LTA. inadequate assessment of true situation Situational awareness by LASD LTA. inadequate assessment of true situation Contract incentives focused on production: metrics, that safely .Il project LASO stated the sess?u risk was "low and occaptable? inconsistent communication regarding true state of operations Report stated that mt safety had Improvi?? since 2007 Mixed message: sent it? contractor by awarding 43!! fee, even with infractions LASQ assessed program as understaffed", but stated no dramatic changes needed insufficient follow up tin catsuioted Ein?iits Annual crit satietyr LASU co report submitted to transmits the crit it crit satetv assessment nducts nuclear at LAHI. Findings transferred to IANL in Aug 20:39 CDNS Biennial Review at LASO Jun 2009 550 oi 55 crit safety Jul 2009 safety PIP Rev to i LASD Dec 2008 Feb 2009 Crlticalitv limit posting errors discovered at Tint-55 vb- Performance ha sod incentive documents crit safe . a- improvements Oct 2003 Apr 2009 Situational awareness by LASO inadequate assessment at true situation Inconsistent communication regarding true state oi operations Contract Incentives focused on production metrics, not safety LASO stated the residual project risk was ?low and acceptable" Also noted that budget crisis to him several more CSE Report stated that was w?hh?d based on "compensatory actions to: tack pwduam" of Ha? ill LANL generally raqgi'ra delay oi fissile activities" Significant attention at Site Ui'fice required to address MSG worm-:5 50-130 with no comments recommend.? ion LASO assessed program as tinderstailed?, but stated mu dramatic changes needed 50430 sent from toLASOior approval recommendation 2009?2 isSuedt related possible lee awarded to cornin with based on PBI 15.1 as SE. . 0 420.13 schedule was not met a Sept 2009 Oct 2009 NW 2009 Sigma project commences and require significant crit safety support Nov 2009 4. Annual safety report submitted to Pi? sigma and BTF Jan 2010 Jan 2010 Sent 2010 Additional work at LASG approves NCS onrse renuired significant i:rit safety evaluations LANL and ?$95qu an Eltr: :ion to conduct the review Letter was sent from LASO to LANI. regarding Area 6 crit safety concerns Perception at Site Office that problems hiring crit safety- staff was an HR problem only Culture of deference to experts. at the laboratory Culture of non- compliance with procedures due to situational awareness LTA. [also assumption that Conan: program was strung Hiring was considered but not mim'itlied with additional workload Ineffective process at site office to hold contractor accountable to correct problems Hiring proved dif?cult due to low morale among current staff and lab culture of "growing our own experts" P1P notes thin 151 (if 165 ml: safety evaluations are no. Individuai W35 Encouraged to ??mpwm rectify . rur without reporting; Positiom? were approved but never hired If Violation of procedures when individual attempted to to ire photo of reactive material Four new crit safety in response to LASO latter. LAHL committed to conduct a crit safety assessment of Area in 2011 LANL sends letter to LASU with the corrected crit sal'ett.r effectiveness positions approved Rev 5 engraved by mm Aug 2011 FY 2011 checklist Mar 2011 Feb 201 1 Ineffective process at Site Of?ce to follow up and hold contractor accountable Io correct problems Perception at Site Office that problems hiring crit safety staff was an HR problem only No response to email was identified Ineffective at! me! with Lab Deputy I Director and retontmended a: on actions and hold contractor accountable to reorganization of the group and . . {ah Dimmer rephed "veg Of??i?ii'i?d bonus structure correct problems CSSG lo "however we are working mitigation actions? Report indicated 8 (fit safety staff, including manager; 51?. adviser and 2 consultants Lab not accept some CSSG Stated Canons core elements recommendations 0 bsewatio implemented .. included that all safety attrition was an shortegos are worsening, long term stalling plan needed SUM sent letter to Lab Director highlighting crit safety prolems Deputy 50M sent SUM sends email to letter to lab Lab Director asking counterpart about shortage of cril: requesting review at safety rescurces Con?ps Sept 2011 CSSG limit scope review notes potential loss of expertise Annual cril: safety report submitted to Noted area was ?understaffed? Sept 2011 Jli directs LANL to develop a CAP to address 11555 findings Jan 2012 Feb 2012 Feb 2012 May 2012 Inconsistent communication regarding true state of operations. Issue nut raised to NNSA senior management Multiple meetings occurred between LASG and LAN ta discuss urgent sta?' Issues it June 1012 responds to CSSG findings and notes they are not going to reorganize the C5 group July 2012 ll Management assessment report {er Tit?55 notes that it Is short on crit safety evaluations Aug 2012 PIP Rev 6 is approved by LASD Sept 2012 Series in? projects thraugimut 2012 required extensive crit safety evaluations Last senior quali?ed crit safety engineer leaves LANL late 2012 NSC cammittee sent letter to Director noting risks late 2012 ineffective Feedback from contract tools to F00 regarding why al'fecl safety fee was awarded performance LTA Review found "persistent lath ol trust? in the organization Action removed the contract tool the Maid Of?ce assume-ti it had to affect performance Report noted start It:st were "ralastrophir" and res-adequate to support and operations" 1 Fieid Of?ce Free Determining Senior NNSA Difitials NSC Chair asked to recommends no award Official did not accept disagree regarding SDM at LASD step dorm fee. Cites trit safety Field Of?ce and magnitude of out reassigned . noted area was of "Am and M?sr? performance as one awards full fee to LAM. safety Issues Late 2012 reason contractor LANL Dec 1012 understaffed Sept 2012 on 2012 Late 2012 2013 Annual crit safety CSSG limited review report submitted to conducted at request A A .l 11 crit safety stair LANL Director orders have departed Tin-55 pause END rt lune 2013 June 2013 APPENDIX B. SUMMARY OF DOCUMENTS REVIEWED AND INTERVIEWS CONDUCTED Documents Reviewed - DOE Policy 226. A. Department af?Energv Oversight Policv DOE Order 226.13. Implementation ofDepartment ofEnergy Oversight Police. April 25. 20] 1 DOE Order 420. C. Facilitjt Safety-i. December 4. 2012 - NNSA Policy Letter NAP-21. Transformational Governance and Oversight. February 28. 201 - LA SO Plan 00.14. integrated Management Svstem Description including Functions. Responsibilities and Authorities January 2012 LASO MP 00.03. implementation ofLos Alamos Site Office Line Oversight. Rev. 4. December 13. 2009 LASO MP 00.12. LASO independent Assessment Process. Rev. 1. October 19. 2009 LASO W1 00.04. Assessment .S?liadow Activitv Reporting. Rev. 3. January 26. 2009 LASO WI 06.01. LASO Field Operations. Oversiglit/Surt-eilianre Issues Reporting. Rev. 2. March 5. 2010 Contract Number DE-AC52-06NA25396. Los Alamos National Security and the Department of Energy. National Nuclear Security Administration. 2005 - Los Alamos National Laboratory. Policy 09.02. Nuclear Criticality Safety Group. Augmented Limit Review and Operational Release. October 26. 2007 - National Nuclear Security Administration. Technical Evaluation oftlie Los Alamos National Laboratorv Nuclear Criticality Safety Program. October 2005 - National Nuclear Security Administration. Chief of Defense Nuclear Safety. NNSA ('riticality Sty?ety Review at the Los Alamos National Laboratory. January 2007 0 National Nuclear Security Administration. Headquarters Biennial Review ofSite Nuclear Safety Performance. Final Report?tr the Los Alamos Site Q?ice. August 2007 National Nuclear Security Administration. Criticality Safety Coordinating TeamiCriticality Safety Support Group. Nuclear Critical ity Safety Assessment oftlze Los Alamos Nationai Laboratarv. (.?ondacterlJulv 2l-2-i, 2008 - National Nuclear Security Administration. Criticality Safety Coordinating 'l?eam. Nuclear Criticalitv Safety Assessment of'tl'te Los Alamos National Laboratmjt. Conducted April 6-9. 3009 National Nuclear Security Administration. Criticality Safety Coordinating Team. Nuclear 'rit ical ity Safety of the Los Alamos National Laboratory. Conducted June 28- July 1. .3010 National Nuclear Scourity Administration. Criticality Safety Support Group. Focused Criticaliit-i Safety Review at LANL Plutonium Facilitfv (PF-4). April 13. 2012 - Los Alamos Site Of?ce. LASO Self Assessment Form. riticaiitv Safety, April 2009 Los Alamos National Laboratory. Office of the Laboratory Director. External Review oftite Los Alamos Nuclear Criticality Safety Program. Final Report. Rev. 0. October 7. 2013 - 1-05363. Los Alamos National Laboratory. Nuclear Criticality Safety Committee June 301? Assessment at 154-55. September 20. 201 1 3-1 LA-UR-13-29297. Los Alamos National Laboratory, Criticalitv Safety ln?'actions Causal Analvsis. November 12. 2013 National Nuclear Security Administration, Headquarters Biennial Review of'Site Nuclear Safety Performance. Final Report for the Los A lamos Site Of?ce (LA 50). June 2009 3-001-R0. Los Alamos National Laboratory. Final Reportfor Nuclear Criticalitjv Sty?ety Program Assessment. April 30. 20 3 47. Los Alamos National Laboratory Nuclear Critical ity Safety Progran-t improvement Plan. Revision l. December 1 l. 2006 NC S-Memo?03-002. Los Alamos National Laboratotjt Nuclear Critical ity So?'tv Program improvement Plan. Revision 2. April 9. 2008 NC S-M EM 009-006. Los Alamos National Laboratory Nuclear Critical ity Safety Program improvement Plan. Revision 3. March 2. 2009 1-003. (UCNI) 1?329050) Los Alamos National Laboratory Nuclear Criticalitv Safety Program improvement Plan. Revision 5. March 201 I 2-006. Los Alamos National Laboratory Nuclear riticalitv Su?-iv Program Improvement Plan. Revision 6. September 28. 2012 SECS-CA P- I 2265. Corrective Action Plan For Nuclear Criticality Safety Program. November 3. 2012 Corrective Action Plan or Nuclear Criticality Safety Program, Rev. 1. February 14. 2013 Los Alamos National Laboratory, Management Assessment (M4) Reportfor lid-55 Criticalitjy Safety, Plutonium Processing Facility. 2145.5. August 16. 2012 Department ofEnergy. National Nuclear Security Administration. Los Alamos Site Office. 200? Performance Evaluation Report oftlte Los Alamos National Security LLC. Management and Operation [lifting Los Alamos National Laboratory. Contract No. DE- A Performance Period October 1. 2006 through September 30. 2007. December 7. 2007 Department of Energy. National Nuclear Security Administration. Los Alamos Site Of?ce. Fl" 2008 Performance Evaluation Planjor the Los Alamos National Security LLC. Management and Operation oftlte Los Alamos National Laboratory. Contract No. DE- AC52-06NA25396. Performance Period October 1. 2007 through September 30. 200?. December 7. 2009 Department of Energy. National Nuclear Security Administration, Los Alamos Site Of?ce. FY 3009 Performance Evaluation Plan for the Los A lamos National Security LLC Management and Operation of the Los Alamos National Laboratory, Contract No. DE- AC52-06NA25396. Performance Period October I. 2008 through September 30. 2009. August 3 . 2009 Department of Energy. National Nuclear Security Administration. Los Alamos Site Office. Fl" 20] 0 Performance Evaluation Plan?tr the Los Alamos National Security LLC Management and Operation ofthe Los Alamos National Laboratorv. Contract No. DE- Performance Period October i. 2009 through September 30. 2010. SEptember 29. 20] 0 Department of Energy. National Nuclear Security Administration. Los Alamos Site Of?ce. FY 20} 1 Performance Evaluation Planfor the Los Alamos National Securitv LLC Atlanagement and Operation oftlre Los Alamos National Laboratoty. Contract No. DE- Performance Period October I. 2010 through September 30. 2010. Summary. September 18. 201 1 Department of Energy. National Nuclear Security Administration. Los Alamos Site Office. Performance Evaluation Reportfor the Los A lamos National Security LLC Management and Operation oftne Los Alamos National Laboratory, Contract No. Performance Period October 1. 201 I through September 30. 201 1. December 6. 20] 1 . Department of Energy. National Nuclear Security Administration. Los Alamos Site Office. FY 20! 2 Performance Evaluation Plan for the Los Alamos National Security LLC Management and Operation of the Los Alamos National Laboratory. Contract No. DE Performance Period October 1. 201 1 through September 30. 2012. September 28. 20] I. Department of Energy. National Nuclear Security Administration. Los Alamos Site Of?ce. Ft" 20l2 Performance Evaluation Reportfor the Los Alamos National Security LLC Management and Operation attire Lost A larnos National Laboratory. Contract No. DE- Performance Period October 1. 201 I through September 30. 2012. Revfi. November 26. 2012. Fiscal Year 20} 3 NNSA Strategic Performance Evaluation Plan (PEP) FOR noraroenranr AND TION ofLos Alamos National Seem-int. LLC. Contract No. Performance Period October 1. 2012 through September 30. 2013. September I l. 2012. National Nuclear Security Administration. Los Alamos Field Office. FY 2013 PEP. LOS ALAMOS NATIONAL SECURITY, LLC. Performance Evaluation Report. Performance Period: October EDIE?September 2013. December 16. 2013. FY 2008 Completion Documentation. FBI Element 7.6.1, Title: Criticality Safety improvement. October 17. 2008. FY 2009 FBI Completion Documentation. PEI Element 2.5. 1. Title: Criticality Safety improvement. October 16. 2009. Recommendation 2008-l. Salient Classification of'Fire Protections Sit-arteries. January 29. 2008. DNF SB Recommendation 2009-2. Los Alamos National laboratory Plutonium Facility Seismic Sry?etv. October 26. 2009. Letter To: The Honorable Earnest .1. Moniz, Secretary of Energy. Washington DC. From: Peter S. Winokur. Chairman. July 15. 2013. Memorandum For: S. Stokes. Acting Technical Director. From: D. KuptErer and McComb. Staff issue Report. Subject: Criticalitv Safety at Los Alamos National Laboratory-i. May 21 - 23. 2013. NNSA Letter To: The Honorable Peter S. Winokur. Chairman. From: James J. McConnell. NNSA. December 6, 2013. NNSA Letter To: The Honorable John T. Conway. Chairman. From: David 1-1. Crandall. ADA for Research. Development. and Simulation. Defense Programs, NNSA. Submittal of the Status of the Department of Energy Nuclear Criticality Safety Program for Calendar Year 2003. February 13. 2004. NNSA Letter To: The Honorable John T. Conway. Chairman. From: David H. Crandall. ADA for Research. Development. and Simulation. Defense Programs. NNSA. Submittal of the Status ofthe Department of Energy Nuclear Criticality Safety Program for Calendar Year 2004. February 1. 2005. NNSA Letter To: The Honorable A.J. Eggenberger. Chairman. From: David H. Crandall. ADA for Research. Development. and Simulation, Defense Programs. NNSA, Submittal of the Status of the Department of Energy Nuclear Criticality Safety Program for Calendar Year 2005. February 08. 2006. NNSA Letter To: The Honorable AJ. Eggenberger. Chairman. From: Thomas D?Agostino. Deputy Administrator. Defense Programs, NNSA. Submittal of the Status of the Department of Energy Nuclear Criticality Safety Program for Calendar year 2006. March 12. 2007'. NNSA Letter To: The Honorable A.J. Eggenberger. Chairman. From: Thomas D?Agostino. Deputy Administrator. Defense Programs. NNSA. Submittal of the Annual Report on Nuclear Criticality Safety Programs. National Nuclear Security Administration. February 23. 2009. NNSA Letter To: The Honorable John E. Mans?eld. Chairman. DNF SB. From: Garrett Harencak. Brig. Gen. . USAF. PADA for Military Application. Defense Programs. Transmittal ofthe Annual Report on Nuclear Criticalin Safety Programs. January 19. 2010. NNSA Letter To: The l'lonorable Peter S. Winokur. Chairman. From: Donald L. Cook. Deputy Administrator. Defense Programs NNSA, FYI I Annual Report on Nuclear Criticality Safety Programs. February 23. 2012. . NNSA Letter To: The Honorable Peter S. Winokur. Chairman. From: Neile L. Miller. Acting Under Secretary for Nuclear Security. DOE. Fiscal Year (FY) 2012 Annual Report on Nuclear Criticality Safety Programs. March 25. 2013.. NNSA Memorandum For Robert W. Kuckuck. Director LAN L. Ed. L. Wilmot. Manager. LASO. James .1. McConnell. CDND. From: Jerry McKamy. 17. Subject: Transn-tifiai of the Les Alamas Nationai Labrn'ataryNaciear Criticai?iiy Safety Program Review Report. December 8. 2005. NNSA Memorandum For The Revitalization Manager. LASD. from Thomas P. D?Agostino. Administrator. Subject: ?03 A iamos Site Q??ice Bienniai Review afSiie Naciear Safety Performance Report. September 27. 2007. NNSA Memorandum For William 1. White Manager. Los Alamos Field Of?ce. and Robert B. Raines. Associate Administrator for Project Acquisition and Project Management. From: Edward Bruce Held. Acting Administrator. HQ. NNSA. Subject: Los Airimos Naiionai Security, LLC. Fiscal Year 2013 Performance Fee. December 16. 2013. LASO Memorandum To: Thomas D?Agostino. . From Donald L. Winchell. Site Manager. 1.05 Aiamas Site Q??ice (LASO) Corrective Action Pianfor Chief De ense Nuclear Safety (CDNS) Management Concerns. December 4. 2007. LASO Memorandum To: Mr. Robert L. McQuinn. ADNHHO. LANS. From: Joseph C. Vozella. COR. LASO. Subject: Sabmiirai erhe National Naciear Security .tidministraiirm Safety Review Report. September 22. 2003. LASO Memorandum To: Mr. Robert L. McQuinn. ADNHHO. LANS. From: Joseph C. Vozella. COR. OSO. LASO. Subject: Apprami Criticaiity Program. Revision 0. October 13. 2009. LASO Memorandum SO: I 9PM-333659, To: Mr. Robert L. McQuinn, ADNHHO, LANS. From: Roger E. Snyder. DM. OOM. LASO, Subject: Approva.l oanciear Criticaiity Safer}! Program improvement Plan (ASS PIijor i March 29, 20] l. LASO Memorandum To: Charles F. McMillan, Director, LANS, From: Kevin W. Smith, 00M, LASO, Subject: Los Aiamos National Laboratory improw?ng Nuciear Safety anal tjtperations, September 16, 20l LASO Memorandum To: Mr. Carl Beard. PADOP, LANS. From: C.H. Keilers, OR, SO. LASO, Subject: Piutoninm Facititv (PF-4) Criticaiity safety Program. September 16. 20] l. LASO Memorandum To: Charles B. Anderson, ADNHHO, LANS, From: C.H. Keilers, COR, SO, LASO. Subject: Piutoniam Facility (PF-4) Criticaiity Safety Program. December I4. 201 l. LASO Memorandum To: Carl A. Beard. PADOPS, LANS. From: Juan L. Griego, Subject: Transmittat Criticaiity Safety Support Group Assessment. May I4. 20I2. LASO Memorandum To: Charles E. Anderson. ADNHHO. LANS, From: .H. Keilers. COR. SO, LASO, Subject: Corrective Action Ptanfor the Criticaiitv Safety Support Group Assessment. August 8, 2012. LASO Memorandum To: Charles E. Anderson, ADNHHO, LANS, From: CH. Keilers, COR. SO. LASO, Subject: LosAian-tos Nationai Laboratory Improving the Criticaiity Safetv Program. December 21, 2012. LASO Memorandum To: Charles E. Anderson, ADNHHO. LANS, From: .H. Keilers. COR, SO, LASO, Subject: Criticality Safety Program C'oncarrence in Reiease to Work Four Level 2/3 Anatyses. April I. 2013. LASO Letter To: Mr. Robert L. McQuinn. ADNHHO, LANS. From: Joseph C. Vozella, COR. OSO. LASO, Subject: Nat-tear C'riticaiity Safety Improvement Plan P1P) for 2008. April I7, 2008. LASO Letter To: Robert L. McQuinn, ADNHHO, LANL and Mr. Carl A. Beard. ADSMS, LANL, From: Patrick S. Moss. LASO. Subject: eeriback on Criticatity .?S?a?ay ALR completed at 3714?55. September I7, 2008. LASO Letter To: Mr. Robert L. McQuinn, ADHNNO, LANS, From: Joseph C. Vozella. COR, LASO, Subject: Suhmittai (qr/National Nuclear Security Administration Criticaiity SafeCV Review Report. April 13. 2009. LASO Letter To: Mr. Robert L. McQuinn, ADHNNO, LANS. From: Joseph C. Vozella, COR. OSO. LASO, Subject: Nat-tear Critic-aim! Sa?atv Fragrant improvement Plan (NCS Pt?tjor Fr 2009 LASO Letter To: Mr. Robert L. McQuinn. ADHNNO. LANS. From: Joseph C. Vozella, COR, SO. LASO, Subject: Sabmittat tn'Nationai Naciear Secaritv Administration Criticaiity Safety Review Report, August 3, 2010. NA-LA Letter SO-40PM-523751, To: Dr. Charles McMillan, Director, LANS, From: Geoffrey L. Beausoleil. Acting Manager, OOM, Subject: Los Aiamos Nationat Laboratory the (.?riticaiity Safetv Program implementation and Operationai Petjortnance. July I7, 2013. LANS Letter To: Mr. Joseph C. Vozella. LASO. NNSA. From Robert L. McQuinn, ADNHHO, LANS. Subject: Transmittal of'Attgmented Limit Review anti ()perationai Reiease Poiitjtf'or Criticatity Safety! Reviews at 734-55, October 30, 2007'. LANS Letter To: Mr. Joseph C. Vozella. LASO. From Robert L. McQuinn. ADNHHO. LANS. Subject: Nuclear Criticality Safety Program Improvement Plan (NCS Fl? 2008. April 9. 2008. LANS Letter. To: Mr. Joseph C. Vozella. LASO. From Robert L. McQuinn. LANS. Subject: Nuclear CriticalitySate!)t Program improvement Plan PlP)_for FY2009. March 13. 2009. LANS Letter. To: Mr. Joseph C- Vozella. LASO. From Robert L. Mc-Quinn. ADNHHO. LANS. Subject: Sulnnission Description (SD) 130. Nuclear Criticality Sate-{v Program. September 30. 2009. LANS Letter. 1-053, To: Mr. Charles Keilers. LASO. From Robert MeQuinn. ADNHHO. LANS. Subject: Submittal of Corrected Critieality Safety Effectiveness Evaluation Guidance Checklist. February 16. 201 1 . LANS Letter. 1?072. COR-1702.18.21.11 1-32-4901. To: Mr. Charles H. Keilers. AM SO. LASO. From Robert L. MeQuinn. ADNHHO. LANS. Subject: Nuclear Critieality Sa??ty Program. improvement Plan for 201 1. March 1 1. 201 l. LANS Letter. To: Mr. Juan Griego. 00M. LA SO. From: Charles E. Anderson. ADNHHO. LANS. Subject: Response to Transmittal ofCritiealitv Safety Support Group Assessment. July 2012. LANS Letter. COR-SO-10.2.2012-469133. To: Mr. Charles H. Keilers. AMSO. LASO. From Charles B. Anderson. ADNHI IO. LANS. Subject: Nuclear Critieality Satetv Program. improvement Plan. September 12. 2012. LANS Letter PADOPS 1 1-1 16. To Kevin Smith. DOM. LASO. NNSA. and Charles Keilers. C0 R. SO. LASO. NNSA. Subject: Improving Nuclear Safety and Operations. September 23. 201 1. LANS Letter. DIR. To: Kevin Smith. Manager. 00M. NNSA. From: Charles F. McMillan. DIR. LANS. Subject: Improving Nuclear Safety and Operations 74635. June. 27. 2012. LANS Letter. COR-BA-1.8.2012-479164. To: Mr. Juan Griego. 00M. LASO, From: Carl A. Beard. PADDPS. LANS. Subject: Transmittal ofa Corrective Action Plan and Measures to Strengthen the LANL Nuclear Critical it__v Safety Fragrant. November 8. 2012. LANS Letter. To: Mr. Charles H. Keilers. AMSO. LASO. From: Charles E. Anderson. ADNHHO. LANS Subject: Criticalitfv Safety Accelerated Training and Qualification "Boot Camp December 20. 2012. LANS Letter. COR-SO-2.1 2013-4952712, To: Mr. Charles H. Kcilers. AMSO. LA-FO. From: Charles E. Anderson. ADNHHO. LANS Subject: Complete Current TS Critieality Safety Aetion?n' the Nitric Acid Bat-Wow in TA -55. January 31. 2013. LANS Letter. 1 . To: Contracting Of?cer. BA. LASD. From: Steve Shook. Prime Contracting Chief. LANL. Subject: Contract No. Requestjor Approval. Walt-?L?t? to Retention Pay Policy: Retention Incentive Compensationfor Critical it Safety January 28. 201 3. LANS Letter. To: Mr. Charles H. Keilers. AMSO. . From: From: Charles E. Anderson ADNHHO. LANS Subject: Transmittal ofa Revision to the Corrective Action Plan (CA P) and Compensatory Measures to Strengthen the LANI. CritiealitjvSatety Program. February 14. 2013. 8-6 LANS Letter. AD-NHHO: 1 3-044. COR-SO-2. I 52013-495394. To: Mr- Charles H. Keilers. AMSO. LASO. From: Charles B. Anderson. ADNHHO. LANS Subject: Miriam of Naciear Criticaiitv Program Metrics and Other Feedback A/feeitanisms. February 15. 2013. LANS Letter. COR-OOM-3.7.2013-498579. To: Mr. Juan Griego. 00M. NA-LA. From: Carl A. Beard. PADOPS. LANS. Subject: C'artaiied Workioad due to C'riticalitv .SrgfetyAnaiurt Attrition. March 6. 2013. LANS Letter. AD-NHHO: 1 3-067. To: Mr. Charles H. Keilers. AMSO. LASO. From: Charles E. Anderson. ADNHHO. LANS. Subject: Lr-zvetr 2/3 Critieat'itv Safety Evaluations: Request to Release. March 23. 2013. LANS Memorandum. LA-UR-I 1-05363. 1-384089. To: Charles F. McMillan. DIR. LANS. From: Laboratory Nuclear Criticality Safety Committee. Subject: Nutriear Critic-(titty Safety Committee June 20.? 1 Assessment of 214-55, September 20. 201 1. LANS Memorandum 1-023a. To: Carl Beard. PADOPS. LANS. From: Tim George. ADPSM. LANS. Subject: ADPSM Remmnse to 201 i Naciear Safety Committee Assessment, September 28. 201 1. LANE Memorandum. DIR-124 83. To: Distribution. From Charles F. McMillan. DIR. LANS. Subject: Thank tbafor Your Service an the Los Aiamas Nuclear C'riticaiity Safety C'ommittee. November 8. 2012. L-ANS Memorandum. Distribution. From Charles F. McMillan. DIR. LAN S. Subject: .r'lppointment to Las Alamas tit'iear Criticaiitv Safety Committee. Navember 8. 2012. LANS Memorandum. To: Distribution. From Charles E. Anderson. AD-NHHO. LANS. Subject. Safety Basis-Criticality Safety Support to Operations. November 28. 2012. LANS Memorandum. To: Distribution. From James H. Miller. SIB-DO. LAN L, Subject: Review of the Las Aiamas National Laboratory Criticaiitv Erger-i Officer (030) Program at 714-55. CMR. and I?ll-54, Area G. April 4. 2013 LANS Memorandum. To: Robert C. Mason. FOD. TA-SS. LANL. From: William T. Bivens. ADNHHO. LANS. Subject: .S'afety Program Assessmeatfar TA-55. April 12. 2013. E-MAIL: E-MAIL: E-MAIL: E-MAIL: E-MAIL: E-MAIL: E-MAIL: EMAIL: E-MAIL: E-MAIL: E-MAIL: E-MAIL: E-MAIL: E-mail Correspondence Reviewed January 2012. March 6-2. 2012 ?Friday Meeting with [Deputy Lab Director]? June 14.2012 ?Any News?" June 14. 2012 Crti [Sic] Safety Staffing" June 18. 2012 ?After Action Report" October 17. 2012 ?Status of LANL October 17. 2012 ?Criticality Train Wreck Coming at LAN October 23-24. 2012 - ?Status of LANL October 29-31. 2012 "Moving on? October 31 2012 ?Moving on" October 31. 2012 6:28 PM November 1.2012 11:25 AM "Moving on - LANL November I. 2012 12:39 PM talking points on LANL NCS situation" E-MAIL: November 6. 20l2 - "Crit Safety Executive Risk Management Item" - E-MAIL: December IS. 2012 ?My Comments on the LANL CAP in Response to the CSSG Assessment and the NCSP Staf?ng Shortage" - January 2013 Status? - E-MAIL: January 22. 20 IS NCS Program? - E-MAIL: February 25, 2013 ?Debrieffrom LANL NCS Discussion with [Acting Administratorf? - E-MAIL: February 28. 2013 ?My Personal Crit Safety 'Watch? List As ofToday" E-MAIL June IO, 20l3 ?Path Forward on Criticalin Safety at LAN - E-MAIL: June 2 2013 ?Crit Safety at - E-MAIL: June 26. 20 3 "Discussion with LANL Director About Potential Stand-down of Selected Nuclear Operations for Criticality Safety Concerns" lnterviews Conducted - Associate Administrator for Safety and Health - Acting Associate Administrator for Infrastructure and Operations Associate Deputy Administrator for Major Modernization Programs - Federal Nuclear Criticality Safety Program Manager - Senior Technical Advisor for Criticality Safety Program - Criticality Safety Subject Matter Expert Los Alamos Field Of?ce Facility Representative. Los Alamos Field Of?ce - Assistant Manager for Field 8: Safety Operations. Los Alamos Field Of?ce Former Los Alamos Field Of?ce Manager Office of Safety and Health, Criticality Safety Subject Matter Expert - Former Assistant Manager for Safety Operations, Los Alamos Field Office APPENDIX C: TEAM MEMBER BIOGRAPHIES Jeffry L. Roberson is the Startup and Restart Program Lead for for the Of?ce of Environment. Safety. and Health. He has led the NNSA readiness process for the enterprise as well as leading or advising on multiple readiness reviews. He was a principle author in the development of the Line Oversight/Contractor Assurance System af?rmation process. He has completed assignments as the Project Director of the Zheleznogorsk Plutonium Production Elimination Project and Federal Project Director for the Seversk Plutonium Production Elimination Project for He served in this line position for 5 years managing these projects through critical decisions establishing the cost range and baseline. and approving the start of construction. He is a certi?ed level project director for the Department of Energy. Mr. Roberson holds a BS in Nuclear Engineering from the Georgia Institute of Technology. and a MS from the Industrial College ofthc Armed Forces. He has over 25 years? experience in the nuclear ?eld. He spent the first years ofhis career at the E. Hatch. Nuclear Generating Facility of the Georgia Power Co. in Baxley. Ga in the reactor controls division during a refueling outage and subsequent startup. He then served in the Navy's Nuclear Power Program where he served as a division of?cer aboard a nuclear submarine completing overhaul. startup testing. and sea trials. He was certi?ed as a Chiet'Nuclear Engineer by the Naval Reactors Branch of the DOE. As a result ofhis Navy and civilian experience. he has signi?cant background in many areas of nuclear operations. maintenance. health physics. and nuclear design. He is quali?ed by the Department of Energy as a Senior Technical Safety Manager and was a signi?cant contributor to the development ofthe Defense Programs readiness review process. He has served as a team member. team leader. and senior adviser for readiness reviews throughout the nuclear weapons enterprise. Patrick Cahalane is the Deputy Director for the Office of Environment. Safety and Health. NA-UU-IU. NNSA Headquarters. He has been an Excepted Service. since 2004. He has nearly 29 years of experience encompassing: safety oversight of high-hazard nuclear facility operations. including nuclear weapons facilities: international nuclear material protection (Russia); nuclcan?radiological emergency response: accident/incident investigation; and aerospace human factors and system safety engineering. This includes 24 years of Headquarters. ?eld and international experience with the DOEr?National Nuclear Security Administration (NNSA). He was a quali?ed fissile material (plutonium) handler at the Los Alamos National Laboratory (LANL) Plutonium Facility with hands-on. operational experience in the PF-4 non-destructive assay laboratory and vault. Mr. Cahalanc is a DOE trained accident investigator. and served on a number of DOE accidentfincident investigation committees while working at the Pantex Plant and LANL. This included serving as Chairman ofa major (?Type DOE Incident Investigation Committee involving a radiologically contaminated shipment across multiple states. He was also a member ofthe NNSA Safety Culture Assessment Team led by Dr. Sonja Haber in 2013. His prior positions/responsibilities include: Deputy Director for the Of?ce ofNuclear Safety and Governance. NA- 1 7 NNSA Headquarters C-I - Technical Lead for Authorization Basis. Of?ce of the Chiefof Defense Nuclear Safety. NNSA Headquarters - Technical Voting Member. LANL Contract Source Evaluation Board - Senior Technical AdvisorfEmergency Response Of?cer. Office of Emergency Operations. NA-40. NNSA Headquarters Director. Of?ce othIclear Material Protection (Russian Program), Niel-252. NNSA Headquarters - DOE Facility RepresentativeiTeam Leader. Plutonium Facility and Weapons Engineering Tritium Facility (WETF). LANI.. Los Alamos. NM - DOE Team Leader, Radiological Assistance Program (RAP) Team. Los Alamos. NM Senior Safety Engineerf'feam Leader (nuclear safety and nuclear explosive safety). DOE Amarillo Area Of?ce. Pantex Plant. Amarillo. TX Senior System Safety Engineer. General Dynamics Space Systems Division. San Diego. CA - Captain/Engineer. U.S. Air Force. Air Force Operational Test and Evaluation Center. Kirtland. AFB. NM (served four years active duty and four years reserve duty) Mr. Cahalane has a 8.8. in Aerospace Engineering from the University of Virginia. Charlottesville (P933). and an M.S in Industrial Engineering from Texas University. College Station (1985). In 2012. he requalified as a Senior Technical Safety Manager (STSM). and completed Nuclear Executive Leadership Training (NELT). David George currently serves the National Nuclear Security Administration (NNSAJ as a Senior Facility Representative (FR) and the Los Alamos Field Office Nuclear Startup and Readiness Program Manager. As an FR. he is responsible for the day-to-day oversight and operational awareness for the Balance of Plant. which includes Nuclear Environmental Sites. Material Packing and TranSportation. non-nuclear Facilities. and utilities at the Los Alamos National Laboratory (LAN L). Mr- George has over 33 years of professional engineering. leadership and management experience. including over 20 years with the U.S. Department of Energy. He has over l3 years of Facility Representative experience. having previously worked in this capacity at the Rocky Flats Plant. the ldaho National Engineering Laboratory. Brookhaven National Laboratory. and for Headquarters. DOE EM. Dave also worked for over 7 years as a Manager during the closure of Rocky Flats. As a Manager. he supported DOE Headquarters and Rocky Flats management. performing reviews of Contractor data submittals. cost analysis. independent cost estimates. and scope validation. Mr. George has participated on several DOE Readiness Assessment teams and has performed numerous Field Office and CDNS reviews. Mr. George has lead two site ISM annual assessments. at Rocky Flats and at the Office of River Protection. In addition. he has lead comprehensive laboratory wide assessments on safety basis and conduct of operations implementation at LANL and shadowed an arrangement of Contractor assessments (CRAs. lVRs). He has successfully lead mold-disciplinary teams during the reviews ofproject cost. baseline scope. and schedule validations. in his career. he has lead or participated in over 150 "facility assessments. evaluating facility safety. security. environmental compliance. work control. readiness and conduct of operations. His educational background includes a Bachelor of Science Degree in Engineering from the Colorado School of Mines and a Masters Degree in Environmental Management from the University of Denver. He is a graduate ofthe U.S. Army Command and General StaffCollege. a licensed Professional Engineer and a Registered Environmental Manager. He retired as a Lieutenant Colonel in the Army Corps of Engineers in 2006. Mr. George has been the recipient ofover 50 military and civilian awards. including the Service to America Medal and the Department of Energy Secretary?s Appreciation Award. Anika Khanna is a General Engineer within the O?ice of Infrastructure and Operations and serves in an occupational safety role providing support to the Office of Environment, Safety and Health Ms. Khanna has over it) years experience related to occupational safety and health. Prior to 0 Ms Khanna worked in the Of?ce of Defense Programs, where she provided oversight and support to the NNSA site of?ces related to the DOE Worker Safety and Health Regulatory Program I and Chronic Beryllium Disease Prevention Program Ms. Khanna has taken the DOE Accident investigator training and is certi?ed in Occupational Safety in the Technical Qualification Program. Prior to joining DOE. she worked as the lead Safety Officer at Sterigenics international. a national medical sterilization company at their location in Maryland. In her role at Sterigenics. she implemented a fully compliant Occupational Safety and Health (OSHA) program at the site and conducted training of all employees to maintain OSHA program requirements. Ms. Khanna has conducted several assessments both at Sterigenics and at DOE including operational readiness reviews. technical assist reviews. biennial reviews and quality assurance reviews. Ms. Khanna has a BS in Chemical Engineering from Stevens Institute of Technology. Hoboken. New Jersey. Dr. Kelli Markham is the ChiefofNuclear Safety for the Office ofNuclear Energy (N where she advises the Assistant Secretary for NE and the Deputy Assistant Secretary for Nuclear Facilities Operations. in NE on nuclear safety. Prior to this, Kelli was a Director for the Environment. Safety and Health (ESH) Division for the Of?ce of Science (SC). where she had headquarter-level ESH responsibilities for ten DOE-SC laboratories. Dr. Markham comes to DOE from the Nuclear Regulatory Commission where she was a Chemical Safety Reviewer and lead areas ofthe Mixed Oxide Fuel Fabrication Facility license application review. Also. she was the Project Manager and principal author of several white papers to the Commission on the development of regulations to license commercial reprocessing facilities. Kelli has a in Organic Chemistry from the University of Iowa and prior to her civil service career. she was in academia as an Adjunct Faculty and an Assistant Professor. instructing at the graduate and undergraduate levels. Stephen J. Wallace is a Senior Advisor with the National Nuclear Security Administration office of Safety and Health. In this capacity. he advises the Associate Administrator on various issues. He has participated in several safety assessments. and was the Executive Representative on the 2013 Nevada Enterprise Safetnyecurity Culture Assessment. Before joining NNSA. he held positions in the government as the Director ofthe Office of Environment. Safety, and Health at the Department of the Treasury and lead investigator with the United States Chemical Safety Board. During his tenure. Treasury received recognition by the Occupational Safety and Health Administration (OSHA) for having the lowest injury and illness rate in government and was the only Department to receive green ratings from the Of?ce of Management and Budget in all areas of environmental and energy performance. Beforejoining the government. Mr. Wallace held positions as a risk assessment consultant. production manager, safety and health manager. and process safety engineer in the chemical industry for facilities that were part ofthe OSHA Voluntary Protection Program, a program recognizing the safest facilities in the country. He also worked as a consultant on the DOE Performance Indicator program and developed reports for the Secretary of Energy related to the safety and environmental performance of facilities nation- wide. He has presented at numerous conferences. and has written several peer-reviewed journal articles on health. safety. and environmental issues. and the Best Practices book chapter for the Safety Professional?s l-landhook. He is a Certi?ed Safety Professional, Professional Engineer registered in multiple states. and certi?ed Senior Technical Safety Manager. He holds a BS. in Chemical Engineering and a MA. in Liberal Studies with a concentration in Social and Public Policy.