^OE/EH-O204.vol.i °E92 010629 U.S. Department of Energy Environment, Safety, a n d Health Tiger T e a m Assessment of t h e Los Alamos N a t i o n a l Laboratory W a s h i n g t o n , DC 20585 November 1991 _^_ MASTER uJ^y'' DISCLAIMER This report was prepared as an account of work sponsored by an agency of the United States Government. Neither the United States Government nor any agency Thereof, nor any of their employees, makes any warranty, express or implied, or assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe privately owned rights. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not necessarily constitute or imply its endorsement, recommendation, or favoring by the United States Government or any agency thereof. The views and opinions of authors expressed herein do not necessarily state or reflect those of the United States Government or any agency thereof. DISCLAIMER Portions of this document may be illegible in electronic image products. Images are produced from the best available original document. PREFACE This report documents the Tiger Team Assessment of the Los Alamos National Laboratory (LANL) located in Los Alamos, New Mexico. LANL is operated for the U.S. Department of Energy (DOE) by the University of California. The Tiger Team Assessment was conducted from September 23 to November 8, 1991, under the auspices of the DOE Office of Special Projects, Office of the Assistant Secretary for Environment, Safety and Health. The assessment was comprehensive, encompassing environmental, safety, and health (ES&H) disciplines; management; and contractor and DOE selfassessments. Compliance with applicable Federal, state, and local regulations; applicable DOE Orders; best management practices; and internal LANL site requirements was assessed. In addition, an evaluation of the adequacy and effectiveness of the DOE and the site contractors' management of ES&H/quality assurance programs was conducted. The content of this draft report has been reviewed for factual accuracy by representatives of the Office of the Assistant Secretary for Defense Programs, DOE-Headquarters; the DOE Field Office, Albuquerque; the Los Alamos Area Office; and Federal, state, and local regulatory agencies. The final report will reflect the factual changes from that review. The LANL Tiger Team Assessment is part of a larger, comprehensive DOE Tiger Team Independent Assessment Program planned for DOE facilities. The assessment program is part of a 10-point initiative announced by the Secretary of Energy, Admiral James D. Watkins, U.S. Navy (Retired), on June 27, 1989, to conduct independent compliance oversight and management assessments of ES&H programs and waste management operations at DOE facilities. The objective of the initiative is to provide the Secretary with information on the compliance status of DOE facilities with regard to ES&H management programs, response actions to address the identified problem areas, and DOE-wide ES&H compliance trends and root causes. November 1991 Washington, DC iii TABLE OF CONTENTS Page GLOSSARY OF ACRONYMS AND ABBREVIATIONS xxi EXECUTIVE SUMMARY ES-1 1.0 INTRODUCTION 1-1 1.1 PURPOSE 1-1 1.2 SCOPE 1-2 1.3 APPROACH 1-3 1.3.1 1.3.2 1.3.3 1.3.4 1-4 1-4 1-5 1-6 Pre-Assessment Site Planning Onsite Activities Reporting Corrective Action Plan and Process 1.4 SITE DESCRIPTION 1-6 1.5 DEFINITION OF OVERSIGHT 1-7 2.0 KEY FINDINGS, ROOT CAUSES, AND NOTEWORTHY PRACTICES 2-1 2.1 ENVIRONMENTAL KEY FINDINGS 2-1 2.2 SAFETY AND HEALTH 2-2 2.2.1 Key Concerns 2-2 2.2.1.1 2.2.1.2 2-2 2.2.1.3 2.2.1.4 2.2.2 Plutonium and Enriched Uranium Reactor, Critical Assemblies, and Tritium Facilities Accelerators Other Selected Facilities and Activities 2-4 2-6 2-7 Noteworthy Practices 2-9 2.2.2.1 2.2.2.2 2-9 2.2.2.3 2.2.2.4 Plutonium and Enriched Uranium Reactor, Critical Assemblies, and Tritium Facilities Accelerators Other Selected Facilities and Activities 2-10 2-11 2-11 2.3 MANAGEMENT KEY FINDINGS 2-11 2.4 ROOT CAUSES 2-15 v Page 3.0 ENVIRONMENTAL ASSESSMENT 3-1 3.1 PURPOSE 3-1 3.2 SCOPE 3-1 3.3 APPROACH 3-1 3.4 ENVIRONMENTAL ASSESSMENT SUMMARY 3-2 3.5 ENVIRONMENTAL FINDINGS 3-8 3.5.1 3-9 3.5.2 3.5.3 3.5.4 3.5.5 3.5.6 3.5.7 Air (A) 3.5.1.1 Overview 3-9 3.5.1.2 Compliance Findings 3-14 Surface Water/Drinking Water (SW) 3-31 3.5.2.1 3.5.2.2 Overview Compliance Findings 3-31 3-35 3.5.2.3 Best Management Practice Findings 3-63 Groundwater/Soil, Sediment, and Biota (GW) 3-65 3.5.3.1 3.5.3.2 Overview Compliance Findings 3-65 3-70 3.5.3.3 Best Management Practice Findings 3-80 Waste Management (WM) 3-85 3.5.4.1 3.5.4.2 Overview Compliance Findings 3-85 3-93 3.5.4.3 Best Management Practice Findings 3-130 Toxic and Chemical Materials (TCM) 3-131 3.5.5.1 Overview 3.5.5.2 Compliance Findings 3.5.5.3 Best Management Practice Findings Quality Assurance (QA) 3.5.6.1 Overview 3.5.6.2 Compliance Findings 3.5.6.3 Best Management Practice Findings Radiation (RAD) 3.5.7.1 Overview 3.5.7.2 Compliance Findings 3.5.7.3 Best Management Practice Findings 3-131 3-137 3-174 3-175 3-175 3-179 3-214 3-217 3-217 3-222 3-250 VI Page 3.5.8 3.5.9 Inactive Waste Sites (IWS) 3-253 3.5.8.1 3.5.8.2 3.5.8.3 3-253 3-258 3-293 Overview Compliance Findings Best Management Practice Findings National Environmental Policy Act (NEPA) 3-297 3.5.9.1 Overview 3-297 3.5.9.2 Compliance Findings 3-302 4.0 SAFETY AND HEALTH ASSESSMENT 4-1 4.1 PURPOSE 4-1 4.2 SCOPE 4-1 4.3 APPROACH 4-1 4.4 SAFETY AND HEALTH ASSESSMENT SUMMARY 4-3 4.4.1 4.4.2 4-5 4.4.3 4.4.4 4.5 Plutonium and Enriched Uranium Reactor, Critical Assemblies, and Tritium Facilities Accelerators Other Selected Facilities and Activities 4-10 4-14 4-18 SAFETY AND HEALTH FINDINGS AND CONCERNS 4-27 4.5.1 Plutonium and Enriched Uranium 4-27 4.5.1.1 Organization and Administration (OA) 4-27 4.5.1.1.1 Overview 4-27 4.5.1.1.2 Findings and Concerns 4-29 4.5.1.2 4.5.1.3 4.5.1.4 Quality Verification (QV) 4-41 4.5.1.2.1 Overview 4-41 4.5.1.2.2 Findings and Concerns 4-43 Operations (OP) 4-56 4.5.1.3.1 Overview 4-56 4.5.1.3.2 Findings and Concerns 4-59 Maintenance (MA) 4-74 4.5.1.4.1 4.5.1.4.2 4-74 4-76 Overview vii Findings and Concerns Page 4.5.1.5 4.5.1.6 4.5.1.7 4.5.1.8 4.5.1.9 Training and Certification (TC) 4-88 4.5.1.5.1 Overview 4-88 4.5.1.5.2 Findings and Concerns 4-91 Auxiliary Systems (AX) 4-101 4.5.1.6.1 Overview 4-101 4.5.1.6.2 Findings and Concerns 4-103 Emergency Preparedness (EP) 4-116 4.5.1.7.1 Overview 4-116 4.5.1.7.2 Findings and Concerns 4-118 Technical Support (TS) 4-122 4.5.1.8.1 Overview 4-122 4.5.1.8.2 Findings and Concerns 4-124 Packaging and Transportation (PT) 4-129 4.5.1.9.1 Overview 4-129 4.5.1.9.2 Findings and Concerns 4-131 4.5.1.10 Nuclear Criticality Safety (CS) 4-139 4.5.1.10.1 Overview 4-139 4.5.1.10.2 Findings and Concerns 4-141 4.5.1.11 Security/Safety Interface(SS) 4-153 4.5.1.11.1 Overview 4-153 4.5.1.11.2 Findings and Concerns 4-155 4.5.1.12 Experimental Activities (EA) 4-160 4.5.1.12.1 Overview 4-160 4.5.1.12.2 Findings and Concerns 4-162 4.5.1.13 Site/Facility Safety Review (FR) 4.5.1.13.1 Overview 4.5.1.13.2 Findings and Concerns viii 4.5.1.14 Radiological Protection (RP) 4.5.1.14.1 4.5.1.14.2 Overview Findings and Concerns 4-166 4-166 4-168 4-174 4-174 4-176 Page 4.5.1.15 Personnel Protection (PP) 4.5.1.15.1 4.5.1.15.2 4-191 Overview Findings and Concerns 4-191 4-193 4.5.1.16 Worker Safety and Health (OSHA) Compliance (WS) 4-204 4.5.1.16.1 Overview 4-204 4.5.1.16.2 Findings and Concerns 4-206 4.5.1.17 Fire Protection (FP) 4.5.2 4-212 4.5.1.17.1 Overview 4-212 4.5.1.17.2 Findings and Concerns 4-214 4.5.1.18 Natural Phenomena (NP) 4-228 4.5.1.18.1 Overview 4.5.1.18.2 Findings and Concerns Reactor, Critical Assemblies, and 4-228 4-230 Tritium Facilities 4-247 4.5.2.1 4.5.2.2 4.5.2.3 4.5.2.4 4.5.2.5 Organization and Administration (OA) .... 4-247 4.5.2.1.1 Overview 4-247 4.5.2.1.2 Findings and Concerns 4-249 Quality Verification (QV) 4-262 4.5.2.2.1 Overview 4-262 4.5.2.2.2 Findings and Concerns 4-263 Operations (OP) 4-271 4.5.2.3.1 Overview 4-271 4.5.2.3.2 Findings and Concerns 4-276 Maintenance (MA) 4-293 4.5.2.4.1 Overview 4-293 4.5.2.4.2 Findings and Concerns 4-295 Training and Certification (TC) 4-304 4.5.2.5.1 4.5.2.5.2 4-304 4-306 Overview ix Findings and Concerns Page 4.5.2.6 4.5.2.7 4.5.2.8 4.5.2.9 Auxiliary Systems (AX) 4-317 4.5.2.6.1 Overview 4-317 4.5.2.6.2 Findings and Concerns 4-319 Emergency Preparedness (EP) 4-327 4.5.2.7.1 Overview 4-327 4.5.2.7.2 Findings and Concerns 4-329 Technical Support (TS) 4-334 4.5.2.8.1 Overview 4-334 4.5.2.8.2 Findings and Concerns 4-335 Packaging and Transportation (PT) 4-342 4.5.2.9.1 Overview 4-342 4.5.2.9.2 Findings and Concerns 4-344 4.5.2.10 Security/Safety Interface(SS) 4-353 4.5.2.10.1 Overview 4-353 4.5.2.10.2 Findings and Concerns 4-354 4.5.2.11 Experimental Activities (EA) 4-356 4.5.2.11.1 Overview 4-356 4.5.2.11.2 Findings and Concerns 4-358 4.5.2.12 Site/Facility Safety Review (FR) 4-362 4.5.2.12.1 Overview 4-362 4.5.2.12.2 Findings and Concerns 4-364 4.5.2.13 Radiological Protection (RP) 4-372 4.5.2.13.1 Overview 4-372 4.5.2.13.2 Findings and Concerns 4-374 4.5.2.14 Personnel Protection (PP) 4-397 4.5.2.14.1 Overview 4.5.2.14.2 Findings and Concerns 4.5.2.15 Worker Safety and Health x (OSHA) Compliance (WS) 4.5.2.15.1 Overview 4.5.2.15.2 Findings and Concerns 4-397 4-399 4-405 4-405 4-408 Page 4.5.2.16 Fire Protection (FP) 4-414 4.5.2.16.1 Overview 4-414 4.5.2.16.2 Findings and Concerns 4-415 4.5.2.17 Medical Services (MS) 4.5.3 4-422 4.5.2.17.1 Overview 4-422 4.5.2.17.2 Findings and Concerns 4-424 Accelerators 4.5.3.1 4.5.3.2 4.5.3.3 4.5.3.4 4.5.3.5 4.5.3.6 4.5.3.7 4.5.3.8 4-435 Organization and Administration (OA) .... 4-435 4.5.3.1.1 Overview 4-435 4.5.3.1.2 Findings and Concerns 4-437 Quality Verification (QV) 4-445 4.5.3.2.1 Overview 4-445 4.5.3.2.2 Findings and Concerns 4-447 Operations (OP) 4-458 4.5.3.3.1 Overview 4-458 4.5.3.3.2 Findings and Concerns 4-460 Maintenance (MA) 4-468 4.5.3.4.1 Overview 4-468 4.5.3.4.2 Findings and Concerns 4-470 Training and Certification (TC) 4-480 4.5.3.5.1 Overview 4-480 4.5.3.5.2 Findings and Concerns 4-482 Auxiliary Systems (AX) 4-488 4.5.3.6.1 Overview 4-488 4.5.3.6.2 Findings and Concerns ..... 4-490 Emergency Preparedness (EP) 4-502 4.5.3.7.1 Overview 4-502 4.5.3.7.2 xi Findings and Concerns 4-504 Technical Support (TS) 4.5.3.8.1 4.5.3.8.2 Overview Findings and Concerns 4-507 4-507 4-510 Page 4.5.3.9 Packaging and Transportation (PT) 4-520 4.5.3.9.1 Overview 4-520 4.5.3.9.2 Findings and Concerns 4-522 4.5.3.10 Security/Safety Interface(SS) 4-529 4.5.3.10.1 Overview 4-529 4.5.3.10.2 Findings and Concerns 4-531 4.5.3.11 Experimental Activities (EA) 4-534 4.5.3.11.1 Overview 4-534 4.5.3.11.2 Findings and Concerns 4-536 4.5.3.12 Site/Facility Safety Review (FR) 4-541 4.5.3.12J Overview 4-541 4.5.3.12.2 Findings and Concerns 4-543 4.5.3.13 Radiological Protection (RP) 4-548 4.5.3.13.1 Overview 4-548 4.5.3.13.2 Findings and Concerns 4-550 4.5.3.14 Personnel Protection (PP) 4-565 4.5.3.14.1 Overview 4.5.3.14.2 Findings and Concerns 4.5.3.15 Worker Safety and Health (OSHA) Compliance (WS) 4.5.3.15.1 Overview 4-565 4-566 4.5.3.15.2 4-578 4-578 Findings and Concerns 4-580 4.5.3.16 Fire Protection 4.5.4 4-587 4.5.3.16.1 Overview 4-587 4.5.3.16.2 Findings and Concerns 4-588 Other Selected Facilities and Activities 4.5.4.1 Organization and Administration (OA) 4.5.4.1.1 4.5.4.1.2 Overview Findings and Concerns xii 4-597 .... 4-597 4-597 4-600 Page 4.5.4.2 4.5.4.3 4.5.4.4 4.5.4.5 4.5.4.6 4.5.4.7 4.5.4.8 4.5.4.9 Quality Verification (QV) 4-615 4.5.4.2.1 Overview 4-615 4.5.4.2.2 Findings and Concerns 4-617 Operations (OP) 4-638 4.5.4.3.1 Overview 4-638 4.5.4.3.2 Findings and Concerns 4-640 Maintenance (MA) 4-648 4.5.4.4.1 Overview 4-648 4.5.4.4.2 Findings and Concerns 4-650 Training and Certification (TC) 4-659 4.5.4.5.1 Overview 4-659 4.5.4.5.2 Findings and Concerns 4-662 Auxiliary Systems (AX) 4-678 4.5.4.6.1 Overview 4-678 4.5.4.6.2 Findings and Concerns 4-680 Emergency Preparedness (EP) 4-691 4.5.4.7.1 Overview 4-691 4.5.4.7.2 Findings and Concerns 4-694 Technical Support (TS) 4-708 4.5.4.8.1 Overview 4-708 4.5.4.8.2 Findings and Concerns 4-710 Packaging and Transportation (PT) 4-719 4.5.4.9.1 Overview 4-719 4.5.4.9.2 Findings and Concerns 4-722 4.5.4.10 Security/Safety Interface (SS) 4-747 4.5.4.10.1 Overview 4-747 4.5.4.10.2 Findings and Concerns 4-749 4.5.4.11 Experimentalxiii Activities (EA) 4.5.4.11.1 4.5.4.11.2 Overview Findings and Concerns 4-755 4-755 4-757 Page 4.5.4.12 Site/Facility Safety Review (FR) 4-762 4.5.4.12.1 Overview 4-762 4.5.4.12.2 Findings and Concerns 4-764 4.5.4.13 Radiological Protection (RP) 4-772 4.5.4.13.1 Overview 4-772 4.5.4.13.2 Findings and Concerns 4-774 4.5.4.14 Personnel Protection (PP) 4-790 4.5.4.14.1 Overview 4.5.4.14.2 Findings and Concerns 4.5.4.15 Worker Safety and Health (OSHA) Compliance (WS) 4.5.4.15.1 Overview 4-790 4-792 4.5.4.15.2 4-819 4-819 Findings and Concerns 4-822 4.5.4.16 Fire Protection (FP) 4.5.4.16.1 Overview 4-829 4.5.4.16.2 Findings and Concerns 4-831 4.5.4.17 Aviation Safety (AS) ... 4-853 4.5.4.17.1 Overview 4-853 4.5.4.17.2 Findings and Concerns 4-856 4.5.4.18 Explosives Safety (ES) 4.6 4-829 4-854 4.5.4.18.1 Overview 4-864 4.5.4.18.2 Findings and Concerns 4-865 NOTEWORTHY PRACTICES 4-873 4.6.1 4.6.2 4-873 4.6.3 4.6.4 Plutonium and Enriched Uranium Reactor, Critical Assemblies, and Tritium Facilities Accelerators Other Selected Facilities and Activities 4-874 4-875 4-876 4.7 SYSTEM FOR CATEGORIZING CONCERNS 4-877 4.8 CATEGORIZATION AND TABULATION OF CONCERNS 4-879 4.8.1 Plutonium and Enriched Uranium 4-879 4.8.1.1 4.8.1.2 4-879 4-885 Categorization of Concerns Tabulation of Concerns xiv Page 4.8.2 4.8.3 4.8.4 4.9 Reactor, Critical Assemblies, and Tritium Facilities 4-903 4.8.2.1 Categorization of Concerns 4-903 4.8.2.2 Tabulation of Concerns 4-908 Accelerators 4-924 4.8.3.1 Categorization of Concerns 4-924 4.8.3.2 Tabulation of Concerns 4-928 Other Selected Facilities and Activities 4-943 4.8.4.1 Categorization of Concerns 4-943 4.8.4.2 Tabulation of Concerns 4-951 TEAM COMPOSITION AND AREAS OF RESPONSIBILITY 4-980 4.9.1 4.9.2 4-980 Plutonium and Enriched Uranium Reactor, Critical Assemblies, and Tritium Facilities 4.9.3 Accelerators 4.9.4 Other Selected Facilities and Activities 5.0 MANAGEMENT ASSESSMENT 4-983 4-985 4-987 5-1 5.1 PURPOSE 5-1 5.2 SCOPE 5-1 5.3 APPROACH 5-1 5.4 MANAGEMENT ASSESSMENT SUMMARY 5-2 5.5 MANAGEMENT FINDINGS 5-6 5.6 NOTEWORTHY PRACTICES 5-68 5.7 TEAM COMPOSITION AND AREAS OF RESPONSIBILITY 5-68 6.0 EVALUATION OF SELF ASSESSMENT PROGRAMS AND REPORTS FOR THE LOS ALAMOS NATIONAL LABORATORY, THE LOS ALAMOS AREA OFFICE, THE FIELD OFFICE, ALBUQUERQUE, AND THE PROGRAM SECRETARIAL OFFICES 6-1 6.1 INTRODUCTION 6-1 6.2 SCOPE 6-1 6.3 EVALUATION STRATEGY 6-1 XV Paae 6.4 6.5 EVALUATION SUMMARY 6-5 6.4.1 Summary of Program Findings 6-5 6.4.2 Evaluation of Self-Assessment Reports 6-7 EVALUATION OF LOS ALAMOS NATIONAL LABORATORY 6-7 6.5.1 6.5.2 6.6 6.7 6-7 6-17 6-18 6-22 6-23 6-23 EVALUATION OF THE DEPARTMENT OF ENERGY LOS ALAMOS AREA OFFICE (LAAO) 6-26 EVALUATION OF THE DEPARTMENT OF ENERGY FIELD OFFICE, ALBUQUERQUE (AL) 6-30 6.7.1 6.7.2 6.8 Evaluation of Self-Assessment Program Evaluation of Self-Assessment Report 6.5.2.1 Environmental 6.5.2.2 Safety and Health 6.5.2.3 Management 6.5.2.4 Self-Assessment Evaluation of Self-Assessment Program Evlauation of the Department of Energy Field Office, Albuquerque/Los Alamos Area Office's Pre-Los Alamos National Laboratory Tiger Team Self-Assessment Report 6-32 6-37 EVALUATION OF PROGRAM SECRETARIAL OFFICES--DEFENSE PROGRAMS (DP), ENERGY RESEARCH (ER), ENVIRONMENTAL RESTORATION AND WASTE MANAGEMENT (EM), AND NUCLEAR ENERGY (NE) 6-39 APPENDICES A TIGER TEAM ASSESSMENT PERSONNEL AND BIOGRAPHICAL SKETCHES A-1 A-2 A-3 A-1 Biographical Sketches of Tiger Team Assessment Team Leader and Team Leader Staff Biographical Sketches of Environmental Subteam Members Biographical Sketches of Safety and Health Subteam Members A-3-1 A-3-2 Biographical Sketches of Plutonium and Enriched Uranium Subteam Members Biographical Sketches of Reactor, Critical Assemblies, and Tritium Facilities Subteam Members xvi A-1-1 A-2-1 A-3-1 A-3-1-1 .... A-3-2-1 A-3-3 A-3-4 A-4 Biographical Sketches of Accelerators Subteam Members A-3 Biographical Sketches of Other Selected Facilities and Activities Subteam Members A-3 Biographical Sketches of Management Subteam Members A B ENVIRONMENTAL SUBTEAM ASSESSMENT PLAN C ENVIRONMENTAL SUBTEAM DAILY AGENDA D E ENVIRONMENTAL/MANAGEMENT SUBTEAMS CONTACTS AND INTERVIEWS (Available on Microfiche) LIST OF DOCUMENTS REVIEWED BY THE ENVIRONMENTAL/MANAGEMENT SUBTEAMS (Available on Microfiche) F OSHA NONCOMPLIANCES (Available on Microfiche) G TIGER TEAM HOT LINE CALLS AND RESPONSES H TIGER TEAM SELF-ASSESSMENT TASK GROUP MEMORANDUM; FINDINGS AND CONCERNS DATA EG&G/ENERGY MEASUREMENTS, INC., LOS ALAMOS OPERATIONS I xvii LIST OF FIGURES AND TABLES Figures Page 2-1 Root Cause Structure 2-17 5-1 Historical LANL ES&H Costs (Institutional Funds) A-1 Tiger Team Organization 5-8 A-1-1 Tables 3-1 3-2 3-3 3-4 3-5 3-6 3-7 3-8 3-9 3-10 3-11 3-12 4.4.1 4.4.2 WS-1 WS-2 WS-3 WS-4 Environmental Findings List of Air Regulations/Requirements/Guidelines List of Surface Water/Drinking Water Regulations/ Requirements/Guidelines List of Groundwater/Soils, Sediment, and Biota Regulations/Requirements/Guidelines List of Waste Management Regulations/Requirements/ Guidelines List of Toxic and Chemical Materials Regulations/ Requirements/Guidelines List of Quality Assurance Regulations/Requirements/ Guidelines List of Radiation Regulations/Requirements/Guidelines . . . . List of Inactive Waste Sites Regulations/Requirements/ Guidelines List of National Environmental Policy Act Regulations/ Requirements/Guidelines Identification of NEPA Findings in LANL, LAAO, and AL Self-Assessments NEPA Determinations made by LANL for Projects Listed on the Master Data Base (N-93) January through September 1991 Comparison of Self-Assessment Problem Identification with TSA Concerns, LANL Comparison of Self-Assessment Problem Identification with TSA Concerns, DOE/AL/LAAO Technical Area TSA Team 1 Technical Area TSA Team 2 Technical Area TSA Team 3 Technical Area TSA Team 4 3-4 3-10 3-32 3-66 3-86 3-132 3-176 3-218 3-254 3-298 3-300 3-304 4-25 4-25 Inspections and Noncompliance Information, 4-205 Inspections and Noncompliance Information, 4-405 Inspections and Noncompliance Information, 4-579 Inspections and Noncompliance Information, 4-820 xviii LIST OF FIGURES AND TABLES (Continued) Tables (Continued) 6-1 6-2 6-3 6-4 6-5 Page Summary of Self-Assessment Findings Comparison of LANL, LAAO, and AL Self-Assessment Reports Findings and Concerns Comparison of LANL Self-Assessment Report Findings and Concerns Comparison of LAAO Self-Assessment Report Findings and Concerns Comparison of AL Self-Assessment Report Findings and Concerns xix 6-5 6-7 6-17 6-26 6-31 THIS PAGE INTENTIONALLY LEFT BLANK. XX ermm>m< >20 GLOSSARY OF ACRONYMS AND ABBREVIATIONS A A AC ACIS ACM ACR AD ADAL ADCM ADDRA ADET ADM ADNWT ADO ADP ADR AE AL ALARA ANPR ANSI AO AP AR ASER ASME AT AW Air Analysis and Assessment Anchor Canyon Site (TA-39) Automated Chemical Inventory System Asbestos-Containing Material Air Conditioner, Cooling Only Associate Director Associate Director at Large Associate Director of Chemistry and Materials Associate Director of Defense Research and Applications Associate Director of Energy And Technology Action Description Memorandum Associate Director of Nuclear Weapons Technology Associate Director of Operations Administrative Data Processing Associate Director of Research Anchor Site East (TA-9) DOE Field Office, Albuquerque As Low As Reasonably Achievable Advance Notice of Proposed Rulemaking American National Standards Institute Administrative Order Administrative Procedure (LANL) Administrative Requirements Annual Site Environmental Report American Society of Mechanical Engineers Accelerator Technology Anchor Site West (TA-8) BANSHEE BAT BFP BHW BMP BMPF BOSS BRASS BS BWS Beam Accelerator for Novel Super High Energy Electron Best Available Technology Backflow, Preventer Boiler, Hot Water Best Management Practice Best Management Practice Finding Badge Office Security System Basic Rapid Alarm Security System Boiler, Steam Boiler, Water Supply C CA CAE CAS CAW CEARP Computing and Communications Compressor, Air (Instr/Lab) Cooler, Air (Evaporative) Central Alarm Station Cooler, Air (Chilled Water) Comprehensive Environmental Assessment and Response Program Council on Environmental Quality Comprehensive Environmental Response, Compensation, and Liability Act CEQ CERCLA * Indicates acronym is spelled out once per major section. xxi CF CFR CGA CHGS CJ CLS CLS-1 CLS-2 CM CMR CMS CMS CNLS COD CONT CR CRA CRE CRM CRP CRPP CTO CWA CWDR CWE CWF CWR CX D&D DAC DAD DAD DAR DD DEC DF DHR DIR DM DO *DOE DOT DP DQO DRE DRM DU EAP ED EDS EES-1 * Compliance Finding Code of Federal Regulations Compressed Gas Association Center for Human Genome Studies Crane, Jib Chemical and Laser Sciences Analytical Chemistry Group Physical Chemistry Group Crane, Monorail Chemical and Materials Research (Building) Center for Materials Science Corrective Measures Study Center for Nonlinear Studies Chemical Oxygen Demand Controllers Office Compressor, Refrigeration Condenser, Refrigerant (Air Cool) Condenser, Refrigerant (Evaporative) Communications and Records Management Community Relations Plan Community Relations Program Plan Crane, Bridge Chiller, Water (Absorption) Chemical Waste Disposal Request Coller, Water (Evaporative) Chiller, Water (Fan/Coil) Chiller, Water (Refrigerated) Categorical Exclusion Decontamination and Decommissioning Door, Air Curtain Dryer, Compressed Air (Desiccant) Deputy Associate Director Dryer, Compressed Air (Refrigerated) Los Alamos National Laboratory Deputy Director DOE Environmental Checklist DF Site (TA-40) Director of Human Resources Los Alamos National Laboratory Director Door, Motorized Division Office U.S. Department of Energy U.S. Department of Transportation DP Site (TA-21) Data Quality Objectives Door, Roll-up (Electric) Door, Roll-up (Manual) Depleted Uranium Employee Assistance Program Collector, Dust Employee Development System Geology and Geochemistry Group Indicates acronym is spelled out once per major section. xxii EH-1 EM EM EM-7 EM-8 EM-9 EM-13 EMD EMO EMP EMP ENG ENG-1 ENG-2 ENG-4 ENG-5 ENG-6 ENG-8 ENSR EO EOC *EPA EPZ ERP ERT ES&H ES&H CC ES&H Manual ESS FAB FAC FAH FAL FAM FAP FAR FE FEH FFCA FG FHS FIN FM FPI FRA FRL FS FY GEMS GET Assistant Secretary for Environment, Safety and Health Environment Management DOE Office of Environmental Restoration and Waste Management Waste Management Group Environmental Protection Group Environmental Chemistry Group Environmental Restoration Group Environmental Management Division Emergency Management Office (Organization) Emergency Management Office Environmental Monitoring Plan Facilities Engineering Group Engineering Project Management Engineering Planning Group Estimating Group Field Operations Group Maintenance Group Fire Protection and Utilities Group Exact Company Name Executive Order Emergency Operations Center (Facility) U.S. Environmental Protection Agency Emergency Planning Zone Emergency Response Plan Emergency Response Team Environment, Safety, and Health ES&H Coordination Center The Laboratory Manual, Chapter 1, "Environment, Safety and Health" Earth and Environmental Sciences Filter, Air (Bag) Filter, (Cleanable) Filter, Air (HEPA) Filter, Air (Carbon/Charcoal) Filter, Air Mat (Boxed Pleat) Filter, Air Coolpad Filter, Air Replaceable Fan, Exhaust Fume Hood Exhaust Federal Facilities Compliance Agreement Furnance, Gas Spare Fenton Hill Site (TA-57) Financial Operations Frijoles Mesa Site (TA-49) Facility Project Index Fan, Return Air Filter, Air Roll Fan, Supply Fiscal Year Los Alamos Guide to ES&H Management Structure General Employee Training Indicates acronym is spelled out once per major section. xxi i i GJPO GMP GPMPP GTA GWC HAS HAW HAZMAT HAZPACT HDG HE HE HEPA HM HP HP HRD HRL HS HS-1 HS-3 HS-5 HS-6 HS-8 HS-12 HSE HSE HSEAC HSWA HT HTO HUE HUG HUI HUS HUW HV HVA HW HWE HWG HWM HWS HXG HXR HXS HXW IBF IBML Ice House * Grand Junction Project Office Groundwater Monitoring Program Groundwater Protection Management Program Plan Ground Test Accelerator Group Waste Coordinator Humidifier, Air (Steam-spray) Humidifier, Air, (Water-spray) Hazardous Material Emergency Response Team Hazardous Material Packaging and Shipping Heater, Duct (Gas) High Explosive Hoist, Electric High-Efficiency Particulate Air Hoist, Manual HP Site (TA-33) Health Physics Human Resources Development Health Research Laboratory (TA-43) Health and Safety Division Radiation Protection Group Safety and Risk Assessment Group Industrial Hygiene Group Criticality Safety Group Environmental Surveillance Group Health Physics Policy and Programs Group Heater, Unit (Steam-Electric) Former Health, Safety, and Environment Health, Safety, and Environment Advisory Council (University of California) Hazardous and Solid Waste Amendments Tritium Tritiated Water Heater, Unit (Electric) Heater, Unit (Gas) Heater, Unit (Infrared) Heater, Unit (Steam) Heater, Unit (Water) Heating and Ventilating Unit Heating, Ventilating and Air Heater, Water Spare Heater, Water (Electric) Heater, Water (Gas) Hazardous Waste Manifest Heater, Water (Steam) Heater, Exchanger (Glycol) Heater Exchanger (Refrigerated) Heat Exchanger (Steam) Heat Exchanger (Water) Ion Beam Facility (Van De Graaff), TA-3, SM-16 Ion Beam Materials Laboratory, TA-3, SM-32 Weapons Subassembly Area, TA-41 Indicates acronym is spelled out once per major section. xxiv ICF ICP INC INC INC-4 IS ISEC IT ITS/DARHT IWP J *JCI JENV KAPPA KIVA *LAAO Laboratory LACEF LAM LAMPF * Inertia! Confinement Fusion Inductively Coupled Plasma (Mass Spectrometry Laboratory) Isotope and Nuclear Division Isotope and Nuclear Chemistry Isotope and Structural Chemistry Group Information Sciences Internal Security International Technology Integrated Test Stand/Dual Axis Radiographic Hydro Test Environmental Restoration Installation Work Plan Field Test Johnson Controls World Services, Inc. JCI Environmental Department Kappa Site (TA-36) Buildings That House Critical Assemblies, TA-18 LANL LANSCE LAO LAT LC LDCC LLMW LLW LS LS-1 LS-2 LWTP Los Alamos Area Office Los Alamos National Laboratory Los Alamos Critical Experiments Facility Los Alamos Airport Clinton P. Anderson Meson Physics Facility (formerly the Los Alamos Meson Physics Laboratory) Los Alamos National Laboratory Manuel Lujan Jr., Neutron Scattering Center, TA-53 Laboratory Assessment Office Laboratory Assessment Team Laboratory Council Laboratory Data Communication Center, TA-3 Low-Level Mixed Waste Low-Level Waste Life Sciences Division Cell Growth, Damage and Repair Genomics and Structured Biology Liquid Waste Treatment Plant M M-1 M-4 M-DO M&H MAA MAA MAC MASS MAT MAT MEC MEE MP MP-4 MP-8 Dynamic Testing Explosives Technology Group Hydrodynamics Group Dynamic Testing Division Office Mason and Hanger-Silas Mason, Inc. (Protective Guard Force) Material Assess Area Magazine Area A (TA-28) Magazine Area C (TA-37) Material Accountability and Safeguards System Materials Management Group Materials Management Mechanical and Electronics Support Mechanical and Electrical Engineering Medium Energy Physics Nuclear and Particle Physics Engineering and Maintenance Group Indicates acronym is spelled out once per major section. xxv MPF MSDS MST MST-DO MTE Meson Physics Facility (TA-53) Material Safety Data Sheet Materials Science and Technology Materials Science and Technology Division Office Measuring and Test Equipment N NCP NDA/NDE NEPA NESHAP NFPA NIST NMED NMHWMR NMLWDR NMRGWS NMSEO NMT NMT-6 NMT-8 NMHWMR NMLWDR NMRGWS NMUSTR NMWQCC NMWQR NP NPDES NPL NRC Nuclear Technology and Engineering National Contingency Plan Non-Destructive Analysis/Non-Destructive Evaluation Facility National Environmental Policy Act National Emission Standards for Hazardous Air Pollutants National Fire Protection Association National Institute of Standards and Technology New Mexico Environment Department New Mexico Hazardous Waste Regulations New Mexico Liquid Waste Disposal Regulations New Mexico Regulations Governing Water Supplies New Mexico State Engineer Office Nuclear Materials Technology Actinide Materials Chemistry Group TA-55 Facilities Management Group New Mexico Hazardous Waste Regulation New Mexico Liquid Waste Disposal Regulations New Mexico Regulations Governing Water Surplus New Mexico Underground Storage Tank Regulations New Mexico Water Quality Control Commission New Mexico Water Quality Regulations DOE Office of New Production Reactor National Pollutant Discharge Elimination System National Priorities List Nuclear Regulatory Commission O&M OH OS OSHA OSR OWR Operations and Maintenance OH Site (TA-59) Operational Security and Safeguards Occupational Safety and Health Act (or Administration) Operational Safety Requirement Omega West Reactor P PA PA (Security) PBF PC PCOC PCR PCT PCW PDH PDW PDW PF PF Physics Public Affairs Office Protected Area Pump, Boiler Feed Pump, Condensate LANL Pest Control Oversight Committee Pump, Circulating Pump, Cooling Tower Pump, Chilled/Coolant Water Pump, Hot Water (Domestic) Pump, Chilled/Coolant Water Pump, Deionized Water Protective Force Plutonium Processing Facility (TA-55) Indicates acronym is spelled out once per major section. xxvi PHERMEX PHW PI DAS PIXY PL PRO PS PS PSO PSW PT Q QA QAP QAPP QOO QPP R RAD RC RCA RCRA RD REF RFA RFI RPF RPW RQ RSA RSWD RUA RVS S S&A S&H SAR SCAM SCYLLAC SDWA SEN SHPO SJT SM SMCB SMG SNM SPCC SRC SSC * Pulsed High Energy Radiographic Machine Emitting X Rays Pump, Hot Water Perimeter Intrusion Detection and Assessment Systems Pulsed Intense X-Ray Pajarito Laboratory (TA-18) Protocol Pump, Sump (Regardless of Use) Personnel Services Program Secretarial Officer Pump, Sealant Water Packaging and Transportation Q Site (TA-14) Quality Assurance Quality Assurance Program Quality Assurance Program Plan Quality Operations Office Quality Program Plan R Site (TA-15) Radiation Radiochemistry Site (TA-48) Root Cause Analysis Resource Conservation and Recovery Act Reactor Development Site (TA-52) Radiation Exposure Facility (TA-51) RCRA Facility Assessment RCRA Facility Investigation Records Processing Facility Regulator Pressure, Water Reportable Quantity Runway Safety Area Radioactive Solid Waste Disposal (form) Refrigeration Unit Regular Valve, Steam S Site (TA-16) Sampling and Analysis Safety and Health (a Subteam of the Tiger Team) Safety Analysis Report Scanning and Alarm Monitoring TA-3, Building 287 Safe Drinking Water Act Secretary of Energy Notice State Historic Preservation Officer Small Job Tickets South Mesa Site (TA-3) Senior Management Construction Board Senior Management Group Special Nuclear Material Spill Prevention Control and Countermeasures (Plan) Safety Review Committee Siting and Space Committee Indicates acronym is spelled out once per major section. xxvi 1 * SST Space Science and Technology T T&E TA TB TC TCA TCS TCW TD TECC TEGD TLD TM TMAC TRU TSA TSD TSL TSTA TTOC TWC TWH TWT TX Theoretical Division Threatened and Endangered Technical Area Technical Bulletin Tower, Cooling Tank, Compressed Air Tank, Condensate Steam Tank, Condensate (Water) TD Site (TA-22) Training and Education Coordinators Committee Technical Enforcement Guidance Document Thermoluminescent Dosimeter Two Mile Mesa Site (TA-6) Toxic Materials Advisory Committee Transuranic Technical Safety Appraisal Treatment, Storage, and Disposal Ten Site Laboratory (TA-35) Tritium Systems Test Assembly Tiger Team Operations Center Tank, Water, Chill/City/Cool Tank, Water Hot (All) Tank, Waste Treatment Tank Expansion/Compression University USQ UST University of California Unresolved Safety Questions Underground Storage Tank VWR VWR Scientific (Inplant store that supplies chemicals and safety-related equipment) W WA WA WAC WET WETF WFO WIPP WM WMC WPR WSL WX X W Site (TA-41) WA Site (TA-46) Washer, Air Waste Acceptance Criteria Weapons Engineering Tritium (Facility) Weapons Engineering Test Facility Work for Others Waste Isolation Pilot Plant WM Site (TA-50) Waste Management Coordinator Waste Profile Request Weapons Subsystems Laboratory Design Engineering Applied Theoretical Physics Indicates acronym is spelled out once per major section. xxvi11 EXECUTIVE SUMMARY EXECUTIVE SUMMARY This report documents the results of the U.S. Department of Energy's (DOE's) Tiger Team Assessment of the Los Alamos National Laboratory (LANL), Los Alamos, New Mexico; LANL subcontractors; DOE Field Office, Albuquerque (AL); DOE Los Alamos Area Office (DOE/LAAO); Ross Aviation; Los Alamos Fire Department; and EG&G Los Alamos, conducted September 23 to November 8, 1991. The assessment was performed by a team of approximately 150 professionals from DOE, its contractors, and outside consultants for the purpose of providing to the Secretary of Energy the status of environment, safety, and health (ES&H) programs at LANL, LAAO, and AL as they apply to LANL. During the assessment, a trenching operation was terminated by the Laboratory after a Tiger Team member found that the shoring did not conform to occupational safety and health requirements. The Tiger Team concluded that other operations did not present an imminent hazard to workers, and no LANL operations presented an imminent hazard to the public; therefore, curtailment or cessation of any current operations at LANL is not warranted. All compliance issues identified by the Tiger Team are known to Federal, State, and local regulatory agencies. LANL is managed and operated for DOE by the University of California. DOE line management authority is through the Assistant Secretary for Defense Programs as the lead Program Secretarial Officer (PSO), AL; and LAAO. Other PSOs (Assistant Secretary for Nuclear Energy; Director, Energy Research; and Director, Environmental Restoration and Waste Management) also have programs at LANL. Most program direction flows directly from the responsible PSO to LANL. LANL is one of DOE's oldest and most complex sites. Established in the early 1940s as part of the "Manhattan Project," the principal mission of LANL remains research and development in support of this nation's nuclear deterrent. However, LANL has developed into a multi-program, multi-discipline institution. Today, LANL provides a wide range of expertise from basic scientific research to applied engineering development in support of defense, energy, and general scientific programs for government and nongovernment sponsors. LANL has always strived for and achieved a well-deserved reputation for technical and scientific excellence. LANL has stated a commitment to strive for similar excellence in its conduct of ES&H programs and facility operations. However, numerous significant ES&H issues exist at LANL as identified in other sections of this summary. The challenge for LANL management is to instill a strong ES&H culture at all levels within the organization, take a proactive position to remedy the identified deficiencies, and take proactive steps to preclude recurrence of similar problems. Particularly commendable has been the attendance by all LANL senior management at the Conduct of Operations course conducted by DOE-Headquarters (HQ). LANL has started implementing the Conduct of Operations concept. To ensure widespread knowledge of this concept within LANL and its contractors, LANL developed and conducted a site-specific training course. Just prior to the Tiger Team arrival, LANL performed a comprehensive and critical self-assessment. This self-assessment has identified institutional root causes for unsatisfactory performance of ES&H programs, and the corrective ES-1 action plan under development is intended to form the blueprint for the ES&H excellence which DOE requires of its contractors. The majority of the findings reported by the Tiger Team have been at least partially identified by LANL in their self-assessment report. In some cases, remedial actions were initiated prior to arrival of the team. Many others are more complex and require planning and prioritization to ensure the implementation of an integrated and lasting solution which will not produce an unexpected consequence. In still other cases, the pace of longer-term solutions may be limited by available resources, and the actions must be carefully prioritized. As a result of actions initiated by the LANL Director, many of the ES&H programs and activities are in a state of transition. However, the Tiger Team evaluated the status and effectiveness of each function or program as it is today as opposed to what it is expected to be in the future. The LANL Director has begun setting the mechanisms in place to alter the long-standing ES&H culture which has prevailed at LANL by establishing Laboratory-wide ES&H Director's policies. If the current momentum and sense of purpose can be sustained over an extended period of time, it could produce an ES&H program which will be responsive to the Secretary's stated expectations. LAAO and AL management has also demonstrated a commitment to improve the quality and depth of its oversight activities at LANL for ES&H matters and has completed a self-assessment of its ES&H activities and functions. In addition, LAAO is implementing a facility representative program at LANL, the purpose of which is to make LAAO management aware of ES&H problems and issues during the formative stages before they escalate to become major problems. Summary of Key Findings and Probable Root Causes Environmental: The Environmental Subteam identified findings of potential noncompliance with Federal and state regulations and DOE Orders and a failure to effectively apply acceptable best management practices. However, none of the deficiencies present a near-term risk to public health or the environment. Environmental findings, root causes, and observations of LANL operations illustrate an absence of strong management and control of environmental activities. Major concerns relate to organization and implementation of programs; although, technical deficiencies were identified. Management accountability and oversight are lacking as are many other basic elements necessary to ensure effective implementation of environmental programs. The key areas of concern are inadequate sitewide programs for the management of wastes; lack of a regulatory permit strategy and management; inadequate identification, monitoring, and control of effluent releases; and a lack of oversight of environmental activities. Safety and Health: The four Technical Safety Appraisal subteams identified 633 concerns of which 582 are directed to LANL, 42 to DOE, and 9 to Ross Aviation. Of the concerns related to LANL, one was classified as Category I and 40 as Category II. Of the DOE concerns, three were classified as Category ES-2 II and the remaining 39 as Category III. All of the concerns associated with Ross Aviation were classified as Category III. Of the 582 concerns directed to LANL, 76 percent were judged to be noncompliance concerns which suggests that management either does not have the mechanisms in place to implement DOE Orders and mandatory standards or does not have a strong compliance or oversight capability. The findings are replete with examples of nonexistent or inadequate policies, programs, plans, procedures, and guidance. In many cases where adequate policies or procedures do exist, they have not been properly implemented or consistently applied. The central hierarchy of documentation necessary to provide the control is missing or flawed. Safety analyses and technical specifications, as well as operational safety requirements, that meet the requirements of DOE Orders need to be completed, revised, and updated, where necessary, and mechanisms put in place to demonstrate that the facilities are being operated within the defined safety envelope. Once the above has been achieved, a strict quality and configuration management program will be necessary to continue to demonstrate safe operations. Safety programs such as quality verification, training, emergency preparedness, radiological protection, personnel safety, packaging and transportation, and nuclear safety need to be evaluated against DOE Orders and mandatory standards. In some cases these programs do not exist or are in such a formative stage that they cannot be effectively applied. The first steps have been taken to make the transition to a new safety culture. Management and staff are enthusiastic about the change and want to exhibit the same level of safety excellence as they have in the management of their technical programs. Management: The Management Subteam identified 34 findings and 4 key findings. With respect to the planning criteria, the subteam noted deficiencies in both AL's and LANL's strategic planning efforts due mainly to the lack of a methodology to integrate and prioritize ES&H issues. Organizational deficiencies were related to LANL's (1) lack of a comprehensive and effective Laboratory-wide ES&H program, (2) improperly defined ES&H roles and responsibilities, (3) incomplete implementation of conduct of operations requirements, (4) lack of full implementation of DOE's quality assurance requirements, and (5) a failure to meet DOE's requirements in the Occupational Medical Program. It was also found that LAAO does not have formalized management systems that clearly define ES&H roles and responsibilities. A number of deficiencies were noted in human resource planning at LANL, AL, and LAAO with respect to the systematic examination of ES&H staffing needs and training which lacked uniformity and formality. LANL was found deficient in ES&H career development, external recruiting, performance appraisals, and employee relations. In general, many of the staff members and particularly those in the line organizations are not well trained or knowledgeable of the laws and regulations they are expected to enforce or apply. ES-3 Oversight activities within AL and LANL are not adequate to meet DOE's ES&H oversight requirements including LANL appraisals and triennial reviews. ES&H subcontract provisions were found to, be insufficient, and the priority given to ES&H issues in subcontract award fee administration do not meet DOE standards. The Management Subteam noted incomplete guidance and documentation for decisions relating to the acquisition of ES&H support and for ensuring adequate review of ES&H issues relating to non-DOE-funded work. LAAO administration of the Los Alamos County Fire Department contract and University of California contract was not adequate. There is evidence of confusion relating to the implementation of the Agreement in Principle between DOE and the State of New Mexico. The subteam also noted a lack of clarity for the ES&H public affairs program roles among LANL, LAAO, and AL. Communication on ES&H matters to external groups was not totally effective and coordinated. LANL has not fully implemented an aggressive ES&H outreach program, and internal communications were occasionally conflicting. The University of California does not currently provide effective ES&H policy guidance or oversight. Self Assessments: The Laboratory has developed and submitted an initial program plan which has not yet been approved by DOE. The plan is fairly comprehensive in scope; however, the self-assessment process has not been institutionalized. The Laboratory is in the initial stages of implementation, but staffing resources assigned to the task are extremely limited. Extensive staff training and education, as well as enhanced management systems, will be required in both AL and LAAO to fully institutionalize the self-assessment program. Currently, AL has not established an organization to implement self-assessment. There is also a notable absence of DOE-HQ's program office direction regarding self-assessment, and the process for integration and coordination among the appropriate PSOs has left the Laboratory and field organizations without the necessary guidance for timely implementation of appropriate self-assessment programs. Root Cause: The Tiger Team conducted an integrated root cause analysis on the combined findings and concerns of the three subteams. The team did not identify a single independent factor as the root cause of the findings. Rather, the "true" root cause is considered to be a set of 18 interrelated causes. Two of the causes relate to ES&H guidance from DOE-HQ, AL, and LAAO. As a result of this analysis, it is clear that LANL has not effected a change of culture toward ES&H excellence. A significant number of other causes related in large part to a lack of formality, structure, and control of ES&H activities. Correction of the root causes will require that each of the component causes be addressed in a coordinated fashion with close attention being paid to their interrelationship. ES-4 1.0 INTRODUCTION 1.0 INTRODUCTION On June 27, 1989, Secretary of Energy, Admiral James D. Watkins, U.S. Navy (Retired), announced a 10-point initiative to strengthen environment, safety, and health (ES&H) programs and waste management operations in the U.S. Department of Energy (DOE). One of the initiatives involved conducting independent Tiger Team Assessments at DOE operating facilities. The Office of Special Projects in the Office of the Assistant Secretary for Environment, Safety and Health (EH) has the responsibility to conduct Tiger Team Assessments for the Secretary of Energy. This report represents the Tiger Team Assessment of the buildings, facilities, and activities at the Los Alamos National Laboratory (LANL), Los Alamos, New Mexico. LANL is the twentyseventh DOE site to be reviewed by a Tiger Team. LANL is a multiprogram national laboratory of DOE. Since its establishment in 1943, it has been operated by the University of California as a governmentowned, contractor-operated facility for the Manhattan Engineering District of the U.S. Army, for the Atomic Energy Commission, for the Energy Research and Development Administration, and now for DOE. The contract administration and oversight of LANL is assigned to the DOE Field Office, Albuquerque (AL) and the Los Alamos Area Office (LAAO). The major DOE program office with primary programmatic responsibility for LANL is the Office of Defense Programs (DP). LANL's primary mission is nuclear weapons research, development, and testing to help ensure the nation's nuclear deterrent. Using core competencies, LANL also makes contributions in technical assistance to the DOE's weapons complex, works for other Federal agencies, cooperates in ventures with U.S. industry, and conducts basic research. LANL has received a number of specific research and development (R&D) assignments, ranging from nonnuclear strategic defense and conventional munitions R&D to environmental and energy R&D. LANL has also been charged with helping to ensure a continuous supply of technical personnel for DOE programs. Therefore, LANL supports science and engineering education at all levels through local outreach programs and programs targeted at undergraduates, graduate students, and university faculty. The National Competitiveness and Technology Transfer Act of 1989 specifically included technology transfer in the mission of LANL. LANL maintains active collaborations with industry to commercialize new technologies, promote personnel exchanges, and operate many user facilities. 1.1 PURPOSE The purpose of the LANL Tiger Team Assessment is to provide the Secretary of Energy with concise information on the following: • current ES&H compliance status at the site including deficiencies; • root causes for noncompliance; • adequacy of DOE and site contractors' ES&H management programs; 1-1 • adequacy of response plans which address identified problem areas; and • adequacy of ES&H self-assessment and the institutionalization of the self-assessment process within the LANL organization, LAAO, and AL. This assessment will assist DOE in determining trends in ES&H compliance and probable root causes and the effectiveness of the self-assessment process and will provide guidance for management to implement corrective actions. 1.2 SCOPE The scope of activities, facilities, and operations evaluated during the LANL Tiger Team Assessment included the following: • LANL, including the Hot Dry Rock Geothermal Site activities; • LANL subcontractors; • Los Alamos Airport; • Ross Aviation activities in support of DOE; • EG&G Energy Measurements, Inc., Los Alamos Activities; • abandoned or inactive waste sites, including those off LANL on private, public, or Indian land; • utilities and other services provided to LANL by the County of Los Alamos; • LAAO; and • AL, as it pertains to LANL management and oversight. The scope of the ES&H functional areas reviewed for these activities, facilities, and operations included, but were not limited to, the following: • compliance with applicable Federal, state, and local regulations, requirements, permits, agreements, and enforcement actions; • compliance with DOE Order requirements for ES&H activities; • compliance with Occupational Safety and Health Administration/Act (OSHA) regulations and standards as applicable under DOE Orders; • adequacy of AL and LANL ES&H management programs, including policy and procedures, internal oversight, planning and budgeting, organization, resources, training, and quality assurance; • conformance with applicable "best" and "accepted industry practices"; 1-2 identification of root causes; 1.3 • identification of noteworthy practices; and • adequacy of the self-assessment process to identify, track, and resolve significant ES&H issues. APPROACH The LANL Tiger Team Assessment was conducted in accordance with the Tiger Team Guidance Manual (February 1990), "Performance Objectives and Criteria for Technical Safety Appraisals at Department of Energy Facilities and Sites" (June 1990), applicable DOE Orders and guidance material, and generally accepted audit techniques. The assessment was conducted by a team of specialists from various DOE offices and support contractors. The team was managed by a Tiger Team Leader, a senior DOE official; a Deputy Tiger Team Leader; and three subteam leaders (a Management Subteam Leader, Environmental Subteam Leader, and Safety and Health Subteam Leader). The Safety and Health Subteam Leader was assisted by three Technical Safety Appraisal Team Leaders. Team members, with their areas of responsibility and work-related experience, are identified in Appendix A. Each subteam focused on major facilities, operations, and systems to conduct a comprehensive evaluation that was representative of the overall status of the ES&H programs at LANL. The Environmental Subteam performed its assessment consistent with the Tiger Team Guidance Manual (February 1990) and the Environmental Audit Manual (January 1990). These documents were used as tools in preparing for the assessment and were supplemented with current regulations, regulatory guidance documents, and references applicable to identifying best management practices. The objective was to assess current environmental compliance status at the site with regard to Federal, state, and local regulations; DOE Orders; agreements and consent decrees; and applicable permits. The environmental assessment examined site performance against best or accepted industry practices and evaluated the adequacy of DOE and contractor environmental program management and resources. The Safety and Health Subteams conducted four separate TSAs. Using TSA protocols, as delineated in DOE 5482.IB and the "Performance Objectives and Criteria for Technical Safety Appraisals at Department of Energy Facilities and Sites" (June 1990), major facilities operated by the various site contractors were reviewed. Performance objectives used for the safety and health assessment are derived from DOE Orders, Secretary of Energy Notices (SENs), other policy statements, industry standards, and nuclear industry lessons learned. The objectives of the Management Subteam were to determine the effectiveness of DOE and contractor ES&H program management and to identify underlying probable root causes for observed weaknesses or deficiencies. The Management Subteam conducted its assessment in accordance with the Office of Special Projects (OSP) recent draft "Management Performance Objectives and Criteria for Tiger Team Assessments." The subteam also used the Tiger Team Guidance Manual (February 1990) as guidance. The subteam coordinated with the 1-3 Environmental and Safety and Health Subteams to share information and ideas on management issues identified during the course of the Tiger Team Assessment, as well as to identify management issues that were common to the findings of all subteams. A systematic approach was implemented to perform the probable root cause analyses. This approach began with the analysis and evaluation of detailed background information and assessment data by the individual subteams to develop their findings and concerns. These individual findings were integrated by the subteams through identification of probable causal factors. The last step in the process was a collective determination of a set of probable root causes for the findings and concerns identified. The Tiger Team Assessment process includes four distinct phases: preassessment planning, onsite activities, reporting, and corrective action plan and process. 1.3.1 Preassessment Planning Planning for the assessment included the issuance of an introduction and information request memorandum, a preassessment site visit, an initial review of the requested documentation provided to the Tiger Team by the site contractors, and development of an assessment agenda. The preassessment site visit was conducted August 27 through 29, 1991, by the Tiger Team Leader, the Deputy Tiger Team Leader, the Environmental, Safety and Health, and Management Subteam Leaders, and representatives from the Office of Special Projects and DP. The managers of AL and LAAO and senior managers of the site involved with LANL activities provided overviews of site operations and ES&H programs. The Tiger Team Leader, the Deputy Tiger Team Leader, and subteam leaders discussed the Tiger Team Assessment program and necessary support requirements for the onsite assessment. Federal, State of New Mexico, and local regulators were invited, as well as Indian leaders and trade union representatives. Representatives of Federal and state agencies and union representatives as well as Indian leaders participated in the preassessment activity. The assessment approach and agenda were provided to the site contractors and DOE Field Offices prior to initiation of the assessment so that counterparts could be identified for each technical area to be reviewed. 1.3.2 Onsite Activities Onsite activities for the assessment took place from September 23 through November 8, 1991. These activities included field observations; document reviews; and routine operations, emergency exercises, and the physical condition of the site and facilities. In addition, reviews were conducted of previous audits and assessments; and interviews were conducted with DOE, LANL site personnel, Indian leaders, and personnel from Federal, State of New Mexico, and local regulatory agencies. 1-4 Using these sources of information, the Tiger Team developed issues that are reported as either findings (Environmental and Management Subteams), concerns (Safety and Health Subteam) or noteworthy practices. Section 1.3.3 discusses this development process in more detail. The Tiger Team Assessment process was conducted in an open manner with LANL, AL, and LAAO staff and management and regulators to enhance communication and to ensure the accuracy of information and issues. During the process, all three subteams conducted daily debriefing sessions which were open to site personnel. The daily debriefing sessions were well attended, and site personnel actively participated in the sessions. In addition, the Tiger Team Leader held daily meetings with senior managers from the site operating contractors to provide a summary overview of team progress and to discuss major issues identified by the subteams. Prior to the closeout briefing, each subteam provided draft findings and concerns to DOE and LANL site personnel to conduct factual accuracy reviews. 1.3.3 Reportinq Section 2.0 is an overall summary of the key Tiger Team Assessment findings, concerns, noteworthy practices, and probable root causes as identified by the subteams. Sections 3.0 through 5.0 contain the environmental, safety and health, and management findings and concerns, respectively. Section 6.0 is an evaluation of the AL, LAAO, and LANL self-assessment programs and reports. For the Environmental Subteam, identified issues are categorized as a "compliance finding (CF)," a "best management practice finding (BMPF)," or a "noteworthy practice." Compliance findings are conditions that, in the judgment of the assessment team, may not satisfy applicable ES&H regulations, DOE Orders (including internal DOE memoranda, where referenced, and draft DOE Orders), internal ES&H site operating standards, enforcement actions, agreements with regulatory agencies, or permit conditions. Best management practice findings are derived from regulatory agency guidance, draft DOE Orders, accepted industry practices, and professional judgment. Each finding is prefaced by a statement of an applicable performance objective. Performance objectives for compliance findings are derived from promulgated regulations and final DOE Orders, consent orders, agreements, and permit conditions. Performance objectives for best management practice findings are derived from regulatory agency guidance, accepted industry practices, and professional judgment. Findings for the Environmental and Management Subteams are not necessarily arranged in order of relative significance. The Safety and Health Subteam employed a reporting format that maintains consistency and integrity with the TSA process. Each identified issue is developed into a "concern," which is supported by "findings," and has the characteristics of being explicit (stating the problem), measurable (auditable), and justifiable. A concern addresses a situation that, in the judgment of the subteam, meets one or more of the following criteria: (1) reflects less than full compliance with a DOE safety and health requirement or mandatory safety standard; (2) threatens to compromise safe operations; or (3) if properly addressed, would substantially enhance the excellence of that particular situation even though that part of the operation was judged to have a currently acceptable margin of safety. Because of this last category addressing the excellence of the operation, more concerns are reported than 1-5 would result from a strictly compliance-oriented assessment. Each concern is categorized by its seriousness, potential hazard consideration, and compliance consideration. Findings and concerns are prefaced by a statement of the performance objective in each discipline area. The objective of the OSHA portion of the appraisal of LANL facilities was to measure workplace safety and health against DOE-prescribed OSHA regulations. General Industry Standards (29 CFR 1910) and Construction Industry Standards (29 CFR 1926) were used as criteria. A full report of the OSHA assessment is in Appendix F. The Management Subteam evaluated the effectiveness of management structure, processes, and systems relative to ES&H programs to identify findings and develop probable root causes based upon findings and concerns developed by all subteams. The Management Subteam findings were derived from analysis of key management areas that impact on ES&H activities and considered DOE policy and Orders, generally accepted management principles, and industry standards. Each finding is supported by a summary and discussion, which identifies further detail as to the background, factual basis, and, where appropriate, management implications of the finding. In addition to identifying findings and concerns, the subteams looked for exceptional practices in accomplishing performance objectives or meeting ES&H objectives. Any noted exceptional practices, which may have general application at other DOE facilities, are identified as "noteworthy practices" and are documented for the purpose of information transfer. This assessment reflects a fixed point in time. Improvements in the ES&H areas that were planned, but were not completed at the time of this assessment, are identified as findings or concerns to provide a complete and accurate picture of the site's conditions from the onset of the assessment. This Tiger Team Assessment Report was transmitted to the Managers of AL and LAAO; site contractor management personnel; DOE-HQ PSOs, including the Assistant Secretary for Defense Programs (DP-1), the Assistant Secretary for Environment, Safety and Health (EH-1), the Office of General Counsel; Federal and State of New Mexico regulators; and trade union representatives for technical and factual accuracy review. Upon receipt of comments, the Tiger Team will be responsible for preparation and issuance of the final report incorporating review comments, suggested changes, and modifications, as appropriate. 1.3.4 Corrective Action Plan and Process AL, LAAO, and LANL will prepare a draft action plan that addresses the findings and concerns identified by the Tiger Team Assessment. The draft action plan will be submitted by the Manager of AL to DP-1 for submission to EH-1 for review and concurrence. The Secretary will approve the final action plan and direct its implementation. 1.4 SITE DESCRIPTION LANL is located in north-central New Mexico, approximately 100 kilometers (km) (60 miles) by air nortli-northeast of Albuquerque and 40 km (25 miles) 1-6 northwest of Santa Fe. The Ill-square-kilometer (43-square-mile) Laboratory site and adjacent communities of Los Alamos and White Rock are situated on the Pajarito Plateau, a volcanic shelf on the eastern slope of the Jemez Mountains, at an approximate elevation of 7,000 feet. The Pajarito Plateau is cut by a number of steeply sloped, deeply eroded drainage canyons which have formed isolated finger-like mesas running generally west to east and north to south in some areas. Highways provide the primary access to the Laboratory. Los Alamos has no bus or rail connections, but regularly scheduled commuter air service is available between Los Alamos and Albuquerque. LANL is situated on approximately 27,500 acres (43 square miles) of DOE land, 24,000 acres (87%) of which are located within Los Alamos County. There are currently 50 designated technical areas with locations and spacing that reflect historic development patterns, topography, and functional relationships. Presently, LANL's onsite population is approximately 11,000 people (including University and subcontractor employees) housed in more than 2,200 buildings totaling about 7,500,000 square feet. Most LANL and community developments are confined to mesa tops; although, some significant sites are in the canyons. The surrounding land is largely undeveloped with large tracts of land north, west, and south of the LANL site being held by the Santa Fe National Forest, Bureau of Land Management, Bandelier National Monument, General Services Administration, and Los Alamos County. The San Ildefonso Indian Pueblo borders LANL to the east. LANL land, divided into Technical Areas, is used for building sites, experimental areas, waste disposal locations, roads, and utility rights-of way. However, the above uses account for only a small part of the total land area. Most land provides isolation for security and safety and is a reserve for future structure locations, if needed. Limited access by the public is allowed in certain areas of the LANL reservation. DOE controls the,area within the LANL boundaries and has the option to completely restrict access. 1.5 DEFINITION OF OVERSIGHT Seveal findings and concerns address the lack of effective oversight by LANL management. The use of the term "oversight" has created some confusion among LANL and LAAO personnel because a consistent definition of the term is not used throughout the site. Unless the context requires a specific (and cited) definition, this document defines "oversight" as an organized set of activities with the objective of ensuring that ES&H concerns are adequately addressed. Internal oversight by line management includes both formal and informal mechanisms that allow line management at each level to be cognizant of their organization's ES&H performance. Such mechanisms include the following: • walkthroughs of facilities; • a system for staff members to report ES&H concerns for resolution; 1-7 • a formal system to track and trend problems and corrective actions; and • a process for real time measures of ES&H performance. Oversight by groups internal to the facility, but external to the operating organizations, includes the following mechanisms: • interpretation of ES&H policies, standards, and requirements; • a system of performance measures that provides timely measures of ES&H performance; • a formal mechanism for support personnel to report ES&H issues for resolution; • a formal system to track and trend ES&H issues for resolution; • authority to review and concur on ES&H-related activities; • authority to enforce compliance with ES&H policies, standards, and requirements; and • regularly scheduled ES&H audits, appraisals, and surveillance. DOE oversight includes all of the items listed above except the third bullet. 1-8 2.0 KEY FINDINGS, ROOT CAUSES, AND NOTEWORTHY PRACTICES 2.0 KEY FINDINGS. ROOT CAUSES. AND NOTEWORTHY PRACTICES 2.1 ENVIRONMENTAL KEY FINDINGS One of the objectives of the Environmental Subteam was to assess the effectiveness of environmental programs and environmental program management at the Los Alamos National Laboratory (LANL). U.S. Department of Energy (DOE) Orders, Federal and state regulations, and consensus standards lay the foundations upon which DOE strives to build its environmental programs. How effectively these requirements and standards are implemented is assessed by each of the Environmental Subteam specialists within their technical disciplines. The Environmental Subteam evaluated overall program effectiveness and concerns which may affect long-term implementation and resolution of deficiencies identified. The Environmental Subteam identified four key findings, each of which is comprised of multiple findings, or portions of individual findings from Section 3.5. In some cases, the component findings, taken individually, might not appear to be significant enough to be identified as key, but collectively they represent those issues of greatest concern. The key findings are as fol1ows: Inadequate Sitewide Programs for the Management of Wastes. The management of hazardous, radioactive, mixed, and solid wastes is inconsistent throughout LANL. The authority and responsibility for waste generating activities have been delegated to the line organizations. Responsibilities for the management of waste are not well understood by these organizations and are generally not sufficiently well defined or formalized to ensure compliance with DOE Orders or regulatory requirements. Key deficiencies were noted in LANL's waste acceptance criteria and waste characterization and certification programs. In addition, accountability and oversight of waste generating and management practices are weak. Inadequate Identification, Monitoring, and Control of Effluent Releases. LANL does not have the necessary programs in place to ensure accurate identification, monitoring, or control of effluent releases. Deficiencies have been noted in a number of the key program elements for air quality protection and water discharges. LANL does not have a comprehensive program to monitor or characterize effluent releases, and the programs to control, reduce, and mitigate releases were found deficient. The inadequacy of the monitoring programs undermines the foundation for future NEPA reviews, permit documentation, and demonstration of compliance with DOE Orders and requirements and U.S. Environmental Protection Agency (EPA) regulations. Inadequate Regulatory Permit Strategy and Management. The management of environmental permits is fragmented and lacks an overall strategy and approach to ensuring compliance. Often, permit requirements are not clearly understood by the line managers responsible for compliance with the permit. Management has delegated responsibilities for permit compliance to such a level that noncompliances cannot be effectively addressed and 2-1 corrective actions implemented. Several findings relating to out-of-compliance conditions with permits were fully identified in the LANL Self-Assessment, yet the Environmental Subteam found little effort being made to address these issues or implement corrective actions. Both a lack of understanding of the responsibilities for compliance as well as lack of effective line oversight and accountability hampers LANL's ability to develop effective long-term permit strategy and management programs. Lack of Oversight of Environmental Activities. A key component of several environmental findings is a general lack of oversight of environmental activities. Line management has the responsibility for implementing environmental protection requirements, but no organization has been assigned responsibility for developing environmental policies and standards, there is no formal mechanism to monitor environmental performance, and no organization below the Director's Office has been delegated the authority to enforce compliance with environmental standards or mandate corrective actions. Further compounding the problems related to LANL's lack of internal oversight is that neither the DOE Field Office, Albuquerque (AL) nor the Los Alamos Area Office (LAAO) are providing effective oversight of LANL environmental activities. 2.2 SAFETY AND HEALTH 2.2.1 Key Concerns 2.2.1.1 Plutonium and Enriched Uranium The appraisal of TA-55 and the other plutonium and enriched uranium operations at LANL addressed 18 technical areas including natural phenomena (The performance objectives and criteria for natural phenomena were applied for the first time in this Technical Safety Appraisal (TSA)). Aviation Safety, Explosives Safety, and Medical Services were addressed by Safety and Health Subteam - Technical Safety Appraisal (TSA) Team 4. The most significant concerns were (1) the large number of noncompliances identified by the team, and (2) that management cannot demonstrate that the plutonium facilities are being operated within an approved design basis and safety envelope. Other significant concerns were identified to be in the core areas of Organization and Administration, Operations, Emergency Preparedness, Worker Safety, Nuclear Criticality Safety and Fire Protection and in the ancillary areas of Quality Verification, Maintenance, Personnel Protection, and Training and Certification. Of the 134 concerns in the TSA Team 1 report, 99 (74%) were judged to be a noncompliance (compliance level CI) with DOE Orders or mandatory standards; and 29 (22%) were judged to present a potentially serious hazard (hazard level HI). Of these concerns, 129 were directed to TA-55, and 5 to LAAO, AL, and DOE-Headquarters (HQ). Eleven Category II concerns were identified during the appraisal which relate to significant hazards or noncompliance with a DOE Order or mandatory standards and regulations. Of the 10 addressed to LANL, the first dealt with the inability of LANL and the Nuclear Materials Technology Division management to demonstrate that TA-55 is being operated within an approved safety envelope 2-2 or design basis. In Operations, a Category II concern was identified in the area of shift supervision. This concern related to the lack of an individual with the responsibility and authority to exercise command and control of TA-55 operations. Emergency Preparedness received a Category II concern because of significant deficiencies in the emergency management and response organization. Two Category II concerns were identified in the Worker Safety area with the LANL respiratory protection program and lockout/tagout practices. Five Category II concerns were identified in area of Fire Protection which related to significant noncompliance with the Life Safety Code for egress, safe haven and detention of personnel, and reliability of fire protection and suppression systems. DOE received one Category II concern which relates to the lack of oversight and guidance to assure that TA-55 is being operated within an approved design basis and safety envelope and deficiencies in the DOE system for closeout of TSA findings, concerns, and recommendations. Key concerns were identified from the technical areas assessed on the basis of the seriousness of their impact on the safety of TA-55 and the other plutonium and enriched uranium activities. These key concerns are as follows: There is a lack of compliance with DOE Orders and mandatory standards throughout TA-55 and the other plutonium and enriched uranium operations. Approximately 74 percent of the concerns identified by the Safety and Health Subteam relate to practices or conditions that do not comply with DOE Orders or recognized mandatory standards. This suggests that Nuclear Materials Technology Division management does not have mechanisms in place to develop an understanding of DOE Orders and mandatory standards or to ensure that programs and practices are in place to assure compliance with the requirements. These deficiencies resulted in the Category II concerns regarding the safety envelope and design basis, fire protection, emergency planning, operations, and worker safety. It should be recognized that the Nuclear Materials Technology Division has not received effective guidance and support from LANL management and the LANL environment, safety, and health (ES&H) organization. Finally, Nuclear Materials Technology Division management has not established performance assessment measures to assure that personnel are accountable for compliance to ES&H requirements. TA-55 and the other plutonium and enriched uranium activities cannot demonstrate that these facilities are being operated within an approved design basis and safety envelope. Nuclear Materials Technology Division management is unable to demonstrate, through an approved Safety Analysis Report and associate document, that TA-55 is being operated within the originally intended design basis. Deficiencies relating to this concern appear across most, if not all. Nuclear Materials Technology Division safety-related programs such as operations, maintenance of equipment important to the safety of the facility, nuclear criticality safety practices, review of experiments and operations, and quality verification of equipment materials and other activities performed at the facility. Operational Safety Requirements (OSRs) for the facility do not meet the requirements of DOE 5481.IB and may not represent an adequate margin of safety for the facility. 2-3 The TA-55 Occupational Safety and Industrial Hygiene Programs have significant noncompliance with DOE and Occupational Safety and Health Act (OSHA) requirements. Nuclear Materials Technology Division management has not effectively established standards for protection of personnel working in TA-55. Workplace monitoring for hazards is incomplete or not performed. Hazards communication and chemical hygiene programs have not been developed. Hazards analysis and identification is incomplete. The occupational safety programs have significant noncompliance in the areas of machine guarding, lockout/tagout, electrical hazards and respiratory protection. Nuclear Materials Technology Division does not have in place a program to effectively identify, investigate, and abate hazards and their root causes and to systematically apply lessons learned. Nuclear Materials Technology Division training and certification program elements do not fully support a11 safety and health program activities. The oversight and control functions of training activities fail to meet the requirements of DOE 5480.5, such as recordkeeping, auditability, or verification of training. Job-specific training within Nuclear Materials Technology Division does not ensure that all assigned workers have been properly trained, job-specific training lacks documentation of examinations, and there is an overall lack of implementation of a formally documented training program. Hazardous material emergency response has not been effective with respect to planning, recognition, and response. And finally, oversight and control of training of personnel performing maintenance on equipment at TA-55 does not ensure that these personnel possess adequate knowledge and skills to safely and correctly complete assigned tasks. DOE-HQ, AL, and LAAO oversight of LANL and the Nuclear Materials Technology Division activities has been deficient In providing guidance and timely approval of safety documentation to assure safe operation of TA-55. There has been no DOE assurance that past TSA concerns have been effectively completed prior to their closeout. DOE has not provided timely approval of the LANL and TA-55 safety analysis documents as required by DOE 5480.5. The DOE facility representative for TA-55 has not been provided facility-specific training to provide effective oversight of the TA-55 operations. AL has not performed all periodic appraisals relating to a number of technical areas such as criticality safety, occupational safety, and industrial hygiene. 2.2.1.2 Reactor, Critical Assemblies, and Tritium Facilities In the 17 technical areas examined by TSA Team 2 at the tritium and reactors facilities, all applicable performance objectives were evaluated. A total of 134 concerns were identified. Of these, 131 were assigned to LANL, and 3 to the AL and the LAAO. Of the 134 concerns, 5 were assigned a seriousness level of Category II. All five were directed to LANL. One hundred and three (77%) of the 134 concerns were a noncompliance (compliance level CI) with DOE Orders or mandatory standards, and 24 (18%) were designated as presenting a potentially serious hazard (hazard level HI). 2-4 Of the five Category II concerns, three were in operations, and two were in radiological protection. The key concerns are as follows: LANL does not have a hierarchy of documentation to provide policies, programs, plans, procedures and guidance to ensure consistent safety practices at the tritium and reactor facilities. The past LANL management style of delegating maximum authority, responsibility, and autonomy to lower levels of the Laboratory has resulted in an organization with few central management policies and controls; and an informality of operations that is inconsistent with the Secretary of Energy's new safety culture. A large number of TSA Team 2 concerns address the lack of, or inadequacy of, policies, programs, plans, procedures, and guidance. The bases for an even larger number of concerns are attributed to the absence of this hierarchy of central management documents. LANL does not have a central, unified program at the tritium and reactor facilities to achieve safety excellence and is currently not in compliance with many DOE Orders and mandatory standards. A long history of successful operation of LANL by the University of California, and initially being in the forefront of nuclear technology development, may be the reason for the current complacency and lack of compliance with DOE Orders and regulations. As stated earlier, 77 percent of the total concerns in the TSA Team 2 report have been judged to be a noncompliance with required orders, standards, and regulations. The Laboratory has no central program that includes the setting of auditable, measurable, challenging, and achievable safety goals to promote a unified, sitewide effort towards achieving safety excellence. Operating activities at the tritium and reactor facilities lack Independent safety review and LANL/DOE management oversight. This lack of independent safety review has led to three Category II concerns in the TSA Team 2 report. A Category II concern addresses a significant risk or substantial noncompliance with DOE Orders. These concerns are as follows: (1) technical specification compliance at the Los Alamos Critical Experiments Facility cannot be demonstrated, (2) operations have been performed at the High Pressure Tritium Laboratory after its shutdown, and (3) the Godiva IV has been operated with a cracked fuel ring. Other concerns that can be attributed to the lack of line safety and independent safety oversight include the following: lack of management attention to the High Pressure Tritium Laboratory, lack of a defined line safety program, lack of independent safety review of experiments prior to running the experiment, lack of an independent safety review committee for tritium experiments and activities, lack of safety reviews of security enhancements, and the lack of independent safety evaluation of the continued operation of a critical experiments facility with a cracked, uneven floor. 2-5 The LANL radiological protection program does not provide the required level of safety. This has lead to two Category II concerns in radiological protection. The first concern addresses a contamination control program at the Ion Beam Facility that does not provide radiation workers the necessary protection against internal tritium exposure. The second Category II concern addresses the lack of LANL capability to calibrate and test highrange instruments used for emergency warning and evacuation. Other concerns address the lack of training for radiation protection technicians, the lack of definition of responsibilities and authorities of safety and radiation protection officers, the lack of assurance that the x-ray safety program is providing an adequate level of safety, and the lack of capability to calibrate and test portable high dose equivalent rate instruments. Training programs at the tritium and reactor facilities are not complete and fully implemented to ensure quality operations and safety excellence. The TSA Team 2 report addresses the lack of training plans, training not meeting requirements, lack of validation of training, inadequate examinations, uncertified test directors, lack of control of examinations, and staff and security guards not being trained regarding hazards in facilities. Jobspecific training does not ensure that all workers have been properly trained to perform their assigned tasks. The overall control of the training program is lacking and there is no positive assurance that personnel possess adequate knowledge and skills to safely and correctly complete and manage the assigned work. 2.2.1.3 Accelerators Concerns are cited by TSA Team 3 in all 16 technical categories examined. The most significant concerns are judged to be in the core areas of Organization and Administration, Quality Verification, and Training and Certification, and in the ancillary areas of Radiological Protection, Worker Safety, and Fire Protection. Six Category II concerns are identified that relate to significant hazards or noncompliance with a DOE Order or mandatory standard. One deals with lack of safety training; another addresses deficiencies in the accelerator interlock and warning systems; two pertain to inadequate training in chemical and hazardous waste cleanup and to floor-guard, handrail, and fall protection deficiencies; and two others relate to inadequate fire protection design review and to noncompliance with the Life Safety Code. Of the 112 concerns in this TSA Team 3 report, 77 (69%) were judged to be a noncompliance (compliance level CI) with DOE Orders or mandatory standards; and 32 (29%) were judged to present a potentially serious hazard (hazard level HI). From these 112 concerns, the following 5 key concerns are determined on the basis of the seriousness of the impact on the safety of the LANL activities: 2-6 LANL management has not provided the guidance and oversight needed to ensure conformance to ES&H program requirements. No LANL guidance has been provided to define requirements for ES&H assessment by accelerator organization management. LANL has not implemented an effective quality assurance program. LANL management has not ensured proper procedural control. LANL has not established requirements to record accelerator maintenance activities. LANL accelerator personnel do not receive the necessary training to ensure excellence in the performance of ES&H activities. Accelerator facility personnel have not received the initial and continuing safety training required by DOE Orders. Welders have not been properly trained and certified to perform work on programmatic (Class B) equipment for accelerator facilities. Formal training and qualification programs are not in place for packaging and transportation employees. Training of radiation protection technicians and radiation workers at facilities with radiation-producing devices does not meet the requirements of DOE Orders. LANL accelerator facilities do not meet the requirements stipulated by DOE and OSHA safety regulations. Safe operating procedures related to work within confined spaces in accelerator activities do not conform with ANSI Z117.1-1989. LANL does not provide floor guarding, handrails, or fall protection required by 29 CFR 1910, Subpart D, Walking Working Surfaces. Several accelerator facilities at LANL do not comply with the hazardous materials requirements of 29 CFR 1910. Significant deficiencies exist in the LANL fire protection program. Most accelerator facilities do not comply with the NFPA 101, Life Safety Code. Not all areas of TA-53 Bldg. 3 are provided with automatic fire suppression systems and passive systems that ensure that fires do not result in unacceptable program losses. Fire protection features, such as fire-rated separation, are not provided in all accelerator and accelerator support facilities. Administrative controls have not been Imposed on accelerator operations to a degree that ensures conformance with DOE Orders. Approved safety analyses and operational safety requirements are not available for all accelerator operations. Document control systems are not functional for most accelerator organizations. Most accelerator organizations have not developed and implemented quality assurance programs. Accelerator operations are not conducted in accordance with the requirements of DOE 5480.19. 2.2.1.4 Other Selected Facilities and Activities During this assessment, TSA Team 4 identified 253 concerns. Of these concerns, 214 were directed to LANL, 9 to Ross Aviation, and 30 to LAAO, AL, and DOE-HQ. One hundred ninety six (78%) of the concerns involved the lack of compliance with DOE Orders or mandatory standards. This high percentage of noncompliance was due, to a large extent, to the failure of LANL to develop 2-7 and fully implement systems and programs consistent with these requirements, standards, and accepted practices. There was one Category I concern identified which involved the failure of LANL to ensure that proper shoring was in place for the personnel working in the bottom of an excavation. In addition, there were 21 Category II concerns. Nineteen were directed to LANL, one to LAAO, and one to AL. The 19 Category II concerns were identified within the TSA categories of Maintenance, Emergency Preparedness, Packaging and Transportation, Personnel Protection, Worker Safety, and Fire Protection. These Category II concerns resulted from the failure of LANL management to develop and enforce safe work control programs (e.g., lockout/tagout, asbestos abatement, and confined space entry), and the lack of positive controls for radiation exposure at the Laboratory gamma irradiators. The single Category II concern directed to LAAO was the result of deficiencies attributed to the lack of direction and oversight of fire department operations. LAAO has not ensured that fire department personnel and apparatus will be available to mitigate fire emergencies at vital LANL facilities. A Category II concern, involving the lack of a plan for the timely resolution of a potential problem with a DOE-owned 12-inch natural gas line, was directed to AL. The subteam identified key concerns that represent the major deficiencies observed during this assessment. These key concerns are as follows: LANL has not fully defined and implemented an organizational structure to carry out Its safety and health programs and initiatives. Although organizational realignments and the creation of new offices have been recently made, these changes have not been sufficient to support the implementation of the Laboratory's safety and health programs. Roles, responsibilities, authorities, and interfaces among most of the Laboratory organizations, with reference to safety and health, are poorly defined and understood. The relationship between the Health and Safety Division and line operating groups is not well defined. Overall, the existing organizational structure for carrying out safety and health programs and initiatives of the Laboratory is not well defined, and the relationship among the safety and line organizations is not well established and understood. LANL has not developed a plan for managing and applying its health and safety resources. An approach to managing and utilizing the health and safety resources of the Laboratory has not been aggressively pursued by Laboratory management. A final decision on the organizational structure to be used in managing these resources has yet to be formulated. An ad hoc committee was recently established to study this issue; however, this initiative was begun only after the problem of resource utilization arose. There has been strong competition between the Health and Safety Division and the Laboratory line and other support organizations for safety and health staff. This competition has resulted in the transfer of staff internally and competition for new staff externally which has further diluted and delayed effective deployment of these resources and, thus, has diminished the 2-8 effectiveness of existing programs. Overall, management has failed to address the classification, salary grade, and growth opportunities for its ES&H staff. LANL has not fully Implemented many of the mandatory DOE safety, health, and quality program requirements. Approximately 77 percent of the concerns identified by TSA Team 4 were a result of noncompliance with DOE requirements and prescribed policies and standards. The lack of adherence to DOE requirements was manifested in the widespread program deficiencies observed. LANL has not implemented a sitewide safety and health program as noted in nearly all of the functional areas of this report. Overall, management has not ensured that important safety and health programs, consistent with DOE requirements, have been implemented sitewide. An integrated plan for implementing the safety and health programs for LANL has not been developed. LANL management has not communicated its expectations and direction for the Laboratory's safety and health programs which has resulted in the lack of a consistent and coherent approach for their implementation. Safety programs are being developed largely within divisions without specific top level management direction and, thus, there are a variety of programs being structured with varying degrees of rigor across the Laboratory. There is no system for the implementation and control of safety and health policy which has caused confusion for line organizations. The Laboratory Director has issued to the Laboratory ES&H S^-91-1435, "ES&H Policy Vision Goal Objectives Strategies," July 16, 1991, which contains broad ES&H objectives. Yet, these objectives are not tied to any overall implementation plan or strategy for the Laboratory divisions and groups to focus upon as part of an overall implementation process. LAAO has not provided sufficient oversight and direction for the health and safety programs of the LANL. Numerous deficiencies were identified during the course of this assessment related to the lack of LAAO oversight of LANL health and safety programs. These deficiencies were noted in many functional areas throughout the report. Many of the noted LAAO deficiencies are due to the lack of fully developed programs and allocation of staff resources. Although there is an initiative underway to correct these deficiencies, continued LAAO and AL management attention and commitment will be required if effective oversight programs of the Laboratory are to be instituted in the near future. 2.2.2 NOTEWORTHY PRACTICES 2.2.2.1 Plutonium and Enriched Uranium TC.7 TRAINING FACILITIES AND EQUIPMENT PERFORMANCE OBJECTIVE: The training facilities, equipment, and materials should effectively support training activities. 2-9 NOTEWORTHY PRACTICE: A comprehensive glovebox training laboratory was included in the initial design and construction of the TA-55 Training Center. This training laboratory simulates typical conditions and capabilities found in a typical laboratory within Bldg. PF-4. There is a change room associated with the training laboratory, and access to the laboratory is gained through an airlock, and a set of double swinging doors. The inside of the training laboratory is authentically finished and equipped, and it appears that it would be difficult for a trainee to imagine he or she is not actually within the operating facility from the moment of entering the change room. This duplication extends even as far as the color schemes, operational eyewash stations and safety showers, hand and foot monitors, ceiling height, door size, corridor width, etc. The training laboratory and installed gloveboxes are equipped with wet vacuum, dry vacuum, compressed air, chilled water, industrial water, and domestic water. Also included in the design is glovebox negative pressure of one-half -inch water, accurately mimicking Zone 1 pressure conditions within Bldg. PF-4 gloveboxes. There are three parallel lines of gloveboxes in the training laboratory. Two overhead transfer trolleys are included, situated at 90degree angles to one another, with drop boxes at appropriate locations, so transfers can be made between the trolleys and between glovebox lines. Capability exists to install an inert-atmosphere glovebox, although this has not yet been accomplished. Training which is routinely conducted in the training laboratory includes general glovebox operational safety (e.g., working with sharp objects, working with power tools, handling wet glassware, etc.), bag-out operations, trolley operations, glove change-out, window change-out for the various types of windows in use at TA-55, HEPA filter changeout. The five Bldg. PF-4 safety system alarms are all duplicated in the training laboratory and are used during routine training operations. These include ventilation failure, emergency evacuation, continuous air monitor, and the two fire alarms. 2.2.2.2 Reactor, Critical Assemblies, and Tritium Facilities OP.3 OPERATIONS PERFORMANCE OBJECTIVE: Approved written procedures, procedure policies, and data sheets should provide effective guidance for normal and abnormal operation of each facility on a site. NOTEWORTHY PRACTICE: In the P-10 Group, an experimenter has generated the "Operating Instructions for the D2-DT-T2 Gas Handling System No. 1" with warnings or other highlights to the operator printed in colored ink. Green signifies a step that must be addressed to satisfy quality requisites, red indicates that the step is critical to safety, and blue denotes safe or final condition. Also the text in the operation instructions and the signs in the laboratory are printed the same color. The printing is not overly expensive; the printer costs under $1,000 and is most likely available at most DOE sites. Different characters can be used in the color highlights that would stand out to those operators who have trouble differentiating among colors. To those of normal color discrimination, the color highlights truly provide a trigger to the operator that the step deserves some special attention which will increase potential for safe operations. 2-10 2.2.2.3 Accelerators No noteworthy practices were identified by this team. 2.2.2.4 Other Selected Facilities and Activities No noteworthy practices were identified by this team. 2.3 MANAGEMENT KEY FINDINGS A total of 34 findings were identified by the Management Subteam. These findings were distilled into four key findings that capture the substance of the Management Subteam's findings and address the most significant ES&H management issues found by the Management Subteam. LANL does not have a comprehensive, fully Integrated ES&H program. The LANL Director has made a commitment to bring the Laboratory up to the level of excellence specified by the Secretary of Energy including compliance with applicable laws, regulations, and standards. As a first step in the fulfillment of that commitment, he issued 15 new Director's Policies, with more to follow, intended to provide a strong sense of purpose and the basic framework for a comprehensive ES&H program within the Laboratory. However, those management policies and objectives have not yet been reflected in working-level policies and procedures which can be communicated to all organizational components of the Laboratory, subcontractors, and employees. Until such time as that element of the process has been completed, the Laboratory will not have the foundation of a comprehensive, fully integrated ES&H program that clearly identifies and defines specific management expectations, roles, responsibilities, authorities, and requirements as well as a uniform interpretation and application of DOE policies and regulations. The continued absence of a comprehensive Laboratory ES&H program over an extended period of time has resulted in fragmentation of ES&H-related efforts, inefficient application of resources, and an inconsistent interpretation and application of appropriate DOE policies, regulations, and standards. Moreover, efforts to date have not been well focused and prioritized in a manner that would provide the basis for an orderly and systematic identification and allocation of manpower and funding resources. The majority of the current ES&H functions and efforts are in a state of transition. The desired results or end objectives have been rather broadly defined but the detailed planning and central direction for the accomplishment of those objectives are notably absent. During the past 2 years, a great deal of the Laboratory effort and ES&H resources have been focused on preparations for the Tiger Team review. Although these efforts have produced some useful results, it is not apparent that the future course of action for the redirection of these resources has been well defined or communicated to the Laboratory staff. There appears to have been an inclination to delay any additional definitive ES&H planning until such time as the Tiger Team appraisal has been completed. 2-11 This suggests that the Laboratory may still be operating in a reactive mode as opposed to an aggressive, proactive style of management. In view of the foregoing findings and observations, the Management Subteam has concluded that, although the Laboratory has some individual elements or components of an ES&H system, they do not currently have a comprehensive, fully integrated, operational ES&H program nor are they likely to achieve that level for some period of time. The management structure and organizational alignment which is being applied to the development phase of a comprehensive, fully integrated ES&H program and the subsequent implementation phase closely parallels the management style and structure which has been very successfully applied to the research and development programs of the Laboratory. Although these concepts appear to have worked exceptionally well in producing good scientific results, they may not be totally suitable for the development and management of a complex program such as ES&H which crosses all organizational lines and which has the potential to significantly impact the management of all operational programs as well as research activities. The degree of independence and autonomy exercised by the scientific and technical elements of the Laboratory may not be totally compatible with the development of a fully integrated ES&H program with a particular emphasis on uniform and consistent compliance with regulatory requirements. This observation is not intended to suggest that the management of scientific and technical programs should be restructured. However, a new approach may be required for ES&H in order to fully accomplish the Laboratory Director's goals and objectives for the future. Moreover, the current organizational location of ES&H may not be totally consistent with the Secretary of Energy's guidance which indicates that ES&H should be, at least, equal in status to operational, mission-related programs. AL, LAAO, and LANL have not fully Implemented effective ES&H oversight programs to assure compliance with DOE policies, procedures, and standards. AL and LAAO oversight programs have not been effective in identifying and initiating appropriate remedial actions to resolve long standing deficiencies within the Laboratory. DOE-HQ, ES&H oversight of the DOE Field organization is minimal. The Laboratory oversight program has not been an effective ES&H management tool to assure compliance with DOE policies, procedures, and standards as evidenced by the significant number of noncompliance findings and deviations identified by the Tiger Team. Moreover, the oversight program does not comply with DOE policies and criteria for the scheduling and conduct of mandatory annual or triennial inspections and appraisals. The inspections and appraisals which have been conducted are not sufficiently well documented to enable auditing of their adequacy. There is also some question as to the true independence of some of the 2-12 appraisals since some of the appraisal team members are also members of the organizational unit being appraised. The overall Laboratory program is highly fragmented and suffers from a lack of consistent direction and control and from a lack of formality of operations including the administrative and technical discipline necessary to assure that important ES&H requirements are uniformly and consistently applied throughout the Laboratory structure. Most of the Laboratory Directorates have not yet formalized and documented the Laboratory policies and requirements for ES&H oversight programs applicable to their line organizations. Consequently, there is a notable absence of formal, rigorous dayto-day management oversight within the line organizations which has resulted in a failure to fully comply with DOE requirements. A well-designed program also identifies the roles and responsibilities of individual employees that would eliminate or minimize some of the confusion and misunderstandings that seem to exist in many sectors of the organization. In summary, the Management Subteam concluded that the current decentralized oversight program has led to fragmentation of staff resources, a lack of uniform and consistently applied oversight criteria, and an inadequate system for scheduling and controlling mandatory compliance reviews or appraisals. Moreover, the location of the regulatory compliance or oversight functions within the current organizational structure does not provide adequate authority or stature to enforce prompt remedial actions by line officials unless they are consistently escalated to the Associate or Laboratory Director levels. It is also apparent that the potential negative consequences to an individual employee as a result of continued noncompliance is viewed as minimal. AL, LAAO, and LANL have not effectively Incorporated ES&H issues and programs into their strategic planning process which creates adverse Impacts on the subsequent budgeting and resource allocation functions. LANL has developed an internal strategic planning process and plan identified as LA 2000. Although this plan is updated periodically, it is primarily oriented toward programmatic issues. LANL has not considered ES&H as a strategic issue since important elements of the program have not been fully incorporated into the current planning process. AL and LAAO do not currently have an operative strategic planning process appropriate to their respective operational responsibilities. AL does have plans to develop and implement a strategic planning program and is currently examining both the process and the elements to be included. It appears that LAAO requirements will be included in the master plan for the entire office as opposed to the development of an independent strategic plan. Since AL does not currently have an effective strategic planning process, they have been unable to incorporate the LANL Plan into 2-13 an overall strategic plan or to consider the LANL plans in relationship to the totality of ES&H concerns which could affect the entire complex under Albuquerque's jurisdiction. This problem is compounded by the fact that the Headquarters' program organizations generally provide strategic program guidance and assumptions directly to the Laboratory, thereby bypassing the Field Office and making it difficult for AL to integrate important ES&H concerns into the planning process. Due to the absence of comprehensive strategic plans, there are no subordinate implementation plans which integrate ES&H into organizational missions. Consequently, ES&H issues are not adequately evaluated and prioritized on a global scale or in relationship to programmatic objectives, such that funding resources can be effectively allocated or subsequently monitored. The continued absence of a comprehensive strategic planning system, which integrates ES&H considerations, has placed both AL and LANL in positions where they must deal with important compliance issues in a reactive mode. In some cases, resource requirements to support ES&H programs appear for the first time during the budget formulation process or, even worse, during the execution or allocation phase. These circumstances make it difficult to prepare operational plans for scheduling and acquisition of the resources required in support of the ES&H program such as recruitment of a professional staff with appropriate qualifications and expertise, the development of comprehensive Laboratory-wide training programs, and the development of necessary management systems to provide an effective means of characterizing and resolving ES&H deficiencies. AL, LAAO, and LANL have not developed comprehensive, integrated ES&H training programs that Include adequate planning, controls, documentation, and a validation process. AL, LAAO, and LANL have some elements of an ES&H training program; however, each of the programs are deficient in that they lack formality, consistency, and do not contain sufficient depth to assure that members of both staff and line organizations have been properly indoctrinated and trained to uniformly interpret and apply DOE policies, regulations, and standards in the performance of their day-to-day responsibilities. The current LANL ES&H training program is largely decentralized, is not well integrated and many elements are poorly documented. It is difficult to determine whether individuals working in a potentially hazardous area have received requisite specialty training as well as site-specific indoctrinations. Moreover, many of the records do not reflect schedules for updated or refresher training, and virtually none of the decentralized systems contain provisions for validating the effectiveness of the training that has been provided. Since the training program is essentially decentralized, there is no effective mechanism to assure that all occupants of a multiprogram facility have been properly indoctrinated and trained to recognize and respond to ES&H hazards which might be encountered. 2-14 ES&H training programs developed by the two major onsite LANL subcontractors have similar deficiencies, and it does not appear that any attempt has been made to coordinate the collective efforts or requirements of the participating organizations. For example, LANL policies require that all personnel working in high risk areas receive site-specific training. However, the majority of the security force employed by Mason & Hanger have not received site-specific training even though they regularly operate fixed guard stations and roving patrols in all of these areas. Even more importantly, these employees have not been trained in the potential ramifications of discharging a firearm in the vicinity of reactor facilities or those containing high explosives. As a further example, the fire fighters employed by Los Alamos County under a prime contract with DOE have not received adequate specialty training to enable them to properly respond to a structural fire in facilities that contain large concentrations of chemicals, high explosives, or radioactive materials. The absence of a well-documented and effective training program within LANL was a significant concern to each of the TSA teams and the Environmental Subteam. 2.4 Root Causes The LANL Tiger Team conducted an integrated root cause analysis (RCA) on the combined findings and concerns of the three subteams. This resulted in a root cause composed of a set of interrelated causes that is representative of the overall Tiger Team Assessment. The presentation of the RCA is designed to assist LANL in the development of corrective actions by illustrating the logic flow that relates the somewhat esoteric management root causes to the findings and concerns. The method used by the LANL Tiger Team to conduct the RCA was to assemble, for the Environmental, Safety and Health, and the Management Subteams, three independent root cause analysis groups (RCAG) to review the findings and identify the causes comprising the first tier, that is, the causes that are the most directly related to the findings. The next step was to ask why the first tier causes had occurred. The result of this yielded the second tier causes. The same question of "why?" can be applied at each tier until it is concluded that the highest level cause has been identified. For the purpose of the LANL Tiger Team, the Environmental and Safety and Health RCAGs focused their independent evaluations to the two tiers closest to the findings, while the Management RCG emphasized the higher tiers. Following the three independent RCAGs, an integrated Tiger Team RCAG was assembled. This RCAG was made up of representatives from each of the three subteams and the Tiger Team Leader. The process followed was similar to that used by the independent RCAGs--that is, repeatedly asking the question "why?" when considering the findings/concerns or the root causes in the lower tiers. The only difference between the processes was that Tiger Team RCAG began with the first and second tier root causes identified by the Environmental and Safety and Health Subteams, and consolidated them, together with the Management Subteam's perspective, to form the first and second tier root causes for the overall assessment results. The question "why?" was then 2-15 applied to these root causes until the question could no longer be answered and the top tier had been identified. The tiers were then represented in a schematic that illustrates their interrelationships. As a final check, the group reviewed the root cause structure to verify that the tiers flow logically from one to the another. Five root cause tiers were identified for the findings/concerns of the LANL Tiger Team Assessment. The root cause tier structure is presented in Figure 2-1. The Tiger Team considers the true root cause of the aggregate assessment findings and concerns to be this complete set of 18 interrelated causes. Sixteen of the causes are associated with LANL and two involve DOE guidance and support. The DOE-related causes are shown to the side of the overall structure, because although they are significant causes at their respective tiers, they do not necessarily relate to the causes in higher tiers. It must be recognized that because the focus of the root cause analysis was on the overall assessment, it will not necessarily be the case that every root cause will directly relate to each individual finding or concern. This is especially so for the first two root cause tiers. In some cases, the statement of the finding/concern may be equivalent to one of the identified causes. In those cases, the identified causes would more appropriately apply to the observations or specific problems that support the finding/concern. The preferred way to view the root cause structure is to not try to develop a direct correspondence between the causes and findings, but to recognize that these causes relate to basic deficiencies in the way LANL approaches ES&H protection. If a lasting improvement in ES&H performance at LANL is to be effected in a timely manner, it is necessary to develop and implement a plan to address all of the component causes in a coordinated, organized manner. The following discussion will address the potential causes in each tier, as they relate to LANL. Root Cause Tier 1 At the tier closest to the findings and concerns are the following six interacting potential causes: (1) a widespread lack of adequate procedures, (2) ES&H training is not comprehensive, (3) ES&H resources are not readily available, (4) there is no effective system of performance measures, (5) personnel do not have sufficient knowledge and understanding of ES&H requirements, and (6) individuals have not accepted ownership and accountability for ES&H. Procedures LANL has a general lack of procedures for the conduct of ES&H protection activities and activities that might have an ES&H impact. This situation exists both within the HS and EM Divisions and the line organizations. The implementation of ES&H protection at LANL, including procedure development, is the responsibility of the line organizations. The only Laboratory-wide guidance for the use or development of procedures relates to standard operating procedures, and this guidance is yery general without detailed requirements for format, content, or applicability. There are no formal. Laboratory-wide requirements for the use of stepwise procedures, or incorporation of ES&H considerations into any stepwise operating procedures. Where procedures do not exist they are often not properly implemented. As a consequence, the use of 2-16 Root Cause Tiers ES&H Culture ES&H Organizational Framework Root Cause Tier 4 Root Cause Tier 3 Roles/ Responsibility/ Authority Root Cause Tier 2 Resource Management Root Cause Tier1 Procedures Management ES&H Involvement ES&H Technical Knowledge «» Nonuniform Performance Requirements Training Resource Availability I DOE/HQ ~\ Policy Guidance ES&H Program Strategies Integration of ES&H Programs ; i AULAAO Direction/ Support .»^ Performance Measures Findings and Concerns FIGURE 2-1 ROOT CAUSE STRUCTURE Oversight Knowledge/ • j Understanding of Requirements Ownership/ Accountability ES&H-related procedures and the quality of the procedures is inconsistent, as is ES&H performance. Rather than operating from a complete set of well-coordinated, controlled, formal procedures, LANL has been relying upon an informal system based on verbal instruction, an informal system based on verbal instructions, informal memoranda, and the assumption that individuals will intuitively understand the ES&H aspects of their jobs. This approach has many weaknesses and can lead to frequent ES&H difficulties as a consequence of misunderstandings of the requirements and rapidly changing regulations. A system of well-coordinated formal procedures, including requirements for control and sitewide consistency, can be effective for clearly defining requirements to which individuals must conform. A complete set of accurate procedures can also serve as the basis for developing effective training programs and performance measures. Training Training in ES&H-related activities has not been sufficiently formal or coordinated to ensure that individuals receive all the training necessary for them to understand their roles, responsibilities, and job requirements related to ES&H. While LANL is staffed with skilled, motivated individuals who are generally extremely knowledgeable about the technical aspects of their jobs, ES&H is complex, and requires knowledge of many complex and varied regulations, standards, and good practices. Research personnel cannot be expected to independently review all available ES&H literature and determine what is applicable to their jobs. A more efficient and effective approach is to determine what information individuals require and provide it to them in a well-controlled manner. There is some formal training in ES&H, such as that for waste coordinators, but there has been no formal sitewide assessment of ES&H training needs, no formal system to verify that individuals receive the training they require, and no mechanism to measure training effectiveness. The knowledge necessary to manage ES&H cannot be effectively transferred through informal channels, because this does not provide the type of control that is necessary to ensure that individuals receive an adequate and consistent level of knowledge. Nor can it be gained through uncoordinated professional continuing education courses. If personnel are expected to be cognizant of the ES&H implications of their jobs, it is essential that they be provided with not only adequate procedures, but also the needed job-related training. Resource Availability The Tiger Team observed that there is insufficient availability of ES&H resources to individuals within the line organizations at LANL. If personnel are to properly address ES&H issues related to their activities, it is necessary that they have ready access to reliable sources of information, technical and regulatory assistance, and timely review of safety-related activities and issues. Many individuals at LANL do not understand how, or where, to obtain ES&H assistance, and 2-18 many have reported difficulty in contacting knowledgeable individuals. Even when the proper individuals are finally contacted, there have been delays in receiving the needed support. There have been particularly severe delays in reviews of procedures and ES&H-related activities. Performance Measures In general, LANL does not have a system of ES&H performance measures. An effective system to control ES&H-related activities requires that management, oversight groups, and individuals have accurate, timely information to judge whether these activities are being effectively accomplished. In other words, if individuals are expected to do a job properly, they must know whether or not they have done it right in the past. The ability to obtain such information requires that a comprehensive set of performance measures be developed and that they be incorporated into a system that provides for their documentation, tracking, trending, and evaluation for use in corrective action development. Such a system must go beyond such activities as formal audits which are often conducted only quarterly or annually and incorporate day-to-day measures of ES&H performance. While a system of performance tfieasures will not prevent occasional mistakes, they will help identify systemic weaknesses that are resulting in widespread, repeated ES&H problems. Knowledge/Understanding of Requirements One of the potential causes that the Tiger Team identified as being directly related to the findings is a general lack of knowledge or understanding of the requirements that govern the ES&H aspects of many activities. This cause is closely related to the procedure and training causes, but goes further to encompass an insufficient awareness of the importance of ES&H protection and the need to comply with ES&H requirements. The Tiger Team found that as a general rule, LANL personnel had a sincere desire to perform their jobs in accordance with good ES&H practices, but were often unaware of the requirements, and in some cases, unaware that their activities could have ES&H impact. In the case of the former, individuals sometimes devised their own "requirements" based upon their personal knowledge. This approach has produced results that are of variable effectiveness, but rarely fully compliant with appropriate regulations or standards. This weakness in knowledge and understanding of requirements includes individuals with the responsibility for addressing ES&H issues, such as Section and Group Leaders, Building Managers, and in some cases, even ES&H Officers. An example of this was in the area of accelerator interlocks where individuals were unaware of an American National Standards Institute (ANSI) standard for the design of interlock systems. Of even greater concern than a lack of technical understanding is a frequently observed misunderstanding of the importance of compliance with regulations and standards. It appears that some findings and concerns occurred in part because individuals believed that ES&H requirements were optional and they could make decisions on whether or not to comply on the basis of personal value judgements on the importance or technical validity of the requirement. Not everyone at LANL has recognized that conformance to regulations, DOE Orders, and 2-19 DOE-mandated standards is mandatory, and that if special considerations such as security or conflicting requirements dictate otherwise, prior approvals must be obtained. Ownership/Accountability One factor that was identified as a significant potential cause contributing to many of the findings and concerns is a widespread failure of individuals to accept "ownership" of the ES&H aspects of their jobs and to recognize their accountability for potential ES&H impacts. The Tiger Team often heard people specifically state, or at least imply that ES&H was the job of some other individual or organizational unit. Consequently, they made no effort to understand ES&H beyond what they were specifically told, and took no initiatives to prevent ES&H problems unless specifically tasked to do so. The positive note is that while such attitudes are not uncommon at LANL, they are by no means universal and there is evidence that ownership and accountability for ES&H is beginning to gain recognition. Root Cause Tier 2 While the first root cause tier most directly relates to the findings, the question that must be asked is why these causes exist. The RCAG identified four closely related causes at the second tierz: (1) ES&H resources are not being managed in an effective manner, (2) LANL has not established uniform ES&H performance requirements, (3) ES&H programs have not been developed and integrated into the Laboratory's activities, and (4) neither line managers nor any other LANL organizational unit have established effective oversight of ES&H activities. Resource Management Many individuals at LANL have attributed the cause of a number of problems to a lack of adequate ES&H resources. While there may be some validity to this, the Tiger Team has observed that a more pertinent issue may relate to the way in which existing resources are managed. The policy of LANL is that ES&H is a line management responsiblity. This is certainly an appropriate assignment of responsibility, but the manner of implementation has contributed to the resource management difficulties. With the acceptance of the concept of line management responsibility, there has been only limited sitewide control of ES&H policies, standards, and procedures. This has resulted in an extreme duplication of efforts as numerous organizational units maintained parallel efforts to develop standards and procedures for identical issues. An additional concern is the manner in which work assignments are identified. Since LANL does not have a coordinated system for ES&H resource management, organizational units, both line and support, have been primarily focusing their efforts on the basis of internal priorities without proper consideration of LANL's most pressing ES&H needs. A coordinated resource management system would allow LANL to make the most efficient use of existing resources by prioritizing Laboratory needs; identifying policies, standards, and procedures applicable on a Laboratory-wide basis; and assigning the appropriate 2-20 individuals to ES&H activities so that their skills are properly utilized and efforts are not unnecessarily duplicated. Non-Uniform Performance Requirements Another probable cause at the second cause root tier is the general lack of laboratory-wide, uniform ES&H performance requirements. This is one of the manifestations of LANL's approach to implementation of line management responsibility for ES&H, with each organization setting many internal ES&H policies and requirements. This has generally been done without coordination between organizational units and at times with little or no input from the ES&H support organizations. This has resulted in inconsistent ES&H performance, with some good practices, some poor ones, and some issues that are not addressed. If ES&H is to be properly addressed within LANL, it is essential that there be a laboratory-wide consistent set of ES&H policies and requirements with detailed implementation guidance, and these must be effectively communicated throughout the Laboratory. On September 20, 1991, the Laboratory Director issued a set of 15 mandatory ES&H policies. This is a good first step, but it is only a first step, and there remains much work to be accomplished before they can be translated into a workable set of ES&H requirements. Integration of ES&H Programs LANL has not organized its ES&H activities into a structured, well-coordinated set of discipline-specific programs. This has occurred in part because the collegial, informal management approach that LANL has successfully applied to research and development has also been applied to the accomplishment of ES&H objectives. Unfortunately, ES&H protection requires a more formal, organized approach that includes some elements of discipline that are not common to research activities. ES&H protection is complex, requiring the integration of many regulations, DOE Order requirements, and mandatory standards, and coordinating the activities of the many organizational units within LANL. This can be accomplished only through planning, development, and implementation of detailed, well-considered, structured programs that address the ES&H-related responsibilities of all operations. The relationship between all corollary plans, programs, procedures, and operations must be clearly established and well defined. The basic precepts and technical details must be communicated to the appropriate personnel through procedures, training, and other means, and a system for tracking performance must be in place to keep management apprised of the effectiveness of programs and the status of conformance to requirements. Oversight LANL does not have an effective system of oversight by either line management or any other organizational unit. There is no mechanism for any organization to provide consistent interpretation of policies and standards, mandate and verify their implementation, provide timely evaluations of ES&H performance, or enforce corrective actions. It is 2-21 essential that oversight systems be in place. Without them, there can be neither ensurance or assurance of adequate ES&H performance, nor any mechanism to identify problem areas and, as necessary, elevate ES&H issues to higher levels of management for resolution. Oversight that does occur at LANL is informal in nature with no requirements, little documentation, and no formal followup. When ES&H problems are identified, the resolution is handled informally, and if difficulties in resolution are encountered, the issues are to be elevated to higher levels of management only through the personal initiative of the individuals involved. Root Cause Tier 3 As was the case with Tier 1, there are underlying causes for Tier 2. Four interacting causes were identified at the third root cause tier: (1) on a Laboratory-wide basis, organizational and individual roles, responsibilities, and authorities are not well defined, or well understood; (2) ES&H technical knowledge of management is weak; (3) LANL does not have knowledge of or experience with the strategies needed to develop ES&H programs; and (4) there has been a lack of ES&H direction and timely response to ES&H issues from AL and LAAO. Roles, Responsibilities, and Authorities The first Tier 3 cause is that roles, responsibilities, and authorities, for ES&H protection are not clearly defined or understood at all levels of the organization. This applies to both individuals and organizational units. The responsiblity for ES&H is delegated to the line organizations; however, it has not been clearly defined how they are held accountable for ES&H performance. In addition, it is not clear to what extent any organization within LANL has the responsibility to develop environmental programs and standards, or the authority to establish them as sitewide requirements and, subsequently, enforce adherence to them. While individuals appear willing to comply with ES&H requirements, they generally do not understand their roles in ES&H protection, the level of responsibility, or the authority they have to take action to prevent ES&H difficulties. Knowledge of ES&H Program Strategies The design and implementation of environmental programs can be difficult, because of the many regulatory requirements that must be addressed and the wide variety of skills and disciplines that are needed. This requires that individuals responsible for these programs have an understanding of and experience with the techniques that can be used to manage complex, multidisciplinary activities and organizations. The management of ES&H protection activities requires the development of organizational and implementation strategies that will provide sufficient control and oversight to ensure that ES&H issues are considered in the conduct of all activities within LANL, whether performed by line organizations or support organizations. ES&H activities at LANL have not traditionally been managed as a part of an integrated sitewide program. The Tiger Team has not seen convincing evidence that LANL has a sufficient depth of knowledge and experience 2-22 with the type of all encompassing organizational and planning strategies that are necessary to effectively develop and implement ES&H programs. ES&H Technical Expertise One of the keys to development and implementation of a successful ES&H program is the presence of appropriate ES&H technical expertise at all levels within an organization. While it is clearly neither necessary nor practical for all managers to be ES&H experts, a certain level of ES&H understanding is needed to enable them to recognize the potential ES&H impacts associated with activities for which they are responsible. Further, it is essential that managers have available either within their own organizations, or through effective support organizations, technical expertise to aid them in implementing their ES&H responsibilities. The Tiger Team has observed that many LANL managers do not have a sufficient understanding of ES&H principles to allow them to recognize what must be done to achieve ES&H excellence. The Tiger Team further observed that the qualifications, responsibilities, and activities of ES&H support personnel, within both the line and the support organizations, are not sufficiently well defined to ensure that managers and staff at LANL are receiving consistent, technically accurate, and timely guidance and support. The team further observed that there is no mechanism in place to ensure that individuals assigned ES&H responsibilities, such as ES&H Officers, Waste Coordinators, and Group Laser Safety Officers have sufficient qualifications or training to properly fulfill their responsibilities. ES&H Implementation Guidance and Support by AL and LAAO In several instances, AL and LAAO have not developed site-specific ES&H policy implementation guidance for the Laboratory. This lack of guidance is the result of AL not having developed an adequate process for interpretation, consolidation, and coordination of Headquarters ES&H policy. This guidance by AL and two-way communication between AL and the Laboratory is essential in achieving a coordinated understanding of ES&H policy at all levels. A lack of AL coordination and direction on ES&H policy has led to contractor confusion caused by conflicting policy statements and requirements. AL and LAAO actions which are necessary for the completion of Laboratory work processes are not always timely. For example, late issuance of ES&H external assessment reports by AL and the lack of timely response on corrective action closeout by LAAO and AL impedes the Laboratory work process and diminishes the DOE credibility in support of self-assessment. Root Cause Tier 4 At the fourth root cause tier, the RCAG identified three interacting causes that potentially resulted in the Tier 3 causes: (1) management has not become sufficiently involved with ES&H, (2) there is no effective organizational framework for the management of ES&H activities, and (3) there has been insufficient guidance from DOE Headquarters for the implementation of policies. 2-23 Management Involvement in ES&H There is not a strong, focused, personal involvement by all levels of Laboratory management, across all organizations, to assure that ES&H policy is implemented through proper programs and procedures and that issues and problems which inhibit policy implementation are recognized and resolved in a timely way. Policies intended to improve ES&H performance in Laboratory operations have been issued by the Director's Office. However, in many instances, these policies have been "passed through" by the Associate Directors without the development of programs and procedures for implementation. In some cases, this has led to the development of programs and procedures by the lower level organizational units responsible for work performance, while in other cases, organizations have done nothing at all. Managers have not taken active ownership to cause the Laboratory's objectives to be realized throughout the Laboratory. Not all programmatic line personnel and ES&H personnel have fully understood their responsibility and authority for implementing sound ES&H practices throughout the Laboratory. Additionally, not all personnel are fully cognizant of ES&H institutional requirements in the conduct of their day-to-day activities. ES&H Organizational Framework The Tiger Team determined that the lack of an effective ES&H organizational framework is one of the principal causes at the fourth tier. LANL has not developed a management organizational framework by which ES&H functions and requirements can be implemented in a consistent and sustainable manner. One of management's primary responsibilities is to provide an organizational structure which can establish the policies, processes, and formalities whereby the program can function. The Secretary of Energy has established that compliance with ES&H requirements is as important a mission as production or research and development. The position of the ES&H organization within the LANL organizational structure, the authority granted to the organization, and the resources provided, all need to reflect this importance. Headquarters Policy Implementation Guidance The Tiger Team found the deficiencies were due, in part, to the lack of ES&H policy guidance from Headquarters Program Secretarial Offices (PSOs). DOE-HQ PSOs for Los Alamos National Laboratory have not provided the necessary ES&H policy implementation guidance to AL, LAAO, and LANL. DOE-HQ develops policies for its various program activities. Guidance for policy implementation is usually documented in supplemental directives and program guidance letters. This policy implementation guidance is developed and processed through PSOs to provide direction to the various DOE Field Offices, Area Offices, and contractors. Historically, this process has produced either a lack of timely guidance or differing guidance and requirements imposed by the various PSOs regarding implementation of ES&H requirements, thus causing confusion, 2-24 excessive efforts to coordinate, and generally inconsistent approaches, which undermine an effective and efficient ES&H program. Root Cause Tier 5 At the fifth and final root cause tier, is one cause: LANL has not yet successfully fostered a positive ES&H culture throughout the Laboratory. Culture The culture of ES&H excellence, which is the focal point of the Secretary's 10-Point initiative, is not exhibited across the Laboratory. Historically, the Laboratory's predominant objective has been to support the Nation's nuclear deterrent. The preeminent importance of research and the value of the individual's pursuit of knowledge led to organizational structures which typically have not addressed cross-cutting issues. There has also been a limited role for external parties in the operation of the Laboratory. This situation has been the norm for almost 50 years. Today, the Laboratory organization is more complex as are the conditions and requirements under which it operates. Integration of Environment, Safety, and Health with the programmatic mission requires a more comprehensive outlook and demands a higher degree of individual and collective ownership. The individual pursuit of knowledge and the collective need to protect Environment, Safety, and Health are not mutually exclusive objectives. Accordingly, achievement of these objectives demands that managers and staff members exhibit a level of commitment to ES&H which is comparable to the degree of excellence that they have achieved in the pursuit of scientific and technological challenges. To date, the Laboratory has not effected the crucial elements of cultural change of staff acceptance of and accountability for ES&H. The Laboratory has recognized that circumstances are different and has initiated steps to effect the necessary changes. It is apparent that the Director's Office is firmly committed to redirect and modify the culture at the Laboratory. However, it is evident that the Laboratory at large has not recognized or accepted that a transformation of the magnitude required necessitates several fundamental elements, including the following: an organizational structure which establishes ES&H as a critical, independent element whose functions are implemented in an integrated fashion across the Laboratory; a recognition of ownership and a management commitment at all levels which is effective and focused to ensure that the ES&H mandate is clear and permeates the entire organization; a philosophy of conducting the work process which emphasizes formality of operations to the same extent that it expects excellence in the conduct of research and development; and 2-25 an awareness that successful implementation of ES&H within the Laboratory requires an individual as well as a collective attitude regarding its importance. Finally, it must again be emphasized that the Tiger Team has not identified a single independent factor as the root cause of the LANL assessment. Rather, the "true" root cause is considered to be the set of 18 interacting causes discussed above. Any plan to correct the root cause of this assessment must consider all of the elements of the root cause structure, and address them in a coordinated manner. 2-26 3.0 ENVIRONMENTAL ASSESSMENT 3.0 ENVIRONMENTAL ASSESSMENT 3.1 PURPOSE This section presents the findings developed by the Environmental Subteam during the Tiger Team Assessment of the Los Alamos National Laboratory (LANL), Los Alamos, New Mexico. The assessment was conducted from September 23 through November 8, 1991, LANL is a U.S. Department of Energy (DOE) multiprogram research and development (R&D) laboratory. The scope of the environmental assessment included LANL, the DOE Field Office, Albuquerque (AL), and Los Alamos Area Office (LAAO). Johnson Controls World Services, Inc., and EG&G/Energy Measurements EG&G/EM, Los Alamos Operations were also assessed by the Environmental Subteam. The results of the environmental portion of the Tiger Team Assessment will provide the Secretary of Energy with information on current environmental regulatory compliance status and associated vulnerabilities of each facility, root causes for noncompliance, adequacy of DOE and site contractor environmental management programs, and response actions to address the identified problem areas, and it will aid in tracking DOE-wide environmental compliance trends. 3.2 SCOPE The scope of the environmental assessment of LANL was comprehensive, covering all environmental media and applicable Federal, state, and local regulations and requirements, DOE Orders, and best management practices. The environmental disciplines addressed in this assessment include air; surface water; groundwater, soil, sediment and biota; waste management; toxic and chemical materials; quality assurance; radiation; inactive waste sites; and requirements of the National Environmental Policy Act (NEPA). Both the size of the Laboratory and complexity of programs precludes an indepth assessment of every facet of environmental operations. It should, therefore, be noted that while a comprehensive evaluation was made of issues affecting the environment, the Environmental Subteam did not visit every installation at the Laboratory. 3.3 APPROACH The Environmental Subteam assessment of LANL was conducted in accordance with the Tiger Team Guidance Manual (February 1990) and followed accepted assessment techniques. The assessment was conducted by a team managed by a Team Leader and Assistant Team Leader from the DOE Office of Environmental Audit, an Assistant Team Leader from the Nevada Field Office, and technical specialists from other DOE offices and support contractors. The names, responsibilities, affiliations, and'biographical sketches of the subteam members are provided in Appendix A-2. The environmental assessment of LANL, included three phases: planning, onsite activities, and reporting. The Environmental Assessment Plan, which outlines the key issues to be addressed, the general approach, and specific onsite activities, is provided in Appendix B. The Environmental Subteam Tentative Agenda, included as part of the Environmental Assessment Plan, details the planned daily activities of the team. The finalized daily agenda is included as Appendix C. Appendices D and E reflect the Contact/Interviews and Site 3-1 Documents, respectively, that the Environmental Subteam used in developing its assessment and findings. In addition to LANL, EG&G/EM, Los Alamos Operations facility was also assessed. While not part of the Laboratory, EG&G/EM operations were included within the scope of the assessment because of proximity to LANL and association with the Laboratory. One best management practice finding relating to waste management at EG&G/EM is presented in Appendix I. A pre-assessment site visit was conducted August 27 through 29, 1991, to describe the purpose and assessment methodology to LANL, AL, and LAAO personnel. Meetings were held with State of New Mexico and local environmental regulators, collective bargaining unit officials, and representatives of the Indian Nations to explain the process and to identify their ES&H concerns. The onsite activities for the environmental assessment took place from September 23 through November 8, 1991. Onsite activities included document review; observation of site operations; interviews with DOE and site contractor staff, and personnel from Federal, state, and local regulatory agencies; review of previous surveys, audits, and self-assessments; Environmental Subteam daily debriefs; and the development of the findings presented in this section of the report. The approach used by the Environmental Subteam was to identify findings in three categories: compliance findings (CFs), best management practice findings (BMPFs), and noteworthy practices (NWPs). Compliance Findings are conditions that, in the judgment of the assessment team, may not satisfy environmental regulations, applicable DOE Orders (including internal DOE memoranda, where referenced), consent orders, agreements with regulatory agencies, or permit conditions. When programs or procedures are not sufficiently developed or implemented to ensure compliance, then any related issues are considered compliance findings, A failure to follow internal procedures may also be considered a compliance finding, if in the judgment of the team, the intent of the procedure is to support environmental compliance. Best Management Practice Findings are conditions, in the judgment of the assessment team, where best management practices could and should be employed. The BMP findings are based on regulatory guidance, accepted industry procedures and practices, and professional judgment of the team members. Noteworthy Practices are those practices which, in the judgment of the assessment team, are beneficial and unique, would have general application to other DOE facilities, and should be documented for the purpose of information transfer. 3.4 ENVIRONMENTAL ASSESSMENT SUMMARY The Environmental Subteam identified 114 findings in its assessment of LANL. None of the findings reflect situations that present a near-term threat to public health or the environment. There are 105 findings reflecting problems 3-2 that satisfy the definition of a compliance finding. Nine findings represent conditions in which best management practices are not employed. The titles of the environmental findings are presented in Table 3-1 by media or discipline, as appropriate. The Environmental Subteam did not identify any noteworthy practices; although, some technical practices were found to be implemented in a superior fashion. For example, LANL has (1) taken proactive steps in recovery and recycling of chlorinated fluorocarbon refrigerants, (2) conducted advanced studies in closure cap designs which are being incorporated into the environmental restoration activities, and (3) operates an acoustic sounder to obtain atmospheric data for dispersion analysis. As part of the Environmental Subteam assessment, other reports on environmental compliance or environmental problems at LANL were reviewed. These reports included the LANL Self-Assessment Report (September 1991), DOE-AL Self-Assessment Report (September 1991), and the Los Alamos Area Office Self-Assessment Report (September 1991). The subteam reviewed the self-assessment reports to evaluate the effectiveness of the site's self-assessment in relation to the Tiger Team environmental assessment findings. The LANL Self-Assessment Report is discussed in each individual finding. Section 6,0 addresses all three self-assessments. Environmental Assessment Key Findings One of the objectives of the Environmental Subteam was to assess the effectiveness of environmental programs and environmental program management at LANL, DOE Orders, Federal and state regulations, and consensus standards lay the foundations upon which DOE strives to build its environmental programs. How effectively these requirements and standards are implemented is assessed by each of the Environmental Subteam specialists within their technical disciplines. The Environmental Subteam evaluated overall program effectiveness and concerns which may affect long-term implementation and resolution of deficiencies identified. The Environmental Subteam identified four key findings, each of which is comprised of multiple findings, or portions of individual findings from Section 3.5. In some cases, the component findings, taken individually, might not appear to be significant enough to be identified as key, but collectively they represent those issues of greatest concern. The key findings are as follows: Inadequate Sitewide Programs for the Management of Wastes. The management of hazardous, radioactive, mixed, and solid wastes is inconsistent throughout LANL. The authority and responsibility for waste generating activities have been delegated to the line organizations. Responsibilities for the management of waste are not well understood by these organizations and are generally not sufficiently well defined or formalized to ensure compliance with DOE Orders or regulatory requirements. Key deficiencies were noted in LANL's waste acceptance criteria and waste characterization and certification programs. In addition, accountability and oversight of waste generating and management practices are weak. 3-3 TABLE 3-1 ENVIRONMENTAL FINDINGS Air (A) A/CF-1 A/CF-2 A/CF-3 A/CF-4 A/CF-5 A/CF-6 A/CF-7 A/CF-8 (NESHAP) for Radionuclides from DOE Facilities Radioactive Air Effluent Monitoring Program Control of Radionuclide Emissions Radiological Ambient Air Sampling Meteorological Data Acquisition Programs Asphalt Plant Open Burning TA-16-1409 Incinerator Surface Water/Drinking Water (SW) SW/CF-1 SW/CF-2 SW/CF-3 SW/CF-4 SW/CF-5 SW/CF-6 SW/CF-7 SW/CF-8 SW/CF-9 SW/CF-IO SW/CF-11 SW/CF-I2 SW/CF-13 SW/BMPF-1 National Pollutant Discharge Elimination System (NPDES) Permit Programs - Permitting of Point Source Discharges National Pollutant Discharge Elimination System (NPDES) Permit - Compliance with Effluent Limits Programs for Compliance with Water Discharge Requirements Quality and Characteristics of Wastewater Discharging to National Pollutant Discharge Elimination System (NPDES) Outfalls Operation and Maintenance of Processes Discharging to National Pollutant Discharge Elimination System (NPDES) Outfalls Effluent Monitoring and Environmental Surveillance Programs Stormwater Pollution Control Spill Prevention Control and Countermeasure Plan Spill Prevention Control and Countermeasure Plan Implementation Backflow Prevention and Cross-Connection Control Program Drinking Water Program Septic System Program National Pollutant Discharge Elimination System (NPDES) Monitoring and Reporting Radioactive Liquid Waste Treatment Plant Characterization of Effluent Quality in NPDES Permit Reapplication Groundwater/Soil. Sediment, and Biota (GW) GW/CF-1 GW/CF-2 GW/CF-3 GW/CF-4 GW/CF-5 Groundwater Protection Management Program Plan Sitewide Hydrogeologic Monitoring Well Network Groundwater Sampling Procedures Environmental Surveillance Program Control of Radiologically Contaminated Soils and Sediments 3-4 TABLE 3-1 (Continued) ENVIRONMENTAL FINDINGS GW/BMPF-I GW/BMPF-2 GW/BMPF-3 Closure and Protection of Wells and Boreholes Seismic Hazard Analysis Groundwater Discharge Plan Waste Management (WM) WM/CF-1 WM/CF-2 WM/CF-3 WM/CF-4 WM/CF-5 WM/CF-6 WM/CF-7 WM/CF-8 WM/CF-9 WM/CF-IO WM/CF-11 WM/CF-12 WM/CF-13 WM/CF-14 WM/CF-15 WM/CF-16 WM/CF-17 WM/CF-18 WM/BMPF-1 Waste Characterization Hazardous Waste Management Training Management of Wastes in Temporary Storage Areas Manifesting of Hazardous Waste Pre-Transportation Requirements Characterization of Surface Impoundments Contingency Plan Hazardous Waste Minimization Program EPA Identification Number for Fenton Hill Site Management of Excess Government Personal Property Los Alamos County Landfill Underground Storage Tank Program Low Level Waste Segregation Low-Level Waste Volume Reduction Low-level Waste and Mixed Waste Certification Low-Level and Mixed Waste Acceptance Criteria Mixed Waste Storage at TA-54 Transuranic Waste Signature Authority for RCRA Permit Applications Toxic and Chemical Materials (TCM) TCM/CF-1 TCM/CF-2 TCM/CF-3 TCM/CF-4 TCM/CF-5 TCM/CF-6 TCM/CF-7 TCM/CF-8 TCM/CF-9 TCM/CF-IO TCM/CF-Il TCM/CF-12 TCM/CF-13 TCM/CF-14 TCM/BMPF-1 Registration of Polychlorinated Biphenyl (PCB) Transformers Development and Maintenance of Polychlorinated Biphenyl (PCB) Inventory and Records Storage of Combustible Materials Near Polychlorinated Biphenyl (PCB) Transformers Storage of Radiologically Contaminated Polychlorinated Biphenyl (PCB) Wastes Management of Polychlorinated Biphenyl (PCB) Spill Cleanups Asbestos Management Program Oversight and Coordination of Pesticide Program Pesticide Disposal and Storage Practices Program for Handling and Storage of Chemical Materials Toxic and Chemical Materials Purchasing Toxic and Chemical Materials Inventory System Toxic and Chemical Materials Packing, Transport, and Receiving Storage of Compressed Gases Community Right-to-Know Use of Perchloroethlyne in Polychlorinated Biphenyl (PCB) Transformer Retrofilling Operations 3-5 TABLE 3-1 (Continued) ENVIRONMENTAL FINDINGS Quality Assurance (QA) QA/CF-1 QA/CF-2 QA/CF-3 QA/CF-4 QA/CF-5 QA/CF-6 QA/CF-7 QA/CF-8 QA/CF-9 QA/CF-IO QA/CF-1I QA/CF-12 QA/CF-13 QA/CF-14 QA/CF-15 QA/CF-16 QA/BMPF-1 LANL Quality Assurance Program Plans Environmental Management Quality Assurance Environmental Laboratory Procedures Quality Assurance Procedures Procurement Process for Materials and Services Computer Program Validation Document Control Standards and Instrument Calibration Chain-of-Custody Sample Storage Recordkeeping Environmental Management Division Records Management Program Environmental Quality Assurance Audit and Appraisal Corrective Action Program Johnson Controls World Services, Inc. (JCI) Quality Assurance Program (QAP) DOE Oversight of Environmental Activities Laboratory Workspace Radiation (RAD) RAD/CF-1 RAD/CF-2 RAD/CF-3 RAD/CF-4 RAD/CF-5 RAD/CF-6 RAD/CF-7 RAD/CF-8 RAD/CF-9 RAD/CF-IO RAD/CF-1I RAD/CF-12 RAD/CF-13 RAD/CF-14 RAD/BMPF-1 Environmental Thermoluminescent Dosimetry (TLD) Program Environmental Monitoring Plan Preoperational Environmental Studies of Facilities, Sites, and Operations Radiological Environmental Emergency Planning Outdoor Storage of Materials Contaminated with Radioactivity Contamination Control of Outdoor Areas Radiological Posting of Outdoor Areas Liquid Discharges to Previously Contaminated Areas Liquid Radiological Effluent Monitoring Best Available Technology Analysis for Liquid Waste Discharges Tritium Control in Liquid Waste Streams Radioactive Effluent/Onsite Discharge Reports Radiological Environmental Surveillance at Inactive Waste Sites Program for Decommissioning Contaminated Facilities Annual Site Environmental Report 3-6 TABLE 3-1 (Continued) ENVIRONMENTAL FINDINGS Inactive Waste Sites (IWS) IWS/CF-I IWS/CF-2 IWS/CF-3 IWS/CF-4 IWS/CF-5 IWS/CF-6 IWS/CF-7 IWS/CF-8 IWS/CF-9 IWS/CF-10 IWS/CF-11 IWS/CF-12 IWS/BMPF-1 Sitewide Integration of the Environmental Restoration Program Review of Construction Projects for Environmental Restoration Management of Transferred Inactive Waste Sites Management of Inactive Underground Storage Tanks Resource Planning and Control Release Reporting Procedures HSWA Module Permit Milestones Appraisal of Environmental Restoration Program Activities Risk Management Natural Resource Damage Assessments Administrative Record Community Relations for the Environmental Restoration Program Characterization of Inactive Waste Sites National Environmental Policy Act (NEPA) NEPA/CF-1 NEPA/CF-2 NEPA/CF-3 NEPA/CF-4 NEPA/CF-5 National Environmental Policy Act (NEPA) Determinations National Environmental Policy Act (NEPA) Documentation National Environmental Policy Act (NEPA) in Planning and Budget Review Adequacy of National Environmental Policy Act (NEPA) Documents National Environmental Policy Act (NEPA) Procedures and Recordkeeping 3-7 Inadequate Identification, Monitoring, and Control of Effluent Releases. LANL does not have the necessary programs in place to ensure accurate identification, monitoring, or control of effluent releases. Deficiencies have been noted in a number of the key program elements for air quality protection and water discharges. LANL does not have a comprehensive program to monitor or characterize effluent, releases, and the programs to control, reduce, and mitigate releases were found deficient. The inadequacy of the monitoring programs undermines the foundation for future NEPA reviews, permit documentation, and demonstration of compliance with DOE Orders and requirements and U.S. Environmental Protection Agency (EPA) regulations. Inadequate Regulatory Permit Strategy and Management. The management of environmental permits is fragmented and lacks an overall strategy and approach to ensuring compliance. Often, permit requirements are not clearly understood by the line managers responsible for compliance with the permit. Management has delegated responsibilities for permit compliance to such a level that noncompliances cannot be effectively addressed and corrective actions implemented. Several findings relating to out-of-compliance conditions with permits were fully identified in the LANL Self-Assessment, yet the Environmental Subteam found little effort being made to address these issues or implement corrective actions. Both a lack of understanding of the responsibilities for compliance as well as lack of effective line oversight and accountability hampers LANL's ability to develop effective long-term permit strategy and management programs. Lack of Oversight of Environmental Activities, A key component of several environmental findings is a general lack of oversight of environmental activities. Line management has the responsibility for implementing environmental protection requirements, but no organization has been assigned responsibility for developing environmental policies and standards, there is no formal mechanism to monitor environmental performance, and no organization below the Director's Office has been delegated the authority to enforce compliance with environmental standards or mandate corrective actions. Further compounding the problems related to LANL's lack of internal oversight is that neither AL nor LAAO are providing effective oversight of LANL environmental activities. 3.5 ENVIRONMENTAL FINDINGS The findings are presented in sections identified by media (e.g., air and surface water/drinking water), or regulation (e.g., National Environmental Policy Act). Titles chosen for the individual findings are topical, rather than descriptive. Each finding is preceded by a Performance Objective. The Performance Objectives for compliance findings are derived from promulgated environmental regulations and applicable DOE Orders and policies, compliance agreements, and facility permit conditions. The Performance Objectives for best management practice findings are derived from regulatory agency guidance, accepted industry practices, and the professional judgment of the technical specialists. The findings within each section are not arranged in order of relative significance. Parenthetical references in Section 3.0 refer to document and interview citations listed in Appendices D and E, respectively. 3-8 3.5.1 Air 3.5.1.1 Overview The air assessment of LANL consisted of an evaluation of current practices at the facility,with regard to (1) regulations promulgated under the Clean Air Act by the EPA, New Mexico Air Quality Standards and Regulations, and permits issued by the New Mexico Environment Department (NMED) pursuant to those regulations; (2) DOE Orders; and (3) best management practices. A list of the air regulations, DOE Orders, and guidelines used in this assessment is provided in Table 3-2, The general approach to the air portion of the assessment included the following activities: (1) an examination of major facilities and major sources, including emission control and emission sampling and monitoring programs and systems; (2) an examination of ambient air surveillance and meteorological monitoring programs and systems; (3) interviews with personnel in LANL's Health & Safety, Environmental Management, Facilities Engineering, and Mechanical Fabrication Divisions as well as in the technical line divisions, Johnson Controls World Services, Inc. (JCI), LAAO, and NMED; and (4) a review of site documents, including air permits, correspondence with regulatory agencies, standard operating procedures, the Environmental Surveillance at Los Alamos During 1989 report, and various other internal documents. Air contaminant emissions at LANL include both radioactive and nonradioactive materials. The radioactive air emissions are regulated by DOE Orders and the "National Emission Standards for Emissions of Radionuclides Other than Radon from DOE Facilities," 40 CFR 61, Subpart H, The nonradioactive air emission sources at LANL are regulated by the NMED, which ensures consistency with Federal regulations. Airborne radioactive emissions are continuously sampled or monitored at 87 release points (A-2), Radionuclides released to the atmosphere during 1990 included gaseous activation products, tritium and tritium oxide; argon-41; mixed fission products; phosphorus-32; uranium-234, -235, and -238; and plutonium-238, -239, and -240; and americium-241 (A-29). The major source of radionuclides released to the atmosphere was the Los Alamos Meson Physics Facility (LAMPF), which released gaseous activation products. Approximately 95 percent of the committed effective dose equivalent from measured releases at LANL were attributable to LAMPF activation products. Tritium and tritium oxide releases occurred from operations at TA-3, TA-21, TA-33, TA-35, TA-4I, TA-53, and TA-55, with approximately 69 percent originating at TA-41-47, where gaseous tritium is handled. Mixed fission products were largely attributable to TA-48-1, the Radiochemistry Site, A large portion of the total plutonium emissions was from a single stack (FE-19) at the Chemical and Materials Research Building (CRM) in TA-3, These emissions are continuing to occur, but in varying levels from year to year (see Finding A/CF-3), Estimation of the committed effective dose equivalent values to members of the public resulting from radionuclide emissions from LANL sources is performed using the CAP-88 version of the EPA-required AIRDOS model. The maximum committed effective dose equivalent to a member of the public for 1990 was 8.1 mrem (A-29). The EPA has indicated that this committed effective dose equivalent from LANL sources meets the standard established in 40 CFR 61.92; however, the EPA has also indicated that a Notice of Noncompliance would soon 3-9 TABLE 3-2 LIST OF AIR REGULATIONS/REQUIREMENTS/GUIDELINES (filiations/ ftequiremetits/ Qaiileline$ ; Secti«fi$/Tit1e 1 Authority 40 CFR 60 Standards of Performance for New Stationary Sources EPA 40 CFR 61, Subparts A and H National Emission Standards for Hazardous Air Pollutants EPA Regulation of Fuels and Fuel Additives EPA 1 40 CFR 80 New Mexico Air Quality Standards Sections 100 through 1301 NMED DOE 5400.1 General Environmental Protection Program DOE DOE 5400.5 Radiation Protection of the Public and the Environment DOE DOE 5480.19 Conduct of Operations for DOE Facilities DOE 1 DOE 6430.lA General Design Criteria DOE 1 D0E/EH-0173T Environmental Regulatory Guide for Radiological Effluent Monitoring and Environmental Surveillance DOE 3-10 1 1 be forthcoming with regard to issues related to radionuclide emission sampling and monitoring activities at LANL (A-19) (see Findings A/CF-1 and A/CF-2). Radiological ambient air sampling is performed at 39 stations. Thirty-two of the samplers form the routine environmental surveillance air sampling network (onsite, perimeter, and regional), five samplers are used for monitoring in and around waste disposal sites, and two samplers are used to take duplicate samples for the quality assurance program. Samplers are operated continuously to measure airborne concentrations of tritium, isotopes of uranium (uranium-234, -235, and -238), and plutonium (plutonium-238, -239, and -240). Americium-241 is monitored at 11 of the locations, and radioiodines are monitored at 6 of the locations. Local meteorological conditions are determined from continuous measurements from a network of four meteorological towers and a Doppler sodar; two additional meteorological towers that have been installed are awaiting instrument installation. Precipitation, relative humidity, solar radiation, wind turbulence intensities, and temperature are measured at all four meteorological towers. Dataloggers for each tower compute and record the average values of all signals every 15 minutes. The Doppler sodar uses acoustic energy to probe the atmosphere and provides profiles of wind speed and direction up to 700 meters above ground. Several sources of nonradioactive air contaminants are located at LANL, including a power plant at TA-3 and two steam plants at TA-16 and TA-21, These facilities normally burn natural gas, but are also capable of burning fuel oil. Typical emissions are particulate matter, nitrogen oxides, carbon monoxide, hydrocarbons, and when burning fuel oil, sulfur dioxide. No emission control devices are required. Visible emission opacity observations are required on the stack exhausts, and nitrogen oxides measurements are made on exhausts from the power plant stacks. An asphalt plant is operated in TA-3 to produce an asphalt concrete mix for road and parking lot paving and patching. The plant uses natural gas to heat and dry the aggregate and to melt the asphalt, the two of which are combined to produce the paving mixture. Typical emissions consist of particulate matter and hydrocarbons. The plant is equipped with a cyclone separator and wet scrubber to control particulate matter emissions in the exhaust stream. Periodic observations of visible emissions opacity are required (see Finding A/CF-6). Open burning is practiced in TA-11 to evaluate the effects of fire on ordnance devices and shipping containers, in TA-16 to dispose of bulk high explosives (HEs) and HE-contaminated materials, and in TA-36 to dispose of wood waste potentially contaminated with HEs. Emissions consist of nitrogen oxides, particulate matter, carbon monoxide, and hydrocarbons. Some of these operations have obtained permits from the NMED while others have not (see Finding A/CF-7). Disposal of bulk HEs by burning does not require a permit. Beryllium operations are conducted in several locations in TA-3 and one location in TA-35. Exhaust streams from these operating areas are filtered to minimize emissions of beryllium dust to the atmosphere. These operations have permits from the NMED and have demonstrated compliance with very strict emission limitations specified in those permits. A permit application is being filed to cover beryllium activities at TA-55. 3-11 A lead melting and casting operation that has potential for emission of lead particles and fumes is located in TA-3, The operation is of a small enough scale that no permit is required and essentially no potential exists for ambient air concentrations to exceed air quality standards. Landfill operations at Area G of TA-54 include a low-level radioactive waste landfill. The low-level radioactive waste landfill is equipped with a sprinkler system that is to be used to minimize the potential for resuspension of radiologically contaminated dust from the landfill. Road surfaces in this area are not paved and, as a result, wind and vehicular movements tend to resuspend particulate matter into the atmosphere, A water-distribution truck is being obtained to spray road surfaces to minimize particulate matter emissions. Volatile organic compounds are released to the atmosphere as a result of solvent uses at TA-16-340 and from paint spray booths in TA-3. These facilities are small emission sources that are being included in an emissions inventory data base currently in preparation. An incinerator is used in TA-16 to burn solid combustible waste that is contaminated with HE residues. The facility is permitted under Hazardous Waste Permit No. NM 0890010515-1. New Mexico Air Quality Control Regulation (NMAQCR) 401 limits visible emissions from stationary combustion sources to an opacity of less than 20 percent. There is no requirement for an air permit. Recent opacity observations were in excess of the 20 percent limit (see Finding A/CF-8). An emissions inventory is being assembled for nearly 700 substances considered by NMED to be toxic air pollutants. An estimated 1,200 sources will be involved in the inventory, which is being entered into a computerized data base. Only one substance, lithium hydride, has potential emissions large enough to have required registration with the NMED. During the course of the air portion of the environmental assessment at LANL, personnel interviewed in the Environmental Management Division, the Health and Safety Division, the line organization, and JCI gave the impression that there is genuine interest in providing proper protection to air quality. Beyond the fact that there is interest being displayed by these persons, an almost universal comment was that personnel and funding were not adequate to achieve desired goals in a timely fashion, such as evaluation and upgrade of the emission monitoring systems for sources of radionuclide emissions to the atmosphere. The informality of operations is perceived by the Tiger Team to be a contributing cause of some of the problems observed during the environmental assessment. On the other hand, some activities at LANL are considered to be positive and even proactive. Activities at LANL that are considered to be positive aspects of the operations include (1) the program for periodic in-place testing of air-filtration-system efficiency, (2) the program for periodic measurement of stack exhaust flow rates, (3) proactive recovery and recycle of chlorinated fluorocarbon refrigerants from air conditioners and refrigeration systems in advance of regulatory requirements, (4) preparation and update of an emissions inventory data base, and (5) operation of an acoustic sounder (Sodar) to obtain atmospheric data useful in dispersion analyses. 3-12 The air portion of the Environmental Subteam assessment identified eight compliance findings. These findings deal with the following subjects: lack of formality of operations and release of particulate matter in excess of the allowable limit at the asphalt plant, open burning of materials contaminated with HEs without permits from the NMED, issues regarding measurement of radionuclide emissions, inadequacies related to control of radionuclide emissions, problems with continuous air monitors and alarm systems on radiological stack effluents, issues regarding the ambient air surveillance for radionuclides, meteorological program problems, and opacity exceedances at an incinerator. As part of the Environmental Subteam assessment of LANL, a review was made of the air findings and issues discussed in the Los Alamos National Laboratory ES&H Self-Assessment Report (August I99I). Of the eight compliance findings identified in this current assessment, only one is considered to have been fully addressed in the LANL Self-Assessment; five of the findings were partially addressed as specific deficiencies. Two of the findings were not addressed. 3-13 3.5.1.2 Compliance Findings FINDING A/CF-1: National Emission Standards for Hazardous Air Pollutants (NESHAP) for Radionuclides from DOE Facilities Performance Objective 40 CFR 61, Subpart H, "National Emission Standards for Emissions of Radionuclides Other than Radon from Department of Energy Facilities," promulgated on December 15, 1989, includes a number of detailed requirements, some of which are summarized below: 1. Paragraph 61.92 establishes a maximum effective dose equivalent of 10 mrem/yr to any member of the public, which is applicable to the combined sources at LANL. 2. Paragraph 61.93(b)(4)(ii) requires that an evaluation be conducted to determine whether each potential release point is subject to the emission measurement requirements of 61.93(b), using an emission rate estimate based on the discharge of the effluent stream that would result if all pollution control equipment did not exist. 3. Paragraph 61.93(b)(4)(i) requires continuous emission measurements at all release points that have a potential to release radionuclides (assuming pollution control equipment did not exist) into the air in quantities that could cause an effective dose equivalent in excess of 1 percent of the standard. For other release points, periodic confirmatory measurements are required to verify that emissions continue to be at or below 1 percent of the standard. 4. Paragraph 61.93(b) requires that radionuclide emission rates from point sources be measured in accordance with EPA-prescribed methods. 5. Paragraph 61.93(b)(2)(iv) requires that a quality assurance program be conducted in accordance with EPA-prescribed performance requirements. 6. 40 CFR 61.05(c) states that 90 days after the effective date of any standard, no owner or operator shall operate any existing source subject to that standard in violation of that standard. 7. 40 CFR 61.13(a) states that if required to do emission testing by an applicable subpart, the owner or operator shall test emissions from existing sources within 90 days after the effective date. Finding LANL does not have a program in place that incorporates the necessary elements to meet all requirements of 40 CFR 61, Subpart H. 3-14 Discussion LANL has recognized, in its Environmental Protection Implementation Plan (October 19, 1990) (A-34), that the radiological air effluent monitoring program is not completely in compliance with the new EPA regulations (40 CFR 61, Subpart H ) . On August 21, 1991, LANL, LAAO, and AL personnel met with EPA Region VI officials to discuss LANL's status with regard to meeting the requirements of the regulation. EPA has indicated that LANL is in compliance with the Paragraph 61.92 effective dose equivalent limit of 10 mrem/yr, but that a Notice of Noncompliance would be issued regarding the emission sampling procedures used at LANL, and that a Federal Facilities Compliance Agreement would need to be negotiated (A-19). A task group of 22 LANL staff members has undertaken a review of stacks to identify those that need to be evaluated for potential radionuclide emissions (I-A-49). The Environmental Subteam identified the following specific deficiencies relative to current practices at LANL: 1. LANL has not demonstrated compliance with the monitoring requirements of Subpart H within 90 days as called for in 40 CFR 61.13(a). 2. LANL is presently measuring emissions of radionuclides from approximately 90 stacks. However, an evaluation has not been completed to determine whether an additional 64 stacks (I-A-46) may be potential radionuclide emitters that are subject to emission measurement requirements (A-19). 3. Stacks that require continuous emission measurements or periodic confirmatory measurements to verify that emissions continue to be low have not been identified (A-19). 4. Methodologies and equipment currently in use to collect and measure radionuclide emission rates do not conform to the methods prescribed in 40 CFR 61, Appendix B, Method 114 (A-19). 5. A quality assurance program that meets the requirements of 40 CFR 61, Appendix B, Method 114, has not been fully developed and implemented (A-15), This finding is partially identified in the LANL Self-Assessment. 3-15 FINDING A/CF-2: Radioactive Air Effluent Monitoring Program Performance Objective 40 CFR 61.93(b), "The National Emission Standard for Emissions of Radionuclides Other than Radon from Department of Energy Facilities," requires that emission rates from point sources (vents or stacks) be measured in accordance with EPA procedures (Reference Methods 1 and 2 of Appendix A to 40 CFR 60, ANSI N13.1-1969, and Appendix B Method 114). DOE 5400.5, "Radiation Protection of the Public and the Environment," Chapter I, Section 8, contains requirements for effluent monitoring to demonstrate compliance with dose limits. This section states, "It is the intent of DOE that the monitoring and surveillance programs for the DOE activities, facilities, and locations be of high quality," DOE 5400,5, Chapter II, Section l,b,(3), allows for demonstration of compliance with dose limits through environmental or effluent measurements using EPA-approved techniques. The Environmental Regulatory Guide for Radiological Effluent Monitoring and Environmental Surveillance (D0E/EH-0173T), Section 3, contains recommendations for DOE facilities to use in performance of airborne effluent monitoring programs. This section contains a wide variety of programmatic recommendations, including requirements for demonstrating compliance with 40 CFR 61, performance standards for air sampling systems, design criteria for system components, point source design criteria, alarm levels, and quality assurance. DOE 5400.1, "General Environmental Protection Program," Chapter IV, requires that effluent monitoring be performed to verify compliance with all applicable regulations and Orders, evaluate effluent treatment and control and effectiveness, identify potential environmental problems, support permit documentation, and detect, characterize, and report unplanned releases. It also requires that airborne releases comply with the requirements of 40 CFR 61. This chapter is required to be implemented by November 9, 1991. Finding LANL has not implemented a comprehensive air effluent monitoring program in accordance with NESHAP and DOE requirements. Discussion LANL's air effluent monitoring program is focused on the facilities that handle the largest quantities of radioactive materials and the more radiotoxic nuclides, such as plutonium. However, LANL cannot demonstrate compliance with the requirements of 40 CFR 61, Subpart H, "National Emission Standard for Emissions of Radionuclides Other than Radon from Department of Energy Facilities." These requirements went into effect on December 15, 1989. 40 CFR 61.13(a) allowed a 90-day interval for facilities to achieve compliance (see Finding A/CF-1). In addition, LANL's effluent monitoring program lacks many of the aspects deemed by DOE to be necessary for a facility to adequately monitor effluent releases and demonstrate compliance with dose limits. The below listing of noted deficiencies in LANL's radioactive air effluent 3-16 monitoring program is not meant to be all inclusive, but rather a representative sampling of the overall program. 1. LANL has not evaluated and documented all potential radiological release sources. LANL is currently performing an evaluation of a multitude of radioactive release sources from the facility. LANL does not believe that any significant new sources will be discovered in this evaluation; however, evaluation and documentation of all sources is required to demonstrate compliance with EPA regulations (I-RAD-227). 2. Calibrations of effluent monitoring equipment is not in accordance with DOE guidance. The Tritium Systems Test Assembly (TSTA) bubbler stack sampler is calibrated every 2 years rather than annually. Alarming monitors in the TSTA are calibrated electronically rather than by the radionuclide standard. There is no calibration for the TA-35-213 tritium stack monitor. 3. Calibration curves for stack monitors were not observed in any facility (I-RAD-212, I-RAD-214, and I-RAD-237). Calibration curves are important to "allow conversion of instrument signals to release rates from which both the current concentrations and the total specific radionuclide emissions can be estimated." 4. Periodic source checks are not performed on effluent monitoring systems or are not performed on a regular basis. Source checks are used to confirm continued acceptable operation of a system between calibrations. No source checks are performed on the alarming tritium monitors in the TSTA. There is no formal source check schedule for the Los Alamos Meson Physics Facility (LAMPF). Use of process control charts to trend source check acceptability was not observed in any facility, 5. There is no real-time stack effluent monitoring in various facilities, i.e., LAMPF, TA-50, Bldgs. 1 and 37, and the Liquid Waste Processing Facility. Real-time stack effluent monitoring should be incorporated for facilities with the potential for exceeding a large fraction of the emission standard. 6. There is little or no training for personnel who have stack effluent monitoring responsibilities (I-RAD-237). 7. There are no procedures for the use of the various stack effluent monitors, e.g., FE-19 and Omega Reactor. Use of procedures are essential for ensuring that the systems are being properly operated (I-RAD-237 and I-RAD-228). 8. There are no alarms for various LAMPF and Omega Reactor, There effluent monitor in the control a remote area where the monitor before the alarm would be noted 9. There is no stack effluent monitoring at various facilities, e,g,, at TA-33 one tritium effluent monitor is not installed, another 3-17 stack effluent monitors, i.e., is no readout for the FE-19 stack room. This monitor is located in could be alarming for some time (I-RAD-228), tritium effluent monitor is not calibrated, and there is no tritium effluent monitor at the Ion Beam Facility, Stack effluent monitoring is required to demonstrate compliance with dose limits. In addition, the TA-41 tritium effluent monitor was disconnected for approximately 6 months during 1989-1990 so there was no stack effluent monitoring for that facility during that time. 10, There is no backup or uninterruptable power supply for various stack effluent monitoring systems, e,g,, FE-19, Omega Reactor, TA41 Icehouse (I-RAD-228, I-RAD-237, and I-RAD-243), Backup or uninterruptable power supplies are important to ensure that monitoring is continued during loss of power, especially in an accident condition, 11, There has been no particle size analysis performed to verify particle sizes. This analysis, for each facility, is important to verify treatment efficacy prior to discharge. Treatment processes have different efficiencies for different particle sizes; therefore, it is important to know the particle size to verify that the proper treatment techniques are being employed prior to discharge and that the proper sampling is performed for the particle sizes in the effluents, 12, LANL's Special Monitoring Instructions - Air Sampling (RAD-524), Section 3.3.4 states that the Health Physics Analysis Laboratory (HPAL) assumes that stack effluent filters collect samples for 168 hours. The procedure also states that this assumption would add a maximum of a 5 percent error to the sample concentration calculation. Additional error should not be added into assessment of air effluent concentrations. There is no overall cognizance of the radiological air effluent monitoring program. The "Quality Assurance Program Plan for HS Radiological Air Effluent Monitoring Program" (RAD-516) states, "It is the responsibility of the Laboratory's operating groups to meet EPA and DO[E] environmental, health, and safety requirements, including those for radiological air effluent sample collection." This management approach does not permit consistency in the overall program, LANL has no central organization responsible for ensuring that consistent sample collection, analysis, and results are obtained (RAD525), This finding was partially identified in the LANL Self-Assessment, 3-18 FINDING A/CF-3: Control of Radionuclide Emissions Performance Objective DOE 5400,5, "Radiation Protection of the Public and the Environment," paragraph 6, states that it is DOE's objective that potential exposures to members of the public be as low as reasonably achievable (ALARA), LANL's Administrative Requirements (AR) 3-8, "ALARA Program," stresses that ALARA is an integral part of the Laboratory's overall safety program, DOE 6430,lA, "Design Criteria," Section 1304.5, "Special Design Features," states that exhaust ventilation systems serving plutonium processing and handling facilities shall be provided with high-efficiency particulate air (HEPA) filtration. Finding Atmospheric emissions of radionuclides from some facilities at LANL are not adequately controlled to provide ALARA protection to members of the public. Discussion Based on observations of selected facilities, interviews, and review of pertinent documentation, the following are examples of facilities that are considered to have less than ALARA emission control: 1. Activation products released to the atmosphere from the Los Alamos Meson Physics Facility (LAMPF) cannot be controlled by any physical device, such as filters, absorbers, or scrubbers, prior to release; however, the LANL Environmental Surveillance 1989 report (A-2) states, "the emissions receive appropriate treatment before discharge, such as . . , absorption for activation products," These emissions constitute over 95 percent of the maximum individual dose from LANL facilities (A-29). Actions taken previously to reduce emissions from LAMPF included a complete rebuild of the beam stop area in 1985 that resulted in reducing the overall stack emission rate by a factor of six. In addition, a closed-loop air box was installed early in 1991 to reduce the volume of air through which the high-intensity proton beam may pass, thus reducing the volume of air subjected to activation, which is ultimately exhausted through stack FE-3 to the atmosphere (A-74). Funding has been released for a project to modify the air exhaust system in FY 1992 to delay release of the short-lived radionuclides, allowing additional decay time to further reduce emissions of radionuclides to the atmosphere (A71). 2. Stack FE-19 ventilates plutonium processing and handling facilities in the Chemical and Materials Research (CMR) Building at TA-3. FE-19 is the largest source of plutonium emissions at LANL (I-A-49 and I-A-59). The filtration system serving this facility does not have the necessary level of efficiency to provide ALARA protection to members of the public. Recent in-place filter tests show that the filters are only 74 percent 3-19 efficient (A-33). HEPA filters would provide in excess of 99 percent particulate removal. 3, Releases of tritium and tritium oxide during 1990 from operations in TA-3, TA-21, TA-33, TA-35, TA-41, TA-53, and TA-55 totaled 6,400 curies (A-29), These releases are not subjected to any sort of physical control devices prior to release. This finding was partially identified in the LANL Self-Assessment, 3-20 FINDING A/CF-4: Radiological Ambient Air Sampling Performance Objective DOE 5400.1, "General Environmental Protection Program," Chapter IV, Paragraph 5.b.(l), requires that an environmental surveillance program be implemented by November 9, 1991, to monitor the effects of DOE activities on the offsite environment. DOE 5400.1, Section 9, requires management oversight and audits of the environmental programs required by DOE 5400,1. DOE 5400,5, "Radiation Protection of the Public and the Environment," Chapter 1, paragraph 8, specifies that DOE facilities shall have the capability to detect, quantify, and adequately respond to unplanned releases of radioactive material to the environment by May 8, 1990. The Environmental Regulatory Guidance for Radiological Effluent Monitoring and Environmental Surveillance (D0E/EH-0173T), Section 5, sets forth an objective to properly and accurately measure radionuclides in ambient air media. Also, Section 5.7.1 states, "because air is a primary exposure pathway to humans from radionuclides released to the atmosphere, environmental sampling should be conducted to evaluate potential doses to environmental populations from inhaled or ingested radionuclides or from external radiation." The draft LANL air volume procedure (RAD-497) requires quarterly audits of flowmeters. Nuclear Regulatory Commission (NRC) Regulatory Guide 8.25, Calibration and Error Limits of Air Sampling Instruments for Total Volume of Air Sampled, Section C.l, contains calibration frequency recommendations for airflow of volume metering devices. DOE 5480.20, "Personnel Selection, Qualification, Training, and Staffing Requirements at DOE Reactor and Non-Reactor Nuclear Facilities," Chapter I, Section 7.a,, requires training for technical support personnel based on the results of an assessment of position responsibilities. Finding LANL has not implemented an ambient air sampling program with all the elements required by DOE 5400.1, DOE 5400.5, and D0E/EH-0173T. Discussion LANL will not implement a radiological ambient air monitoring program in accordance with DOE requirements and recommendations by November 9, 1991, In addition, noted deficiencies in LANL ambient air sampling activities inhibit LANL's ability to detect, quantify, and adequately respond to unplanned releases of radioactive material to the environment as required by DOE 5400.5. LANL emissions result in doses to members of the public. Specific deficiencies in radiological ambient air sampling practices include the following: 3-21 There are no formalized procedures for the ambient air sampling program, A draft procedure is being developed. No management oversight or audits of the ambient air sampling program had occurred until immediately prior to the Tiger Team Assessment, when the Section Leader performed an audit of the program (I-RAD-258). There are no chain-of-custody procedures for the ambient air sampling program samples; therefore, there is no documented traceability of samples from the time of collection through analysis and final disposition. The Environmental Subteam observed filter and silica gel cartridge changes at several ambient air sampling stations. At one sampling station, the person changing the cartridge started to use a cartridge on the station which had been taken from a previous station, rather than using the new cartridge designated for that station, A supervisor corrected the error (I-RAD-225). The ambient air sampling systems are not periodically leak-tested. Also, there are no connections (i.e,, quick disconnects) for the sample lines. Observation of the ambient air sampling systems indicated that sample line connections are not secure and that there is a possibility of air leakage into the pumps around the fittings. Unsecured connections can introduce a negative bias to air sample results. Also, many of the sample line connections look as if they are close to falling off. If they fall off during a sampling interval, the sample results will be invalid (I-RAD225), Some sampling stations are located near roadways, trees, and buildings which could produce localized air circulation effects that could adversely affect the validity of the sample results. The frequency of collection for the ambient air samples is monthly instead of biweekly as recommended in DOE/EH-0173T. This has, in the past, resulted in saturation, or breakthrough, of silica gel cartridges used to monitor for tritiated water (HTO) vapor releases, thus invalidating sample results. LANL has not performed particle-size measurements to characterize resuspension of previously deposited material as recommended in D0E/EH-0173T. LANL does not sample for elemental tritium gas (NT). Although the dose conversion factors for HT are much lower than those for HTO, the activity of HT released is much greater than that of HTO released, and the dose assessment analysis of this pathway cannot be complete without an adequate evaluation of the HT component of the dose (D0E/EH-0173T). The ambient air samples are not adequately protected from the elements. Tritium sample cartridges are located outside the sampling station, on the sample tube, completely open to the 3-22 environment and accessible for sample tampering. In the past, tritium samples above TA-41 were tampered with (this area has subsequently been enclosed by a fence). During observation of ambient air sample changeout, one tritium cartridge was observed to have a silica gel volume much less than that of the other cartridges. This could have been attributable to tampering with the sample, i.e., removing some of the silica gel. Also, some sample stations were locked while others were not. Unlocked sample stations leave the samples open to tampering and raise a question about the validity of the sample results (I-RAD-257). 11, The airflow calibrations performed for HTO ambient air monitoring are not traceable to the National Institute of Standards and Technology (NIST). 12, Quarterly audits of the flowmeters were not conducted during 1990. These audits were not conducted due to a lack of staff and misplacement of the equipment required to perform the audits (IRAD-257), 13, Particulate air filter samples retrieved from the ambient air sampling stations are placed in plastic zip-lock bags. The filters are not folded over or placed in small envelopes. Loss of sample could result from either the sample falling off the filter and remaining in the bag, or the sample adhering to the bag due to electrical attraction between the particulates and the bag, 14, In accordance with the draft air sampling procedure, LANL calibrates airflow metering devices on an annual basis rather than every 6 months as recommended by NRC Guide 8.25, 15, There are no training procedures for the ambient air sampling program, DOE 5480.20 requires that training programs consist of a combination of classroom-type and on-the-job training. Personnel presently receive on-the-job training from others who have performed the function in the past. The personnel performing the training have not received any formal training, thus propagating errors in program performance objectives. There is no documentation of training or any verification that personnel are qualified or competent to perform the sampling functions. An additional concern in the area of ambient air sampling (AIRNET) and the environmental thermoluminescent dosimetry (TLD) programs is the lack of adequate staffing to complete the program duties (I-RAD-257). Since 1986, there has been a decrease in the overall staffing of these programs. Part of the staff member decrease has been compensated for with a graduate research assistant (GRA). The concern with replacing staff with a GRA is that an experienced staff member is being replaced by someone with much less experience; this results in an overall decrease in oversight. This decrease in staffing has occurred at a time when the overall workload has increased by about a factor of two due to added sampling stations and the work associated with operating and maintaining them and the increased documentation requirements specified in documents such as D0E/EH-0173T. This finding was partially identified in the LANL Self-Assessment. 3-23 FINDING A/CF-5: Meteorological Data Acquisition Programs Performance Objective DOE 5400.1, "General Environmental Protection Program," Chapter IV, Section 6, requires the development and implementation of a meteorological information and monitoring program to collect representative meteorological data in support of environmental surveillance and impact assessment programs by November 9, 1991. DOE 5400.5, "Radiation Protection of the Public and the Environment," Chapter 1, Section 8.a., specifies that the ability to detect, quantify, and adequately respond to unplanned releases of radioactive material to the environment relies on monitoring of environmental transport and diffusion conditions. DOE 5400.5, Chapter 11, Section 5.b,(l), requires the use of updated meteorological information that is appropriate to evaluate actual and potential doses in the environs of DOE facilities. The Environmental Regulatory Guide for Radiological Effluent Monitoring and Environmental Surveillance (D0E/EH-0173), Section 4.0, recommends that each DOE facility establish meteorological monitoring programs that are "appropriate to the activities at the site, the topographical characteristics of the site, and the distance to the critical receptors." Finding LANL does not have a meteorological data acquisition program that completely supports environmental monitoring activities in accordance with the requirements. Discussion LANL has conducted meteorological monitoring since 1943. The current meteorological monitoring activities involve operation of four meteorological towers which monitor various conditions, some towers providing measurements at multiple elevations. However, LANL will not implement a program consistent with the requirements of DOE 5400.1 by the November 9, 1991, implementation date. The LANL site is complex, as far as meteorological monitoring is concerned. Due to the large area and diverse topography, meteorological monitoring to adequately assess Laboratory impacts, especially in an accident condition, is a difficult process and requires an evaluation of many different physical areas. The following are examples of locations that do not have comprehensive meteorological monitoring: 1. There is no meteorological monitoring performed in the Los Alamos Canyon. This canyon is directly below the townsite, and in it are TA-2 (the Omega Reactor) and TA-41 (the Icehouse). Monitoring to assess environmental impacts in this area is very important due to the potential for accidental release of a wide variety of radionuclides from the Omega Reactor, and tritium releases from the Icehouse (in view of numerous tritium releases in the past 3-24 from this facility), and the proximity of these sites to the townsite. 2. There is no meteorological monitoring performed in the town of White Rock to assess transport of windblown materials from areas such as TA-54, through and beyond the townsite, and impacts from radiological and nonradiological releases of hazardous materials from LANL. The meteorological towers for these locations (Los Alamos Canyon and White Rock) have been installed are awaiting instrument installation. 1. There is no meteorological tower at the Los Alamos Meson Physics Facility (LAMPF), TA-53, stack release site; a meteorological tower is required at the release site to characterize where the release is going from its release point. There is a meteorological tower at a receptor site for LAMPF; however, this tower is insufficient as it characterizes the conditions at the receptor site only, not the conditions at the release site. Other areas of concern noted in the meteorological data acquisition activities are as follows: 1. There is only one technician to perform maintenance and calibration for all the meteorological towers. There are four operating meteorological towers and two towers constructed and awaiting instrument installation, plus various other meteorological monitoring devices. 2. There are no procedures for maintenance and calibration of the meteorological monitoring network. 3. LANL currently uses straight-line Gaussian dispersion models which are inappropriate for modeling of the complex and diverse terrain of the canyon system. DOE/EH-0173T states, "Straight-line Gaussian models are not appropriate for facilities that are located in valleys, near coasts or mountains, and on large sites." 4. The Quality Assurance Program Plan (QAPP) does not properly reflect the calibration frequency incorporated into the maintenance program and recommended in D0E/EH-0173T. The calibration frequency described to the Tiger Team (I-RAD-240) was as specified in D0E/EH-0173T {ewery 6 months); however, this is not the same frequency that is specified in the QAPP. This finding was partially identified in the LANL Self-Assessment. 3-25 FINDING A/CF-6: Asphalt Plant Performance Objective New Mexico Air Quality Control Regulation (NMAQCR) 501, "Asphalt Process Equipment," establishes maximum allowable particulate emission rates that are based on the aggregate process rate. NMAQCR 801, "Excess Emissions During Malfunction, Startup, Shutdown, or Scheduled Maintenance," requires the owner or operator of a facility experiencing a malfunction to notify the New Mexico Environment Department (NMED) verbally within 24 hours after the start of the next business day, and to submit a written notification to the NMED within 10 days after the start of the next business day following the occurrence. DOE 5480.19, "Conduct of Operations Requirements for DOE Facilities," Chapter I, Section A, states, "Effective implementation and control of operating activities are primarily achieved by establishing written standards in operations, periodically monitoring and assessing performance, and holding personnel accountable for their performance." Section B indicates that a high level of performance can be accomplished by establishing high operating standards, communicating those standards to the working level, and ensuring that personnel are well trained. Finding A malfunction of the scrubber system on the asphalt plant exhaust stream that resulted in an excess emission of particulates was not properly reported to the NMED. In addition, operations at the LANL asphalt plant are not sufficiently formalized to ensure that particulate emissions are kept at minimal levels, nor to provide for timely shutdown of operations in the event of a particulate emission control malfunction. Discussion The LANL asphalt plant is a direct gas-fired device that combines aggregate materials with asphalt to produce asphalt concrete for road paving and patching. The plant was installed in 1961 (A-1) and was subsequently retrofitted with an off-gas scrubber system to control particulate emissions. The asphalt plant was operating when visited by the Environmental Subteam (September 26, 1991), with a cloud of dust being emitted from the scrubber stack. The release was occurring as a result of a malfunction of the pump motor that supplies water to the scrubber spray system (I-A-9). The asphalt plant was shut down after a required cool-down period to protect the plant equipment from damage. The motor was repaired and the plant was returned to service on September 30, 1991. The malfunction and release were reported verbally to the NMED, by virtue of the fact that an NMED representative was present at the asphalt plant while the incident was in progress. A written report (A-72) was prepared within the required 10 days, but was not submitted to NMED, (A-75) a decision that constitutes a failure to conform to the requirements of NMAQCR 801. 3-26 In addition, several deficiencies have been identified in the facility operation that are indicative of an inadequate program to ensure control of particulate emissions. They include the following: 1. Although there is a Maintenance Operating Instruction (A-5) that primarily covers maintenance activities such as inspections and lubrication of operating parts, there is little information that constitutes operating instructions for the asphalt plant and the scrubber system. The only reference to the plant dust cleaning system is in a special instruction that directs that the system "will be inspected daily and leaks repaired ..." 2. The Maintenance Operating Instruction was written January 22, 1991, and first issued on February 1, 1991, without review and approval. Although the document provides space for a controlled document number, no such number was on the document. The manufacturer's Plant Operating Manual was available; however, that manual did not address operation of the wet scrubber because the scrubber was not installed as part of the original construction. 3. The asphalt plant has two experienced operators; however, there is no formal training or refresher training in the operation of the asphalt plant or the wet scrubber (I-A-7). 4. Although the water spray nozzles in the scrubber are inspected monthly, there is no log that provides a record of the inspections or the findings or corrective actions taken (I-A-10). 5. The asphalt plant can be operated without waterflow to the wet scrubber; however, the consequence is uncontrolled emissions of particulate matter to the atmosphere. No alarm system is available to alert operators of the lack of waterflow (I-A-10). This was partially identified in the LANL Self-Assessment. 3-27 FINDING A/CF-7: Open Burning Performance Objective DOE 5400.1, "General Environmental Protection Program," Section 6.b., recognizes that DOE environmental management activities are extensively, but not entirely, regulated by EPA and state or local environmental agencies. "Where these agencies clearly exercise environmental protection authority through permitting and compliance administrative procedures applicable to DOE, they establish and regulate required performance for environmental protection." New Mexico Air Quality Control Regulation (NMAQCR) 301, "Regulation to Control Open Burning," Section F, states that open burning is permitted for certain specified purposes, including disposal of dangerous materials, when a permit is obtained from the New Mexico Environment Department (NMED). Finding Open burning of materials contaminated with high explosives (HEs) Is being conducted at LANL without the required air quality permits from the NMED. Discussion Although bulk quantities of HE can be disposed of by open burning without a permit (NMAQCR 301 B.3), open burning of HE-contaminated materials is subject to New Mexico permitting requirements (NMAQCR 301 F ) . Activities at TA-16 (I-A-23) that do not have the required air quality permits include the open burning of the following: 1. 2. 3. HE-contaminated solvents, HE-contaminated sludge, and HE-contaminated noncombustible waste. These activities have been given interim status by EPA under 40 CFR 264, Subpart X (A-70). This finding was not identified in the LANL Self-Assessment. 3-28 FINDING A/CF-8: TA-16-1409 Incinerator Performance Objective New Mexico Air Quality Control Regulation (NMAQCR) 401, "Regulation to Control Smoke and Visible Emissions," requires that visible emissions from stationary combustion sources shall not equal or exceed an opacity of 20 percent over a 10-minute minimum for taking opacity readings. DOE 5480.19, "Conduct of Operations Requirements for DOE Facilities," Chapter 1, Section A, states, "Effective implementation and control of operating activities are primarily achieved by establishing written standards in operations, periodically monitoring and assessing performance, and holding personnel accountable for their performance." Section B indicates that a high level of performance can be accomplished by establishing high operating standards, communicating those standards to the working level, and ensuring that personnel are well trained. Finding During a recent burn cycle at the TA-16-1409 Incinerator, opacity observations exceeded the 20 percent limit, as a consequence of Inadequate procedures to control materials being burned. Discussion Visible emission opacity readings taken during a September 4, 1991, burn at the incinerator averaged approximately 42 percent during a 24-minute observation period, with individual 15-second observations as high as 80 percent (A-66 and A-67). The incinerator is used to dispose of combustible solids such as boxes, Kimwipes, rags, and other trash that is potentially contaminated with high explosives (I-A-23). The opacity exceedances on September 4, 1991, have been attributed to burning of more varied materials, including plastic and acrylic materials, in addition to office-related trash (A-67). This finding was not identified in the LANL Self-Assessment. 3-29 THIS PAGE INTENTIONALLY LEFT BLANK. 3?30 3.5.2 Surfacewater/Drlnkinq Water 3.5.2.1 Overview The surface water/drinking water portion of the environmental assessment of LANL consisted of an evaluation of current compliance practices with regard to Federal and New Mexico laws, including regulations promulgated by EPA and the New Mexico Environment Department (NMED), DOE Orders, LANL policies and procedures, and best management practices. Laws and the associated regulations included the Clean Water Act (CWA), including Spill Prevention Control and Countermeasure (SPCC) Plan and National Pollutant Discharge Elimination System (NPDES) regulations; Safe Drinking Water Act; New Mexico Water Quality Act; New Mexico Environmental Improvement Act; New Mexico Water Quality Control Regulations; New Mexico Regulations Governing Water Supplies; and New Mexico Liquid Waste Disposal Regulations. Table 3-3 lists the regulations, requirements, and guidelines used in the assessment. Only nonradiological constituents of discharges were evaluated in this portion of the assessment. See the Radiation and Groundwater/Soils, Sediment, and Biota sections for radiological compliance issues that may relate to surface water discharges. The general approach to the surface water/drinking water portion of this assessment included the following activities: (1) inspection of wastewater and raw water source areas; facilities that use, convey, treat, and/or dispose of water/wastewater; and sampling locations/events; (2) interviews with LAAO, LANL, Johnson Controls World Services, Inc. (JCI) personnel, and New Mexico regulatory officials; and (3) a review of documents related to compliance programs, including correspondence with regulatory agencies, operating procedures, environmental reports and other internal documents. Responsibility for surface water and drinking water compliance at LANL is shared between many different organizations. The Water Quality and Toxics Section of the Environmental Protection Group (EM-8) manages regulatory compliance aspects of NPDES permits, septic systems, the SPCC plan, safe drinking water, and sanitary sludge disposal. The Fire Protection and Utilities Group (ENG-8) is responsible for oversight of sanitary wastewater treatment systems, water supply and distribution systems, and steam and power generating plants. The Utilities Department of JCI manages, operates, and maintains the sanitary wastewater systems, water supply systems, and steam systems under a support services contract administered by ENG-8. JCI manages many of their own environmental responsibilities in the JCI Environmental Department (JENV). Many other operating divisions at LANL are responsible for operation of facilities which discharge wastewater. The potable water supply system at LANL consists of 12 operating wells, including 2 standby wells, which serve the Laboratory, Bandelier National Monument, and the communities of Los Alamos and White Rock. The water is treated by chlorination. DOE owns the water supply and distribution system that serves LANL. Los Alamos County owns the distribution systems serving Los Alamos and White Rock. Sanitary wastewater at LANL is collected and treated in a network of 9 sanitary wastewater treatment systems and 77 septic systems. Eight of the sanitary wastewater treatment systems currently in use and 34 of the septic 3-31 TABLE 3-3 LIST OF SURFACE WATEIVDRINKING WATER REGULATIONS/REQUIREMENTS/GUIDELINES Regulatians/ Requlremeftts/ Sectlofis/Tltle Attthorlty DOE 5400.1 General Environmental Protection Program DOE DOE 6430.1A General Design Criteria DOE DOE 5480.19 Conduct of Operations Requirements for DOE Facilities DOE DOE 4330.4A Maintenance Management Program DOE 33 use 1251 Federal Water Pollution Control Act (Clean Water Act) EPA 40 CFR 110 Discharge of Oil EPA 40 CFR 112 Oil Pollution Prevention EPA 40 CFR 122 National Pollutant Discharge Elimination System EPA 40 CFR 141 National Primary Drinking Water Regulations EPA NMSA 1978 Section 74-1-8 New Mexico Regulations Governing Water Supplies NMED NMSA 1978 Section 74(i)-(8) New Mexico Liquid Waste Disposal Regulations NMED WQCC 82-1 Amendment 7 New Mexico Water Quality Control Commission Regulations NMED NMSA Ch. 74, Article 6 New Mexico Water Quality Act NMED NMSA Ch. 74, Article 1 New Mexico Environmental Improvement Act NMED LANL AR 9-6 Water Pollution Control LANL LANL AR 9-4 Accidental Oil, Chemical, and Airborne Releases LANL LANL AR 9-3 Water Supply and Distribution Systems LANL Docket No. VI-91-1328 EPA Administrative Order to UC/LANL EPA 3-32 systems will be eliminated upon completion of the Sanitary Wastewater Systems Consolidation Project. Most of the existing sanitary wastewater treatment systems use obsolete technology and do not meet modern effluent standards. Industrial wastewater at LANL is discharged from many operating facilities and includes discharges of noncontact cooling water, steam plant boiler blowdown and demineralizer regeneration, blowdown from cooling towers, wastewater from high-explosives research, rinse water from photographic film developing, rinse water from printed-circuit board manufacturing, and treated radiological liquid waste. Discharges of wastewater from LANL are authorized under two NPDES permits. The first (NPDES Permit No. NM0028355) covers the complex system of discharges from the main LANL site at Los Alamos. NPDES Permit No. NM0028355 currently authorizes discharges from approximately 142 outfalls. The permit categorizes outfalls, based on the nature of the operation discharging water to the outfall. The current permit includes 21 outfall categories and sets effluent limitations and monitoring requirements for each outfall category. The permit expired March 1, 1991, but has been continued pending completion by EPA of a new permit. LANL re-applied for the permit in 1990, and EPA issued a new draft permit prior to the expiration of the current permit; however, NMED refused to certify the new permit pending some modifications requested by NMED. Wastewater discharges at LANL are also regulated under an EPA Administrative Order (AO) and a Federal Facilities Compliance Agreement (FFCA), which contain interim effluent limits for some discharges until completion of facility improvements required by a compliance schedule. The University of California (UC), as the operator of LANL, and DOE are co-permittees to the NPDES permit. When taking enforcement action on a wastewater-related problem, EPA first issues an AO to UC/LANL and then negotiates an FFCA with DOE/LAAO. If the terms of the FFCA change during the negotiation, EPA then issues another AO to UC/LANL with language that matches the FFCA. UC/LANL is currently operating under an AO (EPA Region VI, Docket No. VI-91-1328), and DOE/LAAO is negotiating a parallel FFCA (Docket No. VI-91-1329). Both the AO and FFCA replace previous versions. The AO and FFCA also include a compliance schedule for completion of wastewater characterization studies of facilities at LANL that discharge into NPDES permitted outfalls. LANL requested this compliance schedule after recognizing that many outfalls at LANL were either not covered under the existing permit, or existing outfalls were not properly characterized in previous permit applications. Two overriding concerns were raised by the assessment and are addressed in the findings. The first concern is the lack of definition for roles, responsibilities, and authority for the various LANL organization divisions that participate in surface water/drinking water compliance programs. Although EM-8 personnel are responsible for the regulatory aspects of a program, they have no defined responsibility or authority over Laboratory operations that must comply with programs. The second concern is the lack of communication, integration, and implementation of programs for compliance throughout the site. NPDES permit compliance, the SPCC Plan, and the waste stream characterization program are not thoroughly developed, are not communicated, and are, consequently, not well implemented throughout LANL. 3-33 On the positive side, many staff members at LANL are quite knowledgeable about technical and regulatory aspects of water and wastewater operations. The fact that Laboratory compliance is as good as it currently is in surface water/drinking water programs, is a direct result of quality professional environmental staff in key positions. Facility inspections were conducted at technical areas considered to have the greatest risk with respect to surface water issues. Facilities within the following technical areas were inspected: TA-3, TA-9, TA-16, TA-18, TA-21, TA-22, TA-35, TA-41, TA-46, TA-50, TA-53, TA-54, TA-55, TA-57, and TA-60. Facilities inspected included support facilities (e.g. treatment systems, disposal sites, and water wells) and operating division research laboratories and maintenance facilities. Depending on the nature of the facility, programs investigated during inspections included SPCC plan implementation, drinking water and water supply maintenance, backflow prevention and cross-connection control, septic system management, wastewater discharges, operation and maintenance of treatment systems, and stormwater contamination protection. There are 13 surface water/drinking water compliance findings and 1 best management practice finding. The following issues are addressed in compliance findings: inadequacy of the SPCC plan and LANL's implementation of the SPCC plan, backflow prevention and cross-connection control, lack of formality in the drinking water program, septic system management, violations of NPDES effluent limitations, inadequate operations and maintenance of treatment or control systems, inaccurately permitted discharges, inadequate monitoring and reporting, inadequate surveillance of the impact of LANL operations on onsite surface waters, inadequate protection against stormwater contamination, modifications to discharges without EPA notifications, and inadequate development and communication of formal compliance programs. One best management practice finding was identified during the assessment regarding a failure to use available data to accurately characterize a discharge in a permit application. Of the 14 findings, 3 were fully identified in the LANL Self-Assessment, and 2 were fully identified in the AL/LAAO Self-Assessment. Eight findings were partially identified by LANL, six were partially identified by AL/LAAO, three were not identified by LANL, and six were not identified by AL/LAAO. 3-34 3.5.2.2 Compliance Findings FINDING SW/CF-1: National Pollutant Discharge Elimination System (NPDES) Permit Programs - Permitting of Point Source Discharges Performance Objective Title 33 U.S.C. 1251 et seq., "Federal Water Pollution Control Act" (Clean Water Act), Title III, allows discharges of pollutants to waters of the United States only if the discharge is authorized by a permit issued under regulations promulgated by the EPA or a state NPDES program authorized by EPA. 40 CFR 122, "National Pollutant Discharge Elimination System," requires facilities with point source discharges to submit permit applications and authorizes discharges of pollutants which meet specific effluent limitations. 40 CFR 122.21 requires applicants for NPDES permits for point source discharges to accurately describe and characterize the nature of the pollutants being discharged. NPDES Permit No. NM0028355, issued to the University of California and DOE as co-permittees, allows discharges to outfalls that are listed in the permit or added to the permit following addition procedures described in Part III(H). LANL Administrative Requirements (AR) 9-6 (August 30, 1991) requires all existing outfalls and drain pipes from Laboratory facilities that discharge or could potentially discharge industrial or sanitary wastewater to the environment to be permitted under the Laboratory's two NPDES permits (main site and Fenton Hill). EPA Administrative Order (AO) (Docket No. VI-91-1329, "EPA to University of California as Co-permittee," August 29, 1991) contains a compliance schedule which requires LANL to complete waste stream characterizations of all outfalls and contributing operations by certain dates. Federal Facilities Compliance Agreement (FFCA) (Docket No. VI-91-1328, draft, between EPA and LAAO) contains the same compliance schedule as the AO. DOE 5400.1, "General Environmental Protection Program," requires compliance with applicable Federal regulations and environmental standards, permits, and state and local regulations and standards. Finding The LANL NPDES permits do not accurately cover all point source discharges of pollutants to surface water that result from LANL operations. Discussion For the purpose of simplifying LANL's complex system of discharges, the NPDES permit (main site) groups discharges into several outfall categories, based on the similarity of contributing wastewater. Each category has specific effluent limits and monitoring requirements that were selected by EPA for the type of discharge described and characterized in the permit application. For 3-35 example, discharges from cooling towers are included in the Outfall 03A category; sanitary treatment systems are categorized as OlS, 02S, etc.; and photographic film processing discharges are categorized as Outfall 06A. For a particular discharge to be considered as covered by a valid NPDES permit, operations contributing effluents to the discharge must have been accurately described in the permit application. This requirement is particularly significant for the LANL NPDES permit due to the categorization of discharges into outfall categories. For example, all contributing streams to an outfall in category 03A (treated cooling tower discharges) should consist only of discharges of treated cooling water or treated water from very similar operations. If high explosive wastewater was discharged to an 03A Outfall and was not identified as a contributor in the permit application, the outfall would not be validly permitted. When the permit was originally developed, not all LANL point source discharges were included in the permit application and not all streams contributing flows and pollutants to outfalls were accurately characterized. The largest contributor was used to identify the category in subsequent applications and requests for permit modifications, discharges have been included in the permit as they have been identified, and that process goes on to date, as indicated in 1990 and 1991 LANL records. LANL has recognized that not all outfalls or contributor streams that should be included in the NPDES permit are included. In 1990, LANL initiated a wastewater characterization program to identify outfalls that should be added to the permit and to identify waste streams entering outfalls that have not been accurately characterized in the permit application. EPA included a compliance schedule in an AO which requires wastewater characterization studies for the different categories of outfalls to be completed by specific dates. A parallel FFCA, currently in draft form, contains the same schedule and is currently being negotiated by EPA and LAAO. During the assessment, the following discharges were observed that are not currently covered under the permit, but should be: 1. At TA-2, an outfall was observed discharging groundwater that infiltrated the basement of a building to a bordering stream. The water passes across the floor of the basement before entering a sump pump which pumps it to the stream. The basement is an equipment room and, therefore, provides the possibility that the water could be contaminated by contact with oil or grease from the equipment. This is sufficient to define the discharge as industrial wastewater. 2. At TA-46, Bldg. 31 laboratory sinks were observed which had signs that said they discharged directly to the environment and that allowed only handwashing. Environmental Protection Group (EM-8) staff had previously identified these discharges in 1990, and in a memorandum recommended changes in the piping system that have not been completed. (EM-8 has no programmatic authority to require such changes. See Finding SW/CF-3 on compliance programs.) 3. At TA-14, a high explosives wastewater sump was observed, with an outfall that is not currently covered in the permit. No discharge was coming from the outfall at the time, perhaps because activity in the building was minimal. EM-8 staff said that they have 3-36 recommended plugging of the outfall to the responsible operations personnel until the outfall is added to the permit. 4. Draft characterization reports for buildings in TA-16 show a number of streams (e.g., cooling water, floor drains, etc.) that may currently contribute flow to the sanitary treatment system and that are not normally allowed in sanitary wastewater (see Finding SW/CF-4). The 1986 NPDES permit re-application, on which the current permit is based, did not identify these streams as contributors to the TA-16 sanitary treatment system; although, the more recent 1990 permit application did indicate that some wastewater associated with industrial operations could enter the system. LANL has begun the wastewater characterization efforts required to meet the schedule contained in the AO and FFCA. This finding was fully identified in the LANL Self-Assessment. 3-37 FINDING SW/CF-2: National Pollutant Discharge Elimination System (NPDES) Permit - Compliance with Effluent Limits Performance Objective 40 CFR 122, "National Pollutant Discharge Elimination System," Subpart C, requires a permittee to comply with all of the conditions of a permit. NPDES Permit No. NM0028355 requires compliance with effluent limits for specific categories of industrial and domestic wastewater discharges. The EPA Administrative Order (AO), issued to the University of California as LANL's co-permittee, sets interim limits for some NPDES outfalls and contains a schedule for LANL to achieve compliance with the NPDES permit limits. The Federal Facilities Compliance Agreement (FFCA), issued to LAAO as LANL's co-permittee, sets the same interim limits and compliance schedules as the AO. DOE 5400.1, "General Environmental Protection Program," requires compliance with the Clean Water Act and applicable environmental standards (permits), including AOs and FFCAs. Finding Some wastewater discharges from LANL exceed the effluent limitations contained In the NPDES permit, the AO, and the FFCA. Discussion NPDES Permit No. NM0028355 (SW-88) sets effluent limits on categories of discharges from LANL facilities. The permit contains effluent limits for 6 industrial discharge categories, 4 individual industrial discharges, and 11 individual sanitary wastewater discharges. The AO and FFCA relax some permit limits, on an interim basis, pending completion of a compliance schedule. Exceedances of the NPDES permit effluent limitations occur each year. The number of effluent violations for each year since 1989 are listed below: Number of Effluent Exceedances * (Through 10/25/91) 1989 9 1990 51 1991 * 21 Various LANL organizations are responsible for the operations of facilities which produce effluents subject to the requirements of the NPDES permit. Examples of the more frequent exceedances include the following: 1. Sanitary treatment systems operated by Johnson Controls World Services, Inc., under the management of the Fire Protection and Utilities Group (ENG-8), have exceeded effluent limits; although, the frequency has decreased over previous years. During 1991, effluent limits have not been met three times, including fecal coliform (21,400 organisms per 100 mL vs. the 2,000 organisms per 100 mL limit) and visible foam in greater than trace amounts. 3-38 2. Discharges from cooling towers which use chemical treatment have exceeded effluent limitations. During 1991, effluent limits have not been met six times, including total suspended solids (2,072 mg/L, 818 mg/L, vs. the 100 mg/L limit), phosphorus (7.26 mg/L vs. the 5.0 mg/L limit), free chlorine (1.4 mg/L vs. the 0.5 mg/L limit), and visible foam in greater than trace amounts. 3. Discharges consisting of wastewater from operations of steam boilers have exceeded effluent limits. During 1991, effluent limits have not been met seven times (six times at TA-16-540), including pH (10.9 and 10.4 su vs. the 9.0 su upper limit), phosphorus (115, 62, and 384 mg/L vs. the 40 mg/L limit), total suspended solids (464 mg/L vs. the 100 mg/L limit), and floating solids in greater than trace amounts. 4. A wastewater discharge from a high explosives operation exceeded limits for chemical oxygen demand (COD) (1010 mg/L vs. the 250 mg/L limit) in 1991. 5. Printed circuit board rinse wastewater exceeded limits twice in 1991, including pH (9.7 su vs. the 9.0 su limit) and COD (3.9 lbs/day vs. the 3.8 lbs/day limit). This finding was fully identified in the LANL Self-Assessment. 3-39 FINDING SW/CF-3: Programs for Compliance with Water Discharge Requirements Performance Objective Title 33 U.S.C. 1251 et seq., "Federal Water Pollution Control Act" (Clean Water Act), Title III, allows discharges of pollutants to waters of the United States only if the discharge is authorized by a permit issued under regulations promulgated by the EPA. 40 CFR 122, "National Pollutant Discharge Elimination System," requires facilities with point source discharges of pollutants to apply for permits and to comply with all of the requirements of a permit. New Mexico Water Quality Control Regulation (NMWQC) 1-201 requires notifications of intent to discharge (to surface water or groundwater) prior to initiating the discharge. New Mexico Liquid Waste Disposal Regulations contains requirements for disposal of liquid wastes to treatment systems designed for domestic wastes and requirements for disposal of septage from septic systems and holding tanks. EPA Administrative Order (AO) (Docket No. VI-91-1329) requires LANL, as co-permittee for the National Pollutant Discharge Elimination System (NPDES) permit, to meet interim effluent limits. The AO contains compliance schedules for treatment system improvements and wastewater characterization, and requires LANL to report quarterly to EPA on progress. The Federal Facilities Compliance Agreement (FFCA) (Docket No. VI-91-1328, Draft) requires LAAO, as co-permittee for the NPDES permit, to meet interim effluent limits. The FFCA contains compliance schedules for treatment system improvements and wastewater characterization at LANL, and requires LAAO to report quarterly to EPA on progress. LANL Administrative Requirements (AR) 9-6, "Water Pollution Control," describes LANL policies for compliance with water pollution control requirements. Finding LANL does not have formal programs In place that are adequate to ensure compliance with water pollution control requirements. Discussion The principal vehicle for formal sitewide communication of organizational or individual roles, responsibilities, and requirements for water pollution control is AR 9-6. The framework provided in the AR addresses some of the responsibilities, specifically those of the Environmental Protection Group (EM-8) and identifies line management as responsible for ensuring that their discharges and outfalls meet the AR or NPDES permit discharge requirements. The LANL Guide to Environmental Management Structure also describes some of the responsibilities of various LANL organizations. None of these documents, however, describe in detail the manner in which LANL organizations relate to 3-40 each other on specific program issues. The documents also do not provide detailed guidance to line management responsible for implementation of the AR. The following are specific examples of compliance requirements that do not have defined written programs: NPDES Permit Compliance \lery little formal communication has been made to the Fire Protection Utilities Group (ENG-8) from EM-8 that broadly defines the NPDES permit requirements. When asked what criteria they use to evaluate Johnson Controls World Services, Inc. (JCI) performance, ENG-8 staff said that processes and equipment have to work and that effluent limits must be met. They seemed unaware of permit requirements for representative monitoring, and proper operations and maintenance. No one on the staffs of these three organizations (EM-8, ENG-8, and JCI Utilities) seem to clearly understand the authority which each organization or staff member has for decisionmaking. At times, decisions are made by the staff member or group who chooses to take on the authority. An important example of this occurred during the assessment, when industrial wastewater was temporarily diverted from an outfall at TA-3-22, after a diesel oil spill, to the TA-18 sanitary treatment lagoons. EM-8 had "directed" the diversion to TA-18 during the spill cleanup effort and then notified JCI that the water could not be discharged from the lagoons because it was industrial wastewater and the outfall was only approved under the NPDES permit for treated sanitary wastewater. JCI Environmental Department tested the water, determined that it met the sanitary wastewater discharge limits, and JCI Utilities discharged it. Individuals within EM-8 had different opinions on whether EM-8 had the authority to order or prevent such actions by JCI. Wastewater Stream Characterization Program The AO requires LANL to complete a Wastewater Stream Characterization Program by dates listed in a compliance schedule. Although EM-8 has draft internal policies and program descriptions, they have not issued Laboratory-wide communication that outlines the specific program goals, requirements, and schedules or the responsibilities for line organizations to participate in the program. As a result, LANL risked not completing at least one category of outfalls, 06A, by the October 31, 1991, deadline because a line manager at one site prevented an uncleared LANL contract engineer from entering his site during the Tiger Team Assessment. LANL did meet the deadline, only because the problem was brought to the attention of the manager through a facility inspection conducted during the assessment. "Down the Drain Policies" AR 9-6 does not allow discharges of industrial or radiologically contaminated wastewater to septic systems or sanitary drains. However, no implementing procedures have been developed nor are inspections made of facilities with septic systems and sanitary drains to ensure that the AR is followed. Most line organizations do not have formal internal policies or procedures that implement AR 9-6 or its predecessor AR on an organization-specific basis. This finding was partially identified in the LANL Self-Assessment. 3-41 FINDING SW/CF-4: Quality and Characteristics of Wastewater Discharging to National Pollutant Discharge Elimination System (NPDES) Outfalls Performance Objective NPDES Permit No. NM0028355, Part II, Section D(l), requires the permittee to notify the EPA as soon as possible of any planned physical alterations or additions to the permitted facility. Notification is required when the alterations or additions could significantly change the nature or increase the quantity of pollutants discharged. LANL Administrative Requirements (AR) 9-6 requires notification to the Environmental Protection Group (EM-8) of modifications of waste streams by operating groups to allow EM-8 to meet the permit notification requirements. Finding LANL does not always notify EPA of facility alterations that may change the characteristics of wastewater discharges, as required by the NPDES permit. Discussion No formal communication has been made to operating groups throughout the Laboratory that thoroughly explains the EPA notification requirements of the NPDES permit or AR 9-6. EPA requires such notifications to determine if revision of permit effluent limits is appropriate based on the alteration in the facility or process. Both the current AR 9-6 (August 30, 1991) and the previous AR 9-1 ("Air and Water Pollution Control," January 1988) have similar notification requirements, so it is apparent that the requirement has been recognized at LANL for over 3 years. Deficiencies with current practices, observed during the assessment, that contribute to the lack of EPA notification of changes are as follows: 1. Operating groups are not fully aware of the requirements of AR-6. At the TA-3-22 power plant, a boiler treatment chemical mixture was observed in use during the assessment that included cyclohexanol amine, an organic nitrogen compound. The permit does not have limits for organic compounds for Outfall OlA which receives the discharge from the plant. However, neither the 1986 permit re-application or the 1990 permit re-application identified organic compounds in lists of boiler water treatment chemicals in water discharging to this outfall. 2. AR 9-6 is not sufficiently detailed to provide guidance to line management (who are given responsibility in the AR for compliance with the requirement) on what constitutes "changes" to a wastewater characteristic, especially for what may seem, to some managers, to be minor changes. For major facility modifications, however, LANL does conduct an environmental checklist review, in which EM-8 participates, and works well to identify potential changes in discharge activity. 3. No formal inspections are made for the express purpose of identifying potential modifications to discharges. Occasional 3-42 discoveries are made, through compliance sampling, that operating groups have modified their waste streams. For example (SW-46; I-SW-33 and I-SW-47), the Maintenance Group changed water treatment chemicals used for treating cooling tower water. The new chemical mixture contained an organic phosphorus compound which caused effluent violations in compliance sampling performed by EM-8. This is a reactive approach, however, which cannot identify upcoming changes in advance of implementation. This finding was partially identified in the LANL Self-Assessment. 3-43 FINDING SW/CF-5: Operation and Maintenance of Processes Discharging to National Pollutant Discharge Elimination System (NPDES) Outfalls Performance Objective Title 33 U.S.C. 1251 et seq., "Federal Water Pollution Control Act" (Clean Water Act), Title III, allows discharges of pollutants to waters of the United States only if the discharge is authorized by a permit issued under regulations promulgated by the EPA or a state NPDES program authorized by EPA. 40 CFR 122, Subpart C, "Permit Conditions," requires a permittee to comply with all of the conditions of a permit. NPDES Permit No. NM0028355, Part II, Section B requires the permittee to properly operate and maintain all facilities and systems of treatment and control. It also prohibits bypass of treatment facilities unless the bypass does not cause effluent limitations to be exceeded and only if it is also for essential maintenance to assure efficient operation. DOE 5480.19, "Conduct of Operations Requirements for DOE Facilities," Chapter XI, "Logkeeping," requires a system of narrative logs of a facility's status and of all events as required to provide an accurate history of facility operations. Chapter XVI, "Operations Procedures," requires written procedures to provide specific direction for operating systems and equipment during normal and postulated abnormal and emergency conditions. Finding LANL does not have procedures In place to ensure that systems that discharge to NPDES outfalls are properly operated and maintained. Discussion Principal wastewater discharging facilities at LANL requiring proper operation and maintenance (O&M) are (1) steam and power plants, (2) treated cooling tower discharges, (3) sanitary wastewater treatment plants, (4) high explosives wastewater discharges, and (5) the Radiological Liquid Treatment Plant. Of these discharges, most incidents of effluent violations which occurred from 1989 through 1991 were in water discharged from treated cooling towers, power plant discharges, and sanitary treatment plants. Lack of adequate O&M procedures has contributed to poor effluent limit compliance of treatment and control facilities. O&M deficiencies at sanitary wastewater treatment facilities include the following: 1. Johnson Controls World Services, Inc. (JCI) Utilities personnel have not performed inspections and scheduled maintenance on sanitary sewer collection systems for at least 6 months; although, such inspections are considered good O&M practice in the industry and are required by the JCI Operations Manual for the wastewater systems. 3-44 2. A records review for sanitary wastewater operations conducted during the assessment could not confirm that proper O&M of facilities was being conducted by JCI. It appears that JCI has not made substantive corrections in O&M practices, in spite of citations in two New Mexico Environment Department inspections (1990 and 1991) for inadequate O&M. Document deficiencies include operator inspection sheets that record the day but not the time, flowmeter calibration records that were missing the date the calibration was performed, and logs and process control data for all nine wastewater plants kept together making it difficult to identify operating trends in any one facility. The following are O&M deficiencies at steam and power generating plants: 1. A release of a sulfuric acid solution at the TA-3 power plant in May 1990 caused the pH of water in a 2.5-mile-long section of Sandia Canyon to reach as low as 1.9 (effluent limits are 6 to 9 ) . This release was attributed to a valve accidently left open on a sulfuric acid tank. 2. In October 1991, at the TA-16 steam plant, monosodium phosphate was used to neutralize wastewater during a maintenance procedure that bypassed the regular pH control process. This violated both the phosphorus effluent limit and the permit's prohibition against bypasses. Written O&M procedures at the plant are not current and do not include formal written procedures either for operation of the regular pH control system or for the temporary manual system in use during the maintenance procedure. Deficiencies in O&M of treated cooling water discharges include violations of total phosphorus limits caused by field testing for phosphorus that measured only inorganic phosphorus while the treatment chemical being used contained an organic phosphorus compound. This finding was fully identified in the LANL Self-Assessment. 3-45 FINDING SW/CF-6: Effluent Monitoring and Environmental Surveillance Programs Performance Objective DOE 5400.1, "General Environmental Protection Program," Chapter IV, requires implementation of environmental monitoring by November 9, 1991. Environmental monitoring, among other objectives, should identify potential environmental problems, detect unplanned releases, and monitor the impact of DOE activities on onsite and offsite environmental and natural resources. Finding Surface water effluent monitoring and environmental surveillance programs which meet the goals and objectives of DOE 5400.1 will not be Implemented by November 9, 1991. Discussion Current LANL programs do not meet the goals and objectives for environmental monitoring contained in DOE 5400.1 and discussions with LANL Environmental Protection Group staff indicate that the programs will not significantly change before the November 9, 1991, implementation date in the Order. Program deficiencies are summarized below. Effluent Monitoring Program The LANL wastewater effluent monitoring program meets the monitoring requirements of the National Pollutant Discharge Elimination System (NPDES) permit which, for some outfalls, only requires monitoring a few times each year. However, a program based simply on the infrequent sampling required by the permit cannot meet the effluent monitoring objectives of the DOE Order because (1) it cannot identify potential environmental problems that occur on an irregular/infrequent basis, and (2) such monitoring cannot detect or report unplanned releases, both of which are objectives of the Order. It is also standard industrial practice to supplement permit compliance monitoring with additional monitoring for the purpose of pro-actively providing additional assurance that a discharge continues to meet effluent limitations. LANL does perform additional monitoring following an effluent violation at an outfall for the purpose of characterization and identification of causes and determining that the discharge falls back into compliance. Environmental Surveillance Program The current LANL environmental surveillance program is primarily oriented toward identifying potential radiation impacts on public health. Some nonradiological surface water surveillance is conducted, but it does not meet the intent of the DOE Order because impact judgments are only made against drinking water standards as the evaluation criteria, rather than against Water Quality Standards used by EPA and the New Mexico Environment Department (NMED) on which to set water quality goals and to base NPDES effluent limits. Water Quality Standards may contain restrictions on pollutants that are toxic to water organisms, that may not be the same as restrictions in drinking water standards, that do not have drinking water goals, and that are designed to protect other possible uses of water, such as for watering of wildlife. 3-46 Currently, New Mexico Water Quality Standards for the Rio Grande are applied by EPA to the LANL NPDES permit; however, NMED has recently been attempting to apply standards to the quality of the water in the canyons within LANL boundaries, making it important that LANL assess Laboratory impacts on the canyon waters. LANL surveillance reports say that no offsite impacts occur from effluent discharges. It is clear from the reports (but not stated) that onsite, the water in an effluent discharge area in at least one canyon, Mortandad, has been severely impacted. Nitrate levels were measured as high as 117 mg/L (the drinking water standard is 10 mg/L) in 1989 and 85 mg/L in 1990. Other high contaminant levels identified in Mortandad Canyon include total dissolved solids (maximum of 1780 mg/L), sodium (maximum of 320 mg/L) and sulfate (maximum of 107 mg/L). The potential impact of such high pollutant levels on possible uses of the water by wildlife has not been evaluated in the surveillance reports. This finding was not identified in the LANL Self-Assessment. 3-47 FINDING SW/CF-7: Stormwater Pollution Control Performance Objective Title 33 U.S.C. 1251 et seq., "Federal Water Pollution Control Act" (Clean Water Act), Title III, prohibits the discharge of any pollutant by any person except as in compliance with specific provisions of the act and regulations promulgated by EPA. 40 CFR 122.26, "Storm Water Discharges," requires owners or operators for point source discharges of stormwater associated with industrial activity to submit National Pollutant Discharge Elimination System (NPDES) permit applications by November 16, 1991, for individual applications or May 18, 1992, for group applications. These regulations are the principal method by which EPA will begin to put specific requirements on discharges for preventing contamination of stormwater. DOE 5400.1, "General Environmental Protection Program," states that it is DOE policy to conduct its operations in an environmentally safe and sound manner and that DOE is committed to good environmental management of all its programs and at all its facilities, and to minimize risks to the environment. LANL ES&H manual Overall Policy for Environmental Protection (June 1988) declares that the Laboratory will provide the highest possible level of protection to the environment from harm that could arise from Laboratory operations and identifies line management as having the primary responsiblity for environmental protection. LANL Director's Policy No. 103, "Environmental, Safety and Health," declares that no activity or operation will be performed at the Laboratory unless it can be done in a manner that protects the environment. Finding LANL does not have effective Laboratory-wide or site-specif1c programs to minimize discharges of contaminants to the environment a stormwater runoff. Discussion LANL has sewer systems which drain stormwater into the canyons interlacing the site. LANL has an active program to apply for stormwater discharge permits as required by 40 CFR 122.26. Aside from the new permitting requirements, however, regulations have always authorized EPA to require a permit for stormwater discharges where, in EPA's judgment, the discharge threatens water quality. In proceedings not related to LANL, EPA has brought enforcement action against dischargers of pollutants in stormwater, even though EPA had never required the.discharger to apply for a permit. Many examples of Laboratory activities that could cause discharge of contaminated stormwater were observed during the Tiger Team Assessment. Examples include the following: 3-48 1. storage of hazardous wastes without secondary containment is occurring near storm drains in TA-18. 2. storage of toxic, corrosive, and combustible liquids in cabinets near storm drains and without readily available spill cleanup equipment is occurring at TA-2 (see Finding SW/CF-9). 3. A number of PCB oil-filled transformers, without secondary containment, are located near storm drains at TA-53 at the Los Alamos Meson Physics Laboratory. 4. An air compressor was observed, at TA-50-1, that had blown oil onto the pavement near a storm drain. On discovery of the oil stain during the assessment, LANL initiated cleanup activity. 5. At TA-60-2, drums of oil and other hazardous materials were unloaded from trucks onto a dock near a storm drain and spill cleanup equipment was not accessible. 6. At TA-35, a dielectric oil tank and associated piping system were observed leaking oil onto a supporting pad which drains to a portable tank for containment of oil spills from the tank. The tank, piping system, pad, and containment tanks are all exposed to precipitation, and the leakage of oil and runoff of rainwater has produced a containment tank full of oil-contaminated rainwater. During a heavy rainstorm, it is conceivable that the containment tank could overflow. The oil tank system was not covered, and the piping system was not properly maintained to avoid leaks which caused contamination of the rainwater. In addition to the observations made during the assessment, on four separate occasions during the previous 12 months, LANL notified the New Mexico Environment Department of possible releases of oil, following reports of an "oily sheen" on pools of water below stormwater outfalls. Such oily sheens are common after rainstorms that wash oil or other contaminants into an outfall. LANL recognizes that a new stormwater permit, when issued, will likely include the requirements for the Laboratory to develop a best management practice (BMP) stormwater pollution prevention program. Waiting until permit issuance, however, does not relieve LANL from the current, ongoing requirement to minimize discharges of contaminated stormwater. Failure to develop a BMP program now does not meet either DOE's or the Laboratory's policies of conducting operations in an environmentally safe and sound manner. This finding was partially identified in the LANL Self-Assessment. 3-49 FINDING SW/CF-8: Spill Prevention Control and Countermeasure Plan Performance Objective 40 CFR 112.7, "Guidelines for the Preparation and Implementation of a Spill Prevention Control and Countermeasure Plan," requires the preparation and implementation of a Spill Prevention Control and Countermeasure (SPCC) Plan. Specific requirements state that additional facilities or future procedures or methods be discussed in separate paragraphs and that details of implementation be discussed separately. The SPCC Plan must include a previous spill history, with descriptions of spills, corrective actions taken, and plans for preventing recurrence. 40 CFR 112.7 also requires the SPCC Plan to include sections concerning bulk storage tanks and secondary containment, including rainwater drainage and recordkeeping, and fail-safe engineering. Sections covering transfer, pumping, and truck loading and unloading operations should be included. The regulations also state that required inspections should be in accordance with the facility's written procedures. These procedures, including inspection records, should be part of the SPCC Plan and maintained for 3 years. Security issues must be discussed also. Finding The LANL SPCC Plan is incomplete with respect to the requirements of 40 CFR 112.7. Discussion The LANL SPCC Plan was written in 1986 and revised in March 1987 and March 1990. Although the SPCC plan addresses significant spill prevention and control issues at LANL, it does not appear that the current plan is in accordance with all the appropriate regulations. For example, 40 CFR 112.7 states that all planned facilities, procedures, or methods not yet operational should be discussed separately with implementation details included. There are multiple examples in the LANL SPCC Plan where the future tense is used with reference to containment, inspections, spill kits, procedures, etc. However, future actions are not discussed with respect to responsibility or time schedules, and are not always in separate paragraphs as required. Deficiencies observed in the LANL SPCC Plan include, but are not limited to, the following: 1. The spill history section of the SPCC Plan does not include a discussion of corrective actions taken and plans for preventing recurrence. 2. The SPCC Plan does not discuss rainwater discharge from diked or bermed areas, including inspection of accumulated rainwater, to ensure that applicable water quality standards are met before discharge, procedures for discharge, and recordkeeping. 3. The SPCC Plan does not address fail-safe engineering, including installation of at least one device such as a high liquid level 3-50 alarm, pump cutoff device, or fast response system for determining liquid levels for each tank. 4. The SPCC Plan does not address specifications for underground transfer pipelines, 5. The SPCC Plan does not discuss procedures for transferring, pumping, and tank truck loading and unloading operations. 6. The SPCC Plan mentions that periodic visual and structural inspections of storage tanks and pipelines, with proper recordkeeping, will be put into effect (see Finding SW/CF-9). However, inspection procedures have not been developed and included in the SPCC Plan, along with the inspection records, as required. The 3-year requirement for recordkeeping is not discussed. 7. The security of bulk storage areas, including all valves, controls, and pipelines, is not addressed by the SPCC Plan as required. This finding was not identified in the LANL Self-Assessment. 3-51 FINDING SW/CF-9: Spill Prevention Control and Countermeasure Plan Implementation Performance Objective 40 CFR 112.3, "Requirements for Preparation and Implementation of Spill Prevention Control and Countermeasure Plans," requires that Spill Prevention Control and Countermeasure (SPCC) Plans be fully implemented. The LANL SPCC Plan sets forth requirements for visual and structural inspections, preventive maintenance, and recordkeeping; handling and storage practices for drums and laboratory chemicals; spill prevention and control training; and Spill Coordinator (SC) roles and responsibilities. Finding The LANL SPCC Plan has not been effectively implemented as required by 40 CFR 112.3. Discussion spill Although the LANL SPCC Plan includes requirements for for many significant significa Trf^ **»« found -P/M iirtr\ that, +t*-^+ with fPW prevention and control concerns on site, the Tiger Team exceptions, the SPCC Plan was not fully understood or implemented si tewide. The following specific examples are indicative of sitewide observati ons: The LANL SPCC Plan requires preventive maintenance for the two 24,000-gallon Marx oil tanks (TA-3-550) located southwest of TA-3-316. The plan requires that recorded visual inspections be conducted monthly and that properly documented structural inspections of the tanks and underground pipeline be conducted every 5 years. The LANL SC who is responsible for the tanks was not aware of his responsibilities with respect to preventive maintenance of the tanks and line as required by the SPCC Plan. Although visual inspections are conducted e^jery other day and noted in a site logbook, to the best of the SC's knowledge, no structural inspections have been performed since the tanks were moved to their current location in the 1970s (I-SW-244). The SPCC Plan requires specific visual and structural inspections of the Johnson Controls World Services, Inc. (JCI)-operated TA-3-22 Steam Plant fuel oil system. Structural inspections of the two 150,000-gallon tanks (located northeast of the steam plant), pipes, and pumps will be conducted at a minimum of once every 5 years. There are no written JCI procedures for visual or structural inspections. Visual inspections of the tanks are performed weekly, but are not recorded. There are no records indicating that structural inspections of the tanks and pipes have been performed over the 35-year life of the system. Interviews with the JCI steam plant supervisor and the SC revealed that they were not aware of any structural inspections conducted or of the requirements under the LANL SPCC Plan (I-SW-250 and I-SW-251). On September 25, 1991, an underground fuel pipeline break at this facility released approximately 200 gallons of diesel fuel to the environment. 3-52 Section 8 of the LANL SPCC Plan states requirements for handling and storage of drums and laboratory chemicals. Requirements include the use of secondary containment and the presence of appropriate spill kits in each drum and chemical storage area. The following observations are indicative of sitewide drum and chemical storage deficiencies with respect to the SPCC Plan requirements: TA-54, Area L mixed waste storage pad contains 1,000 to 1,500 drums of mixed wastes with ineffective secondary containment. TA-53, south of MPF-25, contains two drum storage areas with no secondary containment, and there are no spill kits. TA-21, Bldg. 228, contains a drum storage area of unknown ownership. Drums are stored on the ground with no secondary containment, and there is no spill kit. TA-54, Bldg. 1013, contains 42 drums of dilute ethylene glycol that have been stored for approximately 4 months with no secondary containment, and there is no spill kit. TA-2, Omega West Reactor, contains three storage cabinets containing toxic, corrosive, and combustible materials located near storm drains. The spill kit is not easily accessible. TA-16, Bldg. 460, contains a flammable chemical storage cabinet located near a floor drain. The spill kit is not easily accessible; the floor drain is not covered. TA-55, Bldg. PF-3, in the chemical mixing room, there is no diking, floor drains are not covered, and there is no spill kit. Section 9 of the SPCC Plan addresses spill prevention and control training requirements. However, there is no formal SPCC training program at LANL. The first class on spill awareness held since 1989 was conducted at LANL on September 17-20, 1991 (SW-213 and SW-2I4). The class was for LANL SCs and an open invitation was made to JCI SCs as well. Not all LANL SCs attended this training session and no JCI personnel attended (I-SW-201). Additional, more specific training sessions are planned. However, there is no enforcement mechanism to ensure that e'^ery SC is properly trained. The SPCC Plan clearly outlines SC roles and responsibilities. These responsibilities include conducting and recording SPCC training activities for their group; ensuring spill kits are appropriately located and stocked; conducting visual and arranging for structural inspections; maintaining chemical inventories; responding to spills; and maintaining records. However, Tiger Team inspections and interviews revealed that frequently, SCs had been assigned just prior to the Tiger Team Assessment, SCs did not know what the SPCC Plan was, SCs had not been trained, and that 3-53 '^ SCs were not aware of their responsibilities (I-SW-224, I-SW-233, I-SW-234, I-SW-236, I-SW-244, I-SW-246, I-SW-248, I-SW-251, and I-SW-255). This finding was partially identified in the LANL Self-Assessment, 3-54 FINDING SW/CF-10: Backflow Prevention and Cross-Connection Control Program Performance Objective New Mexico Regulations Governing Water Supplies (NMRGWS), Section 208(1), states that no physical connections will be permitted between public water supplies and any other water supply source unless the public water supply is protected by a backflow prevention device. Piping arrangements or connections which would allow an unsafe substance to enter a public water supply are prohibited. DOE 6430.lA, "General Design Criteria," Section 0266, states that the quality of domestic water within distribution systems will be protected from degradation by installation of backflow prevention devices. Cross-connections between domestic and industrial or irrigation distribution systems are prohibited. DOE 5480.19, "Conduct of Operations Requirements for DOE Facilities," paragraph 4, "Policy," requires that the conduct of operations at DOE facilities be managed with a consistent and auditable set of requirements, standards, and responsibilities, and that operators have procedures in place to control the conduct of their operations. Finding LANL does not have a formal, written backflow prevention and cross-connection control program to ensure compliance with the NMRGWS. Discussion LANL cannot ensure that cross-connections between potable and nonpotable lines do not exist within buildings. Given the age of many LANL buildings and their frequent modifications due to changing group operations, the potential exists for cross-connections. Three cross-connections between the potable and industrial water lines were discovered in TA-46, Bldg. I (SW-237). Anecdotal evidence supports further examples of industrial water being used for potable purposes at TA-53 and TA-48. Industrial water was being used to make coffee at a location within the Los Alamos Meson Physics Facility at TA-53 before cross-connections were discovered and eliminated (I-SW-205 and I-SW-208). The FY 1992 budget includes funding to initiate a cross-connection inventory and remediation project. The Maintenance Group (ENG-6) is responsible for the installation, testing, and maintenance of backflow prevention devices at LANL. Currently, ENG-6 is in the process of inventorying and ensuring that all buildings plumbed for water onsite are supplied from the water distribution main via a backflow prevention device. This project is approximately 40 percent complete (I-SW-220). Each backflow prevention device is tested twice a year by certified operators to ensure proper operation. ENG-6 maintains an installation, testing, and maintenance log for each device. While the maintenance log is thorough with respect to documenting devices, installation, testing, and maintenance dates, it is unauditable without explanation from the ENG-6 engineer who is responsible for backflow prevention devices. At this time, the status of the backflow prevention program can only be determined 3-55 through interviews with the engineer in charge. program with implementing procedures. There is no formal written This finding was partially identified in the LANL Self-Assessment, 3-56 FINDING SW/CF-11: Drinking Water Program Performance Objective DOE 5480,19, "Conduct of Operations Requirements for the DOE Facilities," paragraph 4, "Policy," requires that the conduct of operations at DOE facilities be managed with a consistent and auditable set of requirements, standards, and responsibilities, and that operators have procedures in place to control the conduct of their operations, DOE 4330,4A, "Maintenance Management Program," states that it is DOE policy that systems important to the safe operation of a facility shall be subject to a maintenance program to ensure that the systems meet or exceed their design requirements throughout the life of the facility. In addition. Section 11 states that each DOE contractor shall develop, implement, and document a program to ensure that maintenance activities are conducted to preserve the reliability of systems important for safe and reliable operation. Finding LANL does not have a formal, written drinking water program with implementing procedures. Discussion The water supply and the distribution system which serve LANL are owned by DOE. Los Alamos County owns the distribution system serving Los Alamos townsite and White Rock. Johnson Controls World Services, Inc. (JCI) operates and maintains the water supply and the LANL distribution system under the management of the Fire Protection and Utilities Group (ENG-8). The Environmental Protection Group (EM-8) monitors water quality and provides regulatory reporting to the New Mexico Environment Department for both the LANL and the Los Alamos County distribution systems. EM-8 advises ENG-8 on issues with drinking water wells, including well rehabilitation and management of water resources. EM-8 also provides support to DOE in the planning and development of new drinking water wells. There are no written procedures outlining how the parties work together within the drinking water program as well as documenting the responsibilities of the individual groups. LANL does not have a formal, implemented water supply and distribution maintenance program as part of its drinking water program. The JCI Utilities Operating Instructions (SW-228) includes maintenance procedures. However, Tiger Team review of JCI water supply and distribution maintenance records found that the documents are incomplete and unauditable. The past and current approach taken by JCI regarding the maintenance of the supply and distribution system was described by JCI Utilities management as reactive (I-SW-206 and I-SW-207). Complaints concerning potable water taste, odor, or color are initially investigated by the Field Operations Group (ENG-5). ENG-5 contacts JCI for more thorough evaluation, including collecting and analyzing water samples. More than five water complaints were investigated between April and June 1991 (SW-237). Low usage of some drinking fountains and proximity to dead end water lines appear to encourage the growth of noncoliform bacteria. Although the bacterial counts are within Safe Drinking Water Act requirements (SW-237), 3-57 some susceptible individuals may experience gastric cramps and vomiting from drinking water from stagnant lines. There is no written procedure to track water complaints and eliminate conditions conducive to bacteria growth. The FY 1992 budget contains funding to inventory and track microbiological concerns. In July 1992, the State of New Mexico will implement the EPA's more stringent standard for levels of lead in drinking water (I-SW-238). Although past potable water samples from drinking fountains and taps have not exceeded the standards for contaminants, the potential exists that some drinking fountains, especially older ones, may exceed the more stringent standard for lead (SW-241). There is no written procedure to inventory and test drinking fountains and taps in preparation of the new requirement. The FY 1992 budget includes funding to begin the inventory and testing. This finding was partially identified in the LANL Self-Assessment. 3-58 FINDING SW/CF-12: Septic System Program Performance Objective New Mexico Liquid Waste Disposal Regulations (NMLWDR), Section 201(A) states that "No persons shall install or have installed a new liquid waste system or modify or have modified an existing liquid waste system, unless that person obtains a permit issued by the Division prior to such installation or modification." NMLWDR 305 requires owners of sanitary holding tanks to maintain records demonstrating sufficient pumping and proper disposal of liquid waste to prevent overflows. Copies of these records must be mailed to the state ewery 6 months. NMLWDR 308 prohibits introduction of any waste into a septic system that is not generally associated with toilet flushing, food preparation, laundry, and personal hygiene. LANL Administrative Requirements (AR) 9-6, "Water Pollution Control," requires line managers to be responsible for ensuring that their septic systems meet all requirements. Also, it states that "no industrial liquid waste may be discharged into a septic tank system or sanitary holding tank." DOE 5480.19, "Conduct of Operations Requirements for DOE Facilities," paragraph 4, "Policy," requires that the conduct of operations at DOE facilities be managed with a consistent and auditable set of requirements, standards, and responsibilities, and that operators have procedures in place to control the conduct of their operations. Finding LANL has no formal, written program to ensure that the Septic System Program is conducted in accordance with the NMLWDR. Discussion LANL has no written program in place to ensure that the Septic System Program is in compliance with the NMLWDR. There are 77 active septic tank systems on site, including 17 with holding tanks. The Environmental Protection Group (EM-8) prepares the permit applications for new or modified septic systems and submits the holding tank pumping records to the state via LAAO. Johnson Controls World Services, Inc. (JCI) maintains all septic systems and is responsible for pumping holding tanks. Individual line managers are responsible for ensuring that their septic systems meet all applicable requirements. There are no written procedures outlining how these responsibilities work together to ensure that the program is in accordance with the NMLWDR. The following deficiencies in the septic system program were observed: 1. On occasion, septic systems have been installed before the approved state permits have been received (I-SW-208). These occurrences are usually the result of delays in the permit application process caused by LANL or LAAO. The state will, within 10 working days, either grant or deny the permit, or notify the applicant that more review time is necessary. Interviews with 3-59 the Program Manager of the New Mexico Environmental Division Liquid Waste Programs indicated that the usual turnaround time for permit approval, once the application is received in Santa Fe, is 2 or 3 days (I-SW-254). A permit application procedure and its strict understanding and implementation sitewide is necessary to ensure that septic systems are permitted and installed in accordance with the NMLWDR. 2. JCI must provide holding tank pumping records to EM-8 so that the appropriate reports can be sent to the state. Records review conducted by the Tiger Team at JCI Utilities found holding tank pumping records that were incomplete and unauditable. JCI does not have a written, holding tank pumping or recordkeeping procedure. 3. As required by NMLWDR, septic systems can receive only sanitary waste. Interviews with LANL staff indicate that septic systems, especially those installed prior to 1970 or with unknown installation dates, may also receive industrial waste. For example, septic systems at TA-18, Bldgs. 23, 32, and 116, could receive industrial waste through the accidental introduction of process liquids through floor drains. Also, the roof drains at Bldg. 116 discharge to the septic system, which is not in accordance with the NMLWDR (SW-77; I-SW-65 and I-SW-66). Other indicative examples include the 10 septic systems which serve TA-15 and the 5 which serve TA-33. It is unknown whether floor and roof drains at these facilities discharge to the septic systems (I-SW-201). 4. Not all the older buildings at LANL have as-built drawings, and some as-built drawings are no longer correct due to the modification of facilities. Document review of septic system records reveal that it cannot be assured that only sanitary wastes are discharged to older septic systems. The only program at LANL to identify waste streams, their discharge points, and disposal techniques is the Waste Stream Characterization Program. A positive result of this program will be updated as-built drawings. Currently, this program has not been formalized or completed (see Finding SW/CF-3). This finding was partially identified in the LANL Self-Assessment. 3-60 FINDING SW/CF-13: National Pollutant Discharge Elimination System (NPDES) Monitoring and Reporting Performance Objective 40 CFR 122, Subpart C, "Permit Conditions," requires a permittee to comply with all of the conditions of a permit, NPDES Permit No. NM0028355, Part II, Section C, requires all samples and measurements to be representative of the volume and nature of the monitored discharge. Part III, Sections C through F, require monitoring to be performed sequentially on a series of outfalls at a specified monitoring frequency and multiple source monitoring to be flow weighted for reporting. DOE 5480.19, "Conduct of Operations," Chapter 1, Operations Organization and Administration, states that an assurance of a "high level of performance in DOE facility operations is achieved through effective implementation and control of operations activities." Chapter IX, "Lockouts and Tagouts," further states that "locks . , , should be placed on controls when for safety or other special administrative reasons controls must be established." Finding LANL has not verified that effluent monitoring is representative of the discharge for all outfalls and does not flow weight samples from multiple source monitoring for reporting. Discussion For industrial discharges, the LANL NPDES permit categorizes many similar discharges for the purpose of setting effluent limitations and monitoring requirements. As an example, the treated cooling water discharge category (03A) includes 31 individual discharges that are listed in the permit. The permit requires one monitoring sample from category 03A each week and sets up a sequence or order by which any particular discharge is selected for sampling. Since LANL's effluent monitoring program is based almost exclusively on the permit requirements, monitoring of any individual discharge, in a category consisting of many discharges, may only be performed two to three times annually. Although the permit monitoring requirements are being met for frequency of sampling for the category as a whole and for each individual discharge, LANL has never attempted to verify that such infrequent sampling of categories, many with widely varying flows and contaminant loadings, can provide data that are representative of the many discharges and possible discharge conditions. In discussions held during the assessment. Environmental Protection Group staff expressed their own reservations about the validity of data from the infrequent monitoring of industrial discharges. At the TA-50-1 Radiological Liquid Waste Treatment Plant operated by the Waste Management Group, a weekly NPDES compliance sample required by the permit is typically taken on Monday. The practice of always sampling an industrial operation on a particular day of the week, particularly on a Monday or a Friday, often results in unrepresentative data because the samples can miss a range of influent characteristics that may occur during other days. 3-61 A number of outfalls have automatic flow measuring devices used for continuously recording discharge flows for reporting purposes. Although several of the devices are in areas that are accessible to personnel not involved in the monitoring program, none of the instruments are kept locked. The instrument enclosures, however, do have a provision for attaching a keyed padlock. In addition, Johnson Controls World Services, Inc. personnel who calibrate the flowmeters on the effluent from the sanitary treatment system do not keep accurate records of the calibrations (see Finding SW/CF-5). Accordingly, LANL cannot verify the accuracy of the flow measuring data. Although the permit requires flow weighting of monitoring data from outfall samples in multiple outfall categories, LANL arithmetically averages the results for all of the outfalls sampled in a category, large volumes or small, for reporting. According to LANL staff, flow weighting calculations have probably never been performed in earlier years under previous versions of the NPDES permit. LANL staff recently recognized that the flow weighting calculations were not being performed, but questioned the meaning of the language in the permit. LANL focuses on the phrase "multiple source discharges" and questions whether the phrase means flow weighting of discharge data from multiple outfalls in a category or flow weighting data from multiple contributing streams entering an outfall. In comments to EPA on the March 1991 draft renewal of the LANL NPDES permit, LANL asked for clarification of the weighting requirement. The permit language in question, however, occurs in a section outlining a sequence for monitoring of multiple outfalls in a category. Nowhere else in the permit are samples required from contributing streams to an outfall, for the purpose of effluent monitoring. It seems clear that the permit language refers to flow weighting the data from multiple outfalls in a category because the permit requires that the data from various outfalls be reported for the category, not for the individual outfalls. The permit language, as written, also makes technical sense; when sampling results from many discharge locations are combined for the purpose of preparing a report that represents all of the discharges, those that consist of larger volumes should receive more weight in an averaging calculation. Reporting results that are not flow weighted, therefore, do not meet the requirement for representative monitoring. This finding was not identified in the LANL Self-Assessment. 3-62 3.5.2.3 Best Management Practice Finding FINDING SW/BMPF-1: Radioactive Liquid Waste Treatment Plant Characterization of Effluent Quality in NPDES Permit Re-Application Performance Objective 40 CFR 122, Subpart B, "Permit Applications and Special NPDES Program Requirements," requires facilities with point source discharges to apply for permits. The permit application must include a description of processes contributing flow to a treatment system, and must include quantitative analytical information for specific types of pollutants that are believed to be present in the discharge. Finding The 1990 National Pollutant Discharge Elimination System (NPDES) permit re-application may not have accurately characterized nonradiological contaminants from the TA-50-1 Radiological Liquid Waste Treatment Plant because LANL did not use available monitoring results. Discussion When evaluating effluent data for inclusion, in a permit application, it is a good management practice to determine if the data accurately represents the discharge. Failure to determine whether data are representative can result in EPA setting effluent limits that are more restrictive than necessary or, if sufficiently inaccurate, render the permit invalid, A series of two special samples were obtained by the Environmental Protection Group (EM-8) for characterization of Outfall 051 (Radiological Liquid Waste Treatment Plant) for the 1990 NPDES permit application. These samples were collected and analyzed as required by regulations. However, these samples represent pollutant concentrations only for the short duration of the sample collection period. Spot samples such as these are not adequate to characterize the range of pollutant concentrations that may occur during the life of the permit. A comparison of these data with other data included in the Waste Management Group (EM-7) 1990 annual report on the operation of the plant shows significant differences in some pollutant categories that are often of concern in protection of public health and the environment. The EM-7 data had been gathered throughout an entire year of operation and, therefore, represent an accurate view of the range of effluent characteristics discharged by the plant. Some important differences are as follows: 1. The maximum nitrate concentration in the EM-7 report is 475 mg/L vs. 356 mg/L in the application. 2. The EM-7 report lists a maximum sulfate concentration of 501 mg/L vs. 121 mg/L in the application. 3. The maximum chromium in the report is 40 ug/L vs. 22 ug/L in the application. 3-63 4. The mercury concentration in the EM-7 report is almost 10 times higher than in the application (2.6 ug/L vs. 0,26 ug/L), 5. Maximum nickel, arsenic, and silver concentrations are listed in the report, but described as "believed absent" in the permit application. Further, the samples from the 1990 EM-7 annual report are the maximum concentrations measured in 12 monthly composite samples, each of which was a composite of multiple daily samples. Therefore, it is reasonable to assume that the actual daily maximum could be even higher, and the differences between the permit application and the actual daily maximum discharges from TA-50-1 even larger, than described by the above examples, EM-8 staff indicated that the analytical data for the permit re-application were probably not compared against either 1989 or early 1990 analytical results from EM-7, As a best management practice, staff responsible for NPDES permit management should make use of the most representative data available to ensure that the data being submitted to EPA accurately represent the discharge. The EM-7 data could also be used to identify potential problems in the wastewater discharges. This finding was partially identified in the LANL Self-Assessment, 3-64 3.5.3 Groundwater/Soil, Sediment, and Biota 3.5.3.1 Overview The purpose of the groundwater/soil, sediment, and biota portion of the environmental assessment of LANL was to (1) evaluate the programmatic and technical status of protection and monitoring programs for groundwater, soil, sediment, and biota, (2) evaluate the potential for and actual contamination of these media by radiological and nonradiological constituents as a result of past and present operations, and (3) evaluate programs and procedures established to prevent future contamination and to prevent the spread of existing contamination. The programs and field activities were evaluated against criteria established in DOE Orders; applicable Federal, state, and local regulations and guidance; industry guidance; and best management practices listed in Table 3-4. Environmental monitoring results for these media were compared with applicable concentration guidelines and regulations. The assessment consisted of interviews, document review, and site inspections. Interviews were conducted with personnel at LANL from the Environmental Management Division (EM), Johnson Controls World Services, Inc., (JCI), and operating groups at individual technical areas. Personnel from LAAO, the New Mexico Environment Department, U.S. Department of the Interior - Bureau of Indian Affairs, and representatives from San Ildefonso Pueblo were also interviewed. Additional information was also obtained by review of documents, such as policies and procedures, reports, departmental abstracts, memoranda, and regulatory documentation. The overall impression gained from this assessment is that LANL's monitoring programs for groundwater, soil, sediment, and biota have been informal, inconsistently implemented, and insufficient to fully determine the impacts of DOE operations on the environment. The programs have in large part been implemented by a small number of technical personnel, without significant oversight from LANL Management, LAAO, or regulatory agencies. The LANL staff responsible for the programs have a high level of technical knowledge and expertise; however, LANL has not prioritized resources so as to provide a comprehensive monitoring program or to implement formal programs and procedures to be consistent with DOE Orders and regulatory guidance documents. This overview is divided into three sections: the groundwater environment, the soil/sediment/biota environment, and a summary of the findings, along with a summary of LANL's Self-Assessment. Groundwater Historical and ongoing operations at LANL have the potential to impact groundwater. Contaminant sources include historical and current industrial and sanitary wastewater discharges; surface impoundments and lagoons; underground storage tanks; waste burial and storage areas; and runoff from active and inactive waste sites, including landfills and firing sites. The principal types of contaminants potentially resulting from site operations are radioactive materials consisting primarily of tritium, cesium-137 (Cs), and isotopes of uranium (U), and plutonium (Pu). Nonradiological contaminants, including heavy metals and organic compounds, are also present in some areas. 3-65 TABLE 3-4 LIST OF GROUNDWATER/SOIL, SEDIMENT, AND BIOTA REGULATIONS/REQUIREMENTS/GUIDELINES Re^tilr^Hients/ Sections/Title 1 i Authority 40 CFR 264 and 265 Standards and Interim Status Standards for Owners and Operators of Hazardous Waste Treatment, Storage, and Disposal Facilities EPA 1 OSWER Directive 9950,1 RCRA Ground Water Monitoring Technical Enforcement Guidance Document Guidance for Conducting Remedial Investigations EPA OSWER Directive 9283,1-2 Guidance on Remedial Actions for Contaminated Groundwater at Superfund Sites EPA OSWER Directive 9502,00-60 RCRA Facility Investigation (RFI) Guidance EPA SW-846 Test Methods for Evaluation of Solid Waste, Physical Chemical Methods EPA Site Development Planning DOE General Environmental Protection Program DOE DOE 5400,4 Comprehensive Environmental Response, Compensation, and Liability Act Requirements DOE DOE 5400.5 Radiation Protection of the Public and the Environment DOE DOE 5484.1 Environmental Protection, Safety, and Health Protection Information Reporting Requirements DOE DOE 6430.lA General Design Criteria DOE DOE/EH-0173T Environmental Regulatory Guide for Radiological Effluent Monitoring and Environmental Surveillance DOE Monitoring Well Construction and Abandonment Policy NMED Groundwater Discharge Plans NMWQR 1 DOE 4320,IB DOE 5400,1 1 NMED NMWQR il 1 3-66 1 11 The LANL site is hydrogeologically complex, considering the mountainous terrain of volcanic origin, complex recharge and discharge regimes, extensive geologic faulting, and highly variable stratigraphy. The presence of springs, high groundwater production flowrates in the vicinity of LANL, and steep vertical groundwater gradients add to the complexity of the hydrogeologic regime. The hydrogeologic setting at LANL consists of two groundwater regimes; shallow perched alluvial aquifers located in canyon valleys within the site boundaries, and the main aquifer, primarily in the Tesuque Formation, which is located within sediments of the Santa Fe Group, Impermeable pre-Cambrian crystalline rock underlies the main aquifer. The depth to the main aquifer in the eastern portion of the site is about 800 feet below land surface and increases to 1,200 feet below surface in the western half. The main aquifer is a regional aquifer of erosional outwash sediments consisting mostly of sand and gravel, which were deposited within an ancient river valley coincident with the top of the Rio Grande Rift. The undisturbed direction of groundwater flow in the Los Alamos vicinity is generally eastward towards the Rio Grande (river). Recharge to the main aquifer is inferred to be largely from infiltration of precipitation that falls directly on the western perimeter of LANL in or near the Valle Grande. Groundwater in the LANL area is used as the source of potable water for LANL as well as the City of Los Alamos and the surrounding communities of White Rock and Pajarito Acres. Additionally, LANL operates the Water Canyon Gallery field to supply groundwater for nonpotable purposes such as steam plant makeup water. The earliest characterization of main aquifer was based on data collected from water supply wells installed by the U.S. Geological Survey (USGS). It should be noted that these wells were designed for potable water supply, not as part of a groundwater monitoring program. The main aquifer has been the focus of subsequent investigations conducted by the USGS until 1970 and by LANL since 1970. LANL currently has 11 onsite monitoring wells (7 designed for groundwater monitoring and 5 potable wells also used for groundwater monitoring) and has no immediate plans to install more wells. The site also obtains data from adjacent potable wells owned by DOE and operated by JCI. In total, regional groundwater characterization is based on approximately 75 wells, springs, and seeps. LANL is in the midst of completing a Groundwater Monitoring Well Inventory Program t,o provide a data base of existing wells. Groundwater monitoring at LANL is conducted by the Environmental Protection Group (EM-8) of EM. Monitoring of both the perched alluvial aquifers and main aquifer is performed on an annual basis. Groundwater sampling and laboratory analyses of groundwater samples are conducted by EM-8 and the Environmental Chemistry Group (EM-9), respectively. Monitoring results of the main aquifer indicate that LANL operations have not impacted the quality of this water. The surface flow from the Los Alamos County-operated Bayo sanitary wastewater treatment facility effluent in Pueblo Canyon infiltrates into the perched alluvial groundwater resulting in a transfer of radionuclides. These radionuclides leach into the perched alluvial groundwater offsite via Los Alamos Canyon. The radiological contaminant concentrations in this groundwater are less than DOE 5400,5 concentration guides for potable water. 3-67 LANL has identified over 2,000 solid waste management units (SWMUs), including past burial sites, septic system discharges, chemical spill sites, and inactive underground storage tank locations. Groundwater quality data for perched alluvial aquifers are generally not available in the immediate area of these sites. Soil. Sediment, and Biota The general approach to the soil, sediment, and biota assessment included reviewing the environmental monitoring program, observing known or suspected contamination sources, and observing contaminant release controls or stabilization procedures. The LANL site lies on the Pajarito Plateau, which consists of volcanic rocks erupted from two significant pyroclastic eruptions that deposited ash and pumice, referred to as the Bandelier Tuff (slightly welded to welded ash, tuff breccia, and crystal fragment tuff). The Bandelier Tuff overlays the Puye Formation of the Santa Fe Group sediments. The Puye Formation's upper member, the Fanglomerate Member, consists of silts, sands, and pebble to boulder breccia of volcanic rocks. The Puye Formation's lower member, the Totavi Lentil, consists of sands, pebbles, and boulders of quartzite, granite, latite, dacite, and other volcanic rocks. The Tesuque formation, consisting of sand, silt, clay, and some interbedded gravels, underlies the Puye Formation. Generally, the Totavi Lentil is overlain by basalt flows of the Chino Mesa on the eastern portion of the plateau. The Puye Formation is interbedded with volcanic rocks of the Tschicoma Formation on the western portion of the plateau, the Sierra de Los Valles. LANL is located within an area of semiarid temperate mountain climate. Vegetation consists of desert shrubs and drought resistant grasses. The most widely distributed type of vegetation on the site is the Pinon Pine and Juniper forest community. The most abundant mammal is the Western Harvest Mouse. Elk, deer, and bear are the predominant large mammals, and bobcat, raccoon, and skunk are the predominant medium-size mammals. There are numerous amphibians, reptiles, waterfowl, and birds, including the Golden Eagle and Cooper's Hawk. Additionally, the Rio Grande (river), which flows at the eastern edge of the LANL site and forms part of the site's eastern boundary, supports a large variety of aquatic wildlife. Soil and sediment monitoring and sampling is performed onsite and at perimeter monitoring and surveillance monitoring stations. No significant concentrations (i.e., greater than background) of radionuclides were reported or detected for any regional stations for soil sediment. LANL's 1989 environmental surveillance report (GW-147) did not include a detailed quantitative analysis of existing data; however, a general summary of radiological contaminants detected in onsite and offsite media was provided, and is discussed below. Soil and sediment perimeter stations reported sediment sample results below established regional background levels. In contrast, results for the onsite station near Potrillo Drive, soil station S-13, indicated tritium contamination at 15 times the established background levels. This contamination is due to historical releases, and does not indicate any new releases. Elevated levels of uranium and plutonium isotopes have also been detected in sediments in onsite canyons. The resultant doses through 3-68 environmental pathways are well below DOE's radiation protection standards for the public. Tritium, cesium-137, strontium-90, and americium-241 have been detected in Los Alamos and Mortandad Canyon sediments. Also, plutonium isotope concentrations have been detected in Pueblo Canyon both on-site and off-site. Uranium isotope concentrations have been detected in Los Alamos Canyon both on-site and off-site in soils at the TA-14, TA-15, and TA-36 firing sites. Resultant radiation doses from this contamination in the canyons are well below DOE's radiation protection standards for the public, Onsite and offsite terrestrial wildlife and vegetation are sporadically sampled and analyzed for radiological constituents at LANL, Additionally, foodstuffs, farm products, and aquatic biota are routinely sampled and analyzed for radiological constituents. The sampling and analysis is conducted to evaluate the effects of current operations, past practices, active and inactive waste sites, and contaminated areas on these media and biota. Foodstuff monitoring results indicate that radiation doses from LANL operations are well below DOE's radiation protection standards for the public. Summary of Findings The groundwater/soil, sediment, and biota assessment identified five compliance findings and three best management practice findings. The compliance findings include the inadequacy of a sitewide hydrogeologic monitoring well network; deficiencies in groundwater sampling and analysis; an incomplete Groundwater Protection Management Program Plan; an incomplete soil, sediment, and biota portion of the environmental surveillance program; and inadequate control of radiologically contaminated soils and sediment. The best management practice findings address inappropriate closure and protection of wells and boreholes; lack of groundwater discharge plans; and an incomplete seismic hazard analysis. LANL's Self-Assessment fully identified six of the eight findings and partially identified the other two. Considerable effort was made by LANL in preparing the self-assessment, and the document demonstrates LANL's understanding of the deficiencies. However, LANL did not identify root causes for these findings and has not implemented corrective actions. 3-69 3.5.3.2 Compliance Findings FINDING GW/CF-1: Groundwater Protection Management Program Plan Performance Objective DOE 5400,1, "General Environmental Protection Program," Chapter III, Section 4,a,, requires that a Groundwater Protection Management Program Plan (GPMPP) be completed by May 1990. Elements of the GPMPP include documentation of the groundwater regime with respect to quantity and quality; design and implementation of a monitoring program; a management program for groundwater protection and remediation; a summary of areas that may be contaminated; strategies for controlling sources of these contaminants; a remedial action program that is part of the site Resource Conservation and Recovery Act program; decontamination and decommissioning programs; and other remedial programs contained in DOE directives. Finding The LANL GPMPP does not fully meet the requirements of DOE 5400.1 Discussion LANL's GPMPP (GW-87) does not fully meet the requirements and lacks specific information and reviews as required by DOE 5400.1. Information deficiencies include the following: 1. The GPMPP does not include an adequate Groundwater Monitoring Plan according to the criteria in DOE 5400.1 (see Finding GW/CF-2). 2. The GPMPP does not adequately define the relationship between the recharge and baseline water quality and quantity of the main aquifer. 3. There is no written, formal relationship between the groups within the Environmental Management Division to implement specific sections within the GPMPP (e.g., underground storage tank management programs). 4. There is no description of training, other than for safety and health that is expected for new and existing employees, to further the goals of the groundwater program. 5. The GPMPP lacks documentation of both quality and quantification of the TA-57 (Fenton Hill) perched groundwater regime. LAAO could not provide documentation indicating that they approved or reviewed the GPMPP initially or annually, as required by DOE 5400.1. The Environmental Protection Group (EM-8) indicated that the document was sent to LAAO for review on April 27, 1991; however, EM-8 did not receive any comments from LAAO (I-GW-95). This finding was partially identified in the LANL Self-Assessment. 3-70 FINDING GW/CF-2: Sitewide Hydrogeological Monitoring Well Network Performance Objective DOE 5400.1, "General Environmental Protection Program," Chapter III, Section 4.a., requires preparation of a Groundwater Protection Management Program Plan (GPMPP) by May 1990. Specific elements of the GPMPP include the "documentation of the groundwater regime with respect to quality and quantity, design and implementation of a monitoring program, a management program for groundwater protection and remediation, a summary of areas that may be contaminated, and strategies for controlling sources of these contaminants." DOE 5400.1, Chapter IV, Section 9, requires that a Groundwater Monitoring Plan (GMP) be developed and implemented as a specific element of the GPMPP by November 9, 1991. The GMP specifies "Groundwater that is or could be affected by DOE activities shall be monitored to determine and document the effects of operations on groundwater quality and quantity." The GMP must address regulations and requirements applicable to groundwater protection and monitoring, sampling strategies, sampling and analysis plans, and data management. DOE 5400.1, Chapter II, Section 10, "Groundwater Protection," states, "The groundwater protection program should be summarized, including a review of the monitoring program that describes the number of wells." Finding LANL's sitewide hydrogeological groundwater monitoring well network will not be extensive enough to be able to characterize the impact of DOE operations on groundwater quality by November 9, 1991, as required by DOE 5400.1. Discussion The existing groundwater monitoring well network at LANL was largely developed by the U.S. Geological Survey prior to 1960 without a GMP. It is not adequate to determine the complex hydrogeologic conditions of the Pajarito Plateau. The LANL GMP, as required by DOE 5400,1, is being drafted, but will not be available for review by November 9, 1991, The well network monitors the main aquifer and perched alluvial aquifers in the Canyons, The following deficiencies regarding the main aquifer monitoring well network on-site have been identified: 1, The 11-well onsite well monitoring network includes no wells on the western perimeter of the site and the western side of the Pajarito fault zone. Site baseline measurements, and the means of detecting migrating contamination from offsite locations, are lacking due to the absence of wells on the western perimeter. The effect of the faults on groundwater recharge and directional flow, potential infiltration zones, and seismic history on both sides of the fault zone cannot be accurately determined because of the lack of wells. 2. Five of the 11 onsite monitoring wells are also potable production wells. When these wells are pumped for drinking water purposes. 3-71 significant cones of depression are created, giving rise to inaccurate measurements for monitoring purposes both in depth to groundwater and generalized groundwater flow direction. This results in inaccurate measurement of piezometric surfaces on a major portion of the monitoring network. Accurate piezometric surface measurements are essential for determining generalized groundwater flow direction. 3. All of the potable production wells and only one of the remaining six onsite monitoring wells have access for depth-to-groundwater piezometric surface measurements. 4. Only the 5 potable production wells are sampled for bacteria. Noncoliform (anaerobic) bacteria counts fluctuate randomly at these wells and were observed to increase during some runoff events, especially at Pajarito Well No. PM-2 (I-GW-12). The wells also contain free floating, nontoxic, edible mineral oil, a standard result of lubricating the line shaft turbines. Neither the source of the bacteria nor the environmental consequences of the mineral oil in the well bores is understood by LANL. The following deficiencies of the perched hydrogeological monitoring well network located in the shallow alluvium have been identified: 1. There are no monitoring wells located in the perched alluvial water located adjacent to the Los Alamos County Landfill to monitor for potential groundwater contamination (I-GW-17). The landfill is located on a zone of intense fracturing (I-GW-73). The possibility exists for contaminant migration to the groundwater located in the perched alluvial water. 2. LANL's characterization of surface flow contaminants infiltrating into perched aquifer zones in Los Alamos Canyon, which ultimately outcrop as seeps and springs at the confluence of the Rio Grande, is not complete (I-GW-54). The understanding of contaminant transport pathway mechanisms is essential for understanding canyon-specific perched aquifer systems. 3. LANL has not adequately characterized the seep-spring recharge mechanism located in the Santa Fe Group (I-GW-54). A thorough understanding of the seep-spring recharge mechanism is required part for adequate comprehension of the sitewide hydrologic regime. LANL has no standard operating procedures for borehole drilling, well construction, disposal of borehole cuttings and drilling fluids, well inspection and maintenance, and well abandonment. Further, LANL does not have a monitoring well inventory program that lists inactive or properly abandoned monitoring wells, piezometers, neutron moisture probe access tubes, or boreholes. Best management practice would suggest the need for standard operating procedures and an inventory to track and manage the well network. This finding was fully identified in the LANL Self-Assessment. 3-72 FINDING GW/CF-3: Groundwater Sampling Procedures Performance Objective DOE 5400.1, "General Environmental Protection Program," Chapter IV, "Environmental Monitoring Requirements," requires that a Quality Assurance Program (QAP) consistent with DOE 5700.6B, "Quality Assurance," be implemented by November 9, 1991. It also states that the QAP shall include chain-of-custody procedures. DOE 5400.1 further states that "Test Methods for Evaluating Solid Waste, Physical/Chemical Methods" (SW-846) should be used as a reference for environmental monitoring. OSWER 9950.1, "Groundwater Monitoring Technical Enforcement Guidance Document," discusses specific procedures for sample collection, including Section 4.2,4, "Sample Withdrawal"; Section 4.3,3, "Special Handling Requirements"; and Section 4,4, "Chain-of-Custody," LANL's Water, Soil, Sediments, and Water Supply Monitoring Quality Assurance Project Plan (revised January 10, 1990) specifies the procedures to be used in conducting groundwater sampling and analysis at the monitoring wells, springs, and sediment sampling locations. Finding LANL groundwater sampling procedures are not consistent with DOE Orders and guidance documents. Discussion Sampling procedures outlined in OSWER 9950,1, "Groundwater Monitoring Technical Enforcement Guidance Document," and DOE 5400.1 requirements for chain-of-custody are not incorporated into the Environmental Protection Group's (EM-8's) Water, Soil, Sediments, and Water Supply Monitoring Quality Assurance Project Plan. In addition, EM-8 does not follow required sampling procedures as contained in the Quality Assurance Project Plan (QAPP). The following deficiencies are present in the QAPP: 1. The QAPP does not contain formal chain-of-custody procedures. Section 5.2 of the QAPP states, "The analytical request form serves as an informal chain-of-custody for the samples." This form is prepared at the laboratory, whereas standard chain-of-custody is prepared in the field. 2. Section 6 of the QAPP specifies "equipment used in routine collection of water, soils, and sediment requires no calibration," Calibration is necessary for standardization and equipment checks. 3. Section 4.6.1 of the QAPP specifies sample acidification prior to filtration for all chemical analysis, which is opposite of OSWER 9950.1 requirements for metal analysis. However, the procedure was consistent with the requirements for the radiochemistry samples as specified in Environmental Regulatory Guide for 3-73 Radiological Effluent Monitoring and Environmental Surveillance (D0E/EH-0173T). 4. Section 4.6.3 of the QAPP does not directly address sample collection techniques to minimize agitation and aeration. 5. The QAPP manual does not address field decontamination procedures for sampling equipment, 6, The QAPP manual does not directly address the need for refrigeration for sulfate, nitrate, nitrite, and semi-volatile organic compounds. Although the information is incorporated by reference in LANL Report No. LA-11738, the requirements should be in a form that is easily accessible during sampling, 7, The QAPP manual does not adequately address well purging requirements. The Environmental Subteam observed three sampling events (October 1, 7-9, and 17, 1991) conducted by LANL. During the sampling events, there was an overall lack of formality, and inadequate field sampling protocols. Sample collection lacked consistency. The following deficiencies in field sampling methods were noted: 1. No environmental chain-of-custody form was used in the field on October 1, 1991 (I-GW-32), No environmental chain-of-custody forms were used in the field during the second sampling event, but were generated later at the laboratory, according to EM-8 staff (GW-89), Environmental chain-of-custody forms were used in the field on October 17, 1991. However, the forms were not properly completed. The EPA SW-846 document states, "The possession and handling of samples should be traceable from time of collection through analysis and final disposition" (GW-147). 2. The pH, temperature, and specific conductivity meters were field checked for accuracy only at the beginning of the sampling event on October 1, 1991 (I-GW-30). Accuracy should be checked at the beginning and end of each sampling event. The two types of pH paper were not checked for accuracy to a known standard prior to the October 7-9, 1991, sampling event. In response to Tiger Team observations, the pH, temperature, and specific conductivity meters were field checked for accuracy at the beginning and end of the sampling event on October 17, 1991 (I-GW-79). 3. Groundwater samples collected on October 1, 7-9, and 17, 1991, were not filtered prior to being preserved with an acidic solution as specified in OSWER 9950.1. However, radiochemistry samples were preserved in accordance with DOE/EH-0173T. 4. Groundwater sample containers for the October 1, 1991, sampling event were acidified (e.g., preserved) in a radiological laboratory prior to field sampling (I-GW-31), Given the possibility for radiological cross-contamination, sample containers should not be acidified in locations that could impact analytical integrity of the sample. 3-74 5. During the October 1, 1991, sampling event, the sampling port of the production well emitted an aerated groundwater sample which is not acceptable for volatile organic compound analyses or semi-volatile organic compound analyses (I-GW-26). 6. Sample containers for parameters other than volatile organic compound analyses were not preserved on ice for transport to the laboratory during the October 1, 1991, sample event (I-GW-30). No samples were preserved on ice for transport to the laboratory for October 7-9, 1991 sampling event (I-GW-55). However, samples were preserved on ice for transport to the laboratory during the October 17, 1991, sampling event (I-GW-76). 7. Tygon sampling tubes and sediment sampling scoops were not properly decontaminated between sampling stations during the October 7-9, 1991, sampling event (I-GW-55). 8. The purging October 17, calculation analysis of 9. Two of the three temperature probes were broken on the October 7-9, 1991, sampling event (I-GW-53). The lack of functioning thermometers could result in a lack of quality data. of groundwater monitoring well MCO-5 during the 1991, sampling event was not based on an appropriate of well-bore volume (I-GW-76). This resulted in well-bore water rather than groundwater. This finding was fully identified in the LANL Self-Assessment. 3-75 FINDING GH/CF-4: Environmental Surveillance Program Performance Objective DOE 5400.1, "General Environmental Protection Program," Chapter IV, Section S.b.(l), requires that environmental surveillance be conducted to monitor effects, if any, on onsite and offsite environmental and natural resources. Environmental surveillance is required to satisfy the following program objectives: verify compliance with environmental laws and regulations; verify compliance with environmental commitments in environmental assessments, environmental impact statements, and safety analysis reviews; characterize and define trends in environmental media; establish baselines of environmental quality; continually assess pollution abatement programs; and identify and quantify new or existing environmental problems. Section 5.b.(2) requires that environmental surveillance programs reflect facility characteristics. Chapter IV requires an Environmental Surveillance Program be implemented by November 9, 1991. DOE 5400.5, "Radiation Protection of the Public and Environment," Section 6, addresses surveillance to demonstrate compliance with public dose limits, and further states, ". . . it is DOE's objective to protect the environment from radioactive contamination to the extent practical." Environmental Regulatory Guide for Radiological Effluent Monitoring and Environmental Surveillance (DOE/EH-0173T), Table 5-1 (5-2) Guidelines for Sampling, recommends an environmental surveillance program that includes "...the collection and analysis of samples of air, water, soil, foodstuffs, biota, and other media from DOE sites and their environs ..." Finding Environmental surveillance of soil, sediment, and biota at LANL does not fully satisfy the DOE 5400.1 requirements for the Environmental Surveillance Program, and there is no overall plan in place to meet those requirements by the implementation date of November 9, 1991. Discussion The LANL radiological and nonradiological Environmental Surveillance Program is not being implemented under a formal, well-defined program and does not include sufficient sampling and analysis of environmental media to determine site-derived contaminant impacts to biota, foodstuffs, and environmental receptors. LANL has conducted a series of special studies in the past that address specific biota and foodstuff contaminant pathways. However, these special studies do not reflect current Laboratory activities, and they are not appropriate as an outline for the Environmental Surveillance Program as required by DOE 5400.1. The following deficiencies with the current Environmental Surveillance Program were identified: 1. There are no adequately documented design criteria, justifications, or program bases for the existing surveillance program. There are no provisions to periodically review the 3-75 program design against current operations to determine if it needs to be modified. 2. The current program involves annual sampling of vegetation, biota, and soil. The sampling frequency, types of constituents analyzed, and the number of locations for some media (e.g., elk, deer, ceremonial and medicinal herbs, grazing bovines, etc.) are not adequate to characterize the effect of LANL operations on onsite and offsite environmental resources. All environmental release pathways (e.g., transported sediment in canyons) have not been evaluated to determine if they require monitoring. 3. No wildlife, such as snakes, birds, gophers, rabbits, coyotes, or water fowl, that inhabit the LANL area are sampled on a routine basis to investigate the potential effects of bioaccumulation (I-GW-39). Only occasional analyses have been performed on "grab samples" collected by LANL. There is no complete program to assess existing contamination levels and patterns in onsite and offsite foodstuffs. 4. Neither the grazing bovines in Pueblo Canyon nor the elk in Mortandad Canyon are being routinely sampled for nonradioactive metals or radionuclides (I-GW-38). No annual surveillance plan or program exists for migrating mammals; however, a special study on elk surveillance was performed approximately 10 years ago (I-GW-17 and I-GW-18). Both the bovines and elk are direct internal radiation exposure pathways to man. 5. Not all known areas of elevated soil contamination are sampled and evaluated routinely. A 1985 LANL report (RAD-342) identified elevated levels of uranium, beryllium, and lead concentrations at firing sites in TA-14, TA-15, and TA-36. However, there has been no regular sampling at these locations to determine whether there is any associated environmental risk. 6. No tritium soil or sediment analysis was reported in the 1989 Annual Environmental Surveillance Report in the contaminated canyons (e.g., Los Alamos, Mortandad, Acid-Pueblo) or in the perimeter sediment stations (GW-147). 7. The foodstuff program has no procedure for health physics overview for sampling design, sample handling, and data interpretation (RAD-164). 8. Current biota environmental surveillance does not provide a foundation for future National Environmental Policy Act reviews and/or Comprehensive Environmental Response, Compensation and Liability Act documentation, such as baseline ecological nonradiological and public health risk assessments (I-GW-17 and I-GW-18). The finding was fully identified in the LANL Self-Assessment. 3-77 FINDING GW/CF-5: Control of Radiologically Contaminated Soils and Sediments Performance Objective The Hazardous and Solid Waste Amendments (HSWA) Module of the Resource Conservation and Recovery Act (RCRA) Part B Permit, effective May 23, 1990, states that "LANL shall, through the maintenance of existing sediment traps or construction of new sediment traps, ensure containment of all residual sediment contamination within the facility boundary" for Mortandad Canyon. LANL's Water, Soil, Sediments, and Water Supply Monitoring Quality Assurance Project Plan (revised January 10, 1990) specifies the procedures to be used in conducting soil and sediment sampling and analysis at sediment sampling locations on-site. DOE 5400.1, "General Environmental Protection Program," Section 5.a., "Policy," states: "It is DOE policy to conduct its operations in an environmentally safe and sound manner. Protection of the environment and the public are responsibilities of paramount importance and concern to DOE. It is DOE's policy that efforts to meet environmental obligations be carried out consistently across all operations and among field organizations and programs." DOE 5400.5, "Radiation Protection of the Public and the Environment," Section 6.b., states, "In addition to providing protection to members of the public, it is DOE's objective to protect the environment from radioactive contamination to the extent practical." DOE 5400.5, Chapter IV, 5.a., "Authorized Limits for Radioactive Material," specifies "The authorized limits for each property shall be set equal to the generic or derived guidelines." Chapter IV, Section 6, "Control of Residual Radioactive Material," specifies that residual radioactive material above the guidelines shall be managed in accordance with 6.a, "Operational and Control Requirements." Chapter IV, 6.c.(2), "Interim Management," specifies "The administrative controls include but are not limited to periodic monitoring as appropriate; appropriate shielding; physical barriers to prevent access; and appropriate radiological safety measures during maintenance, renovation, demolition, or other activities that might disturb the residual radioactive material or cause it to migrate." Finding LANL does not have a contaminated soil and sediment control program. In addition, the procedures to support containment of residual contamination areas in Mortandad Canyon may not be adequate to fulfill the requirements of the HSWA Nodule of the RCRA Part B Permit. Discussion Pursuant to DOE Order requirements and the HSWA Module of the RCRA Part B Permit, contaminated or potentially contaminated soil areas need to be 3-78 surveyed, documented, and posted on a regular basis to properly identify these areas, detect the spread of contamination to uncontaminated areas, and aid in establishing the controls necessary to prevent the spread of contamination. The following deficiencies relating to both program and operational activities were identified: 1. The sediment traps in Mortandad Canyon are in need of maintenance. Effluents from TA-35 and TA-50 are discharged into Mortandad Canyon. Sediments are transported by these effluents and by rain events, and are stored in three sediment traps which were designed to contain approximately 29 acre/feet of sediment. The remaining storage capacity is estimated at only 8 acre/feet (I-GW-36). This storage capacity may not be enough to ensure containment in the event of a large runoff event. During August 1991, two large rain events filled the third trap and resulted in sediment overflow into the Mortandad Canyon valley floor, approximately 500 feet downgradient from the traps. The overflow sediment was sampled in October 1991 without a sampling plan. 2. No sediment traps are located in Pueblo or Los Alamos Canyons to prevent offsite migration of sediments to San Ildefonso Pueblo Reservation. Additionally, no sediment traps are located in Bayo Canyon to contain contamination from the disposal site of the former LANL radiochemistry laboratory (TA-IO), which also supported the firing range in this area. This former LANL property is currently owned by Los Alamos County. 3. TA-14 and TA-15 located adjacent to Canon de Valle Canyon and TA-36, adjacent to Potrillo Canyon, are posted for radiological control due to the "potential for soil contamination" from depleted uranium (DU) firings. Special studies in one technical area have concluded that DU contamination transport by both surface water transport and vertical transport in soil and sediment is occurring (I-GW-82). LANL does not have an adequate program for routine surveillance of DU movement via sediment transport or dissolution. There are no sediment traps located at TA-14, TA-15, or TA-36 that retain contaminated sediments from a rain-induced surface water event. This finding was fully identified in the LANL Self-Assessment. 3-79 3.5.3.2 Best Management Practice Findings FINDING GW/BMPF-1: Closure and Protection of Wells and Boreholes Performance Objective DOE 5400.1, "General Environmental Protection Program," Section 5.a., "Policy" requires that DOE "minimize risks to the environment or public health, and anticipate and address potential environmental problems before they pose a threat to the quality of the environment or public welfare." The 1986 RCRA Groundwater Monitoring Technical Guidance Document (TEGD) suggests that locking caps should be placed on wells to prevent tampering and groundwater contamination. Additionally, the TEGD states that when wells are no longer operable, or give false groundwater analytical data, they should be decommissioned and sealed. The New Mexico Environment Department (NMED) has issued procedures to be used for plugging and abandonment of monitoring wells installed after January 1, 1991. These are best management practices for wells installed before that date. Finding Abandoned or inactive monitoring wells, piezometers, neutron moisture probe access tubes, and boreholes are not adequately closed or sealed to protect the environment. Discussion LANL has not developed procedures or criteria for determining when wells should be decommissioned or in what manner they will be abandoned. There are several monitoring wells, piezometers, neutron moisture probe access tubes, and boreholes which are not properly secured nor protected. However, best management practices suggest that these should be plugged and sealed as suggested by the NMED; otherwise, they present a potential pathway for groundwater contamination. 1. A new monitoring well, MCO-5.1, has no locking cap. The polyvinyl chloride casing is not protected against potential vandalism to the well bore or aquifer (I-GW-23). 2. A monitoring well (TW-2B) that was partially installed in 1947, was observed to be inadequately secured (I-GW-24). Both the production tubing and the annulus between the well casing and the production tubing were open ended. The potential to introduce contaminants to the well bore and perched aquifer exists since it is not plugged and sealed. 3. An older U.S. Geological Survey monitoring well (LAO-5), located in the perched alluvial, was observed to be missing a lock (I-GW-25). 3-80 4. At various locations throughout Mortandad Canyon, piezometers and neutron moisture probe access tubes were observed without caps or locks (I-GW-77). 5. LANL has no procedures for placing permanent identification placards on groundwater monitoring wells (1/22). This finding was fully identified in the LANL Self-Assessment. 3-81 FINDING GW/BMPF-2: Seismic Hazard Analysis Performance Objective DOE 4320.IB, "Site Development Planning," Section 7, requires sites to have a process for site development planning that includes a Technical Site Information Document for use by technical and staff personnel. DOE 4320.IB, Chapter I, Section 2, outlines the requirements for technical site information used in the planning process to address both regional conditions and existing site conditions, and to address physical characteristics, including geology, fault locations, and earthquake potential. DOE 6430.lA, "General Design Criteria," is the controlling criteria for design of facilities at the Los Alamos National Laboratory. On page 1-1, Division 1, General Requirements, is the following statement: "For existing facilities, original design criteria apply to the structure in general; however, additions or modifications shall comply with this Order and the associated latest editions of the references herein." DOE 6430.lA references Natural Hazards Phenomena Modeling Project: Seismic Hazard Models for DOE Sites (UCRL 53582) as a guide to site-specific hazard model studies methodology and known information, and Design and Evaluation Guide for DOE Facilities Subject to Natural Phenomena Hazards (UCRL 15910) for specific guidance on relating frequency of occurrence to facility hazard levels. Best management practices suggest that evaluation of seismic hazards should be consistent with state-of-the-art practice and best available site data. Finding LANL has not completed comprehensive analyses of faults, earthquake potential, or seismic hazards as part of the site development process, and has not completed an updated sitewide analysis of seismic hazards to reflect state-of-the-art practices. Discussion LANL has prepared an annual Site Development Plan/Technical Site Information Document as required in DOE 4320.IB. However, LANL's site development planning process does not provide for complete evaluation of project-specific site conditions and physical characteristics, including earthquake potential and seismic hazards (I-IWS-108). LANL has established a program under the direction of the ES&H Coordination Center for determination of seismic hazard design parameters for new buildings on a project-specific basis as part of the design process and has initiated reevaluation of existing buildings. However, project-specific determinations have not been completed for all existing buildings (I-IWS-108 and I-IWS-149). The existing evaluation of seismic hazards appears to be generally consistent with the requirements of DOE 6430.lA; however, revision of the existing regional seismic evaluation to reflect best available methods for seismic analysis and current data for LANL is not complete. The last comprehensive seismic hazards study was conducted in 1972 and is not considered state-of-the-art practice (IWS-123, IWS-124, and IWS-125). Furthermore, 3-82 geologists and seismologists, including personnel from Engineering and Environmental Sciences (EES-1), have developed new data on fracture and fault locations and movement along faults which indicate an increased potential for earthquakes versus previous estimates (IWS-123, IWS-124, and IWS-125). Several recommendations have been made for revision of the LANL seismic hazards evaluation and for implementation of project- or building-specific seismic hazard analysis and design (I-IWS-108 and I-IWS-126). It should be noted that LANL has recognized these deficiencies. A program for seismic hazards has been initiated under the direction of the ES&H Coordination Center, a Seismic Hazards Investigation Task Force has been established at LANL to oversee this program, and a paleoseismic contractor was retained in March 1991 to conduct a state-of-the-art seismic hazards investigation. However, the investigation is not complete and the existing seismic hazard evaluation is not consistent with best management practices. This finding was partially identified in the LANL Self-Assessment. 3-83 FINDING GW/BMPF-3: Groundwater Discharge Plan Performance Objective New Mexico Water Quality Regulation (NMWQR), Section 3-104, states that no person shall cause or allow effluent or leachate to discharge so that it may move directly or indirectly into groundwater without a Groundwater Discharge Plan approved by the Director of the New Mexico Water Environment Department (NMED). NMWQR, Section 3-106, requires that for discharges existing prior to March 1977, a Groundwater Discharge Plan shall be submitted within 120 days of receipt of notice from NMED that a plan is required. For discharges initiated subsequent to March 1977, a Notice of Intent must be submitted to NMED, which will determine whether a discharge plan is required. NMED has not yet notified LANL that Groundwater Discharge Plans are required. However, as a best management practice, LANL should initiate Groundwater Discharge Plans to ensure compliance with anticipated NMWQR requests. Finding LANL has not initiated preparation of Groundwater Discharge Plans to ensure compliance with anticipated NMWQR requirements. Discussion LANL has not initiated preparation of Groundwater Discharge Plans for existing facilities (with the exception of the plan for the Fenton Hill site, which was required by the Oil and Gas Conservation Commission (OGCC)) and has not established a written procedure for identifying locations that will require plans, or a program for preparation of plans. LANL has indicated that a request is anticipated from NMWQCC for Groundwater Discharge Plans for some or all of the 9 sanitary treatment facilities and approximately 100 industrial outfalls. LANL has also indicated that they would be unable to meet the 120-day schedule for either a sitewide plan or site-specific plans if a request were made at the present time. LANL has currently identified the potential need for plans for continued disposal of sanitary sludge at TA-54, Area G, and for discharges from the unlined sanitary lagoons at TA-53. LANL has also identified the need for a Laboratory-wide Groundwater Discharge Plan to meet potential NMWQCC requests. However, drafting of the plans has not been initiated, and there is currently no program in place to draft the plans. LANL has also identified the need for a Groundwater Discharge Plan for the new Sanitary Treatment Plant at TA-46 and has initiated drafting of the Notice of Intent, but has not initiated drafting of the Discharge Plan so as to ensure compliance with the required schedule. This finding was fully identified in the LANL Self-Assessment. 3-84 3.5.4 Waste Management 3.5.4.1 Overview The purpose of the waste management portion of the LANL environmental assessment was to evaluate the current hazardous, radioactive, mixed, and solid waste management practices as well as the management of underground storage tanks (USTs), with respect to Federal and State of New Mexico regulations, DOE Orders, internal LANL policies and procedures, and industry best management practices. A summary of the regulations and guidelines used in the assessment is listed in Table 3-5. The general approach to the waste management assessment included interviews with LANL Environmental Management Division (EM) staff responsible for compliance with waste management and UST regulatory requirements, as well as Laboratory and site contractor employees and staff whose activities generate waste. The assessment included observations of daily operations, inspection of facilities, review of documents, and discussions with state and Federal regulators. Waste Management at LANL The State of New Mexico has EPA-delegated authority to regulate hazardous waste under the Resource Conservation and Recovery Act (RCRA), and has also obtained mixed waste authority. EPA Region VI has the authority to regulate the Hazardous and Solid Waste Amendments portion of RCRA. The state has essentially adopted RCRA hazardous waste regulations contained in 40 CFR 260-270. LANL is currently operating under RCRA Part B Permit guidelines for treatment, storage, and disposal (TSD) of hazardous wastes according to 40 CFR 264 and Interim Status Guidelines according to 40 CFR 265, for mixed waste operations. LANL generates hazardous, radioactive, mixed, and nonhazardous wastes. These wastes are managed by a variety of onsite and offsite TSD methods. Several groups within EM are responsible for coordinating waste management activities from the point of generation until the wastes are ultimately disposed. EM has developed the following set of guidelines that apply to these activities: 1. Generators are required to identify and characterize their waste, accumulate it in a suitable area, and arrange for its disposal in a timely manner. Technical assistance for identification, characterization, and accumulation is provided by the Environmental Protection Group (EM-8). Disposal services are provided by the Waste Management Group (EM-7). 2. Generators arrange for disposal of wastes by contacting EM-7, who manages both onsite TSD and shipment to offsite TSD facilities. 3. Generators are required to ensure proper characterization by applying process knowledge or by requesting an analysis of their waste. 3-85 TABLE 3-5 LIST OF WASTE MANAGEMENT REGULATIONS/REQUIREMENTS/GUIDELINES ttenulatlons/ R«( ulr^a£^ftts/ Oaldel files Sectiam/im^ AuthoHty DOE 5400.1 General Environmental Protection Program DOE DOE 5400.3 Hazardous and Radioactive Mixed Waste Programs DOE DOE 5400.5 Radiation Protection of the Public and the Environment DOE DOE 5480.19 Conduct of Operation Requirements for DOE Facility DOE DOE 5820.2A Radioactive Waste Management DOE 40 CFR 241 Guidelines for the Land Disposal of Solid Wastes EPA 40 CFR 261 Identification and Listing of Hazardous Waste EPA 40 CFR 262 Standards Applicable to Generators of Hazardous Waste EPA 40 CFR 264 Standards for Owners and Operators of Hazardous Waste Treatment, Storage, and Disposal Facilities EPA 40 CFR 265 Interim Status Standards for Owners and Operators of Hazardous Waste Treatment, Storage and Disposal Facilities EPA 40 CFR 268 Land Disposal Restrictions EPA 40 CFR 270 EPA Administered Permit Programs - The Hazardous Waste Permit Program EPA Technical Standards and Corrective Action Requirements for Owners and Operators of Underground Storage Tanks EPA 1 40 CFR 280 NMSWA New Mexico Solid Waste Act 3-86 NMED TABLE 3-5 (Continued) LIST OF WASTE MANAGEMENT REGULATIONS/REQUIREMENTS/GUIDELINES ll««jaitr«ttentV Sect1ea$/Tlt1e Authority NMSWMR New Mexico Solid Waste Management Regulations NMED NMHWMR New Mexico Hazardous Waste Management Regulations NMED NMUSTR New Mexico Underground Storage Tank Regulations NMED LANL AR 6-9 Safe Handling of Hazardous Gases AMED LANL AR 10-2 Low-Level Radioactive Solid Waste BED LANL AR 10-3 Hazardous, Mixed and Chemical Waste BED LANL AR 10-6 Excess Government Personal Property BED LANL AR 10-8 Waste Minimization BED 3-87 4. Transporters are responsible for matching information on the waste profile with the waste manifest. 5. Training for transporters and onsite TSD operators is coordinated by EM-7 and EM-8 while waste generator and waste coordinator training is coordinated through EM-8. LANL has a series of Administrative Requirements (AR) that outline the responsibilities of some individuals involved in the waste management process; however, its coverage is incomplete, its provisions are not clear, and there is no mechanism for ensuring that the requirements are met. Hence, LANL does not yet have a comprehensive, sitewide system for ensuring adequate "cradle-to-grave" management of wastes. Sitewide waste management at LANL, although addressed by AR, training, and technical assistance from groups within EM, is not a centrally coordinated effort among the groups involved. Generator training at LANL has been conducted for over 4,000 waste generators; however, a quality assurance/quality control system is not in place to evaluate the appropriateness and effectiveness of those generators performing various sitewide waste management operations. Environmental regulatory compliance at LANL appears to be the result of the efforts of several key individuals within EM and not because of a proactive approach to waste management. Waste Characterization Program Hazardous and mixed waste accumulates in satellite accumulation areas (SAAs) at each technical area. When a container is full, it is moved to temporary, less-than-90-day storage areas or a TSD facility. Waste generators at LANL receive technical assistance for waste characterization, accumulation, packaging, transportation, and disposal primarily from the EM-7 and EM-8 groups. Administrative Requirements, based on Federal and state regulatory requirements and DOE Orders, provide guidelines for generators on how to appropriately manage their waste. Upon creating a waste, generators characterize it and document that characterization using a Waste Profile Request (WPR) form, provided by the EM-8 Group. The WPR, which allows generators to provide physical and chemical characteristics of wastes from process knowledge, is completed by the generator and forwarded to EM-8 for approval. Approved WPRs are then utilized by generators to complete a Chemical Waste Disposal Request (CWDR) form or a Radioactive Solid Waste Disposal (RSWD) form. These forms provide waste information to LANL's EM-7 Group which subsequently packages, transports, and either disposes of the Laboratory's waste at designated locations onsite or by transport to offsite TSD facilities. Waste Coordinators are responsible for overseeing the activities of waste generators, waste characterization, waste segregation, and overall management of wastes. Certification of a generator's waste is the responsibility of the generator and Waste Coordinators; however, not all generators or designated Waste Coordinators have received the required training to perform this function and LANL does not verify that the waste generators' knowledge of process is adequate. 3-88 Waste Operations Primary waste management activities at TA-54 include preparing wastes for offsite disposal at Chemical Waste Management, Inc. facilities in Henderson, Colorado and Kettleman Hills, California, and Rollins Environmental Services facilities in Deerpark, Texas and Baton Rouge, Louisiana; storage of transuranic (TRU) and mixed wastes; and disposal of low-level radioactive waste. Although process wastes are generated and stored at other permitted solid waste management units on-site, the bulk of LANL's wastes from research and development activities is managed at TA-54. Solid, low-level radioactive waste is buried at TA-54, Area G. Mixed waste, including hazardous gas cylinders and scintillation vials, is stored outdoors at TA-54, Area L. A large amount of the mixed waste stored at TA-54 is wastewater treatment sludge from the TA-50 Radiological Waste Water Treatment Facility. This waste is stored at Bldg. 49, Area G. TRU waste which is awaiting certification for disposal at the Waste Isolation Pilot Plant (WIPP) is also stored indoors at Bldg. 48, Area G. Overall storage and disposal operations at TA-54 are adequate. However, container management requires improvement, especially outdoor storage of radioactive cylinders and low-level mixed waste. Training for TSD employees was found to be incomplete and the Laboratory has made no attempt to familiarize local emergency response authorities with the potential hazards which exist in this area. Hazardous Waste Management The primary sources of hazardous waste are from chemical research and development areas, such as the Chemical and Materials Research (CMR) Building (TA-3-29), Radiochemistry Laboratory (TA-48), Sigma Building (TA-3-66), and the Health Research Laboratory (TA-43). Wastes from these areas include diverse waste chemical solvents, including mixed waste contaminated rags and analytical reagents. Other research-related activities throughout the Laboratory generate unused or outdated laboratory chemicals which are disposed of as hazardous waste. High explosive (HE)-contaminated wastes generated at TA-36 and TA-16 are burned on-site in open burn pits and firing pads. The State of New Mexico currently allows open burning/open detonation of HEs and HE-contaminated material because the state has not yet drafted a permit or sought public comment for this activity. However, LANL's approach for determining what materials are considered HE-contaminated is extremely conservative in that much of the material burned is done so primarily because of suspect trace HE contamination. In general, LANL's hazardous waste programs are hampered by incomplete understanding of requirements by waste generating organizations. Numerous deficiencies in temporary storage areas were noted, and the waste characterization and certification programs have not been fully developed. Radioactive Waste Operations in the areas of radioactive waste generation, treatment, volume reduction, storage, and disposal were evaluated. Solid and liquid low-level and TRU wastes are generated at LANL. Radioactive liquid is treated at TA-50, and the precipitate is sent as low-level, mixed, or TRU waste for interim storage. Volume reduction processing is accomplished on TRU waste at a 3-89 size-reduction facility where components such as glove boxes are cut up and containerized. Low-level waste volume reduction processes such as incineration and compaction are not currently practiced. TRU waste is stored both above and below ground. Low-level solid waste is buried in disposal cells at TA-54. The current inventory of uncertified TRU waste is 25,000 packages. LANL has identified many of the previously certified TRU waste packages stored at TA-54 as being in poor condition and possibly no longer meeting WIPP waste certification requirements. LANL generates TRU waste at a rate of about nine hundred 55-gallon drums per year, adding to this large inventory of uncertified waste. A TRU waste acceptance and waste certification program has been established. However, LANL lacks the ability to certify waste to WIPP standards because the Non-Destructive Analysis/Non-Destructive Evaluation (NDA/NDE) Facility is not in operation while LANL is processing environmental and safety assessments. Large amounts of low-level radioactive wastes are disposed of at TA-54, Area G, in a disposal pit that will be full by the end of 1991. DOE approval to expand the present area has not been received. Formalized low-level waste acceptance and certification programs have not been implemented. Waste acceptance and certification activities are taking place, but have not yet been formalized into a program since both the disposal site operators and the generators have not implemented mutually compatible, approved procedures. Low-level waste segregation, volume reduction techniques, and generator waste characterization need more management attention to ensure compliance with existing regulations and orders. Low-level solid waste volume reduction practices at generator locations are not productive. LANL waste management personnel have estimated that 50 percent or more of low-level radioactive waste is suspect waste which is possibly not contaminated. Reduction of the amount of unnecessary material entering radiologically controlled areas coupled with better segregation practices are needed to reduce the amount of waste going to disposal as radioactive waste. Mixed Waste Mixed wastes at LANL are generated throughout laboratories and facilities. Individual laboratory activities generate solid mixed wastes consisting of wipes contaminated with RCRA-listed solvents. Other mixed wastes generated at LANL include process wastes from various treatment operations throughout the site. The TA-50 facility is a wastewater treatment facility subject to Clean Water Act regulatory requirements and is, therefore, exempt from certain RCRA regulations. The facility, however, through its treatment process, creates a mixed waste sludge which is regulated under RCRA. Approximately fifty 55gallon drums of sludge are generated at TA-50 per month. This waste is stored at TA-54, Areas G and L. Waste sludge from TA-50 is conservatively characterized as mixed waste primarily because liquids flowing into the facility have not been fully characterized to determine their constituents. LANL has hired a contractor to identify all potential sources of waste from facility drains which lead to TA-50; however, only 50 percent of the sources have been identified. The Environmental Subteam observed several processes which generate mixed wastes. One of these processes, which also contributes wastewater to TA-50, is the Sigma-66 electrochemical plating operation. Plating operations generate 3-90 radiologically contaminated acidic and caustic rinse solutions which may contain cyanide and toxic metals. These rinse solutions are piped directly to TA-50. Although wastewater is pH-adjusted prior to being discharged to TA-50 from Sigma-66, no further characterization is done on the effluent. Spent plating baths and etching solutions are drummed and managed at TA-54. RCRA land disposal restricted (LDR) mixed wastes are currently being stored at TA-54 in exceedance of regulatory time requirements; however, this is a DOE complex-wide problem due to the lack of facilities available to treat and dispose of these wastes. Storage of LDR mixed waste was not identified as a separate compliance finding because a national resolution of this issue is required before any corrective actions can be identified. Solid/Nonhazardous Waste The majority of LANL's solid nonhazardous waste is disposed of in the Los Alamos County Landfill. Solid nonhazardous waste generated throughout the Laboratory site is collected and transported to the landfill by Johnson Controls World Services, Inc. (JCI). The landfill, TA-61, located near TA-3, is operated by Los Alamos County on property owned by DOE. A special use permit, which was originally issued to the county by DOE in 1971 to operate the landfill, has not been revised since 1983 to require the county's compliance with current State of New Mexico and RCRA Subtitle D landfill regulations. The permit does not delineate responsibility for regulatory compliance between the county and DOE. Excess Government and Personal Property and Salvage Management of excess government and personal property at LANL is primarily the responsibility of line management. Property administrators expedite the removal of property considered to be salvageable to the JCI Redistribution center. JCI personnel assist LANL staff in transporting salvageable property to the center. Although the JCI Redistribution Center, which also coordinates LANL recycling activities, is well managed, individual salvage collection activities at the Laboratory are inadequate. Many salvage collection areas visited during the assessment contained hazardous and radioactive materials. Collection of hazardous and radioactive materials, including wastes, in these areas is not appropriate and presents an unnecessary hazard to the environment. Underground Storage Tank Program LANL currently has 30 USTs that require active management under RCRA and State of New Mexico UST regulations. LANL does not have a comprehensive, formal program for managing USTs regulated under RCRA. The LANL UST management efforts are based on a set of coordinating agreements among several LANL environmental groups, including the Environmental Protection Group (EM-8), Environmental Restoration Group (EM-13), Waste Management Group (EM-7), Field Operations Group (EN6-5), and JCI. LANL's long-term UST management strategy has been to decommission USTs in advance of the regulatory deadlines for installation of leak detection systems. This informal system has worked well; however, it lacks the formality necessary to ensure continued compliance with regulatory requirements. 3-91 Waste Minimization Program LANL has not developed a formal, sitewide waste minimization plan. Some line organizations have developed and implemented their own programs and several research groups maintain ongoing efforts to reduce waste generation. However, comprehensive, sitewide guidance for waste reduction has been only partially developed and inadequately implemented through AR 10-8, "Waste Minimization." Summary of Findings Compliance findings at LANL are related to nonconformance with state and Federal regulatory requirements, DOE Orders, AR, and accepted industry practices. These findings addressed the following areas: (1) undeveloped waste minimization program; (2) improper hazardous and mixed waste storage practices; (3) improper management of satellite accumulation and less-than-90-day storage areas; (4) inadequate sitewide waste characterization program; (5) conduct of waste generator activities at the Fenton Hill site without an EPA identification number; (6) lack of a coordinated program to adequately manage underground storage tanks; (7) deficiencies in the hazardous waste contingency plan; (8) improper manifesting of hazardous waste during onsite transport over public roads; (9) lack of clearly defined responsibilities and oversight regarding county landfill operations; (10) deficiencies in the hazardous waste training for generators and waste management personnel; (11) deficiencies in hazardous waste container pre-transport labeling and marking requirements; (12) lack of hazardous, low-level, and mixed waste acceptance criteria; (13) inadequate TRU waste certification and temporary storage practices; (14) deficient hazardous waste analysis plan; (15) inadequate low-level and mixed waste certification; (16) an inadequate program to manage excess government and personal property; (17) low-level radioactive waste segregation practices; and (18) low-level radioactive waste volume reduction practices. The single waste management best management practice finding at LANL related to delegation of signatory authority for RCRA permit applications. Of the 18 compliance findings identified during the assessment, 7 were partially identified, 7 were fully identified, and 4 were not identified in the LANL Self-Assessment. The best management practice finding identified was also not identified in the LANL Self-Assessment. 3-92 3.5.4.2 Compliance Findings FINDING WM/CF-1: Waste Characterization Performance Objectives 40 CFR 262.11 requires that waste generators characterize their waste to determine whether it is a listed hazardous waste under 40 CFR 261, Subpart D. If the waste is not a listed waste, the generator must then determine whether the waste is identified in 40 CFR 261, Subpart C, by either testing the waste according to specified methods, or by applying knowledge of the hazard characteristic of the materials based on the process or materials used in generating the waste. 40 CFR 264.13 and 40 CFR 265.13 require that owners and operators of treatment, storage, and disposal facilities (either permitted or interim status) develop and follow a Waste Analysis Plan which describes the procedures that will be used to obtain a detailed chemical and physical analysis of a representative sample of the waste before it is treated, stored, or disposed of. In addition, the Waste Analysis Plan must describe characterization of all wastes to ensure compliance with land disposal restrictions promulgated in 40 CFR 268. 40 CFR 268.7 requires that any generator of hazardous waste use process knowledge or test his waste or an extract of his waste to determine if the waste is restricted from the land disposal. DOE 5820.2A, "Radioactive Waste Management," specifies the requirements for characterization of transuranic (TRU) waste and low-level waste (LLW) and for certification of LLW and TRU waste. DOE 5400.3, "Hazardous and Radioactive Mixed Waste Program," requires that mixed wastes be managed in accordance with the requirements of Subtitle C of the Resource Conservation and Recovery Act (RCRA) and of the Atomic Energy Act. The Order also requires compliance with DOE 5820.2A for the radioactive component of mixed waste. Finding LANL's waste characterization activities are not sufficiently formalized to ensure that wastes are correctly identified, characterized, and certified. Discussion Waste characterization is a programmatic issue affecting all LANL waste generators. Some of the basic elements are in place, but there are deficiencies in some critical areas. The following observations identify specific deficiencies as well as relate other waste management findings to the lack of formality in waste characterization and certification processes. 1. LANL does not have a formal system to document the characteristics of waste materials through knowledge of the processes or materials used in generating the wastes. Generators provide information on their wastes when they submit a Waste Profile Request (WPR) (I-WM-203). The WPR is designed to provide certain information 3-93 necessary to characterize the waste, but it does not describe the processes by which the waste was generated. LANL Administrative Requirements (AR) 10-2 and AR 10-3 delegate responsibility to waste generators for characterization and certification of their wastes. There are no final procedures which delineate the requirements for characterization or certification. A few organizations within LANL have developed standard operating procedures for waste certification and characterization, but these were primarily for radiological components. This lack of formality may result in inconsistent certification and characterization processes. LANL has implemented a program to train waste generators to complete the WPR and has required each major waste generating group to assign a Waste Management Coordinator (WMC). The waste generator and WMC are responsible for certification of the wastes; however, not all generators and WMCs have received the required training, and there is no mechanism in place to ensure the required training is received (WM-207). The WPR is an excellent means of identifying waste generation activities, but currently lacks the formality necessary to support its use as the primary characterization and certification document. Numerous examples of mislabeled waste packages, incomplete WPRs and Chemical Waste Disposal Request forms, and inconsistent manifests demonstrate that the knowledge of the waste generators and WMCs is lacking (WM-206). In addition, there is no system in place to ensure that the WPR and WPR certification statements are signed by individuals who have received the required training. The WPR does not require reference to formal documentation of waste generating processes used to characterize wastes through process knowledge. AR 10-3 requires generating organizations to formally document generation processes, but it has not been adequately implemented nor are there clearly defined procedures for implementing this requirement. Many waste generators and WMCs were not familiar with this requirement. WPRs do not describe or characterize a discrete waste volume or stream. Instead, WPRs are often used to characterize general waste types and streams without regard to waste volumes generated (WM-206). Generic WPRs are being used for as long as a year on a general type of waste without verifying if the original characterization is still valid. The characterization and certification are, in effect, open ended. No formal audits are conducted of waste generator characterization and certification programs, procedures, or formal documentation of generating processes (I-WM-248). Therefore, the validity of the WPR relies primarily on presumption that management will implement the AR, and generators and WMCs are adequately trained. It should be noted that the waste generator or Environmental Management Division can request chemical and/or radiochemical analyses when 3-94 it is believed that characterization cannot be supported through process knowledge; however, there are no formal processes or procedures for making this determination. WPRs can be used for up to 1 year without recharacterization and recertification of the wastes generated. A new WPR is required when a change in process occurs which could affect the waste profile. However, there are no procedures for documenting waste generating processes; therefore, occurrences of changes in process cannot be tracked. The majority of waste streams identified in the Waste Analysis Plan of LANL's RCRA Part B Permit require only an annual analysis, except for those streams which have had a change in process. The primary mechanism for ensuring compliance with the waste analysis and characterization requirement of the permit is the WPR. Lack of an adequate program to ensure the validity of WPRs does not meet the intent of the permit and could result in noncompliances. As noted in Finding WM/CF-5, waste generating organizations are not adequately marking and labeling waste packages. Contrary to LANL's AR, Waste Management Group (EM-7) personnel are preparing waste packages and assigning waste codes even though they are not the generating organization. This practice continues largely because of the historical role of EM-7 as a waste service provider to the line organizations. However, this does not support the formality of operations required by DOE 5480.19 and the responsibilities delegated to line organizations through AR 10-3 and AR 10-2 for waste characterization. ng was partially identified in the LANL Self-Assessment. 3-95 FINDING WM/CF-2: Hazardous Waste Management Training Performance Objective New Mexico Hazardous Waste Management Regulations (NMHWMR), Part V, and 40 CFR 264.16(b), "Resource Conservation and Recovery Act" (RCRA), require LANL personnel involved in hazardous waste activities to complete a program of classroom instruction or on-the-job training that teaches them to perform their duties in a way that ensures the facility's compliance with the requirements of NMHWMR, Part V, and 40 CFR 264.16. 40 CFR 264.16(d)(3) requires a written description of the type and amount of both introductory and continuing training that will be given to each person filling a position in hazardous waste management at the facility. LANL must ensure that the training program includes all of the elements described. Finding Waste Management Group (EM-7) personnel training and training records do not meet the requirements of 40 CFR 264.16. Discussion The 1989 RCRA Part B Operating Permit requires LANL to provide training to waste operations personnel which is appropriate to their job functions and responsibilities. Records of this training must also be maintained and available for inspection. The provisions of the permit are not specific as to the types of training required and, therefore, it is the responsibility LANL to develop a training curriculum which implements the regulatory requirements. Personnel training matrices were prepared by EM-7 and the matrices, as currently prepared, are intended to more than fulfill the requirements of 40 CFR 264.16(b). The matrices include requirements for training in environmental compliance, general safety, industrial hygiene, operations, radiation, and miscellaneous courses. Training records and matrices were reviewed, and the following observations were made: 1. Training records for 19 EM-7 personnel (approximately 20 percent of the total employees in the group) were reviewed. Of these, none had completed the training required in the matrices for their position. 2. Personnel are not receiving training within 6 months of hire or transfer to a new position as required by 40 CFR 264.16. 3. Matrices of training requirements for Environmental Protection Group (EM-8) personnel who support EM-7 have not yet been prepared (I-WM-130). This finding was fully identified in the LANL Self-Assessment. 3-96 FINDING WM/CF-3: Management of Wastes in Temporary Storage Areas Performance Objective 40 CFR 262.34(c), "Resource Conservation and Recovery Act," and New Mexico Hazardous Waste Management Regulations (NMHWMR), Part 111, Section 301, specify the requirements for accumulation of hazardous waste in temporary storage areas where the generator needs no permit or does not need to have interim status. These temporary storage areas can be either satellite accumulation areas (SAAs) or less-than-90-day storage areas. LANL Administrative Requirements (AR) 10-3, "Chemical, Hazardous, and Mixed Waste," outlines additional requirements for temporary storage of waste. AR 10-3 delineates the responsibilities and the requirements of 40 CFR 262.34(c) and NMHWMR, Part III, Section 301, for the management of wastes in temporary storage areas. Appendix B of AR 10-3 provides specific requirements for operation of SAAs and less-than-90-day storage areas. AR 10-3 also requires that formal records on the composition and/or generating process be maintained for wastes in temporary storage. AR 10-3 also requires generators to follow EM policies and procedures which would include training for waste generators and waste coordinators. Additional EM requirements for waste generators have been provided in a training document Generator Requirements for Temporary On-site Storage of Hazardous and Mixed Waste. Finding LANL has not fully implemented a program for the management of wastes in temporary storage areas that complies with the applicable requirements. Discussion Line management is responsible for ensuring compliance with all aspects of AR 10-3. Direct management of the temporary storage areas has been delegated to the Group Waste Coordinator (GWC). The GWC must ensure temporary storage areas are regularly inspected and safe; appropriate regulations are complied with; and storage inspection records are prepared correctly. LANL has not fully and consistently implemented the above requirements of AR 10-3. Control of wastes entering the temporary storage areas and training of those responsible for these areas are the subjects of Findings WM/CF-3 and WM/CF-22. While temporary storage areas do not require permits issued by the EPA or state, compliance with the requirements of 40 CFR 262.34(c) and NMHWMR, Part III, Section 301, is a condition of the Resource Conservation and Recovery Act (RCRA) Part B permit for LANL. Therefore, inappropriate management of temporary waste storage areas is not in accordance with the RCRA Part B permit. The following are observations made at 33 SAAs and 10 less-than-90-day storage areas: 1. Observations at Satellite Accumulation Areas 40 CFR 262.34(c)(1) states that a generator can accumulate only up to 55 gallons of total waste at a SAA. More than 55 gallons of waste was stored at TA-53-25 (I-WM-322). 3-97 • 40 CFR 262.34(c)(l)(ii) requires that containers be marked with the words "Hazardous Waste" or with the words that identify the contents of the containers. Not all containers were so identified at TA-46-41 (at two locations) (I-WM-224), TA-46-154 (I-WM-226), TA-53-39 (I-WM-325), and TA-3-29-2123 (I-WM-338). • 40 CFR 262.34(c)(2) requires that the amount of waste over 55 gallons be removed from an SAA within 3 days. LANL does not have documentation available to demonstrate compliance. • 40 CFR 262.34(c)(1) states that waste can be accumulated at or near the point of generation. SAAs are not at or near the point of generation at TA-3-SM-34-1-B-1 (I-WM-210); TA-46-41 (at two locations) (I-WM-224); TA-46-154 (I-WM-226); TA-3-SM-39 (I-WM-228); TA-60-10 (I-WM-221); TA-53-25 and TA-53-3-A (I-WM-322); and TA-53-39, TA-53-2, and TA-53-MPE-22 (I-WM-325). • It is a best management practice to store hazardous waste separately from nonhazardous waste. Nonhazardous waste was stored with hazardous waste at TA-3-SM-34-1-B-1 (I-WM-210), TA-3-29-2048 (I-WM-216), TA-46-41 (at two locations) (I-WM-224), TA-53-25 and TA-53-3-A (I-WM-322), and TA-53-39 and TA-53-MPE-22 (I-WM-325). • AR 10-3 requires that SAAs be prominently marked with identifying signs. There were no signs at TA-3-SM-34-108 (I-WM-209), TA-3-SM-34-124 (I-WM-211), TA-60-10 (I-WM-221), TA-21 (at two locations) and TA-33 (tours), and TA-53-3-A (I-WM-322). • Generator training required by AR 10-3 states that generators be knowledgeable in the proper handling of hazardous waste. On several occasions, generators did not appear to understand the difference between less-than-90-day storage areas and SAAs and were confusing the requirements (I-WM-211, I-WM-221, and I-WM-232). • Generator training required by AR 10-3 states that spill control kits containing certain items be available. A complete spill control kit was not available at TA-3-SM-34 (I-WM-210), TA-46-30 (I-WM-223), TA-46-41 (I-WM-224), TA-18-30-116 (I-WM-232), TA-53-25 and TA-53-3-A (I-WM-322), TA-3-66 (I-WM-340), and TA-53-2 (I-WM-325). • Generator trainign required by AR 10-3 states that emergency eye washes be in close proximity to the SAA, Eye washes were not close to the SAA at TA-3-29-2048 (I-WM-216); TA-46-41 (at two locations) (I-WM-224); TA-46-154 (I-WM-226); TA-60-10 (I-WM-221); TA-53-25 and TA-53-3-A (I-WM-322); TA-53-39, TA-53-MPE-22, and TA-53-2 (I-WM-325); TA-3-29-2123 (I-WM-338); and TA-3-66 (I-WM-340). 3-98 Generator training required by AR 10-3 states that emergency showers be in close proximity to the SAA, Showers were not close to the SAAs at TA-3-SM-34 (I-WM-210); TA-46-30 (I-WM-223); TA-46-41 (at two locations) (I-WM-224); TA-46-154 (I-WM-226); TA-3-39 (I-WM-228); TA-60-10 (I-WM-221); TA-53-25 and TA-53-3-A (I-WM-322); TA-53-39, TA-53-2, and TA-53-MPE-22 (I-WM-325); TA-3-29-2123 (I-WM-338); and TA-3-66 (I-WM-340). Generator training required by AR 10-3 states that there be a communication system operating. Communication devices were not in close proximity to TA-46-30 (I-WM-223); TA-60-10 (I-WM-221); TA-53-25 and TA-53-3-A (I-WM-322); and TA-53-39, TA-53-MPE-22, and TA-53-2 (I-WM-325). AR 10-3 states that SAAs should be free of obstacles that could cause a spill or accident or prevent access by emergency personnel. The areas are not free of obstacles at TA-3-SM-34-1-B-1 (I-WM-210), TA-53-25 and TA-53-3-A (I-WM-322), TA-50-1-131 (I-WM-327), and TA-53-2 (I-WM-325). As a best management practice, AR 10-3 recommends that waste containers be stored in a dry, sheltered area. This recommendation was not being met at TA-16 (I-WM-320), TA-53-25 and TA-53-3-A (I-WM-322), and TA-53-2 (I-WM-325). 2. Observations at Less-Than-90-Day Storage Areas 40 CFR 262.34(a) outlines the requirements for temporary storage of hazardous wastes for 90 days or less. Some wastes were stored for more than 90 days at TA-3-30 (I-WM-212), TA-35-TSL-125 (tour), TA-3-SM-38-103 (I-WM-241), TA-16 (I-WM-320), and TA-3-66 (I-WM-340). 40 CFR 265.174 requires less-than-90-day storage areas to be inspected at least weekly. Some weekly inspections, particularly those for the 2-week Christmas-New Years vacation, were not conducted at TA-3-30 (I-WM-212), TA-3-SM-38 (I-WM-241),.TA-46-59 (I-WM-221), TA-16 (I-WM-320), TA-55-PF-4 (tour), and TA-3-66 (I-WM-340). 40 CFR 262.34(a)(3) requires that the date upon which each period of accumulation begins is clearly marked on each container. Some containers were not clearly marked with the start date at TA-3-30 (I-WM-212), TA-3-SM-38-103 (I-WM-241), and TA-3-36 (I-WM-131). 40 CFR 262.34(a)(4) requires that each container be labeled or marked with the words "Hazardous Waste." Some containers were not labeled or marked at TA-35-TSL-125 (tour) and TA-3-36 (I-WM-131). Generator training required by AR 10-3 states that hazardous and nonhazardous waste must be separated. Nonhazardous waste was stored with hazardous waste at TA-3-30 (I-WM-212), 3-99 TA-35-TSL-67 and TA-55-PF-4 (tours), and TA-3-SM-38-103 (I-WM-241). AR 10-3 requires that less-than-90-day storage areas be prominently marked with identifying signs. There was no sign at TA-35-TSL-125 (tour). As a best management practice, AR 10-3 recommends that waste containers be stored in a dry, sheltered area. This recommendation was not being followed at TA-16 (tour) and TA-3-66-MST-6 (I-WM-340). As a best management practice, waste containers should be placed on drip pads. Some waste was not placed on drip pads at TA-35-TSL-125 (tour), TA-16 (I-WM-320), and TA-55-PF-4 (tour). As a best management practice, there should be documentation of each waste removal, including the date and time of removal. Such documentation was not available at TA-3-30 (I-WM-212), TA-46-88 (I-WM-219), TA-16 (I-WM-320), TA-55-PF-4 (tour), and TA-3-66 (I-WM-340). This finding was partially identified in the LANL Self-Assessment. 3-100 FINDING WM/CF-4: Manifesting of Hazardous Waste Performance Objective 40 CFR 262.20, "Resource Conservation and Recovery Act" (RCRA), requires a generator to prepare EPA Form 8700-22, Uniform Hazardous Waste Manifest (HWM), when hazardous waste is offered for transport, offsite treatment, storage, or disposal. 49 CFR 172.205(a), a U.S. Department of Transportation regulation, states: "No person may offer, transport, transfer, or deliver a hazardous waste (waste) unless an EPA Form 8700-22 and 8700-22A (when necessary) hazardous waste manifest is prepared in accordance with 40 CFR 262.20 and is signed, carried, and given as required of that person by this section." 40 CFR 268.7 requires a generator managing a restricted waste (under 40 CFR 268), to notify the disposal facility as,to proper disposition of the waste. Finding LANL has not implemented procedures necessary to ensure compliance with 40 CFR 262.20 nor has LANL addressed the requirement to prepare EPA Forms 8700-22 (manifest) when transporting hazardous wastes from TA-57. Discussion LANL uses two separate manifesting systems for transporting hazardous wastes. The Chemical Waste Disposal Request (CWDR) form is used to transport hazardous wastes from various technical areas to TA-54. EPA Form 8700-22 is used to transport hazardous wastes from LANL to offsite disposal facilities. LANL does not have adequate procedural controls in place to ensure the manifests are properly completed. Also, there have been occasions where waste packages have been returned to LANL by the offsite disposal facility for improper characterization and documentation. The following deficiencies were noted in a sample of 37 hazardous waste manifests for offsite shipments made during October and December 1990, and March and June 1991: 1. Land disposal restriction notification forms were missing from 2 of the 37 manifests. 2. Five land disposal restriction notification forms were not properly completed. 3. A drum containing a reportable quantity (RQ) of a hazardous waste was not so identified on the manifest. In addition, hazardous wastes transported from Fenton Hill (TA-57) to TA-54 were not manifested using EPA Form 8700-22 as required. This facility is located approximately 37 miles from TA-54 and requires transport on public roads (see Finding WM/CF-9). An issue which was not resolved during the Tiger Team assessment was whether or not Pajarito Road or East Jemez Road which intersect the Laboratory are public or private. If the roads are public, then transport of hazardous wastes on public roads constitutes "offsite" movement of wastes, and would require use of the EPA Form 8700-22 instead of the CWDR. 3-101 Even if the roads are private, then as a best management practice, LANL's onsite waste transportation manifesting system should incorporate the necessary elements of EPA Form 8700-22. This finding was not identified in the LANL Self-Assessment. 3-102 FINDING WM/CF-5: Pre-Transportation Requirements Performance Objective New Mexico Hazardous Waste Management Regulations (NHMWMR), Part 111, Section 301, and 40 CFR 262, Subpart C, "Pre-Transportation Requirements" (Resource Conservation and Recovery Act (RCRA)) requires containers to be properly marked and labeled prior to transport. LANL Administrative Requirements (AR) 10-3, "Chemical, Hazardous, and Mixed Waste," states that generators of hazardous or mixed waste must comply with NMHWMR, Part 111, and 40 CFR 262. Finding LANL has no program or procedures in place to ensure conformance with labeling and marking requirements prior to transport of hazardous wastes from temporary storage areas. Discussion It is the responsibility of the waste generator to comply with the requirements of AR 10-3 and 40 CFR 262. These include proper labeling and marking of the generator's containers of hazardous waste in accordance with both RCRA and U.S. Department of Transportation (DOT) requirements prior to transport. The RCRA regulations must be followed if the wastes are hazardous; the DOT requirements apply if the wastes are transported on public roads. Additionally, a LANL directive (SK01336), dated April 15, 1991, requires all movement of hazardous wastes at LANL to be in strict compliance with DOT regulations. Customary procedures at LANL require both waste profiling and preparation of a Chemical Wastes Disposal Request document before the Chemical and Solid Waste Section will approve wastes for transport. Contrary to LANL's AR 10-3, Waste Management Group personnel, rather than the generator, are marking and labeling containers at the temporary storage areas prior to transport. The following observations, made during a tour of TA-54, Area L, are indicative of the absence of a program and procedures to ensure adherence to pre-transportation regulations: 1. TA-54-31. Drum SM-38-02 had no EPA code on the hazardous waste label; the packing list stated the drum contents were Warfarin, a poison. There was no poison label on the drum. 2. TA-54-31. An unnumbered drum had both a hazardous waste label which identified the contents as DOOl (ignitable), and a DOT nonflammable label. 3. TA-54-31. Drum SM-38-01 had a hazardous waste label with an EPA waste code of DOOl (ignitable), and a DOT nonflammable label. 4. TA-54-69. The hazardous waste label on drum C1020541 had no accumulation date. Accumulation dates are to be on labels prior to transport. 3-103 5. Gas cylinder storage area. Several cylinders had no accumulation date on the hazardous waste labels. Accumulation dates are to be on labels prior to transport. 6. TA-54-32. No accumulation dates were observed on the hazardous waste labels of the following drums: D91004957B, D91004955B, D91004492L, and H870595N. Accumulation dates are to be on labels prior to transport. 7. TA-54-32. No EPA waste code noted on the hazardous waste label on drum 91001492L. The specific labeling deficiencies observed in TA-54-31 were remediated within 1 hour after the inspection tour. This finding was partially identified in the LANL Self-Assessment. 3-104 FINDING WM/CF-6: Characterization of Surface Impoundments Performance Objective The Hazardous and Solid Waste Amendments (HSWA) Module of the LANL Resource Conservation and Recovery Act (RCRA) Part B Permit, Section B(5), states, "LANL shall close surface impoundments(s) in existence on November 8, 1984...in accordance with the following provisions: (1) LANL shall not place hazardous waste in the surface impoundment(s)..." 40 CFR 261.4 (RCRA), describes circumstances when materials can be exempt as a solid waste, such as industrial wastewater discharges. This section further states that this exclusion applies only to the actual point source discharge. It does not exclude industrial wastewaters while they are being collected, stored, or treated before discharge, nor does it exclude sludges that are generated by industrial wastewater treatment. 40 CFR 261.3 defines whether a solid waste, as defined in 40 CFR 261.2, is a hazardous waste. 40 CFR 261.3 states that a solid waste is a hazardous waste if (1) it is, or contains, a hazardous waste listed in Subpart D of 40 CFR 261, or (2) the waste exhibits any of the characteristics defined in Subpart C of 40 CFR 261. 40 CFR 264.228 describes the closure and post-closure procedures requirements for surface impoundments that treat, store, or dispose of hazardous waste, as defined in 40 CFR 261.3. Finding LANL has not developed or implemented procedures to characterize sanitary surface iiq)oundments to determine if RCRA-regulated wastes are present. Discussion The nine sanitary sewage treatment impoundments at LANL are classified as sanitary wastewater treatment facilities. Effluents from these sanitary impoundments (one impoundment at TA-9, two at TA-18, three at TA-35, one at TA-46, and two at TA-53) are governed by the National Pollutant Discharge Elimination System (NPDES) point discharge regulations. According to 40 CFR 261.4(a)(2), such sanitary discharges are exempt from RCRA regulation because sanitary sewage effluent is not a solid waste by definition. However, this exclusion applies only to the actual point source discharge. It does not apply to the collection, storage, and treatment of effluents before discharge, nor does it apply to the treatment sludges. Therefore, according to 40 CFR 261.2, these sanitary wastewater treatment facilities are solid waste management units that are subject to Subtitle C if the impoundments contain a listed waste or characteristic waste. The following deficiencies were noted in the Tiger Team review of the sanitary impoundment characterization studies: 1. LANL has not developed or implemented an annual surveillance program at the existing sanitary impoundments to determine whether RCRA-defined hazardous wastes are present. The Environmental 3-105 Protection Group (EM-8) has performed isolated studies on sanitary impoundments during 1987 (TA-9, TA-18, TA-35, and TA-46), 1988 (TA-18, TA-35, and TA-53), and 1989 (TA-35) to determine whether RCRA hazardous waste was present. These studies have been sporadic and have produced inconclusive analytical data. 2. The analytical results from these studies could not be presented to the Environmental Subteam or were determined by LANL personnel to be invalid. As a result, it is unclear whether substances other than sanitary waste have been discharged to LANL sanitary lagoons. 3. Documentation of these studies was inconsistent and lacked formality; consequently, analytical results from the Environmental Chemistry Group (EM-9) could not be located and presented to the Environmental Subteam (I-IWS-36, I-IWS-41, and I-IWS-42). Samples obtained from the 1987 study and analyzed by a commercial laboratory were determined to have poor quality control/quality assurance procedures. These results were disregarded by LANL personnel (IWS-3; I-IWS-36). The sanitary impoundments at TA-9 and TA-46 have not been evaluated following the 1987 study. 4. LANL has not defined line management responsibility for this characterization study. In the past, personnel from EM-8 have initiated studies or developed proposals to investigate certain sanitary impoundments (IWS-3). These responsibilities were never carried out, however, since higher priorities within EM-8 took precedent. This finding was not identified in the LANL Self-Assessment. 3-106 FINDING WM/CF-7: Contingency Plan Performance Objective New Mexico Hazardous Waste Management Regulations (NMHWMR), Part V, Section 501, and 40 CFR 264, Subpart D, "Resource Conservation and Recovery Act," require owners and operators of permitted hazardous waste facilities in New Mexico to prepare and implement contingency plans for these facilities, 40 CFR 264.52 through 40 CFR 264.56 list the requirements for content, copy, currency, distribution, emergency coordinators, and emergency procedures. Finding The LANL Contingency Plan does not meet the requirements of the NNHWNR and 40 CFR 264. Discussion The LANL Contingency Plan is not current, and the RCRA permit has amended to reflect the currency of the plan as required. The plan submitted as part of the RCRA permit application in 1988, and has updated as required by NMHWMR. The following deficiencies in the observed: not been was not been plan were 1. The LANL 1989 RCRA operating permit's contingency plan section has not been amended to reflect changes in either emergency coordinators (required by 40 CFR 264.52(d)) or emergency equipment as required by 40 CFR 264.52(e) (l-WM-137). 2. The LANL Contingency Plan was not distributed in accordance with 40 CFR 264.53(b), which requires that copies of the plan and all revisions to it be distributed to all local police departments, fire departments, hospitals, and state and local emergency response teams that may be called upon to provide emergency services. Interviews with personnel supervising the LANL medical department (I-WM-135), security (I-WM-136), and fire department (I-WM-138) indicated that they had only received copies of the plan within the past few weeks. 3. The number of medical staff available in the event of an emergency does not correspond to the number identified in the plan. The LANL medical department director stated (I-WM-135) that he had not been consulted regarding the number and type of available medical staff at LANL. This information is included in the plan as part of the emergency equipment and staff available in the event of an emergency. This finding was not identified in the LANL Self-Assessment. 3-107 FINDING WN/CF-8: Hazardous Waste Minimization Program Performance Objective DOE 5400.1, "General Environmental Protection Program," Chapter 111, Section 4.b., requires that a waste minimization plan and program be in place by May 9, 1990. As part of the program, a plan is to be developed that would include goals for minimizing wastes with annual reductions, a comparison of reductions achieved with the reductions of the previous year, the methods to accomplish waste minimization, and waste minimization plans required the Resource Conservation and Recovery Act (RCRA). DOE 5820.2A, "Radioactive Waste Management," Chapter VI, requires that facilities report annually to appropriate DOE-Headquarters groups, on waste reduction activities, including hazardous waste activities, as an appendix to the waste management plan. 40 CFR 262.41, "Resource Conservation and Recovery Act" and New Mexico Hazardous Waste Management Regulations (NMHWMR), Part III, Section 301, require the submission of a biennial report describing the changes in volume and toxicity of wastes actually achieved during the year in comparison to previous years. LANL RCRA Part B Operating Permit, Module VIII, requires that a certified waste minimization plan be submitted annually that addresses a list of 10 specific plan elements. LANL Administrative Requirements (AR) 10-8, "Waste Minimization," states that waste generators must complete the forms as outlined in AR 10-3 when waste is ready for disposal, that each generating unit appoint a waste coordinator and these coordinators be trained in waste minimization, and that generators use appropriate operating procedures to implement waste reduction. In addition, various methods of waste minimization are outlined for possible use by generators. Finding LANL has not developed or implemented a Waste Ninimization Program that complies with applicable requirements. Discussion A review of LANL waste minimization activities indicated the following deficiencies: 1. LANL does not have a waste minimization program plan as required by DOE 5400.1 (I-WM-202). The plan was due to DOE-Headquarters (HQ) May 9, 1990. 2. LANL does not have a system in place that will implement the Waste Minimization Program requirements for establishment of goals, measurement of progress, and proposing methods to achieve goals. However, changes in hazardous waste streams are being reported for alternate years on the RCRA biennial report (I-WM-201). 3-108 3. AR 10-8 does not address the requirements for a Waste Minimization Program as outlined in DOE 5400.1. 4. LANL uses the Waste Management Plan as the vehicle for reporting the status of its Waste Minimization Program activities in the body of the report, rather than the appendix as required. More importantly, the report does not include the required program performance results (WM-202). 5. In response to the RCRA operating permit requirement to submit a certified waste minimization plan annually, LANL submitted the 1989 Waste Management Site Plan (WM-202). However, it did not address many of the items listed in Module VIII of the permit. 6. The biennial hazardous waste report for 1989 (WM-201), as required by 40 CFR 262.41, omitted wastes that are treated by elementary neutralization. Also, a review of the 203 waste streams included indicated that waste minimization was achieved on just 7 streams. 7. AL 5-year plan guidance, issued December 1990 (WM-200), specifies that landlords, not the Waste Management Group (EM-7), will pay waste implementation costs. LANL landlord programs for FY 1992 do not include funding for waste minimization implementation. 8. LANL has concluded from a review of the Implementation Guidance for DOE 5400.1 that a Waste Coordinator to represent the landlords is required to work with DOE-HQ on waste minimization issues. No Waste Coordinator has been appointed (I-WM-202). 9. LANL administrative requirements lack controls to ensure that generators correctly segregate wastes to achieve waste minimization. In many instances, it may be more convenient to place a waste into a category where the handling and disposal costs would be greater than if the waste were put into the correct category. Examples noted included nonhazardous waste being discarded into satellite accumulation containers and office waste paper being handled as radioactive or high explosive waste. While a waste minimization program has not yet been developed, some line organizations have implemented their own programs, and there are ongoing efforts to reduce waste generation. However, only TA-55, the Plutonium Processing Facility, has filed a specific waste minimization plan with the Waste Management Group (EM-7) (I-WM-202). This finding was partially identified in the LANL Self-Assessment. 3-109 FINDING WN/CF-9: EPA Identification Number for Fenton Hill Site Performance Objective 40 CFR 260.10, "Resource Conservation and Recovery Act" (RCRA), in its definition of "onsite property," distinguishes between properties owned by a generator that can be considered part of one site, and nearby properties that cannot. "Onsite" is defined as the "same or geographically contiguous property which may be divided by public or private right of way, provided the entrance and exit between the properties is at a crossroads intersection, and access is by crossing as opposed to going along, the right of way. Noncontiguous properties owned by the same person but connected by a right of way which the generator controls and to which the public does not have access, is also considered onsite property." 40 CFR 262.12 states that "generators of hazardous waste must not treat, store, dispose of, transport, or offer for transportation hazardous waste without having received an EPA Identification number from the Administrator". New Mexico Hazardous Waste Management Regulations (NMHWMR), Part III, Section 301, has incorporated the regulatory requirements established in 40 CFR 262. Finding The LANL Fenton Hill site (TA-57) is generating and shipping hazardous wastes without an EPA identification number from the EPA Administrator. Discussion LANL has not examined the definitions of "generator" and "onsite" to determine whether properties it owns and operates require separate EPA identification numbers. The identification number issued to LANL is only for the Laboratory site located in Los Alamos County, which meets the geographically contiguous property requirements of EPA's definition of "onsite" found in 40 CFR 260.10. The Fenton Hill site (TA-57) is also part of LANL, but it is located in Sandoval County, New Mexico, and is geographically separated from the Laboratory site by approximately 35 miles of public roads. TA-57 meets the definition of a generator of hazardous waste as stated in 40 CFR 260.10; however, it does not meet the 40 CFR 260.10 definitional requirements of "onsite" for designation as a geographically contiguous part of the LANL-owned and -operated property. Therefore, TA-57 has been generating and shipping hazardous waste without an EPA identification number. Interviews with LANL staff acknowledge that although the Fenton Hill site is generating hazardous waste, the issue regarding its requiring an EPA identification number has been overlooked (I-WM-346 and I-WM-347). Although the New Mexico Environment Department and EPA Region VI have routinely inspected LANL, they are aware of waste generation activities at the Fenton Hill site and have not made this an issue. This finding was not identified in the LANL Self-Assessment. 3-110 FINDING WN/CF-10: Nanagement of Excess Government Personal Property Performance Objective DOE 5400.5, "Radiation Protection of the Public and the Environment," Section 6.a., states that it is DOE's objective to operate its facilities and conduct its activities to control radioactive contamination through the management of real and personal property. It is also a DOE objective that potential exposures to members of the public be as low as reasonably achievable (ALARA). Section 6.b. states that it is DOE's objective to protect the environment from radioactive contamination to the extent practical. DOE 5480.19, "Conduct of Operations Requirements for DOE Facilities," states that "it is the policy of the department that the conduct of operations at DOE facilities be managed with a consistent and auditable set of requirements, standards, and responsibilities." LANL Administrative Requirements (AR) 10-6, "Excess Government and Personnel Property," outlines the responsibilities of laboratory and service organizations regarding the handling and management of excess material for salvage. Finding LANL lacks the administrative procedures and physical controls necessary to ensure the proper sitewide management of excess government and personal property prior to transfer to the Johnson Controls World Services, Inc. (JCI) Redistribution Center. Discussion Excess government and personal property, as defined in AR 10-6, is property of any kind that is no longer needed (WM-301). Individual personal property owners at LANL, with the aid of line managers, determine if their property is no longer needed. Once this determination is made, appropriate management is required to address the health, safety, and environmental issues associated with reusing, salvaging, and disposing of such property. Although LANL addresses some issues of excess government and personal property management through AR 10-6, comprehensive administrative procedures have not been developed and implemented. A primary shortcoming of AR 10-6 is that it does not provide guidance regarding designation of building- or area-specific holding areas for approved excess property pending transfer to the JCI Redistribution Center, or how such areas should be managed. Contrary to ALARA requirements, radiologically contaminated materials can be moved from controlled areas to holding areas without being surveyed. Numerous excess property accumulation areas and collection points both inside and outside individual buildings were observed throughout the Laboratory. During interviews with LANL staff, it was indicated that no formal system exists for designating these areas as property accumulation areas, nor are they properly managed with regard to the types of materials to be stored (I-WM-312, I-WM-313, and I-WM-317). Inspection of numerous excess property collection points throughout the Laboratory found that many areas, which were either poorly controlled or not controlled at all, contained hazardous and 3-111 radiologically contaminated material and equipment that could potentially be released into the environment. The following observations were made during inspections of excess property collection areas at LANL: 1. The outdoor excess property collection area at TA-53 between sectors D and E, which is not a controlled area, was found to contain materials contaminated with radionuclides. The contaminated material was detected by Radiation Protection Group (HS-1) personnel and disposed of as low-level waste. 2. The excess property collection area between sectors D and E at TA-53 also contained disposable flashlight batteries on the ground, full aerosol cans containing hazardous solvents, a mercury lamp, large flammable gas tanks (pressure gauges indicated the tanks were still pressurized), safety cans labeled with hazardous waste labels, lead sheeting wrapped in plastic on the ground, and a considerable amount of electrical equipment, which may have included PCB-containing capacitors. 3. The outdoor excess property collection area at TA-43 contained lead bricks on the ground without any containment. The bricks were exposed to rain creating the potential for soil contamination from lead corrosion products. 4. An occurrence report was filed by an HS-1 health physics technician after identifying radiologically contaminated machinist tool boxes in the excess property collection area at TA-3, Bldg. 39, which is not a controlled area (WM-304 and WM-305). None of the excess property collection areas inspected at the Laboratory was found to have controlled access, containment, or signs identifying them as excess property collection points. LANL has no system for either designating or controlling access to these property collection areas. This finding was fully identified in the LANL Self-Assessment. 3-112 FINDING WM/CF-11: Los Alamos County Landfill Performance Objective 40 CFR 241, "Guidelines for Landfill of Solid Waste," delineate minimum levels of performance for any solid waste land disposal site operation. New Mexico Solid Waste Management Regulations (NMSWMR), Part I, Section 106, adopted April 14, 1989, establishes recordkeeping and annual reporting requirements for operators of Sanitary Landfills. NMSWMR, Part II, Section 201 B.l, requires operators of existing landfill facilities that will continue to operate after the effective date of the regulation to file with the director a Notice of Intent to continue to operate with the division. NMSWMR, Part III, Section 301, establishes specific facility requirements for landfill operations. DOE 5480,19, "Conduct Of Operations Requirements for DOE Facilities," states that it is the policy of the Department that the conduct of operations at DOE facilities be managed with a consistent and auditable set of requirements, standards, and responsibilities and that they be consistent with the requirements of the Order. Finding LAAO has not ensured that operations at the Los Alamos County Landfill are in compliance with 40 CFR 241 and NNSWNR. Discussion In 1984, LAAO issued a revised special use permit to the Incorporated County of Los Alamos, State of New Mexico, to enter a parcel of DOE property located in upper Sandia Canyon for the purpose of operating a sanitary landfill (WM-310). Under provisions governing special use permits in the Atomic Energy Act, the county is operator of the landfill while DOE retains ownership of the land. Los Alamos County, which operates the landfill with certified operators (I-WM-306), accepts normal sanitary waste (rubbish), dead animals, junk automobiles, bulk metal items, and construction rubble from local households as well as from LANL. Solid waste trash from LANL is collected and transported by Johnson Controls World Services, Inc. (JCI) to the landfill. Approximately 40 percent of all solid waste disposed of at the landfill originates from the Laboratory. The county also conducts recycling activities at the landfill, which include collection of waste oil, scrap metal, and used automobile batteries. During the Tiger Team Assessment of LANL, inspections of the Los Alamos County Landfill and interviews with the landfill superintendent (I-WM-307), as well as interviews with LAAO and LANL staff (I-WM-304, I-WM-305, I-WM-306, I-WM-315, and I-WM-316), indicate the following nonconformances with the NMSWMR regarding landfill operations: 1. Contents of operating record: The landfill operating record, entitled "Landfill Operations Plan" (WM-314), does not include the 3-113 quantity of waste received, the methods and dates of waste disposal, a map or diagram of each cell or disposal area, location and depth of waste within the facility and the quantity at each location, and closure and post-closure cost estimates per NMSWMR, Part I, Section 106. Although all of the required information is maintained at the landfill site, none of it can be found in the operating record. Closure and post-closure costs are not adequately addressed. 2. Landfill operators have not adequately assured that methane and other decomposition gases do not migrate laterally from the landfill site per NMSWMR, Part III, Section 301, and 40 CFR 241.206. 3. Signs located within the landfill did not completely indicate individual waste site locations or specific disposition instructions, and emergency telephone numbers were not posted at various locations throughout the landfill site per NMSWMR, Part III, Section 301. 4. A chain link fence encloses only part of the landfill, thereby potentially allowing unauthorized access by the public and entry by large animals to the active portion of the landfill contrary to NMSWMR, Part III, Section 301. An additional fence surrounds the active cell of the landfill; however, portions of this fence were down due to nearby construction activities at the landfill (l-WM-359). 5. Waste oil recycling operations are not appropriately controlled per NMSWMR, Part III, Section 301. A steel tank used to collect waste oil for recycling is situated in a large hole in the ground without adequate containment. Waste oil pouring operations are not designed to prevent spilled oil from reaching the soil and the pouring area is not protected from the weather. A noticeable amount of spilled oil was on the soil below the tank filling spout. 6. Although not a requirement of the NMSWMR, best management practice suggests that a list of materials which are excluded from the landfill be displayed at the entrance to the landfill per 40 CFR 241.201-203; such a list was not posted at the entrance to the Los Alamos County Landfill. As the property owner on which the county is conducting landfill operations, DOE has the responsibility to ensure that during its operation, all applicable environmental compliance concerns are addressed. Although it is the LAAO legal counsel's position that operation of the landfill in accordance with applicable Federal and state regulations is definitely the county's responsibility (I-WM-358), the special use permit issued to Los Alamos County by DOE does not establish a clear delineation of responsibilities between the county and DOE for environmental regulatory compliance. The ambiguity surrounding responsibility for the landfill's regulatory compliance is further evidenced by inconsistencies in meeting operator reporting requirements. The Notice of Intent to continue landfill operations 3-114 was submitted to the state by LAAO, while the annual operations 1991 was submitted to the state by the Los Alamos County Public The special use permit, as it was drafted, is deficient in that used does not require the county to abide by prevalent laws and during landfill operations. This finding was not identified in the LANL Self-Assessment. 3-115 report for Works office. the language regulations FINDING WN/CF-12 Underground Storage Tank Program Performance Objective DOE 5400.1, "General Environmental Protection Program," Section 5, states that it is DOE policy to conduct the Department's operations in compliance with the letter and spirit of applicable environmental statutes, regulations, and standards. 40 CFR 280, "Resource Conservation and Recovery Act," and New Mexico Underground Storage Tank Regulations (NMUSTR) Sections 100-1400, govern underground storage tanks (USTs) containing regulated substances. 40 CFR 280.40 and NMUSTR, Section 600(c), require that USTs installed before 1969 have leak detection, and 40 CFR 280.41 and NMUSTR, Section 603, specify the methods of leak detection that must be used, depending on the age and size of the tank. NMUSTR, Section 204,B, requires that UST operators notify the state, in writing, within 7 days of a spill of a regulated substance from a UST that exceeds a threshold quantity or that cannot be cleaned up within 24 hours. DOE 5480.19, "Conduct of Operations for DOE Facilities," provides requirements and guidelines for use in developing directives, plans, and/or procedures relating to the conduct of operations at DOE facilities, the implementation of which should result in improved quality and uniformity of operations. Finding LANL has not developed a coordinated, formal program for management of USTs that will ensure compliance with leak detection and spill reporting requirements. Discussion LANL's UST management efforts are based on a set of coordinating agreements among several environmental groups:' the Environmental Protection Group (EM-8), Environmental Restoration Group (EM-13), Waste Management Group (EM-7), Field Operations Group (ENG-5), and Johnson Controls World Services, Inc. (JCI) (I-WM-238). LANL's long-term strategy has been to decommission USTs in advance of the regulatory deadlines for installation of leak detection systems (I-WM-217 and I-WM-238). This informal system has worked well thus far; however, it lacks the formality necessary to ensure continued compliance with regulatory requirements. The following minor deficiencies were noted: 1. 40 CFR 280.41 requires that existing petroleum USTs installed before 1969 be provided with leak detection using one of the volume-specific methods listed in 40 CFR 280.43. However, the method chosen for UST TA-59-6 (3,000 gallons), manual dip stick tank gauging (WM-205), is not acceptable for a tank greater than 2,000 gallons. 2. LANL does not meet the 7-day time requirement for notifying the state of spills of regulated substances. The purpose of the notification is to provide the state with a timely record, in addition to a written one. LANL requests an extension to the time 3-116 requirements for written notification about 25 percent of the time. The reason for these extension requests is LANL's inability to obtain LANL and LAAO concurrence on the written notification in a timely manner (I-WM-217). Recent developments have brought the program to a halt and raise the possibility that the LANL program could fall out of compliance with the leak detection requirements that become effective in 1992 and 1993: 1. LANL lacks onsite disposal capacity for contaminated soil from tank removals, thus preventing scheduled tank removals from proceeding (I-WM-238). These removals are scheduled for FY 1992 and FY 1993 because the leak detection compliance date for all remaining USTs is December 1993. 2. Tank closures and removals are funded through corrective action funds, which run out in FY 1992. Should no funding be provided in FY 1993, costs will be incurred by landlords of the tanks. Therefore, LANL may not be able to meet compliance schedules for tank removals. This finding was partially identified in the LANL Self-Assessment. 3-117 FINDING WM/CF-13 Low-Level Waste Segregation Performance Objective DOE 5820.2A, "Radioactive Waste Management," "Chapter III, Section 3.c.(3), requires that each DOE low-level waste (LLW) generator separate uncontaminated waste from LLW to facilitate cost-effective treatment and disposal. DOE 5820.2A, Chapter III, Section 3.d.(l), requires characterization of waste with sufficient accuracy to permit proper segregation. LANL Administrative Requirements (AR) 3-7, "Radiation Exposure Control" (January 11, 1991), "Releasing Equipment, Materials, and Vehicles from Controlled and Radiological Areas," provides monitoring procedures to be conducted by a radiation protection technician (RPT) and surface contamination release limits. Releasing nonradioactive from radioactive materials equates to segregation. LANL memorandum EM-8:91-3 of August 5, 1991, "Criteria for Distinguishing Radioactive and Non-Radioactive Wastes From Radiation Control Areas," states that solid wastes from a controlled area where all surfaces are exposed and can be surveyed without dismantling are subject to the release limits in AR 3-7. Finding LANL LLW generators are not separating uncontaminated waste from LLW as required by DOE 5820.2A. Discussion The practice of LLW segregation, where each generator separates uncontaminated waste from LLW, is not occurring at LANL. The observed practice at many LANL generator sites is to place all waste within controlled areas and send it for disposal as LLW. It is estimated that over 50 percent of the LLW being disposed of by burial at Area G is not LLW (I-RAD-7 and I-RAD-250); observations made by the Environmental Subteam support this estimate. The following waste segregation deficiencies were noted: 1. LANL has not implemented the approved LLW release procedures included in AR 3-7 and LANL memorandum EM-8:91-3 of August 5, 1991. 2. LANL's waste characterization and certification activities do not rely on formal documentation of the waste generation process (see Finding WM/CF-1). Little effort has been made to document generating processes, thereby hampering implementation of segregation practices. 3. LANL's recent efforts to address the DOE moratorium on release of potentially contaminated wastes discourage segregation practices. LANL instituted a policy of declaring all waste originating from within a radioactive materials management area to be radioactive unless all surfaces of the waste material could be surveyed and determined to be free from fixed and removable contamination. 3-118 4. Segregation of uncontaminated waste from LLW within or at the exit of controlled areas is not practiced at LANL. Many items which are potentially not contaminated, such as office paper, were observed in LLW cans in' controlled areas. In nearly every controlled area, the LLW container was the only "trash can" (I-RAD-3, I-RAD-7, I-RAD-10, I-RAD-11, I-RAD-21, I-RAD-22, and l-RAD-38). 5. Contributing to an increase in volume of suspect waste being sent to LLW disposal is a shortage of counting equipment at the exit to controlled areas. There is also a shortage of personnel that are qualified to perform radiation surveys of materials that are ready for segregation. This lack of counting equipment and survey personnel contribute to the practice of treating all waste as LLW (I-RAD-7, I-RAD-11, and I-RAD-44). This finding was fully identified in the LANL Self-Assessment. 3-119 FINDING WN/CF-14: Low-Level Waste Volume Reduction Performance Objective DOE 5820,2A, "Radioactive Waste Management," Chapter III, Section 3.c., states that technical and administrative controls shall be directed to reducing the gross volume of waste generated and/or the amount of radioactivity requiring disposal. These requirements apply to low-level waste (LLW) and the radioactive component of mixed waste. Waste reduction efforts shall include consideration of process, material substitution, and decontamination. LLW generators shall establish auditable programs to assure that LLW generation is minimized. Each LLW generator shall separate uncontaminated waste from LLW waste to facilitate cost-effective treatment and disposal. LANL Administrative Requirements (AR) 10-2, "Waste Minimization" (February 15, 1991), page 4 of 19, requires specific LLW minimization requirements. AR 10-8, "Waste Minimization" (July 31, 1991) page 3 of 8, requires that waste minimization techniques be taught by the Waste Management Group (EM-7) personnel to Waste Management Coordinators (WMCs). AR 3-7, "Radiation Exposure Control" (January 11, 1991), pages 8 and 15, specifies materials release procedures. Finding LANL has not fully implemented a comprehensive LLW volume reduction program that meets the requirements of DOE 5820.2A and AR 10-2. Discussion Many of the requirements of DOE 5820.2A and AR 10-2 for LLW waste volume reduction have not been implemented at LANL. Although progress has been made towards implementing volume reduction, these efforts have been reactive and are not a part of an integrated program. The following specific deficiencies noted by the Environmental Subteam are indicative of LLW volume reduction program weaknesses: 1. Formal technical and administrative goals for radioactive waste volume reduction required by DOE 5820.2A have not been developed. Generators typically have not adopted goals or submitted forecasts or waste reduction reports (l-RAD-l, I-RAD-3, I-RAD-22, I-RAD-33, and I-RAD-39). 2. DOE 5820.2A required LLW reduction techniques, such as reducing the amount of material entering a controlled area, are not well practiced. Material such as cardboard and office paper is noted in almost every controlled area LLW container. 3. LANL does not have facilities to implement volume reduction techniques such as decontamination, shredding, and compaction as required by DOE 5820.2A, which would reduce the volume of LLW disposed (I-RAD-7). 3-120 4. A review of WMC training lesson plans (RAD-67), dated May 1991, revealed that lesson plans do not include information on LLW volume reduction release procedures contained in AR 3-7. 5. Several of the WMCs have not attended the volume reduction training which is required by AR 10-2 (e.g., LAMPF, TA-2, and Waste Management Group (EM-7) decontamination and decommissioning (D&D)). 6. Reducing the size of controlled areas during facility shutdown or maintenance periods for facilities (i.e., the TA-50 Waste Management Controlled Air Incinerator and Size Reduction Facility) is not being accomplished. This practice would reduce the amount of suspect or potentially contaminated waste by reducing the size of the area from which materials must be released. This finding was fully identified in the LANL Self-Assessment. 3-121 FINDING WN/CF-15: Low-Level Waste and Nixed Waste Certification Performance Objective DOE 5400.3, "Hazardous and Radioactive Mixed Waste Program," Section 6, states that it is the policy of DOE that the radioactive component of mixed waste is subject to the requirements of DOE 5820.2A, "Radioactive Waste Management." DOE 5820.2A, Chapter III, Section 3.e., requires that generators of low-level waste (LLW) implement LLW certification programs to provide assurance that the waste acceptance criteria (WAC) are met for any storage or disposal facility used by the generator. DOE 5820.2A, Chapter 111, Section 3.d., requires that LLW be characterized with sufficient accuracy to permit proper segregation, treatment, storage, and disposal and that the characterization is to ensure that, upon generation and after processing, the actual physical and chemical characteristics and major radionuclide content are recorded and known during all stages of the waste process. LANL Administrative Requirements (AR) 10-2, "Low-Level Radioactive Solid Waste," and AR 10-3, "Chemical, Hazardous and Mixed Waste," provide certification activity requirements. Also, included in AR 10-2 and AR 10-3 are instructions for completing the Radioactive Solid Waste Disposal (RSWD) and Waste Profile Request (WPR) forms. These forms are required for transfer of LLW and low-level mixed waste (LLMW) from the generators to TA-54, Areas G and L disposal sites. Finding LANL has not implemented the LLW and LLNW certification programs required by DOE 5820.2A. Discussion DOE Orders and LANL clearly place the responsibility for waste certification upon the waste generators and line management. The purpose of waste certification is to provide assurance that the generator has complied with WAC, regulatory requirements, and administrative procedures. The following deficiencies were noted by the Environmental Subteam: 1. The waste generator is required to sign a certification statement on the RSWDs and WPR Forms. In most instances, the generator is certifying through process knowledge. However, LANL does not have a formal system documenting waste generating processes, training personnel in certification requirements, or programs/procedures delineating the responsibilities of waste certifiers. Therefore, the certification activities are not conducted with the formality required by DOE 5820,2A. 2, Most waste generators do not have written standard operating procedures (SOPs) that include waste certification activities (e.g., LAMPF, MP-1; TA-3, CMR Building (CLS-1); and decontamination and decommissioning (D&D) as required by AR 10-2 and AR 10-3. 3-122 3. Contributing to the lack of waste certification is the lack of formalization of the Waste Management Coordinator (WMC) training required by AR 10-2. In addition, not all WMCs have completed the training (e.g., MP-1, CLS-1, and D&D). 4. Quality control of generator certification activities is lacking. Containers of LLW and LLMW are not being opened to independently check generator waste characterization (l-RAD-43). This independent check is necessary to meet the periodic audit requirement of AR 10-2. 5. Frequently, the waste generator is required to characterize the waste only after the WPR form information is determined by EM-8 technical staff to be inadequate and the generator's process knowledge is determined to be incomplete (e.g., TA-55, PF-4, room 208; TA-3 Bldg. 29, Laboratory 2123; TA-3, SIGMA 66, room 100; and TA-3, SIGMA 66, basement). This does not satisfy the DOE 5820.2A requirement that mixed waste be correctly characterized at all stages of the waste management process. The radioactive component of mixed waste is not being recorded on the LLW Waste Manifest at the following generating locations: TA-55, Plutonium Facility; PF-4, room 208 (satellite accumulation area (SAA)). TA-3, Sigma 66 Complex; the Mechanical Metallurgy Section, room R-lOO (SAA); the power supply cage, room P-1, and the plating operations mixed rinsewater holding tanks. TA-3, Bldg. 29; Laboratory 2123 (in wing 2 SAA). TA-50, Bldg. 1; Laboratory 30 (SAA). There is a lack of Waste Management Group and waste generator management oversight of LLW and LLMW generator waste certification activities. There is a lack of emphasis on ensuring completion of the requirements of DOE 5820.2A, AR 10-2, and AR 10.3. This finding was fully identified in the LANL Self-Assessment. 3-123 FINDING WN/CF-16: Low-Level and Mixed Waste Acceptance Criteria Performance Objective DOE 5400.3, "Hazardous and Radioactive Mixed Waste Program," Section 6.a., states that the radioactive component of radioactive mixed waste is subject to the requirements of DOE 5820.2A, "Radioactive Waste Management." DOE 5820.2A, Chapter III, Section 3.e., states that waste acceptance criteria (WAC) shall be established for each low-level waste (LLW) storage and disposal facility and submitted to the cognizant field organization for approval, and that LLW generators shall be periodically audited by disposal facility waste management personnel. A WAC should address issues such as allowable quantities/concentrations of specific materials, security, external radiation, and restrictions concerning the stability of packaged waste going to disposal. LANL Administrative Requirements (AR) 10-1, "Radioactive Liquid Waste,"; AR 10-21 "Low-level Radioactive Solid Waste,"; and AR 10-3, "Chemical, Hazardous and Mixed Waste," provide interim acceptance criteria to the generators at each technical area. Finding LANL has not implemented a LLW and mixed waste acceptance program. Discussion A draft WAC document (RAD-27) has been developed, and AL has returned the most recent draft to LANL for corrections. Storage/disposal facilities and generators have a joint responsibility for ensuring compliance with WAC. The following WAC deficiencies were noted by the Environmental Subteam: 1. Generator waste certification activities required by DOE 5820.2A and LANL ARs are incomplete as a result of having no WAC programs. Reliance is placed on using the incomplete ARs as guidance for waste disposal. As a consequence, mistakes are being made such as placing unpackaged or improperly packaged contaminated material in LLW dumpsters (I-RAD-35), and incorrect characterization of waste. Both types of mistakes are documented in waste manifests and waste generator Nonconformance Reports (I-RAD-43). 2. Waste management personnel are not auditing LLW and low-level mixed waste certification programs as required by DOE 5820.2A (I-RAD-7 and I-RAD-37). Although an approved WAC is a prerequisite to preparing a complete generator waste certification program, there are sufficient requirements in AR 10-1, AR 10-2 and AR 10-3 to provide a basis for storage/disposal waste management personnel audits of the waste generators. Waiting for an approved WAC for use as an audit basis has led to incorrect or incomplete waste certification practices. This finding was fully identified in the LANL Self-Assessment. 3-124 FINDING WM/CF-17: Mixed Waste Storage at TA-54 Perfonnance Objective DOE 5820.2A, "Radioactive Waste Management," Chapter III, Section 2.d., requires that low-level waste (LLW) that contains Resource Conservation and Recovery Act (RCRA) hazardous waste components (mixed waste) conform to the requirements of the Order and RCRA. Chapter III, Section 3.d.(l), establishes that LLW shall be characterized with sufficient accuracy to permit proper segregation, treatment, storage, and disposal. DOE 5400.3, "Hazardous and Radioactive Mixed Waste Program," Section 6.a., states that it is the policy of DOE to manage all Departmental hazardous and radioactive mixed waste according to the requirements of Subtitle C of RCRA, and the Atomic Energy Act, respectively. 40 CFR 265 and the New Mexico Hazardous Waste Management Regulations (NMHWMR), Part VI, establish standards for RCRA interim-status treatment, storage, and disposal (TSD) facilities, including inspections, training, preparedness and prevention, arrangements with local authorities, and use and management of containers. 40 CFR 268.7, "Resource Conservation and Recovery Act" (RCRA), requires that waste generators determine whether their waste is restricted from land disposal by actually testing the waste or by using knowledge of the waste. Waste that is determined to be subject to the land disposal restrictions may not be land disposed unless it meets specified treatment standards (40 CFR 268, Subpart D, "Treatment Standards"). 40 CFR 268.50, "Prohibition on Storage of Restricted Wastes," prohibits the storage of land disposal restricted waste unless storage is solely for the purpose of accumulating quantities necessary to facilitate the recovery, treatment, or disposal of the waste. LANL Administrative Requirements (AR) 6-9, "Safe Handling of Hazardous Gases," states that the storage area for any hazardous gas must be dry, cool, well ventilated, away from direct sunlight, and preferably fire resistant. Finding LANL's mixed waste storage at TA-54, Areas L and G, do not fully meet the regulatory requirements of DOE and AR 6-9. Discussion LANL generates mixed wastes which are stored at TA-54, Areas L and G. Area L stores various low-level mixed wastes outdoors, including gas in cylinders, and scintillation vials. Area G, Bldg. 49, stores low-level mixed waste, including dewatered sludge from the TA-50 Liquid Radiological Waste Treatment Plant, uranium metal process waste, and contaminated lead-lined glove boxes. Transuranic (TRU) waste and mixed TRU wastes are stored inside Bldg. 48, Area G. 3-125 The following deficiencies were observed at the TA-54 mixed waste storage areas: 1. Mixed waste gas cylinders were stored outside in direct sunlight. 2. The radiological activity of TA-50 mixed waste dewatered treatment sludge, is analyzed at TA-50, and occasionally found to be between 60 to 70 nCi/g. This is close to the TRU activity criteria of 100 nCi/g (I-WM-356). Drums containing this waste are stored on pallets, on bare soil outside of Bldg. 49. 3. Drums of uranium metal process waste which were labeled as "flammable solid" and "dangerous when wet" were also labeled as "non-regulated" in large, easily visible letters, and "under RCRA" in small lettering. Although this process waste exhibits a characteristic of reactivity, it meets the definition of source material in 10 CFR 20.3 and per 40 CFR 261.4 is excluded from the RCRA regulatory requirements applicable to solid wastes. The waste also does not contain any RCRA-listed wastes. The presence of nonregulated labels on these drums is misleading because the lettering which indicates that the waste is nonregulated under RCRA is not easily visible and may cause confusion. A best management practice would be to clearly indicate with visible lettering on uranium metal waste drums that the waste is not regulated by RCRA. The following programmatic elements of 40 CFR 265 regarding mixed waste storage at TA-54 were deficient: 1. The facility's waste analysis plan is in draft form only and has not been fully implemented (WM-308). 2. Although emergency equipment located in mixed waste storage areas is inspected daily and an inspection log is kept, there is no written inspection schedule (I-WM-356). 3. Although mixed waste handler training is conducted for all employees working in the TA-54 storage areas, training documentation does not indicate the date of employment for employees, thereby making it impossible to determine if all required training has been completed within 6 months after date of hire (WM-325) (see Finding WM/CF-2). 4. Arrangements with local authorities, including familiarizing local hospitals, police, fire departments, and emergency response teams, on the properties of mixed wastes handled at the facility and associated hazards, possible evacuation routes, and places where personnel may be working have not been made (I-WM-356) (see Finding WM/CF-7). 5. Approximately 20 percent of mixed waste stored at TA-54, Areas L and G, most of which are not completely characterized in accordance with DOE 5820.2A, was generated in controlled areas prior to 1989. In previous years, wastes generated in controlled areas which was considered to contain suspect radiological 3-126 contamination, was stored without being fully characterized (I-WM-356) (see Finding WM/CF-15). According to LANL's Part A Permit Application for mixed waste storage (WM-334), the site generates and stores wastes which are subject to the land disposal restrictions (LDR) including wastewater treatment sludge from TA-50, paint stripper waste from TA-55 and miscellaneous oils contaminated with F-listed solvents. LANL has exceeded the 1-year limitation for storage of these wastes; however, treatment standards have not been established for LDR mixed wastes. Exceedance of storage limitations is a DOE complex-wide problem. This finding was fully identified in the LANL Self-Assessment. 3-127 FINDING WM/CF-18: Transuranic Waste Performance Objective DOE 5820.2A, "Radioactive Waste Management," Chapter II, Section 2, requires that transuranic (TRU) waste be certified in compliance with the Waste Isolation Pilot Plant (WIPP) Waste Acceptance Criteria (WAC), placed in interim storage (if required), and sent to WIPP when it becomes operational. Section 3.b.(2) requires that TRU waste be assayed or otherwise evaluated to determine the kinds and quantities of TRU radionuclides present prior to storage. DOE 5820.2A, Chapter II, Section 3.g.(2), also requires that new storage facilities be sited, constructed, and operated to satisfactorily address such matters as minimizing the amount of precipitation runon and runoff. DOE 5820.2A, Chapter II, Section 3.e.(5), requires that temporary TRU waste storage facilities be operated to minimize the possibility of fire, explosion, or accidental release of radiation and/or hazardous components of waste to the environment. DOE 5400.1, Section 5.a., states that it is DOE policy to conduct its operations in an environmentally safe and sound manner. Protection of the environment and the public are responsibilities of paramount importance and concern to the DOE. DOE 5400.5, "Radiation Protection of the Public and the Environment," Section 6.b., states the it is DOE's objective to protect the environment from radioactive contamination to the extent practicable. Finding LANL TRU waste certification activities, TRU waste temporary storage practices, and the Area G closure plan do not comply with the DOE requirements. Discussion Approximately 25,000 containers of uncertified TRU waste and 1,500 containers of previously certified TRU waste are being stored at Area G. The current generation rate of TRU waste is about 7,000 cubic feet a year (approximately 900 drums per year plus a lesser number of other containers). The following certification and storage deficiencies were identified by the Environmental Subteam: 1. LANL does not have the ability to assay or otherwise evaluate (verify) TRU waste as required by DOE 5820.2A. The facility designed and built for this purpose, the Non-Destructive Analysis/Non-Destructive Evaluation Facility (NDA/NDE), has not been placed in operation. The NDA/NDE Environmental and Safety Assessments have been completed by the Waste Management Group (EM-7) and are in the LANL review process. This facility is needed to provide one of the functions in the TRU waste certification process required by DOE 5820.2A and the WIPP WAC. 3-128 2. Interim TRU waste storage practices at two locations in Area G do not meet the interim storage requirements of DOE 5820.2A, DOE 5400.1, and DOE 5400.5 concerning minimizing precipitation runon and runoff. TRU waste in fiberglass-coated plywood at one location and TRU waste cans at another location are stored on the ground in the open without a berm. 3. There is no closure plan for Area G TRU waste storage areas. This finding was partially identified in the LANL Self-Assessment. 3-129 3.5.4.3 Best Management Practice Finding FINDING WM/BMPF-1: Signature Authority for RCRA Permit Applications Performance Objective New Mexico Hazardous Waste Management Regulations (NMHWMR), Part IX, Section 901, and 40 CFR 270.11(a), "Resource Conservation and Recovery Act" (RCRA), address signature authority for permit applications. This requirement states that permit applications shall be signed "by either a principal executive officer or ranking elected official." DOE 5480.19, "Conduct of Operations Requirements for DOE Facilities," requires that a high level of performance in DOE operations be accomplished by establishment of high operating standards by management, and requires administrative procedures defining authority and responsibilities. Finding Authority for delegating signatory responsibility for RCRA permits lacks appropriate formality. Discussion RCRA permits are among the prime regulatory documents governing hazardous waste management at any facility. It is incumbent upon a facility applying for a permit to recognize this primacy, and to empower only senior executives to sign permit applications. A letter dated November 1, 1984, signed by the LANL Director and sent to EPA Region VI, designated the Director of Technical Support or his designee as having signatory authorization for "all reports, applications, and revisions submitted under the RCRA program." The Director of Technical Support is considered by LANL to be a senior executive. However, there is no assurance that the designee signing in place of the Director would also be a senior executive. This finding was not identified in the LANL Self-Assessment. 3-130 3.5.5 Toxic and Chemical Materials 3.5.5.1 Overview The toxic and chemical materials portion of the Environmental Subteam assessment evaluated the status of ;the LANL with regard to applicable regulations promulgated under the Toxic Substances Control Act (TSCA), the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), the New Mexico Pesticide Control Act, the National Emissions Standards for Hazardous Air Pollutants (NESHAP) regulation for asbestos, the Emergency Planning and Community Right-to-Know Act of 1986 (EPCRA), also known as SARA Title III, and the Occupational Safety and Health Act (OSHA). Comparable regulations from the State of New Mexico, applicable DOE Orders and guidance, LANL and contractor directives and procedures, and best management practices (BMPs) were also used in the assessment. These regulations, procedures, and practices establish the requirements for the acquisition, handling, storage, and disposal of toxic and chemical materials. Table 3-6 lists the regulations, requirements, and guidelines used in this assessment. The toxic and chemical materials assessment focused on the management and control of polychlorinated biphenyls (PCBs), pesticides, carcinogens, laboratory and bulk chemicals, and compressed gases. Asbestos management was evaluated with reference to DOE Orders and compliance with the NESHAP regulations. The basic components of the toxic and chemical materials assessment were as follows: 1. Interviews of personnel at LANL facilities regarding the management of toxic and chemical materials. The persons interviewed represented the following LANL organizations: the Environmental Management Division (EM), Health and Safety Division (HS), Safety and Risk Assessment Group (HS-3), Emergency Management Office (EMO), Materials Management Division (MAT), Johnson Controls World Services, Inc. (JCI), VWR Scientific (VWR), as well as the operating groups at each of the technical areas that were visited. 2. Interviews with personnel from the U.S. Department of the Interior, Bureau of Indian Affairs; the State of New Mexico, Department of Public Safety; and the Los Alamos County Fire Department regarding LANL compliance with applicable regulations. 3. Inspections of facilities at LANL where toxic and chemical materials were used, stored, or disposed. The areas visited included TA-3, TA-9, TA-15, TA-16, TA-18, TA-21, TA-35, TA-43, TA-46, TA-53, TA-54, TA-59, and TA-60. 4. Review of documents, such as policies and procedures, required reports, contracts, memoranda, and regulatory documentation. Overall, LANL lacks a well-defined program and procedures to manage its PCB activities. PCB responsibilities shared between the Environmental Protection Group (EM-8), Waste Management Group (EM-7), Industrial Hygiene Group (HS-5), Environmental Chemistry Group (EM-9), Design Group (ENG-3), Field Operations Group (ENG-5), Fire Protection and Utilities Group (ENG-8), and JCI results in 3-131 1 ll TABLE 3-6 LIST OF TOXIC AND CHEMICAL MATERIALS REGULATIONS/REQUIREMENTS/GUIDELINES i 1 II s«ctiiwi$/riti«$ Atttfeorlty SuideliRes 40 CFR 165 Regulations for the Acceptance of Certain Pesticides and Recommended Procedures for the Disposal and Storage of Pesticides and Pesticide Containers EPA 40 CFR 171 Certification of Pesticide Applicators 40 CFR 761 Polychlorinated Biphenyls (PCBs) Manufacturing, Processing, Distribution in Commerce, and Use Prohibitions EPA EPA 40 CFR 355 Emergency Planning and Notification 40 CFR 370 Hazardous Chemical Reporting: Community Right-to-Know Act 40 CFR 372 Toxic Chemical Release Reporting 40 CFR 61, Subpart M National Emission Standard for Asbestos 29 CFR 1910, Subpart H Occupational Safety and Health Standards of Hazardous Materials NMSA 74-4E Hazardous Chemicals Information Act New Mexico Pesticide Control Act Chapter 76, Article 4, Section 5, Storage State of New Mexico SWMR-2, Section 402 New Mexico Solid Waste Management Regulations State of New Mexico AQCR 751 New Mexico Air Quality Control Regulations State of New Mexico DOE 5400.1 General Environmental Protection Program DOE 1 DOE 5480.IB Environment, Safety and Health Program for DOE Operations DOE II 1 1 3-132 EPA EPA EPA EPA OSHA State of New Mexico TABLE 3-6 (Continued) LIST OF TOXIC AND CHEMICAL MATERIALS REGULATIONS/REQUIREMENTS/GUIDELINES Regtflatidds/ S^ctims/inies Authority DOE 5480.4 Environmental Protection, Safety, and Health Protection Standards DOE DOE 5480.19 Conduct of Operations Requirements for DOE Facilities DOE LANL AR 1-9 Hazard Communication LANL LANL AR 6-1 Chemicals LANL LANL AR 6-3 Use of Chemical Carcinogens LANL LANL AR 6-5 Flammable and Combustible Liquids LANL LANL AR 6-9 Safe Handling of Hazardous Gases LANL LANL AR 9-1 Air Pollution Control LANL LANL AR 9-4 Accidental Oil, Chemical and Airborne Releases LANL LANL AR 10-4 Polychlorinated Biphenyls LANL LA-UR-91-2830 Guide to ES&H Management Structure (GEMS) LANL 1 N/A Safe Handling of Compressed Gases P-1, 1965 and 1984 3-133 Compressed Gas Association a lack of cohesive ownership and well-defined roles and responsibilities. LANL has no formal programs or procedures to identify all of its PCB and PCB-oil-filled equipment, to clean up PCB spills in accordance with the EPA PCB Spill Cleanup Policy, to perform inspections of transformers retrofilled and reclassified with perchloroethlyene, and prevent combustibles from being stored near PCB transformers. A Pest Control Policy for Vegetation, Insect, Rodent and Small Animal Control, including procedures, was developed by LANL's Pest Control Oversight Committee (PCOC) in 1984, but does not accurately reflect current pesticide operations. A new draft policy was prepared in 1991 and was still under review at the time of the assessment. Responsibility for implementation of the policy and review of procedures was divided between the Vegetation and Insect Control Program Administrators. These two positions were combined into one position in 1990, the Pest Control Program Administrator. The pesticide activities at LANL are conducted by JCI with limited oversight from LANL. Licensed JCI personnel are responsible for the application of pesticides at LANL facilities, and pesticides and application equipment are stored at the site. All pesticide applications at LANL are performed by properly licensed applicators and are fully documented. However, LANL's pesticide program lacks formal policy and procedure reviews, lacks oversight by PCOC or JCI, and has failed to identify a critically designated habitat of an endangered species. Chemical procurements are initiated by VWR or, for a limited and decreasing number of products, by the LANL Material Acquisition Division. LANL and VWR are responsible for receipt and delivery of their respective chemical procurements. LANL does not have a sitewide comprehensive program for the management of toxic and chemical materials. There is no comprehensive tracking system or inventory for chemicals onsite, the inventories that exist are incomplete, and there are no routine inspections of the storage of chemicals and gases sitewide. Toxic and chemical materials are not always properly stored or inspected. LANL is in the process of creating an acquisition-through-disposal tracking network for toxic and chemical materials called ACIS (automated chemical inventory system). It will be based on purchasing and disposal records, and will be verified by conducting annual inspections in the field. Sitewide procedures to control the use of potentially reactive chemicals and carcinogens and to determine when to dispose of unused chemicals in storage are inadequate. Potentially reactive chemicals are inadequately managed at LANL. There is no sitewide program to identify and dispose of such materials. The inventory of carcinogens is incomplete. Requirements to conduct hazard evaluations of jobs involving carcinogens and to provide training to employees using carcinogens are not being fulfilled. At the time of this assessment, LANL was in the process of disposing of large quantities of chemicals that had been in storage, sometimes unused, for several years. LANL has conducted special waste collection days to encourage disposal of unwanted or excess chemicals. Because of the age of the facility, asbestos is pervasive throughout LANL. Asbestos pipe insulation is routinely removed and disposed of by site personnel as part of maintenance, repair, and replacement activities. 3-134 Asbestos repair and removal work is restricted to trained JCI personnel. LANL is responsible for area monitoring of abatement projects and for ensuring that notifications, removal, and disposal practices comply with NESHAP. There is no accurate, comprehensive survey of asbestos at LANL, nor a sitewide asbestos maintenance and abatement plan. Compared to asbestos in occupied spaces, controlling outdoor asbestos has received a relatively low priority, resulting in releases of asbestos to the environment. Asbestos that is radioactively contaminated is disposed of onsite; otherwise, it is temporarily stored onsite in dumpsters and shipped to a licensed disposal facility in California. SARA Title III establishes the following four major requirements for LANL: (1) emergency planning notification, (2) emergency release notification, (3) reporting on hazardous chemicals present at the facility or community-right-to know, and (4) toxic chemical release reporting. LANL was a participant in the local emergency planning committee at its inception, but the committee has not been active since 1990. The emergency release notification program at LANL is coordinated by LANL personnel in the Environmental Management Division (EM). Personnel in this group are responsible for reporting releases to the National Response Center, in cooperation with the Emergency Management Office (EMO). Hazardous chemical or community right-to-know reporting at LANL is performed by the Health and Safety Division (HS). LANL submits material safety data sheets (MSDSs) or lists of MSDS chemicals and Tier II hazardous chemical inventory forms to LAAO for transmittal. Assuring accurate reporting is not possible because of the inadequate sitewide chemical inventory. LANL is exempt from the requirements of Section 313 because it is a laboratory. Nevertheless, it has voluntarily decided to submit annual reports on Section 313 toxic chemical releases from TA-55 to the state and the EPA because of the magnitude of TA-55's chemical inventory. Overall, LANL lacks well-defined programs and procedures to manage its toxic and chemical materials activities. The responsibilities for these activities are shared among several divisions, sections within divisions, and JCI. While some organizations have implemented strong programs and procedures, most have not. Even where implementation has taken place, the means to coordinate across organizations in a timely and productive manner have not been put in place. In addition, the organizations do not appear to set clear goals and objectives towards which their members can work and measure their progress. Management has not taken steps to ensure that personnel have received the training necessary to carry out their responsibilities. This, coupled with a lack of managerial oversight, results in an inability to assure that toxic and chemical materials programs are conducted in accordance with applicable regulations, DOE Orders, and LANL policies; and an inability to identify the need for possible midcourse corrections. The toxic and chemical materials assessment identified 14 compliance findings and 1 best management practice finding. The compliance findings address the management of toxic and chemical materials, asbestos, pesticides, and PCBs; the handling and storage of toxic and chemical materials, compressed gases, pesticides, PCB spill cleanup; disposal of PCBs and pesticides; and community-right-to-know reporting. The best management practice finding addresses inspection of transformers retrofilled and reclassified with perchloroethylene. 3-135 Of the 15 toxic and chemical materials findings, 1 was fully identified, 10 were partially identified, and 4 were not identified in the LANL Self-Assessment. 3-136 3.5.5.2 Compliance Findings FINDING TCM/CF-1: Registration of Polychlorinated Biphenyl (PCB) Transformers Performance Objective 40 CFR 761.30(a)(l)(vi), "Authorizations," states, "As of December 1, 1985, all PCB Transformers must be registered with fire response personnel with primary jurisdiction...Information required to be provided to fire response personnel includes... (A) The location of the PCB Transformers... (B) The principal constituent of the dielectric fluid in the transformer(s). (C) The name and telephone number of the person to contact in the event of a fire involving the equipment." Finding LANL's management of PCB transformers Is not adequate to ensure that notifications to public safety agencies contain all pertinent information and are made In a timely manner. Discussion LANL has replaced or retrofilled over 65 PCB transformers to non-PCB status since 1989 (TCM-97). LANL provided an updated version of its 1985 registration of PCB transformers with fire response personnel on September 23, 1991 (TCM-96). However, LANL's 1991 PCB transformer registration is incomplete in that it does not include the name and telephone number of a person to contact in case of fire, nor the principal constituent of the dielectric fluid. Although there is no requirement to update PCB transformer registration periodically, the failure to provide fire response personnel with updated and complete PCB transformer registration puts them at risk when responding to a fire because they may be unaware of the PCB status of a transformer. This finding was not identified in the LANL Self-Assessment. 3-137 FINDING TCM/CF-2: Development and Maintenance of Polychlorinated Biphenyl (PCB) Inventory and Records Performance Objective 40 CFR 761.180 (a)(2)(iv)(v)(vi), "Records and Monitoring," requires that the "owner or operator of a facility...develop and maintain at the facility...the written annual document log: which shall include "the total number of PCB Transformers and total weight in kilograms of PCBs contained in the transformers...the total number of Large High and Low Voltage PCB Capacitors...the total weight in kilograms of any PCBs and PCB Items in PCB Containers, including the identification of container contents, remaining in service at the end of the calendar year." 40 CFR 761.180(a)(2) states: "The written annual document log shall include the following: ...(viii) A record of each telephone call...made to each designated commercial storer or designated disposer to confirm receipt of PCB waste transported by an independent transporter..." LANL Administrative Requirements (AR) 10-4, "Polychlorinated Biphenyls," requires that line managers and support services contractors identify all articles, oils, and debris under their control and must provide this information to the Waste Management Group (EM-7) or Environmental Protection Group (EM-8). EM-7 maintains records associated with the storage and disposal of PCB items. EM-8 maintains an inventory of in-service PCB items. Finding LANL's management of PCBs is not adequate to identify, maintain, quantify, and prepare Its PCB Inventory and written annual document log to meet the requirements of 40 CFR 761.180 and AR 10-4. Discussion PCB responsibilities of LANL's EM-8 Water Quality and Toxics Section include maintaining PCB inventories, providing support for LANL's regulatory compliance with 40 CFR 761, sampling oil-filled equipment for PCB analyses, preparing regulatory reports and notifications to EPA, and preparing the written annual document log (TCM-27). The EM-8 Water Quality and Toxics Section has not conducted a comprehensive survey of PCBs and PCB equipment (I-TCM-2) since 1987. Therefore, the written annual document logs, which are prepared from the PCB inventories (I-TCM-3 and I-TCM-4), and that are required by 40 CFR 761 may be inaccurate. A computerized inventory of PCBs and PCB equipment (i.e., capacitors and miscellaneous equipment) is maintained by the EM-8 Water Quality and Toxics Section. The inventory is periodically updated when the EM-8 Water Quality and Toxics Section is notified by owners of oil-filled equipment that the equipment has been sampled, analyzed, and confirmed as containing PCBs, and/or is notified by EM-7 when PCB transformers or capacitors are replaced or taken out of service. Clear guidance and implementation of AR 10-4 has not been provided by the EM-8 Water Quality and Toxics Section to owners of oil-filled equipment to aid them in efforts to identify their PCB items and the need to notify the EM-8 Water Quality and Toxics Section when PCB items are identified. 3-138 PCB identification of oil-filled equipment is done by sampling and analysis. LANL has not developed a sampling procedure specific to LANL operations (I-TCM-3). When the EM-8 Water Quality and Toxics Section cannot take the samples, it delegates sample collection to owners of oil-filled equipment. The EM-8 Water Quality and Toxics Section staff provide on-the-job training (I-TCM-2), but have no written procedures. No periodic followup sampling is done for quality assurance in sampling methodology. The lack of written sampling procedures and quality assurance can lead to non-uniform sampling with the potential of misclassification and inadequate inventory control. Electrical equipment (primarily capacitors, some switches, and power suppliers) (I-TCM-88) loaned to universities over the years represents another source of undocumented PCB items. Although a strategy to retrieve the loaned items has been initiated (TCM-99), EM-8 does not have formal documentation or authorization in place to implement the strategy, nor a defined program with scheduled milestones and completion dates (TCM-208 and TCM-209) to retrieve the loaned equipment. The lack of a well-defined PCB identification program has resulted in an incomplete and inaccurate inventory. The information used from the inventory to prepare the written annual document logs has resulted in potential inaccuracies in the EPA-required documents. Examples of deficiencies in the inventory noted by the Environmental Subteam are as follows: 1. Fifteen PCB transformers at various locations at TA-3 (Bldgs. 40, 66, 200, and 207), which were listed on the July 1, 1991, PCB Transformer Inventory, were replaced with non-PCB transformers. However, the information was not forwarded to the EM-8 Water Quality and Toxics Section when the PCB transformers were replaced so that they could be removed from the inventory (I-TCM-18). 2. Two leaking PCB-contaminated transformers at TA-3, outside Bldg. 105, were not listed on the July 1991, PCB Transformer Inventory (I-TCM-18). 3. Two PCB transformers at TA-3, Bldgs. 146 and 215, listed on an updated September 30, 1991, PCB Transformer Inventory (I-TCM-84). The EM-8 Water Quality ;and Toxics Section had not received disposal information from EM-7 that these transformers had been replaced. The EM-8 Water Quality and Toxics Section does not have procedures to coordinate information with EM-7 when PCB transformers are replaced. 4. Nine PCB-contaminated power supplies at TA-15, room 103A, were not listed on the inventory. Interviews with EM-8 Water Quality and Toxics Section personnel (I-TCM-92) and the owners (I-TCM-90 and I-TCM-91), Hydrodynamics Group (M-4), determined that the power supplies had been sampled and analyzed confirming that the equipment contained PCBs. However, conflicting guidance by Water Quality and Toxics Section personnel was provided to the owners which resulted in a failure to inventory the power supplies. Owners were told (I-TCM-90 and I-TCM-94) by EM-8 Water Quality and Toxics Section personnel that the PCB-contaminated power supplies did not have to be included on the EM-8 Water Quality and Toxic Section inventories because 40 CFR 761 does not require 3-139 PCB-contaminated equipment (i.e., 50-500 ppm PCBs) to be inventoried. Although EPA's PCB regulations do not require PCB-contaminated equipment inventories, the EM-8 Water Quality and Toxics Section maintains inventories of all in-service PCB items and AR 10-4 requires owners to identify all PCB articles, oils, and debris under their control and provide the information to EM-7 and the EM-8 Water Quality and Toxics Section. 5. The Environmental Regulatory Compliance Status Briefing (TCM-97), presented to the Tiger Team on September 24, 1991, reported that 400 PCB capacitors were currently in service at the Laboratory. The September 24, 1991, In-Service Capacitor Inventory, however, listed only 189 PCB capacitors in service (TCM-24). When asked about the discrepancy, EM-8 Water Quality and Toxics Section personnel said (I-TCM-2) that the number of capacitors reported in the Tiger Team briefing was a greater number than that reported on the inventory in order to estimate those unidentified capacitors that still might be in use. 6. The 1990 written annual document log (TCM-5) indicated eight disposal facilities were used during 1990. The log is incomplete in that telephone calls to six of eight designated disposers verifying receipt of PCB waste are not included. The EM-8 Water Quality and Toxics Section prepares the written annual document for storage and disposal activities of the calendar year. EM-7 generates the information required for the written annual document. The EM-8 Water Quality and Toxics Section has no procedure to ensure that EM-7 keeps the required information and transmits it to the EM-8 Water Quality and Toxics Section in a timely manner for incorporation into the written annual document. This finding was partially identified in the LANL Self-Assessment. 3-140 FINDING TCM/CF-3: Storage of Combustible Materials Near Polychlorinated Biphenyl (PCB) Transformers Performance Objective 40 CFR 761.30(a)(1)(viii) of the Toxic Substances Control Act (TSCA) states that combustible materials must not be stored within 5 meters of an unenclosed PCB transformer. LANL Administrative Requirements (AR) 10-4, "Polychlorinated Biphenyls," states, "Combustible materials...must not be stored within a PCB transformer enclosure or within 17 feet of a PCB transformer." DOE 5480.19, "Conduct of Operations," Chapter I, states that "effective implementation and control of operating activities are primarily achieved by establishing written standards, periodically monitoring and assessing performance, and holding personnel accountable. The standard should define operating objectives, establish expected performance levels, and clearly define responsibilities. Procedures or other definitive documentation should specify policies that are to be applied and should also provide for the types of controls necessary to implement policies." Finding Combustible materials are being stored within 5 meters of unenclosed PCB transformers, therefore not meeting TSCA and LANL requirements. Discussion Transformers are inspected on a monthly basis by Johnson Controls World Sciences, Inc. (JCI). The inspection form includes a notation of any combustibles found within 5 meters of PCB transformers. The Environmental Protection Group (EM-8) and ENG-8 have oversight responsibility for JCI PCB activities (TCM-27), including transformer inspections. The LANL Revised Implementation Plan in Response to the DOE Environmental Survey Team (January 12, 1990) noted that a policy memorandum was sent to all user groups to inform them of the rule against storing flammable materials near PCB transformers. The management system is not providing oversight or adequate support of the policy memorandum, and no procedures are in place to provide oversight of inspections and eliminate the recurring practices of storing combustibles near transformers as evidenced by the following: 1. Dried, 4-foot-high weeds and grass were left lying on the concrete pad of two PCB transformers at TA-35, south side of Bldg. 27 (I-TCM-18). These were removed during the assessment. 2. Wood ties (4" x 4"), acting as a platform to support a rigging apparatus, were stored at a PCB transformer at TA-35, south side of Bldg. 29 (I-TCM-18). Additional poor housekeeping practices at the same location include several hundred feet of electrical wiring. 3-141 electrical conduit, and three breaker boxes stored on the transformer pad within 1 foot of the substation. In the event of a spill, these items could become PCB contaminated necessitating additional cleanup and disposal (I-TCM-18). 3. Papers, rags, styrofoam pieces, and garbage debris were left lying within 5 meters of two transformers located at TA-3, west of SM-105. Both of these transformers were discovered to be leaking (I-TCM-18). 4. A 20-foot-high pine tree was growing within 3 meters of a transformer located at TA-3, Ion Beam Facility, northwest corner of SM-16 (I-TCM-84 and I-TCM-85). 5. Wood ties (4" x 4") used to support beams were located within 5 meters of a transformer at TA-3, Ion Beam Facility, northwest corner of SM-16 (I-TCM-84 and I-TCM-85). 6. Three wooden ladders were observed stored on the concrete pad of the transformer located at TA-3, east of SM-141 (I-TCM-84). This was corrected during the assessment. This finding was not identified in the LANL Self-Assessment. 3-142 FINDING TCM/CF-4: Storage of Radiologically Contaminated Polychlorinated Biphenyl (PCB) Wastes Performance Objective 40 CFR 761.65(a) requires that "any PCB Article or PCB container stored for disposal before January 1, 1983, shall be removed from storage and disposed of as required by this Part before January 1, 1984. Any PCB Article or PCB container stored for disposal after January 1, 1983, shall be removed from storage and disposed of as required by Subpart D of this Part within one year from the date when it was first placed into storage." Finding Radiologically contaminated PCB wastes stored at LANL were not disposed of within 1 year from the date they were placed into storage, as required by 40 CFR 761.65(a). Discussion The storage of radiologically contaminated PCB waste is a problem throughout the DOE complex because there are no commercial disposal facilities nationwide that are permitted to incinerate liquid radiologically contaminated PCB waste. Although LANL has a Toxic Substances Control Act (TSCA) permitted incinerator, it is currently going through the National Environmental Policy Act (NEPA) process and, therefore, is not operational. Once the NEPA process is completed, LANL plans to dispose of its radiologically contaminated PCB waste in its own TSCA-permitted, controlled air incinerator. LANL has been storing eleven 55-gallon drums of liquid radiologically contaminated PCB waste since October 1989, and one drum since January 1990 at the TA-54, Area L (I-TCM-93). These drums exceed the 1-year storage limit. Although LANL has not been meeting the storage requirements of radiologically contaminated PCB waste, no actions have been taken to resolve this issue. Interviews with the Waste Management Group (EM-7) (I-TCM-12) indicate that LANL has not notified EPA Region VI of the existence of the material or requested an exemption to the storage limit. Also, on June 10, 1991, EPA issued an Advance Notice of Proposed Rulemaking (ANPR) that it is planning to amend certain TSCA PCB regulations, including requirements under 40 CFR 761.65. In the ANPR, EPA recognized there is insufficient capacity available at EPA-permitted PCB treatment and disposal facilities to handle disposal of radiologically contaminated PCB wastes in storage throughout the country. Through the ANPR, EPA requested comments and recommendations regarding the use of case-by-case extensions to the 1-year storage limitation for radiologically contaminated PCB wastes. A memorandum (TCM-17) from the DOE Office of Environmental Guidance to Regional and Area Offices on June 14, 1991, requested comments on EPA's Proposed Rulemaking on TSCA's PCB disposal regulations, including case-by-case extensions of the 1-year storage limit for radioactive mixed wastes. The memorandum was also submitted to the LANL Environmental Management Division 3-143 (EM) for comments (I-TCM-85). AL, LAAO, and EM did not respond or submit comments to the DOE-wide effort to work with EPA to address this issue (I-TCM-80, I-TCM-82, I-TCM-83, and I-TCM-85). This finding was not identified in the LANL Self-Assessment. 3-144 FINDING TCN/CF-5: Management of Polychlorinated Biphenyl (PCB) Spill Cleanups Performance Objective 40 CFR 761.120, Subpart G, "PCB Spill Cleanup Policy," establishes the EPA's PCB spill cleanup policy and criteria that are used to determine adequacy of cleanup of spills occurring after May 4, 1984, and resulting from the release of materials containing 50 ppm or greater PCBs. 40 CFR 761.125(a)(l)(iii), "Requirements for PCB Spill Cleanup, General," states that where a spill exceeds 10 pounds PCBs by weight, the responsible party will notify the appropriate EPA regional office (Pesticides and Toxic Substances Branch). 40 CFR 761.125(b)(l)(i)(ii)(iii), "Requirements for Cleanup of Low Volume Concentration Spills," which involve less than 1 pound PCBs by weight, states the requirements for cleanup of low concentration (i.e., less than 500 ppm PCB) and low volume (less than 1 pound) PCB spills. 40 CFR 761.125(b)(3), "Records and Certification," states that low concentration, low volume spills shall be documented with records and certification of decontamination. Content of documentation is specified. 40 CFR 761.125(c)(1)(2)(3)(4), "Requirements for Cleanup of High Concentration Spills and Low Concentration Spills Involving 1 Pound or More PCBs by Weight," specify the cleanup requirements for high concentration PCB spills (i.e., greater than 500 ppm PCB) and low concentration spills involving 1 pound or more PCBs. 40 CFR 761.125(c)(5) specifies the recordkeeping requirements for high concentration PCB spills at 1 pound or more. LANL Administrative Requirements (AR) 10-4, "Polychlorinated Biphenyls," states that "leaks must be reported immediately to HSE-8. The support services contractor will promptly clean up leaks and spills using appropriate protective equipment, cleanup materials, and cleanup and disposal procedures." DOE 5480.19, Chapter VII, "Notifications," states, "Timely notifications of appropriate DOE personnel and other agencies, when required, should be employed to ensure the facility is responsive to public health and safety concerns." "For events" (i.e., PCB reportable quantity spills) "that require notification of DOE personnel and...state and local offices), it is essential that information be gathered and transferred in a systematic, controlled method." Finding LANL lacks a formal PCB spill cleanup program and written procedures to ensure cleanup of PCB spills in accordance with EPA, DOE, and LANL requirements. 3-145 Discussion A review of LANL's PCB spills occurring from December 1989 through September 1991 indicates that efforts to manage PCB spills have been fragmented and incomplete. Formal procedures are not in place, and therefore, documentation of cleanup activities is incomplete; pre-sampling is not done when necessary to establish spill boundaries or PCB concentration; post-sampling is not done to verify that decontamination levels required by EPA are achieved; areas of visible contamination are not established, recorded, and documented; spills occurring in 1989 were not documented as to any cleanup practices; and the issue of notification to EPA of spills occurring indoors and/or of undetermined quantity was not addressed. Deficiencies occurring over the past 3 years are indicative of a lack of a formal PCB spill cleanup program. Examples of these are as follows: 1. A transformer at TA-3, SM-16, was reported on the January 1989 PCB Monthly Inspection Report (TCM-45) as "visibly leaking for the month with no containment (e.g., plastic baggie) of the liquid." EPA defines PCB spills as "intentional and unintentional leaks...where the release results in any quantity of PCBs running off or about to run off the external surface of equipment..." LANL has no documentation of cleanup action for this spill. The monthly inspection report indicates the transformer continued leaking for 1 month before any action was taken. 2. High-concentration PCB spills (i.e., greater than 500 ppm PCB) that occurred at TA-3-SM-43 on December 15, 1989; TA-16 on May 17, 1990; and TA-53-SM-72 on July 8, 1990, were documented as "non-reportable" (TCM-47, TCM-48, and TCM-49). The spills occurred inside buildings. No notifications to EPA were made. LANL does not have any policy or procedure on how to report spills of unknown quantities. Also, LANL takes the position (TCM-62; I-TCM-18) that spills inside a building, regardless of amount, do not require reporting to EPA. EPA PCB spill reporting requirements do not distinguish between indoor and outdoor spills. LANL acknowledged during the assessment (TCM-62) that EPA Region VI recommends reporting all PCB spills of 1 pound or more. 3. Cleanup was not initiated within 24 hours when a capacitor containing greater than 500 ppm PCBs ruptured on December 15, 1989, at TA-3, SM-43 (TCM-47). 4. No post-sampling was performed after cleanup of a PCB transformer spill on January 10, 1990, at TA-53, Section E, salvage staging area (TCM-50). Although the asphalt contaminated from the spill was removed, post-cleanup sampling data to document whether soil below the asphalt had been contaminated was not conducted. 5. On June 15, 1990, a PCB transformer at TA-53, Sector M, that was undergoing retrofill with perchloroethylene was identified as leaking (TCM-54). The transformer was put on daily inspection conducted by Johnson Controls World Services, Inc. (JCI). On June 22, 1990, Environmental Protection Group (EM-8) personnel inspecting the transformer noticed that it had released a large 3-146 spill of PCB/perchloroethylene fluid through the mezzanine grating and onto the asphalt parking lot below (TCM-51 and TCM-54). During the 7-day inspection period, no identification of the magnitude of the spill and when it was actually released to the parking lot had been made. EM-8 has oversight responsibilities of JCI's PCB activities (TCM-27). AR 10-4, "Polychlorinated Biphenyls," requires that leaks be reported immediately to EM-8 and that the support services contractor promptly clean up leaks and spills. Yet, EM-8 has no procedure in place to ensure such spills described above are reported and cleaned up immediately. Actual cleanup of this spill was further complicated because the solvent used (1,1,1-trichloroethane) had the effect of driving the PCBs further into the asphalt and causing the asphalt to break up (TCM-54). Cleanup was delayed 1 month. The contaminated asphalt was dug up, but no post-sampling of the area was conducted to determine whether the soil underneath was contaminated. EPA was not notified of the release of potential reportable quantity spill. The PCB spill report (TCM-51) is incomplete, unsigned, not certified, and does not include pre-sampling data, a description of the solid surfaces cleaned, or post-sampling data to verify cleanup results. 6. On February 21, 1991, 10 gallons of PCB/perchloroethylene fluid spilled from a PCB transformer undergoing retrofill at TA-53, Sector M (TCM-55). Cleanup was performed by ENSR, the company performing the retrofill operations. No pre-sampling was done to establish spill boundaries and PCB concentration. EPA was not notified of a spill of a potentially reportable quantity. The spill report does not indicate when cleanup was initiated and completed. The spill response report is not signed or certified that cleanup was performed according to EPA requirements. 7. Approximately 1 quart PCB pyranol (oil) (>500 ppm PCBs) was spilled from a PCB transformer at TA-3-66 (TCM-57) on September 3, 1991. Although post-sampling was conducted after initial cleanup, analytical results to verify decontamination levels to 10/