20 June 2011

Failed Safety Culture at Nuclear Waste Site

	    
[Federal Register Volume 76, Number 118 (Monday, June 20, 2011)]
[Notices]
[Pages 35861-35864]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-15146]


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DEFENSE NUCLEAR FACILITIES SAFETY BOARD

[Recommendation 2011-1]


Safety Culture at the Waste Treatment and Immobilization Plant

AGENCY: Defense Nuclear Facilities Safety Board.

ACTION: Notice, recommendation.

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SUMMARY: Pursuant to 42 U.S.C. 2286a(a)(5), the Defense Nuclear 
Facilities Safety Board has made a recommendation to the Secretary of 
Energy concerning the safety culture at the Waste Treatment and 
Immobilization Plant located at the Hanford site in the state of 
Washington.

DATES: Comments, data, views, or arguments concerning the 
recommendation are due on or before July 20, 2011.

ADDRESSES: Send comments, data, views, or arguments concerning this 
recommendation to: Defense Nuclear Facilities Safety Board, 625 Indiana 
Avenue, NW., Suite 700, Washington, DC 20004-2901.

FOR FURTHER INFORMATION CONTACT: Brian Grosner or Andrew L. Thibadeau 
at the address above or telephone number (202) 694-7000.

    Dated: June 14, 2011.
Peter S. Winokur,
Chairman.

RECOMMENDATION 2011-1 TO THE SECRETARY OF ENERGY

Safety Culture at the Waste Treatment and Immobilization Plant

Pursuant to 42 U.S.C. Sec.  2286a(a)(5)
Atomic Energy Act of 1954, As Amended
Dated: June 09, 2011

Introduction

    Secretary of Energy Notice SEN-35-91, Nuclear Safety Policy, issued 
on September 9, 1991, and superseding policy statement 2 of 
DOE Policy 420.1, Department of Energy Nuclear Safety Policy, issued on 
February 8, 2011, state that the Department of Energy (DOE) is 
committed to establishing and maintaining a strong safety culture at 
its nuclear facilities. The Defense Nuclear Facilities Safety Board 
(Board) has determined that the prevailing safety culture at the Waste 
Treatment and Immobilization Plant (WTP) is flawed and effectively 
defeats this Secretarial mandate. The Board's investigative record 
demonstrates that both DOE and contractor project management behaviors 
reinforce a subculture at WTP that deters the timely reporting, 
acknowledgement, and ultimate resolution of technical safety concerns.

Background

    In a letter to the Secretary of Energy dated July 27, 2010, the 
Board stated that it would investigate the health and safety concerns 
at the WTP at Hanford raised in a letter to the Board dated July 16, 
2010, from Dr. Walter Tamosaitis.
    The Board's investigation focused on allegations raised by Dr. 
Tamosaitis, a contractor employee removed from his position at WTP, a 
construction project in Washington State funded by DOE and managed by 
Bechtel National, Incorporated (BNI). The Board's inquiry did not 
attempt to assess the validity of Dr. Tamosaitis's retaliation claim, 
but rather, as required by the Board's statute, examined whether his 
allegations of a failed safety culture at WTP, if proven true, might 
reveal events or practices adversely affecting safety in the design, 
construction, and operation of this defense nuclear facility.
    The Board is required by statute to investigate any event or 
practice at a defense nuclear facility which it determines may 
adversely affect public health and safety. The Board conducted this 
investigation pursuant to its investigative power under 42 U.S.C. Sec.  
2286a(a)(2). During the course of the Board's inquiry, 45 witnesses 
were interviewed and more than 30,000 pages of documents were examined. 
The Principal Investigator was Joel R. Schapira, Deputy General 
Counsel, assisted by John G. Batherson, Associate General Counsel, and 
Richard E. Tontodonato, Deputy Technical Director. The record of the 
investigation is non-public and will be preserved in the Office of the 
General Counsel's files.
    During the period of the investigation, the Board held a public 
hearing regarding safety issues at WTP. During that hearing the Board 
received additional information related to the kind of safety culture 
concerns raised by Dr. Tamosaitis. Consequently, the investigation was 
expanded to review these new concerns.
    Secretary of Energy Notice SEN-35-91, Nuclear Safety Policy, issued 
on September 9, 1991, and superseding policy statement 2 of 
DOE Policy 420.1, Department of Energy Nuclear Safety Policy, issued on 
February 8, 2011, state that DOE is committed to establishing and 
maintaining a strong safety culture at its nuclear facilities. The 
investigation's principal conclusion is that the prevailing safety 
culture at this project effectively defeats this Secretarial mandate. 
The investigative record demonstrates that both DOE and contractor 
project management behaviors reinforce a subculture at WTP that deters 
the timely reporting, acknowledgement, and ultimate resolution of 
technical safety concerns.
    A key attribute of a healthy safety culture as identified by DOE's 
Energy Facility Contractors Group and endorsed by Deputy Secretary of 
Energy memorandum dated January 16, 2009, and in the Nuclear Regulatory 
Commission's proposed policy statement on safety culture (NRC-2010-
0282, dated January 5, 2011), is that leaders demonstrate clear 
expectations and a commitment to safety in their decisions and 
behaviors. The Board's investigation found significant failures by both 
DOE and contractor management to implement their roles as advocates for 
a strong safety culture.
    The record shows that the tension at the WTP project between 
organizations charged with technical issue resolution and development 
of safety basis scope, and those organizations charged with completing 
design and advancing construction, is unusually high. This unhealthy 
tension has rendered the WTP project's formal processes to resolve 
safety issues largely ineffective. DOE reviews and investigations have 
failed to recognize the significance of this fact. Consequently, 
neither DOE nor contractor management has taken effective remedial 
action to advance the Secretary's mandate to establish and maintain a 
strong safety culture at WTP.
    Taken as a whole, the investigative record convinces the Board that 
the safety culture at WTP is in need of prompt, major improvement and 
that corrective actions will only be successful and enduring if 
championed by the Secretary of Energy. The successful completion of 
WTP's mission

[[Page 35862]]

to remove and stabilize high-level waste from the tank farms is 
essential to protect the health and safety of the public and workers at 
Hanford. However, the flawed safety culture currently embedded in the 
project has a substantial probability of jeopardizing that mission.

Findings

Finding One: A Chilled Atmosphere Adverse to Safety Exists

    In a letter to the Defense Nuclear Facilities Safety Board (Board) 
dated July 16, 2010, Dr. Walter Tamosaitis, a former engineering 
manager at the Waste Treatment and Immobilization Plant (WTP), alleged 
that he was removed from the project because he identified certain 
technical issues that in his view could affect safety. Dr. Tamosaitis 
also alleged that there was a failed safety culture at WTP. With full 
understanding that the formal claims of retaliation raised by Dr. 
Tamosaitis would be looked into by others, the Board decided that his 
assertions raised serious questions about safety culture and safety 
management at WTP. From late July 2010 to May 2011, the Board reviewed 
a large number of documents and interviewed a substantial number of 
persons, including Dr. Tamosaitis, to assess whether or not his 
allegations of safety issues and of a faulty safety culture were borne 
out. The Board's investigation later expanded in scope to address 
matters related to the Board's October 2010 public hearing at Hanford 
on safety issues at WTP. This phase of the investigation consisted of 
closed hearings at which sworn testimony was elicited from DOE and 
contractor personnel.
    The Board finds that the specific technical issues identified by 
Dr. Tamosaitis in his July 16, 2010, letter were known and tracked by 
the WTP project. In a WTP project managers' meeting on July 1, 2010, 
Dr. Tamosaitis raised safety concerns related to the adequacy of vessel 
mixing, technical justifications for closing mixing issues, and other 
open technical issues. The next day he was abruptly removed from the 
project. This sent a strong message to other WTP project employees that 
individuals who question current practices or provide alternative 
points of view are not considered team players and will be dealt with 
harshly.
    The Board finds that expressions of technical dissent affecting 
safety at WTP, especially those affecting schedule or budget, were 
discouraged, if not opposed or rejected without review. Project 
management subtly, consistently, and effectively communicated to 
employees that differing professional opinions counter to decisions 
reached by management were not welcome and would not be dealt with on 
their merits. There is a firm belief among WTP project personnel that 
persisting in a dissenting argument can lead, as in the case of Dr. 
Tamosaitis, to the employee being removed from the project or 
reassigned to other duties. As of the writing of this finding, Dr. 
Tamosaitis sits in a basement cubicle in Richland with no meaningful 
work. His isolated physical placement by contractor management and the 
lack of meaningful work is seen by many as a constant reminder of what 
management will do to an employee who raises issues that might impact 
budget or schedule.
    Other examples of a failed safety culture include:
     The Board heard testimony from several witnesses that 
raising safety issues that can add to project cost or delay schedule 
will hurt one's career and reduce one's participation on project teams.
     A high ranking safety expert on the project testified that 
the expert felt next in line for removal after Dr. Tamosaitis because 
of the expert's refusal to yield to technically unsound positions on 
matters affecting safety advanced by DOE and contractor managers 
responsible for design and construction at the WTP. This safety 
expert's concern was validated by a senior DOE official in separate 
sworn testimony.
     A report prepared by a subcontractor on the WTP project, 
``URS Report of Involvement in WTP Investigation,'' discusses the 
``tension between organizations charged with technical issue resolution 
and development of safety basis related scope and those organizations 
charged with completing design and advancing construction. Some level 
of such tension is normal and healthy in projects of such scope and 
complexity; but at WTP, this tension is higher than what might be 
expected or desired. Some individuals whose personalities tend toward 
avoidance of conflict could view the organizational environment as not 
conducive to raising issues or perhaps even potentially suppressing 
some issues that might deter progress or that might add cost.''
     The investigative record shows that the DOE Office of 
River Protection Employee Concerns program is not effective. One safety 
expert explicitly testified that employees would not and did not use 
the program, and believed that individuals running the program would 
``bury issues'' brought to them. The record shows that in the removal 
of Dr. Tamosaitis, Human Resources (HR) for URS was interested only in 
implementing management's demand that the employee be removed 
immediately. The record shows HR did not assert any consideration or 
concern regarding the effect the process and manner of his removal 
would have on the remaining workforce and the effectiveness of the 
contractor employee protection program required under 10 CFR Part 708.
     An independent review of the WTP safety culture performed 
by DOE's Office of Health, Safety and Security (HSS) found that ``a 
number of individuals have lost confidence in management support for 
safety, believe there is a chilled environment that discourages 
reporting of safety concerns, and/or are concerned about retaliation 
for reporting safety concerns. These concerns are not isolated and 
warrant timely management attention, including additional efforts to 
determine the extent of the concerns.'' Although the HSS report stated 
that most WTP personnel did not share these opinions, the Board notes 
that personnel interviewed by HSS were escorted to their interviews by 
management. The Board's record shows that involving management with the 
interviews clearly can inhibit the willingness of employees to express 
concerns. In its own way, DOE's decision to allow management to be 
involved in the HSS investigation raises concerns about safety culture.
    This environment at WTP does not meet key attributes established by 
DOE's Energy Facility Contractors Group, and endorsed by the Deputy 
Secretary of Energy, that describe a strong safety culture: DOE and 
contractor leadership must have a clear understanding of their 
commitment to safety; they are the leading advocates of safety and the 
public trust demands that they demonstrate their commitment in both 
word and action. The Board's investigation concludes that the WTP 
project is not maintaining a safety conscious work environment where 
personnel feel free to raise safety concerns without fear of 
retaliation, intimidation, harassment, or discrimination.

Finding Two: DOE and Contractor Management Suppress Technical Dissent

    The HSS review of the safety culture on the WTP project ``indicates 
that BNI has established and implemented generally effective, formal 
processes for identifying, documenting, and resolving nuclear safety, 
quality, and technical concerns and issues raised by employees and for 
managing complex

[[Page 35863]]

technical issues.'' However, the Board finds that these processes are 
infrequently used, not universally trusted by the WTP project staff, 
vulnerable to pressures caused by budget or schedule, and are therefore 
not effective. Previous independent reviews, contractor surveys, 
investigations, and other efforts by DOE and contractors demonstrate 
repeated, continuing identification of the same safety culture 
deficiencies without effective resolution.
    Suppression of technical dissent is contrary to the principles that 
guide a high-reliability organization. It is essential that workers 
feel empowered to speak candidly without fear of retribution or 
criticism. In extreme cases, refusal to consider a different view of a 
safety issue can lead to catastrophic consequences. WTP is a complex 
and difficult project that is essential to the nation's nuclear waste 
remediation program. Therefore, federal and contractor managers must 
make a special effort to foster a free and open atmosphere in which all 
competent opinions are judged on their technical merit, to sustain or 
improve worker and public safety first and foremost, and then evaluate 
potential impacts on cost and schedule.
    One of the primary examples of suppressing technical information is 
a study that was performed by BNI in July 2009 on deposition velocity, 
a parameter used in modeling the offsite transport of radioactive 
particles for nuclear facility safety analyses. The study found that 
the correct value of the dry deposition velocity for Hanford fell in 
the range of 0.1 to 0.3 cm/sec. The Board's investigation includes 
testimony by the former manager of DOE's Office of River Protection and 
the DOE Chief of Nuclear Safety in Washington, DC, that the results of 
this study were not shared with them. Consequently, DOE continued to 
follow its policy requiring the WTP project to use a less conservative 
default value of 1.0 cm/sec for dry deposition velocity. In the fall of 
2010, the Chief of Nuclear Safety hired an independent consultant to 
investigate the issue. This consultant also found that deposition 
velocity fell in the range of 0.1 to 0.3 cm/sec, information that was 
already available to the project in the summer of 2009. Suppression of 
the 2009 study delayed the identification of properly conservative 
values for dry deposition velocity to use in the safety analyses that 
determine the need for safety-related controls for WTP facilities. Once 
this information was made available to DOE's Office of Health, Safety 
and Security, a technical study ensued that determined the need for a 
more conservative value of deposition velocity to serve as a default 
value.
    This problem also manifested itself when one of the expert 
witnesses, a nuclear safety professional, specifically asked by the 
Board to testify at the Board's October 2010 public hearing on WTP 
safety issues, failed to support the DOE policy on the appropriate 
value for dry deposition velocity. This witness testified that using 
DOE's prescribed default value for the dry deposition velocity in 
safety basis calculations could not be justified if it were known to be 
non-conservative for the Hanford Site. At the time of the hearing, the 
witness understood the correct value of deposition velocity was not 
being used in calculations of potential dose consequences to the public 
receptor and was unwilling to simply state the DOE position that a 
default value could be used or justified. The expert witness later 
testified for the record that DOE was fully aware of the July 2009 
study on dry deposition velocity at the time of the public hearing. The 
expert witness' testimony during the public hearing clashed with the 
position taken by senior management in the DOE Office of River 
Protection and by the DOE Chief of Nuclear Safety.
    The testimony of several witnesses confirms that the expert witness 
was verbally admonished by the highest level of DOE line management at 
DOE's debriefing meeting following this session of the hearing. 
Although testimony varies on the exact details of the verbal 
interchange, it is clear that strong hostility was expressed toward the 
expert witness whose testimony strayed from DOE management's policy 
while that individual was attempting to adhere to accepted professional 
standards. Testimony by a senior DOE official confirmed the validity of 
the expert witness' concerns. In addition, the expert witness testified 
that they felt pressure to change their testimony, but refused to do 
so.
    Management behavior of this kind creates an atmosphere in which 
workers are reluctant to speak candidly for fear of retribution or 
criticism. Whether or not this behavior possibly violates federal law 
is not for the Board to determine; however, the Board does assert that 
fear of retribution visited on a competent professional for offering an 
honest opinion in a public hearing is incompatible with the objective 
of designing and building a safe and operationally sound nuclear 
facility and sustaining a healthy safety culture.
    Another example of failure to act on technical information in a 
timely manner concerns a report related to the occurrence of a 
potential criticality event at WTP. In April 2010, the WTP project 
issued a plan of action to address recommendations of the WTP 
Criticality Safety Support Group, specifically, to review historical 
information on plutonium dioxide (PuO2) wastes discharged by 
the Plutonium Finishing Plant to the tank farms. The report of the 
review was completed and submitted to the WTP project in August 2010. A 
key finding of the report was that the maximum PuO2 particle 
size of 10 microns assumed in WTP criticality safety analyses was not 
conservative. Instead of receiving immediate attention, the report 
languished without action until February 2011.
    Once the report was finally reviewed, the WTP project reached the 
initial conclusion that it may no longer be possible to assume that 
criticality in WTP is an incredible occurrence. (Based on this 
information, the Hanford Tank Farms operating contractor halted 
activities involving the affected tanks.) If criticality is confirmed 
to be credible, changes in the WTP criticality strategy will be 
required. This will result in changes to the existing safety basis and 
require an assessment of the existing WTP design to determine if design 
changes are required. Depending upon the magnitude of the criticality 
hazard, significant changes in the WTP design may be necessary. DOE was 
not informed of this important finding in a timely manner, and actions 
to better characterize the PuO2 problem were delayed by 
approximately 6 months because the WTP project delayed evaluation of 
the report.

Recommendation

    Taken as a whole, the investigative record convinces the Board that 
the safety culture at WTP is in need of prompt, major improvement and 
that corrective actions will only be successful and enduring if 
championed by the Secretary of Energy. The Board recommends that the 
Secretary of Energy:
    1. Assert federal control at the highest level and direct, track, 
and validate the specific corrective actions to be taken to establish a 
strong safety culture within the WTP project consistent with DOE Policy 
420.1 in both the contractor and federal workforces,
    2. Conduct an Extent of Condition Review to determine whether these 
safety culture weaknesses are limited to the WTP Project, and
    3. Conduct a non-adversarial review of Dr. Tamosaitis' removal and 
his current treatment by both DOE and

[[Page 35864]]

contractor management and how that is affecting the safety culture at 
WTP.
    The Board urges the Secretary to avail himself of the authority 
under the Atomic Energy Act (42 U.S.C. Sec.  2286d(e)) to ``implement 
any such recommendation (or part of any such recommendation) before, 
on, or after the date on which the Secretary transmits the 
implementation plan to the Board under this subsection.''

Peter S. Winokur, Ph.D.,
Chairman.
[FR Doc. 2011-15146 Filed 6-17-11; 8:45 am]
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