**\[DNFSB LETTERHEAD\]**

May 21, 2004

The Honorable Spencer Abraham

Secretary of Energy

1000 Independence Avenue, SW

Washington, DC 20585-1000

Dear Secretary Abraham:

On May 21, 2004, the Defense Nuclear Facilities Safety Board (Board), in
accordance with 42 U.S.C. § 2286d(a), unanimously approved
Recommendation 2004-1, which is enclosed for your consideration.
Recommendation 2004-1 deals with Oversight of Complex, High-Hazard
Nuclear Operations.

After your receipt of this recommendation and as required by 42 U.S.C. §
2286d(a), the Board will promptly make it available to the public. The
Board believes that the recommendation contains no information that is
classified or otherwise restricted. To the extent this recommendation
does not include information restricted by DOE under the Atomic Energy
Act of 1954, 42 U.S.C. §§ 2161-68, as amended, please see that it is
promptly placed on file in your regional public reading rooms. The Board
will also publish this recommendation in the *Federal Register*.

Sincerely,

***John T. Conway***

***Chairman***

Enclosure

c: Mr. Mark B. Whitaker, Jr.

**DEFENSE NUCLEAR FACILITIES SAFETY BOARD**

**RECOMMENDATION 2004-1 TO THE SECRETARY OF ENERGY**

**Pursuant to 42 U.S.C. § 228a(a)(5)**

**Atomic Energy Act of 1954, As amended.**

Dated: May 21, 2004

In furtherance of its statutory duty to oversee the Department of
Energy's (DOE) protection of workers and the public from hazards at
defense nuclear facilities operated for DOE and the National Nuclear
Safety Administration (NNSA), the Defense Nuclear Facilities Safety
Board (Board) conducted eight public hearings to examine DOE's current
and proposed methods of ensuring safety at its defense nuclear
facilities.

In these hearings, the Board also sought to benefit from the lessons
learned as a result of investigations conducted following the Columbia
Space Shuttle disaster and the discovery of the deep corrosion in the
reactor vessel head at the Davis-Besse Nuclear Power Plant. The Board
received testimony from representatives of the Nuclear Regulatory
Commission; the Naval Reactors Program; the Columbia Accident
Investigation Board; the Deputy Secretary of Energy; the Administrator
of NNSA; DOE's Under Secretary of Energy, Science and Environment; DOE's
Assistant Secretary for Environment, Safety, and Health; and selected
site managers of DOE's facilities, senior contractor managers, and
members of the public.

The overall objective of the hearings was to gather information that
could be helpful in assessing DOE's proposals for changing the methods
it uses for contract management and nuclear safety oversight, as they
have been controlled through the DOE Directives System. NNSA has
proposed shifting responsibility for safety oversight from DOE
Headquarters to the DOE field offices and site contractors. The key
question the Board sought to address was: Will modifications proposed by
DOE/NNSA to organizational structure and practices, as well as increased
emphasis on productivity, improve or reduce safety, and increase or
decrease the possibility of a high-consequence, low-probability nuclear
accident?

DOE's programs for national security and environmental protection are
complex, with potentially high consequences if not safely performed.
Mishandling of nuclear materials and radioactive wastes could result in
unintended nuclear criticality, dispersal of radioactive materials, and
even nuclear detonation. DOE has a long and successful history of
nuclear operations, during which it has established a structure of
requirements directed to achieving nuclear safety. That structure is
based on such methods as defense in depth, redundancy of protective
measures, robust technical competence in operations and oversight,
extensive research and testing, a Directives System embodying nuclear
safety requirements, Integrated Safety Management, and processes to
ensure safe performance.

The United States owns the defense nuclear facilities at which its
programs are carried

out by a government agency---DOE. Each such facility is operated by a
contractor that was selected by DOE on the basis of being best suited to
conduct the work for DOE at that site. Under the original Atomic Energy
Act of 1946 and continuing to date in the Atomic Energy Act of 1954, as
amended, the government officials in charge (i.e., the Secretary of
Energy and other line officers) have a statutory responsibility to
protect health and minimize danger to life or property. In any
delegation of responsibility or authority to lower echelons of DOE or to
contractors, the highest levels of DOE continue to retain safety
responsibility. While this responsibility can be delegated, it is never
ceded by the person or organization making the delegation. Contractors
are responsible to DOE for safety of their operations, while DOE is
itself responsible to the President, Congress, and the public.

This reality was highlighted during the course of the Board's hearings.
Many important lessons were cited in the testimony provided. These
included the importance of a centralized and technically competent
oversight authority, central control of technical safety requirements
and waivers for departure from those requirements, an ability to operate
in a decentralized mode when appropriate, a willingness to accept
criticisms, the need for retention of technical expertise and
capabilities at high levels of any organization in which technical
failure could have high consequences, and an awareness that complacency
can arise from a history of successes. DOE representatives testified
that DOE's attention to safety has continued to improve with better
on-site oversight and self-assessment programs, use of Integrated Safety
Management, careful attention to safety statistics, and stabilization
and disposal of high risk nuclear materials. However, cause for concern
with regard to the potential increase in the possibility of nuclear
accidents was also evident in: (1) the increased emphasis on
productivity at the possible expense of safety, (2) the loss of
technical competency and understanding at high levels of DOE's and
NNSA's organizational structure, (3) the apparent absence of a strong
safety research focus, and (4) the reduced central oversight of safety.

Clearly, safety performance can benefit from attention to detail and
lessons learned from small incidents and minor accidents. However,
failures leading to high-consequence, low-probability accidents would
likely have their roots in interactions between engineering failures and
improper human actions. Because the consequences of large nuclear
accidents would be unacceptable, the nuclear weapons complex cannot
permit them to occur. While the potential for such accidents cannot be
completely eliminated, their likelihood can be held to an insignificant
level by rigorous attention to Integrated Safety Management with
technical and operational excellence based on nuclear safety standards
subject to rigorous oversight. In addition, nuclear safety must be
founded on solid research, analysis, and testing to ensure an adequate
understanding of energetic initiating mechanisms under off-normal
conditions.

DOE has taken some preliminary steps toward its proposed changes in
safety practices. These actions may have contributed to some unfortunate
consequences, such as the following:

-   A glovebox fire occurred at the Rocky Flats closure site, where, in
    the interest of efficiency, a generic procedure was used instead of
    one designed to identify and control specific hazards. Apparently,
    success of the cleanup project resulted in management complacency.
    DOE site management had given the impression that safety was less
    important than progress, and contract management had not emphasized
    oversight of work control processes.

-   Downsizing of safety expertise has begun in NNSA's NA-53
    organization, while field organizations such as the Albuquerque
    Service Center have not developed an equivalent technical capability
    in a timely manner. As a result, NNSA field offices are left without
    an adequate depth of understanding of such important matters as
    seismic analysis and design, training of nuclear workers, and
    protection against unintended criticality.

-   DOE's Office of Environmental Safety and Health, with assistance
    from some sites and contractors, has reviewed DOE Directives to
    simplify safety requirements, with the objective of supporting
    accelerated operations that are also more efficient. This shift has
    led to proposals for downgrading some worker safety Directives to
    the level of guidance and modifying some radiation protection
    requirements. It has also led to a proposed modification of the
    Order on Worker Safety and Health to reduce requirements for
    protecting workers from the consequences of fires, explosions, and
    discharges from high-pressure systems.

Proposed modifications to DOE and NNSA's organizational structure,
manpower, contract management, oversight policies and practices, and
safety directives could have unintended consequences. These include
reduction of defense in depth, potentially inconsistent safety-related
decisions caused by decentralization of safety authority, emphasis on
performance as opposed to safety, and reduction of technical capability
at key points in the organizational structure. DOE and NNSA line
managers could be left with inadequate awareness of safety issues.

As a result of testimony it has received, the Board is not convinced of
the benefit of the changes to DOE's and NNSA's organizational structure
and practices as they have been described. The Board cautions that if
any such changes are made, they must be done formally and
deliberatively, with due attention given to unintended safety
consequences that could reduce the present high level of nuclear safety.
DOE should take full advantage of lessons learned from safety problems
discovered by National Aeronautic Space Administration and Nuclear
Regulatory Commission, and it should learn from the success of the good
organizational and safety practices championed by the Naval Reactors
Program. The Board needs to be sure that any fundamental reorganization
does not degrade nuclear safety, and that the likelihood of a serious
accident, facility failure, construction problem, or nuclear incident
will not be increased as a result of well-intentioned changes.

As a result of testimony received at the public hearings and the
potential effects on safety at defense nuclear facilities outlined
above, the Board recommends:

1.  That delegation of authority for nuclear safety matters to field
    offices and contractors be contingent upon the development and
    application of criteria and implementing mechanisms to ensure that:

    a.  oversight responsibility includes the capability for examining,
        assessing, and auditing by all levels of the DOE organization,

    b.  the technical capability and appropriate experience for
        effective safety oversight is in place, and

    c.  corrective action plans consistent with recommendations
        resulting from internal DOE and NNSA reviews of the Columbia
        accident and the Davis-Besse incident are issued.

2.  That to ensure that any features of the proposed changes will not
    increase the likelihood of a low-probability, high-consequence
    nuclear accident, DOE and NNSA take steps to:

    a.  empower a central and technically competent authority
        responsible for operational and nuclear safety goals,
        expectations, requirements, standards, directives, and waivers;

    b.  ensure the continued integration and support of research,
        analysis, and testing in nuclear safety technologies; and

    c.  require that the principles of Integrated Safety Management
        serve as the foundation of the implementing mechanisms at the
        sites.

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3.  That direct and unbroken line of roles and responsibilities for the
    safety of nuclear operations---from the Secretary of Energy and the
    NNSA Administrator to field offices and sites---be insured according
    to appropriate Functions, Responsibilities, and Authorities
    documents and Quality Assurance Implementation Plans.

4.  That prior to final delegation of authority and responsibility for
    defense nuclear safety matters to the field offices and contractors,
    DOE and NNSA Program Secretarial Officers provide a report to the
    Secretary of Energy describing the results of actions taken in
    conformance with the above recommendations.

***John T. Conway, Chairman***