**\[DNFSB LETTERHEAD\]**

January 20, 2004

The Honorable Spencer Abraham

Secretary of Energy

1000 Independence Avenue, SW

Washington, DC 20585- 1000

Dear Secretary Abraham:

The Defense Nuclear Facilities Safety Board (Board) has followed closely
events surrounding the recent discovery of cracked high explosive during
a weapon dismantlement at the Pantex Plant. When damaged, the response
of this particular conventional explosive is difficult to predict, but
it is known that the explosive becomes more sensitive. Also, the
configuration of the partially dismantled weapon and the nature of the
cracks appear to have increased the opportunities for dropping all or
part of the explosive during handling, and hence increased the potential
for a violent reaction.

In such a case, one expects the most careful scrutiny and deliberate
decision-making process in determining the best way to proceed. The
Department of Energy has established mechanisms to ensure that this
deliberate process takes place. These include the Unreviewed Safety
Question (USQ) process, the Nuclear Explosive Safety (NES) review
process, and review by the appropriate design agency of Nuclear
Explosive Engineering Procedures (NEEP). In this case, however,
inappropriate conclusions degraded the effectiveness of these
mechanisms:

-   The USQ evaluation incorrectly concluded that the situation was
    bounded by existing safety analyses. Had the evaluation established
    the need for a more formalized hazard analysis and weapon response
    from the design agency, a USQ would have been declared, and
    processes would have been initiated to ensure a more thorough and
    measured analysis of the hazards involved.

-   The NES review incorrectly concluded that the cracks observed and
    the actions being taken to address them constituted a "trivial"
    change. Taping and moving cracked explosive is not addressed in the
    current NES Study for this system. Had the NES review found this to
    be a "nontrivial" change, NES processes would have been initiated to
    ensure a more thorough and measured analysis of the hazards
    involved.

-   The design agency did not fully identify the potential safety
    concerns associated with the NEEP or with the condition of the
    explosive. The design agency does not appear to have consulted with
    the developer of the explosive regarding its potential hazards when
    damaged. The conclusion of the design agency that the taped
    explosive introduced no new hazards may have contributed to the
    inappropriate conclusions from the NES and USQ processes.

In addition, the recovery procedure and associated training appear to
have been inadequate:

-   The NEEP, a one-time-use procedure developed to provide special
    handling instructions and complete the dismantlement, required
    clarification to the production technicians, did not anticipate
    potential behavior of the cracked explosive, and could not be
    completed. Further, the NEEP provided no cautionary notes to the
    production technicians regarding the condition of the explosive or
    the potential for dropping pieces of explosive.

-   The training established for performing the NEEP did not require
    hands-on demonstration prior to execution. As a result, the required
    taping of the explosive was not performed as intended.

-   Personnel responsible for developing the NEEP were not present to
    supervise its execution. The uncertainties and abnormalities of this
    situation would appear to have called for the presence of at least
    the process engineer.

The prudent response of the production technicians as they saw
unexpected behavior of the explosive provided the only effective barrier
preventing a drop of explosives with potentially unacceptable
consequences. However, the significance of the failures that preceded
the technicians' actions raises questions about the effectiveness of the
mechanisms put in place to ensure safe nuclear explosive operations. The
Pantex Site Office and the Pantex contractor are moving forward with
plans to address many of these questions; however, the Board would like
to be informed of the analysis and corrective measures that will be
taken. Therefore, pursuant to 42 U.S.C. § 2286b(d), the Board requests a
comprehensive report within 30 days of receipt of this letter
documenting a root-cause analysis of each of the failures that led to
this situation, and including commitments for their resolution.

Sincerely,

***John T. Conway***

***Chairman***

c: The Honorable Linton Brooks

The Honorable Everet H. Beckner

Mr. Mark B. Whitaker, Jr.