Audit Report 

U.S. Department of Energy 

Office of Inspector General 

Office of Audit Services 

The Office of Civilian Radioactive 

Waste Management's Corrective 

Action Program 

DOE/IG-0736 August 2006 


REPORT ON THE OFFICE OF CIVILIAN RADIOACTIVE WASTE 

MANAGEMENT'S CORRECTIVE ACTION PROGRAM 

TABLE OF 

CONTENTS 

Corrective Action Program

Details of Finding ........................................................................................1 

Recommendations and Comments ..............................................................9 

Appendices

1. Objective, Scope, and Methodology....................................................11 

2. Prior Reports ........................................................................................13 

3. Management Comments ......................................................................15 
CORRECTIVE ACTION PROGRAM 

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Page 1 Details of Finding 

Background Under the Department of Energy's (Department's) 

Corrective Action Program (CAP), the Yucca Mountain 

Project staff was instructed to report potential conditions 

adverse to quality (hereafter referred to as conditions) or 

safety into the Program database. Potential conditions 

include all failures, deficiencies, defective items, safety 

issues, and nonconformances with Quality Assurance 

requirements, which could affect the quality of the 

supporting technical information. As an alternative, 

employees who wish their identity to remain confidential 

can report potential conditions through the Employee 

Concerns Program (ECP). However, all conditions 

reported in the ECP and other tracking systems that are 

adverse to quality, must also be entered into the CAP 

database and assigned to a line management organization to 

develop and implement timely corrective actions. The 

benefit of a single tracking system is that deficiencies can 

be screened for significance, common cause analyses can 

be performed, and trending analyses can be used to identify 

repeat occurrences and potential significant problems. 

The CAP process also provides for the assignment of a 

significance level to the condition, ranging from Level A to 

Level D, depending on the actual or potential consequences 

of the condition. Level "A" condition reports, the most 

significant, include conditions, which if uncorrected could 

have a serious effect on safety, or serious effects on the 

performance of the repository, such as the ability to isolate 

waste. Level "D" condition reports are the least significant. 

Of the approximately 5,600 condition reports in the 

Corrective Action Program system, 14 were Level A; 783 

were Level B; and, approximately 4,800 were Level C 

or D. 

Management of the The CAP is not meeting all its goals for identifying, 

Corrective Action tracking and resolving all conditions adverse to quality 

Program or safety that could effect the license application process. 

Specifically, we found conditions that had been reported in 

other tracking systems, in line management self-assessment 

reports, and by external review groups that had not been 

included in the CAP system, but should have been. 

Further, corrective actions developed to respond to these 

conditions were not always timely and/or effective in 

resolving the problems identified. 
 

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Page 2 Details of Finding 

Completeness

In keeping with OCRWM's commitment to establish a 

single system to manage problems that could affect the 

license application process, OCRWM and its management 

and operating contractor, Bechtel SAIC Company, LLC 

(Bechtel), required that any potential condition reported in 

any of its 16 other tracking systems be recorded and 

managed in the CAP database. This included potential 

conditions reported by line management through selfassessment reviews and external review groups. Despite 

this requirement, we found at least 102 potential 

deficiencies that had not been included in the CAP system. 

• We identified 90 potential conditions, reported 

between October 2003 and November 2005, in 

other tracking systems, such as the ECP and the 

Work Order Request Systems, which were not in 

the CAP database. For example, in 2004, an 

employee reported through the ECP the presence of 

radon gas during boring operations in the tunnel. 

Although both a potential condition adverse to 

quality and a potential employee safety and health 

issue, the concern had not been included in the CAP 

system. This condition was subsequently closed 

under the ECP even though a final determination 

regarding the validity of the concern had not been 

made. 

In responding to a draft of this report, officials 

commented that this allegation only concerned the 

tunnel boring operations in the 1990's. Since there 

was no regulatory requirement at that time and 

currently no scientific evidence associated with the 

potential synergistic effects of exposure to radon 

and silica, this concern was not identified as a 

condition in CAP. An OCRWM official advised 

that it is waiting for the results of international 

scientific studies regarding the combined effects of 

radon and silica to identify if there is a health risk 

concern. 

We acknowledge that the main tunnel boring 

operations were completed in the 1990's. However, 

since more than 50 emplacement tunnels off the 

main tunnel have yet to be bored, we continue to 
 

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Page 3 Details of Finding 

believe that this allegation should be managed in 

CAP until the determination has been made on its 

health risk to workers. 

• About 25 percent (12 of 51) of self-assessment 

reports we reviewed identified conditions that 

should have been reported in the CAP database, but 

were not. For example, an October 2005 selfassessment report identified the need for improved 

software capabilities to meet new Federal 

requirements on radiation dosage analyses for 

workers and the general public. Even though these 

analyses directly affect the license application, the 

condition was not entered into the CAP system to 

initiate appropriate corrective action. Management 

recently purchased new software needed to meet the 

new requirement. 

Also, externally identified issues, such as findings and 

recommendations from Office of Inspector General and 

Government Accountability Office reports were not being 

managed within the CAP system. These reports addressed 

inadequate quality assurance plans for incentive 

expectations and lingering quality problems with data, 

models, and software and continuing management 

weaknesses. 

Since none of these conditions had been entered into the 

CAP, they were not subject to screening, cause analysis, 

and trending to identify repeat occurrences and potential 

significant problems. We noted that at least 50 of the 71 

conditions reported in other tracking systems, but not 

included in CAP, were determined to be valid; however, 

only 23 of these were closed with corrective actions. 

Timeliness of Corrective Actions

OCRWM procedures require that condition reports be 

assigned to line management to develop a plan and 

schedule for corrective actions and that corrective actions 

be implemented within the timeframe established in the 

plan. However, OCRWM did not meet expectations for 

Levels A and B conditions. Specifically, 6 of the 8 Level A 

conditions closed between April 2001 and July 2004 

required an additional 11 to 495 days beyond the original 

completion date to implement planned corrective actions. 
 

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Page 4 Details of Finding 

For example, a Level A condition report, addressing a lack 

of documentation for validating technical analysis and 

model reports, required a total of 495 days beyond what 

was originally scheduled to implement the corrective 

actions. 

Similarly, for the 96 Level B conditions closed during 

2005, 57 were not completed on time. For example, one 

Level B condition was originally scheduled to be 

completed in October 2003, however, the corrective actions 

were postponed several times beyond the originally 

scheduled completion date, and are now scheduled to be 

completed in February 2007 – a total of 1,200 days later 

than originally planned. 

As of November 2005, we found that the implementation of 

corrective actions for one Level B and five Level C 

condition reports were delayed over 1,000 days from the 

date identified. These involved operability issues of site 

safety systems such as emergency lighting, firewater 

systems, and emergency communication systems in the 

tunnel. We also noted that management frequently revised 

scheduled completion dates and measured timeliness from 

the revised dates. 

Effectiveness of Corrective Actions

Corrective actions were not always effective in resolving 

conditions adverse to quality. An indicator that corrective 

actions are not effectively addressing the conditions is 

whether previously reported problems recur. During the 

audit, we identified at least 16 conditions that continued to 

be reported by employees, even though officials reported 

that corrective actions had been taken to resolve these 

conditions. We found that the planned corrective actions, 

in most of these cases, had not been fully effective. 

OCRWM management acknowledged the need for 

improvement in this area and advised that it has begun to 

take action to address recurring problems. Examples of 

three of the recurring problems follow. 

• Problems related to the flow down of design and 

control requirements to Bechtel's technical design 

documents were reported over 150 times between 

January 2004 and July 2005. Although this 

condition continued to be reported during the 
 

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Page 5 Details of Finding 

period, OCRWM officials concluded that corrective 

actions had been taken and closed the condition 

reports. However, due to the significance of this 

condition and its impact on technical documents, a 

"work suspension" order was issued in December 

2005. Currently, management is taking action to 

address this concern. 

• Between February 2004 and May 2005, a problem 

concerning the recurrence of editorial, technical, 

and procedural non-compliance errors in technical 

reports issued to the Nuclear Regulatory 

Commission (NRC) was reported 31 times. These 

reports described the geologic, hydrologic, physical, 

and chemical processes of the repository. Although 

the corrective action plans were reported to have 

resolved these problems and nearly all had been 

closed, the problems continued to recur and had not 

been corrected at the time of this audit. We noted 

that the NRC previously rejected OCRWM 

documents due to the numerous editorial and 

technical errors. 

• Another recurring problem pertained to the 

verification of employees' education and experience 

to ensure they were qualified to work on licensing 

documents, such as the post closure engineering 

documents. These documents contained analysis 

and modeling of the geologic, hydrologic, physical, 

and chemical processes of the repository. We noted 

that this condition had been reported over 34 times, 

although corrective actions were reported to have 

been taken. Due to the significance of this problem, 

management recently issued a condition report to 

ensure that the necessary corrective actions were 

addressed. 

System to Implement The CAP system was not used to track and manage all 

An Effective Program deficiencies primarily because management officials did 

not always (1) support employee participation in the 

corrective action process; (2) make needed improvements 

to the system procedures and software to facilitate its use; 

(3) conduct reviews to assess the effectiveness of the 

scheduled corrective actions; and, (4) fully utilize its 

trending analysis capabilities. We noted that the 
 

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Page 6 Details of Finding 

complexity of some planned actions and budgetary 

constraints also impacted OCRWM's ability to correct 

problems identified.

Employee Participation in the Corrective Action Program

OCRWM and Bechtel management encouraged employees 

through newsletters and the intranet to self-identify and 

report all conditions into the CAP database; however, some 

employees were reluctant to participate in the process. This 

finding was confirmed by a March 2006 OCRWM selfassessment report which acknowledged that some 

supervisors encouraged a "find and fix" approach to correct 

problems rather than enter issues into CAP. Additionally, 

the report acknowledged that these employees feared that 

there could be negative consequences (personal, business, 

and organizational repercussions) for identifying issues. 

Although the data does not indicate a pervasive problem, 

we found 51 instances of employees' reluctance to report 

issues in the CAP due to fear of negative repercussions. 

These concerns had, however, been filed through the ECP. 

Additionally, two employees raised concerns to us during 

the audit about reporting issues in the CAP system. One 

employee stated that after he raised concerns or identified 

deficiencies, his manager instructed him not to enter the 

issues into the CAP system. The other employee stated that 

he was instructed by a manager to only report specific 

violations to approved requirements, even though 

Department policy required that all deficiencies be 

reported, regardless of whether approved requirements or 

interim guidance were violated. 

Input into the Corrective Action Program 

Potential conditions in some other tracking systems were 

not included in the CAP database because of inadequate 

procedures and software problems. Specifically, 10 of the 

16 other systems, such as the Document Action Request 

and Work Order Request Systems, did not instruct 

employees to enter potential condition reports into the 

CAP. With regard to the ECP, however, procedures 

required that conditions also be entered into the CAP, but 

in many cases, the conditions simply were not entered as 

required. 
 

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Page 7 Details of Finding 

Despite access to a hotline designed to assist with using the 

software, both managers and employees expressed 

frustration with the CAP system software and avoided 

using it to either report or resolve problems. For example, 

some employees cited problems with finding the condition 

reports in the system and the numerous levels of reviews 

needed to resolve the issues. Also, some responsible 

individuals did not have access to information in the CAP 

system to take the corrective actions assigned to them. 

Furthermore, two Department managers told us that 

because the system was not "user-friendly", they preferred 

to resolve conditions outside of the CAP system. 

Validation of Corrective Actions

Bechtel did not always perform effectiveness reviews on 

closed corrective actions to ensure the reported conditions 

were corrected. Since early 2005, Bechtel's policy required 

effectiveness reviews for all closed Level A and selected 

Level B condition reports. To their credit, management 

had completed effectiveness reviews for 7 of the 8 Level A 

condition reports that had been closed. The effectiveness 

review for the remaining Level A condition report is in 

progress. However, we found at least 52 Level B condition 

reports that had been closed since that time, yet 

management had not performed any effectiveness reviews 

of the corrective actions taken for these conditions. We 

also noted that Bechtel sometimes closed corrective actions 

based on plans to address the problems at some future date; 

however, Bechtel did not validate that the planned actions 

were ever completed. For example, we found that Bechtel 

closed three condition reports – 2 Level C's and 1 Level D 

– to future planned corrective actions to develop procedures 

for the Quality Assurance Requirements Document; 

however, after the condition reports were closed, the 

procedures were still not developed, nor had Bechtel 

validated the status of the planned action. 

Trending Concerns

Although some trending capabilities existed within CAP, 

particularly for the more significant condition reports, 

OCRWM and contractor line managers did not adequately 

trend all deficiencies. Specifically, while OCRWM's 

procedure requires that all Level A, B, and C condition 

reports be trended to identify repeat occurrences, generic 

issues, and vulnerabilities at a low level before significant 
 

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Page 8 Details of Finding 

problems resulted, Level D condition reports were not 

included as part of the trending process since they were 

considered recommendations or opportunities for 

improvements. Consequently, managers were not able to 

review all reported deficiencies to determine if a larger 

problem existed or if a problem was being reported 

repeatedly. Furthermore, the ability to trend the timeliness 

of corrective actions was limited because management 

frequently revised scheduled completion dates and 

measured timeliness from the revised dates. 

All conditions should be trended since some of the major 

recurring problems, such as those related to the flow down 

of design and control requirements to technical documents, 

had been included in Level D condition reports. In a recent 

review, OCRWM self-identified that managers were not 

using the trending tools available to them and that 

managers tended to react to condition reports in isolation 

rather than conducting trend analyses that could anticipate 

problems and facilitate a proactive approach to resolving 

issues. During our audit, management agreed that this is a 

significant problem and that trending analyses needed 

improvement. Efforts are now underway to revise its 

reports and procedures. 

Complex Actions and Budgetary Constraints

On-site managers indicated that complicated corrective 

action plans and competing priorities for limited budgetary 

resources, to a limited extent, also impacted OCRWM's 

ability to implement timely corrective actions. For 

example, nine major corrective actions, involving the 

installation of emergency lighting and firewater systems in 

the tunnels – Level B and Level C conditions, respectively, 

and the repair to open slots in tunnel walkways – a Level D 

condition – were not completed as planned because 

corrective actions were more complex than initially 

expected. As a result, these actions were placed on hold 

until a safety analysis could be completed to determine the 

extent of required corrective actions. These corrective 

actions were then further delayed due to competing 

priorities for funds. As of March 2006, six years after the 

first deficiency was raised, corrective actions to tunnel 

lighting were starting to take place and other corrective 

actions were scheduled for completion in 2007. 
 

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Page 9 Recommendations and Comments 

Impact on Yucca Failure to effectively use the CAP to manage potential 

Mountain Project quality and safety conditions could ultimately delay 

issuance of the license to begin construction and 

operation of the repository. Delays in completing 

construction of the repository could have significant 

financial consequences since the annual cost of storing 

and handling Departmental defense waste destined for 

Yucca Mountain is substantial. Additionally, the 

government's liability for not beginning to take 

commercial spent fuel from nuclear utilities could be 

substantial. Unreported and unresolved quality assurance 

conditions could also impact the safety and performance 

of the repository. 

RECOMMENDATIONS We recommend that the Director of OCRWM: 

1. Ensure managers are held accountable for 

implementing the policies and procedures of the 

Corrective Action Program, including reporting all 

conditions potentially adverse to quality and safety; 

2. Improve the Corrective Action Program to make it 

more user-friendly and facilitate broader employee 

participation; 

3. Revise procedures of other related systems to 

require that conditions potentially adverse to quality 

identified in those systems are also entered into the 

Corrective Action Program, as required; 

4. Conduct effectiveness reviews to validate corrective 

actions, including condition reports closed to future 

planned corrective actions; 

5. Improve trending capabilities for management to 

anticipate and mitigate deficiencies; and, 

6. Ensure that corrective action plans are based on 

realistic estimates of the time and budgetary 

resources required to complete planned actions. 

MANAGEMENT Management concurred with our recommendations and 

COMMENTS developed planned actions to ensure that the Corrective 

Action Program is effectively implemented. 

Management has already initiated or plans to, among 

other things:
 

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Page 10 Comments 

• Increase managers' accountability by integrating 

new performance measures for organizations to 

identify deficiencies and respond in a timely 

manner to planned corrective actions; 

• Implement improvements to the Corrective Action 

Program system based on user recommendations; 

• Provide training to all employees on the Corrective 

Action Program and its requirements to facilitate 

broader employee participation; 

• Review procedures from other related systems for 

reference to the processing of conditions adverse to 

quality; and, 

• Conduct effectiveness reviews to validate the 

effectiveness of corrective actions. 

Management's comments, including its corrective action 

plan, are included in their entirety in Appendix 3. 

AUDITOR Management's comments and planned actions are 

COMMENTS responsive to our recommendations. 
Appendix 1 

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Page 11 Objective, Scope, and Methodology 

OBJECTIVE The objective of this audit was to determine whether the 

Corrective Action Program was achieving its goal of 

identifying, tracking, and resolving all conditions that 

could affect the license application process. 

SCOPE The audit was performed between October 2005 and May 

2006, at the Office of Repository Development and 

Bechtel SAIC Company, LLC in Las Vegas, Nevada. 

The scope was limited to the activities associated with the 

Corrective Action Program from October 2003 through 

April 2006. 

METHODOLOGY To accomplish our audit objective, we: 

• Obtained and reviewed applicable Department of 

Energy orders and the Code of Federal Regulations; 

prior audits, and, contract documents; 

• Assessed compliance with the Government 

Performance and Results Act of 1993; 

• Interviewed appropriate program and contract 

personnel; and, 

• Analyzed employee concern files and corrective 

action program documentation, including: condition 

reports, corrective action plans, trending reports, 

and, effectiveness reviews. 

The audit was conducted in accordance with generally 

accepted Government auditing standards for performance 

audits and included tests of internal controls and 

compliance with laws and regulations to the extent 

necessary to satisfy the audit objective. Because our 

review was limited, it would not necessarily have disclosed 

all internal control deficiencies that may have existed at the 

time of our audit. We relied on computer processed data to 

accomplish our audit objective. We performed limited tests 

on the Corrective Action Program system data and 

determined that it could be relied on to achieve the audit 

objective. OCRWM established performance measures 

under the Government Performance and Results Act of 

1993 and passed them down to Bechtel through the 
Appendix 1 (continued) 

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Page 12 Objective, Scope, and Methodology 

Corrective Action Program. While we identified 

deficiencies with the administration of the Corrective 

Action Program, we found the Department complied with 

the Government Performance and Results Act of 1993. 

We discussed the results of the audit with the Office of 

Civilian Radioactive Waste Management on May 4, 2006. 

Management waived the exit conference. 
Appendix 2 

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Page 13 Prior Reports 

PRIOR REPORTS

Office of Inspector General

• Quality Assurance Weaknesses in the Review of Yucca Mountain Electronic Mail 

for Relevancy to the Licensing Process (DOE/IG-0708, November 2005). The 

review identified potential quality assurance issues that had not been entered into 

the Corrective Action Program. The Nuclear Regulatory Commission (NRC) 

process for granting a license for the repository required that the Department of 

Energy (Department) publicly disclose on a website all documents, including 

emails, relevant to the process. The inspection found emails among the 10 

million that identified possible conditions and therefore should have been 

reviewed for entry into the Corrective Action Program. As a result, the Office of 

Civilian Radioactive Waste Management (OCRWM) took action to have 

approximately 10 million archived emails reviewed for relevancy to the licensing 

process. 

• Use of Performance Based Incentives by the Office of Civilian Radioactive Waste 

Management (DOE/IG-0702, September 2005). The audit report identified that 

since 2001, OCRWM paid approximately $4 million in incentive fees, or 

approximately ten-percent of the fees paid, even though Bechtel delivered poor 

quality work and missed deadlines. In administering the contract, OCRWM did 

not establish an adequate quality assurance plan, as required by the Department's 

Acquisition Regulations. Further, OCRWM did not update the quality assurance 

plan when incentive expectations changed nor had it documented its rationale for 

incentive fee payments. The Office of Inspector General recommended that 

OCRWM establish a performance evaluation and management plan with clearly 

defined standards, including acceptable quality levels for incentives and fee 

reductions when performance expectations were not met. 

Government Accountability Office

• Yucca Mountain – Quality Assurance at DOE's Planned Nuclear Waste 

Repository Needs Increased Management Attention (March 2006, GAO-06-313). 

The Government Accountability Office (GAO) reported that the Department 

continues to face substantial quality assurance problems and other challenges that 

could further delay the license application process. GAO cited ineffective 

Department management tools to address these challenges. GAO recommended 

that the Department reassess their coverage of quality assurance management 

tools to: allow effective monitoring of issues; incorporate a project wide trending 

analyses; establish quality guidelines for trend evaluation reports; develop 

consistent performance indicators; and, focus on the significance of issues. 
Appendix 2 (continued) 

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Page 14 Prior Reports 

• Yucca Mountain – Persistent Quality Assurance Problems Could Delay 

Repository Licensing and Operation (April 2004, GAO-04-460). GAO identified 

lingering quality problems with data, models, and software and continuing 

management weaknesses. The Department developed a corrective action plan in 

2002 to fix recurring problems with the accuracy of such data; however, GAO 

found that the plan lacked objective measurements and timeframes for 

determining success. GAO recommended the Department develop a new 

corrective action plan to ensure that recurring problems were corrected. GAO 

noted that without the Department making improvements in their quality 

assurance program, recurring problems could affect the license application 

process. 
Appendix 3 

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Page 15 Management Comments 
Appendix 3 (continued) 

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Page 16 Management Comments 
Appendix 3 (continued) 

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Page 17 Management Comments 
Appendix 3 (continued) 

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Page 18 Management Comments 
Appendix 3 (continued) 

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Page 19 Management Comments 
Appendix 3 (continued) 

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Page 20 Management Comments 
IG Report No. DOE/IG-0736

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