U.S. Department of Energy 

Office of Inspector General 

Office of Audit Services 

Audit Report 

Implementation of Integrated Safety 

Management at Lawrence Livermore 

National Laboratory 

DOE/IG-0797 July 2008 
Department of Energy 

Washington, DC 20585 

July 2, 2008 

MEMORANDUM FOR 

FROM: 

lnspector General 

SUBJECT: INFORMATION: Audit Report on "Impletnentation of 

Integrated Safety Management at Lawrence Livermore National 

Laboratory" 

BACKGROUND 

Safety is one of the Department of Energy's top priorities. In 1996. the Department of 

Energy established an Integrated Safety Management (ISM) system whereby its 

contractors plan, perform, assess, and innprove the safe conduct of work. However, due 

to inconsistent implementation of ISM and recurring deficiencies that led to serio~~s 

accidents, the Department issued guidance in 2001 and 2006 to assist contractors in their 

implementation of ISM and to improve safety. As part of ISM, the Department requires 

contractors to: 1) develop and implement controls over identified hazards, 2) perform 

work within defined hazard controls, and 3) provide feedback on and continuous 

improvement to safety systems. 

The Lawrence Livermore National Laboratory (Livermore) is a government-owned, 

contractor-operated facility which is part of the Department of Energy's National Nuclear 

Security Administration (NNSA). A key mission of the Laboratory is to ensure the 

safety, reliability, and performance of the national nuclear weapons stockpile. To meet 

its mission, Livermore employees perform a wide variety of tasks some of which place 

workers in or near hazardous conditions or materials. Since 2003, Livermore has 

experienced an above average illness and injury rate. relative to other sites within the 

Department's nuclear weapons complex. Beca~~se of the emphasis that you and the 

NNSA Administrator have placed on worker safety. we initiated an audit to determine if 

Livernlore had fully implemented an ISM system. 

RESULTS OF AUDIT 

We concluded that Livernlore had not fully implemented an ISM system to improve its 

safe conduct of work. Specifically, we examined three safety incidents and found that 

Livermore had not always: 

Developed and implemented controls to eliminate hazards; 

Performed work within defined controls; and, 

Provided feedback to managers about identified hazards or aggressively pursued 

continuous improvement in safety. 
These incidents involved a near-miss incident associated with hoisting and rigging heavy 

equipment, a fall from a ladder, and radiation exposure. 

We found that Livermore did not always analyze safety issues to determine the extent of 

condition and root cause. For example, even though Livennore had multiple safety 

deficiencies involving non-standard ladders over a three year period, it had not performed 

an "extent of condition" analysis that would have indicated the existence of a systemic 

problem. Livennore's ability to fully analyze and resolve safety concerns was limited by 

missing and inconsistent data in its system to track safety issues. 

In addition, NNSA's Livennore Site Office (LSO) did not ensure that contractor 

performance measures associated with safety encouraged in~proven~ent in Livermore's 

implementation of ISM. Although Livennore continued to have a higher than average 

illness and injury rate since 2003, LSO had not adjusted Livermore's performance 

measures, or related fees, to establish quantifiable rate reduction goals. We concluded 

that until Livermore implements an effective ISM system, NNSA cannot be assured that 

future worker-related illnesses and injuries will be prevented. The implications of 

preventable accidents occurring are significant, both in terms of lost productivity and 

personal pain and suffering. 

On October 1, 2007, the contract to operate Livermore transitioned to a new contractor, 

Lawrence 1,ivermore National Security, LLC. The new performance-based contract 

includes measures and incentives for the completion of specific safety initiatives that if 

effectively implemented would address a number of issues discussed in this report. For 

example, LSO included a performance measure to reduce the number of illnesses and 

injuries at Livermore. In addition, the new contractor has announced the establishment of 

workshops to identify opportunities for safety improvements and is developing a 

contractor assurance system to address and facilitate needed improvements in ISM. 

While these are positive steps, our report includes additional actions that can be taken to 

improve safety at Livennore. 

MANAGEMENT REACTION AND AUDITOR COMMENT 

Management generally agreed with the report and recommendations. However, 

management disagreed with our statements regarding the application of safety metrics 

relevant to the contractor's performance fee. Management's specific comments and our 

reaction are discussed in the body of this report. Management comments have been 

provided in their entirety in Appendix 3. 

Attachment 

cc: Acting Deputy Secretary 

Administrator, National Nuclear Security Administration 

Chief of Staff 
REPORT ON THE IMPLEMENTATION OF INTEGRATED SAFETY 

MANAGEMENT AT LAWRENCE LIVERMORE NATIONAL 

LABORATORY 

TABLE OF 

CONTENTS 

Recurring Safety Incidents

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

Recommendations and Comments...........................................7 

Appendices

1. Objective, Scope, and Methodology...................................9 

2. Related Audit Reports.......................................................10 

3. Management Comments ...................................................12
Integrated Safety Management at Livermore_____________________

Page 1 Details of Finding 

Recurring Safety The National Nuclear Security Administration's (NNSA) 

Incidents Lawrence Livermore National Laboratory (Livermore) 

sustained an above-average injury rate within the 

Department of Energy's (Department) nuclear weapons 

complex during Fiscal Years (FY) 2003 to 2007. In 

particular, Livermore experienced three significant safety 

accidents and incidents involving a fall from a ladder, 

radiation exposure, and a near-miss incident associated 

with hoisting and rigging heavy equipment. We analyzed 

these safety accidents and incidents to determine whether 

weaknesses in Livermore's implementation of Integrated 

Safety Management (ISM) requirements contributed to 

their occurrence. 

Weaknesses In We determined that Livermore had not fully implemented 

ISM System of its ISM system to improve the safe conduct of work. 

Controls Specifically, Livermore had not always: (1) developed and 

implemented hazard controls; (2) performed work within 

hazard controls; and, (3) provided feedback and continuous 

improvement, which contributed to the three significant 

safety incidents. 

Developing Hazard Controls

Livermore did not always develop and implement hazard 

controls over work processes. On July 31, 2006, an 

employee using a non-standard, permanently affixed ladder 

to perform roof maintenance fell approximately six feet to 

the ground. He sustained multiple fractures and was 

hospitalized for 26 days. Prior to this accident, Livermore 

had identified at least six safety deficiencies related to the 

use of non-standard, permanently affixed ladders. In fact, 

two of these identified safety deficiencies involved 

inadequate handrail spacing; the other four deficiencies 

involved issues such as non-standard rung spacing. Rather 

than implementing controls on a Laboratory-wide basis for 

all non-standard ladders, Livermore implemented hazard 

controls for each deficiency by removing the specific 

ladder from service. Had Livermore developed and 

implemented adequate hazard controls on a Laboratorywide basis, this accident may have been prevented. 
________________________________________________________________

Page 2 Details of Finding 

In another case, Livermore had not developed and 

implemented appropriate controls over a hazard posed by a 

glove-box that exceeded radiation limits. On August 19, 

2004, a repackaging activity involving a transuranic waste 

drum was being conducted inside a vendor designed glovebox. As a result of inadequate containment by the glovebox, contamination was released and four employees 

working in or near the glove-box area were exposed to 

radiation levels exceeding control limits. Prior to this 

exposure, however, eight occurrences of contamination 

levels exceeding the control limits had been detected and 

reported in the same work area. According to Livermore, 

the glove-box had been used at other Department sites and 

had known radioactive contamination that prevented 

Livermore from safety pressure testing the system before 

putting it into operation. Although Livermore implemented 

a number of hazard controls, an analysis of the August 

2004 exposure incident determined that conditions leading 

to prior observed contaminations were not addressed 

aggressively enough. Further, the analysis pointed out that 

appropriate hazard controls including the evaluation and insitu testing of the vendor's radiation confinement system 

had not been implemented. 

Performing Work Within Hazard Controls 

Livermore did not always ensure that work was performed

within established hazard controls. For example, in June 

2007, workers at Livermore's National Ignition Facility 

(NIF) did not hoist and rig heavy equipment within 

established controls, resulting in what Livermore classified 

as a near-miss of a significant accident. Specifically, a 

suspended load shifted off its center of gravity and lodged 

between nearby structures. An incident review found that 

workers had not followed the controls established to 

address hazards associated with hoisting and rigging the 

equipment. 

Livermore assessments determined that during three prior 

hoisting and rigging events at NIF, personnel had failed to 

follow established controls. Fortunately, these situations 

did not result in an accident. The assessments findings, 

however, demonstrated that NIF personnel did not always 

use established controls. These recurrences should have 
________________________________________________________________

Page 3 Details of Finding 

alerted Livermore that it was not meeting the ISM 

requirement for ensuring that work was performed within 

established controls. 

Provide Feedback and Continuous Improvement

Livermore did not effectively use feedback and continuous 

improvement processes to ensure that identified hazards 

were addressed. Specifically, an NNSA appraisal of the 

previously discussed radiation exposure incident noted that 

between February 2003 and December 2004, Livermore 

had issued 12 occurrence reports on similar radiological 

incidents. Concerns about the adequacy of radiological 

contamination controls continued to exist in January 2007, 

when Lawrence Livermore National Security, LLC, 

assumed responsibility for the Laboratory. During a "walkdown" of Livermore, the new contractor concluded that 

contamination controls needed to be improved to avoid 

putting workers at increased risk to exposure. As recently 

as January 2008, an independent assessment confirmed that 

Livermore management had been informed about radiation 

control problems, but had not taken the necessary action to 

correct known problems. 

Analysis of Safety Livermore's ISM program was not fully effective because 

Incidents it did not perform adequate analyses to identify 

and correct systemic safety issues and deficiencies. 

Specifically, the Laboratory did not always analyze safety 

accidents and incidents to define the extent of conditions or 

their root causes and the appropriate corrective actions. In 

addition, Livermore’s ability to analyze safety accidents 

and incidents was hampered by missing and inconsistent 

data in its management information systems. Finally, 

NNSA's Livermore Site Office (LSO), which is responsible 

for administering the Livermore contract, did not ensure 

that performance measures associated with safety 

encouraged improvement in Livermore's implementation of 

ISM. 

Safety Issues Analyses

Livermore did not always analyze safety accidents and 

incidents to identify the existence of systemic safety issues 

and deficiencies. For example, Livermore did not perform 

an extent of condition assessment of recurring safety 

deficiencies associated with the use of non-standard 

ladders. Instead, Livermore corrected deficiencies on
________________________________________________________________

Page 4 Details of Finding 

a case-by-case basis. An investigation board noted that, 

prior to the July 31, 2006, accident, several opportunities to 

identify the hazards associated with non-standard ladders 

existed, but Livermore closed out the findings without 

fixing the problem. However, it was only after the 2006 

accident that Livermore performed an assessment of fixed 

ladders; and determined that 164 unsafe ladders needed to 

be removed from service or repaired. 

In order to effectively develop and implement hazard 

controls and to achieve continuous safety improvement, 

ISM guidance recognizes that it is important for 

organizations to identify the root cause of known safety 

issues and deficiencies. However, Livermore did not 

always perform root cause analyses of similar or systemic 

safety accidents and incidents that could have prevented 

their recurrence. In the case of four workers who were 

exposed to radiation levels above control limits, Livermore 

had not performed root cause analyses of eight previous 

occurrences when radiation levels were above control 

limits in the waste handling process area. 

While Livermore had taken a number of corrective actions 

to minimize the possibility of leaks from the waste 

processing glove-box, an incident investigation conducted 

after the four workers had been exposed found that these 

corrective actions were ineffective. The investigation also 

concluded that root cause analysis had not been 

systematically used to evaluate contamination issues during 

operations. The investigation concluded that the primary 

cause of the incident was that Livermore's formal 

acceptance and testing of the vendor's confinement system 

was less than adequate. 

Missing and Livermore's ability to analyze safety accidents and 

Inconsistent Data incidents was also hampered by missing and inconsistent 

data. Livermore used its Issues Tracking System (ITS) to 

track safety deficiencies and issues. The ITS provides a 

centralized database for managing deficiencies, issues and 

corrective actions arising from assessments and events. 

The data in ITS are also used to identify trends and analyze 

cross-directorate issues and deficiencies Laboratory-wide. 

However, an internal Livermore report noted that not all 

safety issues have been entered into ITS and that some 

information was entered inconsistently. For instance, in 
________________________________________________________________

Page 5 Details of Finding 

 August 2007, Livermore reported that 64 percent of the

issues tracked in the Department's Noncompliance 

Tracking System (NTS) could not be confirmed in ITS. 

The NTS is a database for Department contractors to report 

unsafe actions or conditions that possibly violate nuclear 

safety requirements for protecting workers and the public. 

In other cases, data entered into ITS was not always 

consistent. For example, 24 percent of deficiencies entered 

into ITS did not clearly specify the areas of noncompliance. Although Livermore has recently 

implemented procedures that should ensure all NTS reports 

are entered into ITS, it had not established needed controls, 

such as appropriate edit checks. Livermore has provided 

additional training to employees who enter data that should 

improve data consistency. In addition, Livermore was 

developing procedures to address the absent controls 

indentified during the audit. However, without complete 

and consistent data, ITS analyses may not accurately 

identify systemic safety issues or facilitate the 

identification of the root cause of safety issues and 

deficiencies. 

Additionally, Livermore's ITS database did not show 

whether issues and deficiencies previously reported as 

being corrected had recurred. Such data and use of ITS to 

determine the frequency and recurrence of safety issues and 

deficiencies are vital to effective analyses to identify 

systemic weaknesses over multiple years and the impact of 

corrective actions. 

Safety Performance Measures

Neither NNSA nor LSO ensured that performance 

measures associated with safety encouraged improvement 

in Livermore's implementation of ISM. Even though 

Livermore had a higher than average rate for illnesses and 

injuries, LSO did not establish performance measures that 

quantified an expectation for reducing illnesses and injuries 

at Livermore. For example, from FYs 2004 through 2007, 

Livermore's performance measures related to safety 

included measures such as "Achieve continual 

improvement in ISM." 
________________________________________________________________

Page 6 Details of Finding 

Prior to FY 2003, LSO had established quantifiable 

performance metrics for Livermore such as radiation dose 

levels to workers and the public, and exposures to 

chemical, physical, and biological agents. LSO explained 

that, as part of NNSA's reengineering of the performance 

measures, LSO simplified the Laboratory's performance 

measures and evaluation process. For FY 2003 and 

beyond, the new performance plan consisted of nine high 

level performance objectives that were segregated into two 

categories: Mission, and Management and Operations 

which included safety. Specifically, LSO identified 

measures to encourage improvement of safety performance 

with emphasis on three areas that were considered high 

priority: feedback and improvement, nuclear safety, and 

emergency preparedness. 

In addition, LSO could not adequately explain how it used 

performance ratings or fees to encourage implementation of 

ISM at Livermore. For example, Livermore's contract 

provides for a 50 to 26 percent reduction, or no reduction if 

warranted by mitigating factors, in the award fee for a 

significant accident similar to the one that occurred in 

2006. However, Livermore was rated as satisfactory and 

awarded 80 percent of the available fee for operations 

performance, which included safety, in FY 2006, the same 

rate and award that was given in FYs 2005 and 2007 when 

no significant accidents occurred. There was no 

documentation available to show that LSO had considered 

the accident as part of the operations performance 

evaluation. Furthermore, LSO officials were not aware of 

any mitigating factors that would have warranted a 

reduction in the penalty. 

The Department's Integrated Safety Management System 

Guide (Guide) provides suggestions for performance 

measures that can be used to implement and develop ISM. 

For example, the Guide suggests that field elements, such 

as LSO, should modify contractor performance measures 

annually to determine how effectively the contractor has 

implemented ISM and to reflect improved performance. 

Had LSO modified performance measures and adjusted 

awards to encourage improvement for implementing ISM, 

some illnesses and injuries may have been avoided.
________________________________________________________________

Page 7 Recommendations and Comments 

In FY 2008, LSO revised the performance measures to 

quantifiable performance measures which have been 

incorporated in the Performance Evaluation Plan. These 

measures were established to ensure that the Laboratory 

continues to strive for improvements in Environment, 

Safety and Health. 

Cost of Ineffective Over the past four years, Livermore has sustained higher 

Safety than average injury rates within the Department. Until 

Livermore implements an effective ISM system, workers 

may suffer from illnesses and injuries that could have been 

avoided. In addition, unnecessary costs related to illnesses 

and injuries will continue to be incurred directly through 

lost work hours and also indirectly in support costs. 

RECOMMENDATIONS We recommend that the Manager, LSO, ensure that 

 Lawrence Livermore National Laboratory:

1. Improve safety tracking capability so that it:

a. identifies safety issues, incidents and 

deficiencies that recur; and,

b. contains complete and consistent data. 

2. Performs appropriate analyses, including extent of 

condition and root cause analyses that identify 

systemic safety issues and their causes. 

We also recommend that the Manager, LSO: 

3. Annually adjust Livermore's safety performance 

measures to show continuous improvement in 

implementing ISM; and, 

4. Adjust performance fees, as appropriate, to reflect 

safety contractual requirements. 

MANAGEMENT Management generally agreed with the report and 

REACTION corresponding recommendations; however, they disagreed 

with our statement regarding safety performance measures 

and believed that the examples cited, relevant to 

performance measures, were misleading. While it 

acknowledged that Livermore's contract provides for a 

unilaterally reduced fee, management stated that the 

contract did not require a 50 to 26 percent reduction in the 

award fee for a significant accident, similar to the one that 
________________________________________________________________

Page 8 Comments 

 occurred in 2006. In addition, management stated that the 

Laboratory received 80 percent of the available fee earned 

for 2005 – 2007 based on overall operations performance, 

which included performance measures unrelated to safety. 

NNSA plans to address our recommendations by 

developing and coordinating appropriate corrective 

measures, not only for Livermore, but for the NNSA 

complex as a whole. Management comments are included 

in Appendix 3.

AUDITOR COMMENTS We agree that the contract does not require a specific percentage 

reduction in award fee provided there are mitigating factors. We 

also acknowledge that Livermore received a reduced award fee for 

the operations performance measure that included safety, security, 

environmental management and counterintelligence. However, our 

concern is that LSO could not demonstrate how it assessed 

contractor ISM performance and used performance measures to 

improve safety even though Livermore had a higher than average 

illness and injury rate. In particular, we found no evidence that 

LSO had considered the 2006 ladder accident cited in this report as 

part of the FY 2006 and FY 2007 performance evaluations. The 

ladder accident would be considered a second degree performance 

failure. The Livermore contract provided for the award fee to be 

reduced by 50 to 26 percent for such accidents with consideration 

for any mitigating factors. LSO management could not provide 

evidence concerning the existence of any mitigating factors. 
Appendix 1 

Page 9 Objective, Scope, and Methodology 

OBJECTIVE The objective of this audit was to determine if Lawrence 

Livermore National Laboratory (Livermore) has fully implemented 

an Integrated Safety Management (ISM) system. 

SCOPE The audit work was performed between March 2007 and 

April 2008. We conducted work at the NNSA's Livermore Site 

Office (LSO) and Livermore. Audit work was limited to the 

implementation of ISM between FYs 2004 and 2007. 

METHODOLOGY To accomplish the audit objective, we: 

• Reviewed regulations and policies and procedures relevant 

to the Department's Integrated Safety Management 

systems; 

• Reviewed specific guidance and policies and procedures; 

• Held discussions with the LSO and Livermore officials; 

and, 

• Reviewed specific planning documents, analyses, and 

reports relating to safety. 

We conducted this performance audit in accordance with 

generally accepted Government auditing standards. Those 

standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a 

reasonable basis for our findings and conclusions based on 

our audit objectives. We believe that the evidence obtained 

provides a reasonable basis for our findings and 

conclusions based on our audit objectives. The audit 

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. Also, we 

evaluated the Department's implementation of the 

Government Performance and Results Act of 1993 as they 

related to the audit objective. Finally, we did not rely upon 

automated data processing information to accomplish our 

audit objective. As discussed in the body of this report, our 

audit disclosed that missing and inconsistent data hampered 

analyses of safety accidents and incidents. 

Management waived an exit conference.
Appendix 2 

Page 10 Related Audit Reports 

RELATED AUDIT REPORTS

The Office of Inspector General and the Government Accountability Office have previously 

reported on safety programs at Department of Energy facilities. 

Office of Inspector General

• The report on Beryllium Surface Contamination at the Y-12 National Security 

Complex (DOE/IG-0783, December 2007) found that the Y-12 National Security 

Complex had not consistently implemented key controls of its Beryllium Disease 

Prevention Program in non-beryllium operations areas. Specifically, the Y-12 

National Security Complex, when surface contamination was found outside 

operational areas, had not always (a) posted signs alerting workers to the potential 

for beryllium surface contaminations, and (b) performed or documented hazard 

assessments for beryllium contamination. The report also identified a gap in the 

Department’s regulations which do not address surface contamination found 

outside beryllium operational areas. 

• The report on Beryllium Controls at the Oak Ridge National Laboratory

(DOE/IG-0737, September 2006) found that the Oak Ridge National Laboratory 

did not properly manage activities related to beryllium contaminated equipment in 

Building 9201-2, which is located at the Oak Ridge National Laboratory. In 

particular, beryllium contaminated equipment was transferred to non-beryllium 

areas; employees working with contaminated equipment were not fully identified 

and notified; transferred equipment was not labeled appropriately; and, the 

building was not posted as a potential contamination area. 

• The report on Inspection of K-25 Type A Accident Investigation (S98IS004, 

November 1997) found that five incidents involving welders’ clothing burning or 

catching fire and resulting in medical treatment at Department Oak Ridge sites had been 

reported in a management data system; however, key fire protection personnel at Oak 

Ridge were not aware of the reported incidents prior to the February 1997 welder fatality 

that was the subject of our review. We also found that the current revision of a national 

standard that contained a specific requirement that welders’ protective clothing “shall be 

selected to minimize the potential for ignition, burning, trapping hot sparks, or electric 

shock” was not incorporated into the Department’s contract with the pertinent site 

contractor. 

• The report on Summary Results of the Inspection of Issues Regarding the Scope of the 

Accident Investigation of the TRISTAN Fire at the Brookhaven National Laboratory 

(DOE/IG-0386, March 1996) found that the Type B Accident Investigation Board that 

investigated a March 1994 fire at the Brookhaven National Laboratory did not adequately 

address specific management systems and organizations as a root cause. Without a 

thorough root cause analysis of specific management systems, deficiencies in the exercise 

of oversight responsibilities by “upstream” management organizations may not be 

identified and corrected. Limited experience and training in accident investigation and, 
Appendix 2 

Page 11 Related Audit Reports 

thus, root cause analysis may have contributed to the Board conducting an accident 

investigation that did not adequately address specific management systems and 

organizations. 

Government Accountability Office (GAO)

• Nuclear and Worker Safety: Actions Needed to Determine the Effectiveness of 

Safety Improvement Efforts at NNSA's Weapons Laboratories (GAO-08-73 

October 2007). GAO noted that the nuclear weapons laboratories have 

experienced persistent safety problems, stemming largely from long-standing 

management weaknesses. GAO's review of nearly 100 reports issued since 2000 

found that the contributing factors to these safety problems generally fall into 

three areas: (1) relatively lax laboratory attitudes toward safety procedures; (2) 

laboratory inadequacies in indentifying and addressing safety problems with 

appropriate corrective actions; and, (3) and inadequate oversight by NNSA site 

offices. NNSA faces two principle challenges in its continuing efforts to improve 

safety at the weapons laboratories. First, the agency has no way to determine the 

effectiveness of its safety improvement efforts, in part, because those efforts 

rarely incorporate outcome-based performance measures. Secondly, the recent 

shifts in NNSA's oversight approach to rely more heavily on contractors' own 

safety management controls. Continuing safety problems, coupled with the 

inability to clearly demonstrate progress in remedying weaknesses, make it 

unclear how this revised system will enable NNSA to maintain an appropriate 

level of oversight of safety performance.
Appendix 3 

Page 12 Management Comments 
Appendix 3 (Continued) 

Page 13 Management Comments 
 

IG Report No. DOE/IG-0797

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