NUCLEAR SAFETY

DOE Needs to 

Determine the Costs 

and Benefits of Its 

Safety Reform Effort 

Report to Congressional Requesters

April 2012

GAO-12-347

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-347, a report to 

congressional requesters 

April 2012 

NUCLEAR SAFETY

DOE Needs to Determine the Costs and Benefits of 

Its Safety Reform Effort

Why GAO Did This Study

DOE carries out many of the nation’s 

most critical missions, including 

stewardship of the nation’s nuclear 

weapons stockpile and the 

environmental remediation of 

radioactive and hazardous legacy 

waste left over from the Cold War. 

DOE uses a system of regulations and

internal directives that lay out 

requirements and guidance for 

ensuring the safety of staff and 

contractors, the public, and the 

environment. Over the past 10 years, 

GAO and others have repeatedly made 

recommendations for DOE to improve 

safety performance. In March 2010, 

DOE announced a reform effort to 

revise safety-related directives to 

increase productivity and reduce costs 

while maintaining safety.

This report examines (1) how DOE 

revised safety directives under its 

reform effort, (2) the costs of the 

reform effort and the benefits DOE 

hoped to achieve, and (3) the extent to 

which its reform effort addresses safety 

concerns GAO and others have 

identified. GAO reviewed relevant DOE 

reform effort documents, visited 

selected DOE sites to interview site 

office and contractor officials, and 

analyzed past GAO and other reports 

on DOE’s safety problems.

What GAO Recommends

GAO recommends that DOE analyze 

the costs and benefits of its safety 

reform effort and identify how the effort 

will help address safety concerns. DOE 

agreed with the recommendations but 

commented that it had significant 

concerns about the accuracy of the 

report’s findings and conclusions. GAO 

stands by its findings and conclusions 

for the reasons discussed in the report. 

What GAO Found

Under its safety reform effort, the Department of Energy (DOE) reduced the 

number of safety directives by eliminating or combining requirements it 

determined were unclear, duplicative, or too prescriptive and by encouraging the 

use of industry standards. DOE reduced the number of its safety directives from 

80 to 42, and for some of the directives DOE retained, it made extensive 

revisions. For example, DOE deleted requirements from its quality assurance 

directive addressing a corrective action program because another safety directive 

adequately covered these requirements. DOE obtained comments on its 

proposed revisions from DOE and contractor staff and from the Defense Nuclear 

Facilities Safety Board (Safety Board). 

The benefits of DOE’s reform effort are not clear. DOE intended to enhance 

productivity and reduce costs while maintaining safety, but DOE did not 

determine how the original requirements contained in safety directives impaired 

productivity or added costs before undertaking the reform effort. Moreover, DOE 

did not assess whether the cost to implement the revised directives would 

exceed the benefits, but officials said they had launched an initial study to 

determine, among other things, the costs associated with implementing selected 

safety requirements. DOE also did not develop performance measures in order 

to assess how the reform effort will lead to improved productivity or lower costs 

while maintaining safety. Instead, DOE is measuring success by using outputoriented measures, such as the number of directives eliminated, and not 

outcome measures, such as specific productivity improvements or cost savings. 

In the absence of clear measures linking the reform effort to productivity and 

safety improvements, DOE is not well positioned to know that its reform effort will 

achieve the intended benefits.

DOE’s reform effort did not fully address safety concerns GAO and others have 

identified in three key areas: (1) quality assurance, (2) safety culture, and (3) 

federal oversight. Regarding quality assurance, DOE strengthened its quality 

assurance directive by clarifying that contractors must follow specific industry 

quality assurance standards, but quality assurance problems persist. For 

example, DOE proposed a nearly $250,000 fine against a contractor in July 2011 

after identifying quality assurance problems in an incident where a worker 

punctured his hand with a sharp object contaminated with plutonium. With regard 

to safety culture, DOE revised its Integrated Safety Management directives to

attempt to strengthen the safety culture at its sites, but DOE removed 

requirements for contractors to follow the directives because contractors already 

had to comply with safety management requirements in federal regulation. Safety 

Board officials raised concerns that the requirements in federal regulation are 

less detailed and, as a result, contractors may not implement safety practices as 

rigorously as if they were subject to the more specific requirements in DOE’s 

directives. Finally, regarding federal oversight, DOE revised its approach to place 

greater emphasis on having its independent oversight staff review safety design 

documents before facilities are constructed, rather than after they are built. Other 

changes, however, such as requiring oversight staff to coordinate their 

assessment activities with DOE site office and contractor staff, raise concerns 

about the oversight staff’s ability to provide a critical review of safety at DOE’s 

sites that is independent from DOE site office and contractor staff. 

To view the full product, click on GAO-12-347.

For more information, contact Gene Aloise at 

(202) 512-3841 or aloisee@gao.gov. 
Page i GAO-12-347 Reform of DOE Safety Directives

Letter 1 

Background 4

DOE’s Reform Effort Streamlined Directives, but Views on the 

Revisions Were Not Sought from the Public or Federal Agencies 

Other than the Safety Board 7

Benefits of DOE’s Reform Effort Are Unclear 10

DOE’s Reform Effort Did Not Fully Address Safety Concerns We 

and Others Have Identified 16

Conclusions 24

Recommendations for Executive Action 26

Agency Comments and Our Evaluation 26

Appendix I Scope and Methodology 30

Appendix II Comments from the Department of Energy 33

Appendix III GAO Contact and Staff Acknowledgments 46

Related GAO Products 47

Table

Table 1: Four Key Practices of Management Improvement 

Initiatives 14

Contents
Page ii GAO-12-347 Reform of DOE Safety Directives

Abbreviations

DOE Department of Energy

NNSA National Nuclear Security Administration

NRC Nuclear Regulatory Commission

OSHA Occupational Health and Safety Administration

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Page 1 GAO-12-347 Reform of DOE Safety Directives

United States Government Accountability Office 

Washington, DC 20548

April 20, 2012

Congressional Requesters

The Department of Energy (DOE) carries out many of the nation’s most 

critical missions, including stewardship of the nation’s nuclear weapons 

stockpile and the environmental remediation of radioactive and hazardous 

legacy waste left over from the Cold War era. Work carried out at DOE’s 

sites across the country involves, among other things, (1) research on 

dangerous nuclear materials, such as plutonium, and (2) the handling and 

disposal of radioactive and hazardous waste that, if not handled safely, 

could cause nuclear accidents or expose the public and the environment 

to heavy doses of radiation. DOE’s sites also conduct a wide range of 

other activities, including construction and routine maintenance and 

operation of equipment and facilities that also run the risk of accidents, 

such as those involving heavy machinery or electrical mishaps. The 

consequences of such accidents could be less severe than those 

involving nuclear materials, but they could also lead to long-term 

illnesses, injuries, or even deaths among workers.

DOE relies on contractors and subcontractors to perform day-to-day 

operations at most of its nuclear and nonnuclear facilities located at 

approximately 40 sites across the country.1 To help ensure safety at 

these sites, the department requires its contractors to adhere to federal 

safety laws; departmental regulations;2

 

1

Nuclear facilities include research and test reactors; facilities storing special nuclear 

materials, including plutonium; facilities that perform laboratory experiments on nuclear 

materials; and nuclear waste processing facilities. Nonnuclear facilities include office and 

administration buildings, emergency management facilities, and facilities performing 

experiments on chemical and other hazardous materials. 

and DOE requirements that are 

provided in the department’s system of directives—including DOE’s 

policies, orders, guides, and manuals. Among other things, DOE 

directives address the safe operation of nuclear facilities as well as 

worker safety. The department incorporates directives into contracts and 

holds contractors accountable for meeting them. DOE’s program offices—

2

Federal safety laws and regulations include 10 C.F.R. § 830, which addresses nuclear 

safety; 10 C.F.R. § 835, which addresses radiological safety; 10 C.F.R. § 851, which 

addresses worker safety; and 48 C.F.R. § 970.5223-1, which addresses integrated safety 

management. Contractor compliance with federal laws and regulations is mandatory and 

enforceable under law. For directives, DOE incorporates these into contracts. 

 
 

Page 2 GAO-12-347 Reform of DOE Safety Directives

both at headquarters and its sites—are responsible for directly overseeing 

the contractors to ensure safety requirements are being met. The 

department’s Office of Health, Safety, and Security independently 

oversees and enforces, among other things, nuclear and worker safety at 

DOE’s sites.

Over the years, federal officials, Congress, and others have expressed 

concerns about safety problems at DOE’s sites. For example, the 

Defense Nuclear Facilities Safety Board (Safety Board)—an independent 

executive branch agency created by Congress to independently assess 

safety conditions and operations at defense nuclear facilities at DOE’s 

sites—has held 11 public hearings over the past 10 years to address 

concerns about DOE’s safety practices. Additionally, in January 2005, the 

director of DOE’s Lawrence Livermore National Laboratory suspended all 

programmatic work at the laboratory’s plutonium-handling facility, largely 

because of numerous unresolved safety issues and a failure to address 

these issues adequately. Moreover, in October 2007, we reported that 

nearly 60 serious accidents or near misses had occurred at DOE’s 

nuclear weapons laboratories since 2000.3

In March 2010, the Deputy Secretary of Energy announced a new effort—

the 2010 Safety and Security Reform Plan (reform effort)—to revise 

DOE’s safety and security directives and reform its oversight approach to 

“provide contractors with the flexibility to tailor and implement safety and 

security programs without excessive federal oversight or overly 

prescriptive departmental requirements” while “maintaining the highest 

standards of safe and secure operations” at DOE’s sites. In the 

memorandum announcing this effort, the Deputy Secretary noted that 

burdensome safety requirements were affecting the productivity of work 

at DOE’s sites and that reducing this burden on contractors would lead to 

measurable productivity improvements.

For instance, at DOE’s Los 

Alamos National Laboratory in July 2004, an undergraduate student who 

was not wearing required eye protection was partially blinded in a laser 

accident. Accidents such as this one and nuclear safety violations 

focused attention on needed improvements in safety performance across 

DOE’s sites.

 

3

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

Safety Improvement Efforts at NNSA’s Weapons Laboratories, GAO-08-73 (Washington, 

D.C.: Oct. 31, 2007).
 

Page 3 GAO-12-347 Reform of DOE Safety Directives

In this context, you asked us to evaluate the department’s current reform 

effort. Although DOE’s 2010 Safety and Security Reform effort addresses 

both safety and security directives, this report focuses on revisions to 

DOE’s safety-related directives, which constitute 80 of the 107 directives 

included in the reform effort. Our objectives were to examine (1) how 

DOE revised safety directives under its reform effort, (2) the costs of the 

reform effort and the benefits DOE hoped to achieve, and (3) the extent to 

which DOE’s reform effort addresses safety concerns we and others have 

identified.

To conduct this work, we reviewed documents on DOE’s reform effort, 

including the overall strategy and implementation plan for the reform 

effort. DOE’s reform effort addresses directives both in the safety and 

security areas. This report focuses on safety, including nuclear safety, 

worker safety, quality assurance, oversight, and operating experience.4

We interviewed DOE officials at DOE headquarters in the Office of 

Health, Safety, and Security and in the National Nuclear Security 

Administration (NNSA), a semiautonomous agency within the department 

that is responsible for, among other things, the management and security 

of the nation’s nuclear weapons programs. To gain an understanding of 

the potential impact of the reform effort on DOE’s sites, we visited sites 

that were in various stages of implementing revised safety requirements. 

These sites were the Kansas City Plant in Missouri, the Nevada National 

Security Site in Nevada, the Lawrence Livermore National Laboratory in 

California, and the Hanford Site in Washington state.5 We interviewed 

both DOE and contractor officials at these sites. We also reviewed 

documents relating to safety performance measures,6

 

4

Revisions to DOE’s security directives under its reform effort will be the subject of a 

follow-on review. 

efforts to address 

safety problems, and oversight. We interviewed officials at other 

governmental agencies, including the Nuclear Regulatory Commission 

(NRC), which licenses and regulates commercial nuclear power plants, 

and the Department of Labor’s Office of Occupational Health and Safety 

5

Because this was a nonprobability sample of DOE’s sites, the information we collected is 

not generalizeable to all of DOE’s sites; however, this information is illustrative of various 

stages of the implementation of the revised safety requirements.

6

Performance measures allow an agency to track the progress it is making toward its 

mission and goals, provide managers information on which to base their organizational 

and management decisions, and create powerful incentives to influence organizational 

and individual behavior.
 

Page 4 GAO-12-347 Reform of DOE Safety Directives

(OSHA), which generally regulates worker safety and commercial 

industrial facilities. We also interviewed officials with the Safety Board to 

gain an understanding of the process of changing regulatory safety 

requirements. In addition, we interviewed officials from the American 

Society of Industrial Standards, an industry standards-making 

organization, to determine how industry standards are developed. To gain 

an understanding of DOE’s long-standing safety problems, we reviewed 

51 reports from the past 10 years by GAO, DOE’s Office of Inspector 

General, and the Safety Board. Appendix I presents a detailed description 

of our scope and methodology.

We conducted this performance audit from February 2011 through April 

2012 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.

DOE generally regulates the safety of its own nuclear facilities and 

operations at its sites. In contrast, NRC generally regulates commercial 

nuclear facilities, and OSHA generally regulates worker safety at 

commercial industrial facilities.7 DOE manages the safety of its facilities 

and operations at its sites through federal safety laws; departmental 

regulations; and a system of internal directives—that is, DOE policies, 

orders, guides, and manuals. DOE policies communicate top-level 

expectations for safety issues, such as conducting safe operations at 

high-hazard nuclear facilities. DOE orders are used as the primary 

directives for communicating requirements. DOE guides detail 

acceptable, but not mandatory, methods for implementing requirements 

contained in DOE orders, while manuals may contain both requirements 

and guidance.8

 

7

DOE regulates the safety of most of its own sites with nuclear operations, NRC regulates 

several DOE nuclear facilities, and OSHA regulates occupational safety at DOE sites that 

have no nuclear functions.

In total, DOE’s directives lay out requirements to be 

followed and guidance for implementing requirements to help ensure the 

safety of workers, the public, and the environment at DOE’s sites.

8

For purposes of this report, we refer to all these components as directives.

Background
 

Page 5 GAO-12-347 Reform of DOE Safety Directives 

To ensure adherence to the requirements in DOE’s directives, the 

department oversees its own operations. This oversight has three main 

components. First, DOE’s program offices—such as DOE’s Office of 

Environmental Management9

 and NNSA—have primary responsibility to 

safely carry out their program missions. Second, the site offices oversee 

the contractors that manage and operate DOE’s sites. DOE’s contractors 

are responsible for safely designing, constructing, and operating the 

facilities at these sites that they use to carry out their work. Third, DOE’s 

Office of Health, Safety, and Security is responsible for, among other 

things, the development of safety policy and conducting independent 

oversight of compliance with DOE’s safety regulations and directives, and 

enforcement activities. Within DOE’s Office of Health, Safety, and 

Security, the Office of Independent Oversight conducts periodic 

appraisals of the environment, safety, and health programs at DOE’s sites 

to determine if DOE officials and contractors are complying with DOE’s 

safety regulations and directives.10

DOE also receives safety assessments and recommendations from other 

organizations, most prominently the Safety Board. The Safety Board 

provides independent safety oversight of DOE’s defense nuclear facilities, 

which are located at 13 DOE sites across the United States. The Safety 

Board has broad oversight responsibilities at defense nuclear facilities 

located at DOE’s sites and seeks to use informal interactions with DOE to 

resolve safety issues that are of concern to the Safety Board. However, 

the Safety Board also uses formal communications, such as 

recommendations, to address more substantial safety issues at a facility 

or site as well as broader safety issues across DOE’s sites. Other 

organizations that provide assessments to DOE on the management of its 

sites include DOE’s Office of Inspector General, the National Academy of 

Sciences, and GAO. 

In March 2010, the Deputy Secretary of Energy issued a memorandum 

that announced a reform effort aimed at revising DOE’s 80 safety-related 

 

9

DOE’s Office of Environmental Management is responsible for the treatment and 

disposal of radioactive and hazardous waste created as a by-product of nuclear weapons 

production and energy research. 

10During our review, DOE reorganized offices within the Office of Health, Safety, and 

Security. The Office of Independent Oversight merged with the Office of Enforcement and 

was renamed the Office of Enforcement and Oversight. For the purposes of this report, we 

refer to it as the Office of Independent Oversight. 
 

Page 6 GAO-12-347 Reform of DOE Safety Directives

directives and the department’s approach to regulating and overseeing 

safety at its sites.11 In announcing the reform effort, the Deputy Secretary 

noted that it was aimed at (1) providing increased recognition of program 

management’s responsibility for safety, (2) reviewing opportunities to 

streamline safety requirements, and (3) eliminating safety directives that 

do not add value. The reform effort was intended to provide contractors 

with the flexibility to tailor and implement safety programs without 

excessive federal oversight or overly prescriptive departmental 

requirements, while also maintaining safety at DOE’s sites. Key elements 

of the reform effort included reviewing the department’s safety directives 

to (1) clarify and streamline wording in them; (2) increase the use of 

external (non-DOE) standards, such as industry standards and those 

from other regulatory agencies;12

DOE’s reform effort mirrors another reform effort underway at NNSA. 

Known as “governance transformation,” NNSA’s effort involves revising 

the agency’s business model to, among other things:

(3) focus oversight activities on high-risk 

activities and contractors with poor safety records; and (4) provide more 

reliance on contractor systems that reliably measure the effectiveness of 

their safety management systems and ability to implement effective 

corrective actions.

• more clearly establish roles of federal oversight staff and contractors;

• place more reliance on contractor’s self-oversight through its 

contractor assurance systems to ensure such things as safety 

performance;

• allow contractors to tailor safety and other requirements to their work 

without overly prescriptive DOE requirements; and

 

11As discussed previously, DOE’s reform effort addressed directives in both the safety and 

security areas. This report focuses on the effort’s reform of DOE’s safety directives.

12The use of standards and requirements developed by private standards-making 

organizations is required for federal agencies. The Office of Management and Budget’s 

Circular A-119 directs government agencies to use voluntary consensus standards in lieu 

of government-unique standards except where they are inconsistent with law or are 

otherwise impractical. Voluntary consensus standards are developed by domestic or 

international organizations that use consensus to adopt agreed-upon procedures. Other 

standards, such as industry standards, are developed by private sector organizations, but 

not using a consensus process. An example of a standards-making organization is the 

International Standards Organization.
 

Page 7 GAO-12-347 Reform of DOE Safety Directives

• promote the use of national and international standards as 

appropriate, rather than departmentally unique requirements.

NNSA’s Kansas City Plant has completed implementation of this new 

model, and other NNSA sites—such as the Nevada National Security Site 

in Nevada and Y-12 National Security Complex at Oak Ridge, 

Tennessee—are currently implementing the changes.

Under its reform effort, DOE reduced the number of safety directives by 

eliminating or combining, among other things, requirements it determined 

were unclear, duplicative, or too prescriptive; allowing contractors 

additional flexibility; and encouraging the use of industry standards. In 

revising its directives, DOE followed a systematic process that included 

obtaining the views of staff from within DOE and its contractor community 

and from the Safety Board, but it did not seek input from the public or 

other federal agencies.

In total, under its reform effort, DOE reduced the number of its safety 

directives from 80 to 42. When deciding whether to keep, revise, or 

eliminate a safety directive, DOE identified a justification for the 

directive—that is, why the directive was first established and what it 

should accomplish. For example, DOE’s safety directive requiring the 

development of a departmentwide system to collect, communicate, and 

evaluate lessons learned about operating nuclear and other facilities was 

established in 2006 in response to, among other things, the 2003 

explosion of the Space Shuttle Columbia where inadequate collecting and 

sharing of operating lessons learned was found to have contributed to the 

accident.13

 

13DOE, DOE Corporate Operating Experience Program, DOE Order 210.2 (Washington, 

D.C.: June 12, 2006).

According to DOE documents, the department determined that 

it would not eliminate this directive because it helped establish good work 

practices and enabled the sharing of information across DOE’s sites. In 

contrast, DOE eliminated its policy directive on recruiting and training 

DOE’s Reform Effort 

Streamlined 

Directives, but Views 

on the Revisions Were 

Not Sought from the 

Public or Federal 

Agencies Other than 

the Safety Board

DOE Revised Its Safety 

Directives to Reduce 

Duplication, Allow 

Contractors Additional 

Flexibility, and Encourage 

the Use of Industry 

Standards
 

Page 8 GAO-12-347 Reform of DOE Safety Directives

federal employees that ensured the employees had sufficient technical 

knowledge of safety issues. This directive was established in 1998 to 

provide departmental expectations for maintaining sufficient federal 

technical safety capability. In undertaking its reform effort, DOE 

concluded this policy had served its purpose and was no longer needed 

as a stand-alone directive because a companion directive implementing 

the requirements for recruiting and training staff to safely carry out work 

was sufficient.14

If DOE decided to retain rather than eliminate an entire safety directive, 

DOE officials undertook a line-by-line examination of the specific 

requirements contained within the directive. This examination was 

intended to determine whether revisions to the requirements were 

necessary to make them more easily understandable and to eliminate 

confusion arising from having similar requirements in multiple directives. 

As mentioned, the examination included determining why each 

requirement was initially established. For example, some specific 

requirements in a DOE directive may have been the result of 

recommendations from the Safety Board or the result of a long-standing 

DOE or industry practice. Establishing the reason why a requirement was 

initially created assisted the DOE officials who were undertaking the lineby-line examination to determine whether revisions were necessary.

Within the safety directives that DOE retained, DOE eliminated some 

requirements that department officials determined were unclear, 

duplicative, or too prescriptive. In particular, DOE removed requirements 

that it determined already existed in other safety directives or regulations. 

In its quality assurance directive, for example, DOE deleted 61 of 245 

requirements for a corrective action program because it determined that 

the requirements were adequately addressed in revisions to other 

directives on oversight practices.15

 

14DOE, Federal Technical Capability Policy for Defense Nuclear Facilities, DOE Policy 

426.1 (Washington, D.C.: Oct. 10, 1998).

DOE also eliminated requirements that 

it identified as being too prescriptive. For example, in revising its oversight 

directives, DOE modified requirements that defined specific components 

that a contractor’s oversight system must have. DOE revised the 

requirements to allow contractors the flexibility to develop their own 

15DOE, Quality Assurance, DOE Order 414.1C (Washington, D.C.: June 17, 2005). 
 

Page 9 GAO-12-347 Reform of DOE Safety Directives

oversight systems, as long as those oversight systems could generally 

provide assurance that work was being performed safely.16

DOE also revised directives to promote greater use of industry standards. 

For example, DOE modified its quality assurance directive to require its 

contractors to follow industry standards—or its equivalent—for nuclear 

facility quality assurance that were developed by the American Society of 

Mechanical Engineers.

In addition, DOE revised directives to refocus federal oversight on the 

performance of high-risk activities and placed greater responsibility on 

contractors to oversee lower-risk activities. For example, DOE revised a 

directive detailing how accident investigations should be carried out by 

eliminating one of two categories under which a federally led accident 

investigation would take place. Under the revision, a federal investigation 

would be initiated using some, but not all, of the criteria previously 

established under the two categories. Accidents not meeting these 

criteria, including some that would have initiated federal accident 

investigations, are the responsibility of the contractors themselves to 

investigate.17

As part of its process to revise its directives, DOE obtained comments 

from federal and contractor officials on proposed revisions. For example, 

DOE used “red teams”—groups of management-level staff who reviewed 

each of the proposed revisions before a revised directive received 

departmentwide review. DOE’s red teams reviewed proposed revisions to 

directives to determine (1) whether the original requirements provided 

adequate safety protection, (2) the impacts of the proposed revisions and 

whether unintended consequences were analyzed, and (3) whether the 

original requirements provided sufficient flexibility in implementation 

without increasing safety risks or whether further revisions were needed. 

The red teams were intended to provide an independent review of 

proposed revisions to ensure they met the objectives of the reform effort.

 

16DOE, Implementation of Department of Energy Oversight Policy, DOE Order 226.1A

(Washington, D.C.: July 31, 2007). 

17DOE, Accident Investigations, DOE Order 225.1A (Washington, D.C.: Nov. 26, 1997).

DOE Obtained Views on 

Proposed Changes from 

DOE and Contractor Staff 

and from the Safety Board, 

but Did Not Seek the 

Views of the Public or 

Other Federal Agencies
 

Page 10 GAO-12-347 Reform of DOE Safety Directives

DOE generally obtained comments on proposed revisions to its directives 

from affected DOE federal and contractor staff by using its departmentwide 

review system. This review system—called RevCom—is an online system 

that disseminates proposed revisions to DOE federal and contractor staff 

for their review and comment on the revisions’ content, relevance, 

applicability, accuracy, impact, and implementation cost.

DOE also obtained comments from the Safety Board, which is 

responsible for overseeing nuclear safety at DOE and for independently 

reviewing proposed revisions to relevant safety directives. DOE officials 

told us they generally discussed the reform process with trade unions 

whose members are employed at DOE’s sites. However, DOE did not 

provide other stakeholders or the public with an opportunity to comment 

on proposed revisions to the directives, according to DOE officials we 

spoke with. Other external stakeholders that could have provided input 

included agencies that have similar safety expertise, such as NRC or 

OSHA. NRC and OSHA officials told us that they are required by law to 

obtain the public’s views on any changes in their safety regulations, which 

generally contain requirements for private employers. Although DOE is 

required to obtain comments on changes to its safety regulations, DOE is 

not required to obtain the public’s views on its internal directives, many of 

which contain requirements for DOE’s contractors. NRC and OSHA 

officials told us that obtaining a wide range of comments on proposed 

revisions can be very helpful in developing quality regulations that 

balance cost with the expected benefits of the regulations. They said that 

obtaining a wide range of comments also assists them to build support for 

the changes.

Under its reform effort, DOE intended to enhance productivity and reduce 

costs while maintaining safety, but it is unclear whether its effort will 

achieve these benefits, or whether the benefits will outweigh the costs to 

implement the reform. For example, DOE did not determine how the 

original requirements contained in safety directives impaired productivity 

or added costs before undertaking the reform effort. Moreover, DOE did 

not establish clear goals and performance measures to determine the 

potential benefits of its reform effort. As a result, DOE is not well 

positioned to know that its reform effort will achieve its intended benefits.

Benefits of DOE’s 

Reform Effort Are 

Unclear
 

Page 11 GAO-12-347 Reform of DOE Safety Directives

According to the Deputy Secretary’s March 2010 memorandum 

announcing the reform effort and discussions with DOE officials, DOE 

undertook the reform effort to realize productivity and cost benefits while 

maintaining safety. According to the memorandum, achieving these 

benefits would be accomplished, in part, by revising requirements 

considered to be burdensome and overly prescriptive.18

To identify safety requirements that were burdensome and overly 

prescriptive, DOE’s Associate Deputy Secretary told us that DOE and 

contractor officials used their experience and judgment. It is unclear, 

however, whether the safety requirements these officials identified were 

indeed burdensome because DOE and contractor officials we spoke with 

could not provide clear examples of how these requirements negatively 

affected productivity or costs or criteria that they used for making a 

determination that they were burdensome. Specifically:

• At the request of the Secretary of Energy, senior managers at DOE’s 

national laboratories participated in an informal May 2011 study of the 

DOE policies they considered to be the most burdensome. Four of the 

18 most burdensome policies the laboratory managers identified in 

this study addressed safety-related issues—excessive oversight; 

duplication between directives and industry standards; directives with 

requirements that provide no value, including DOE’s quality 

assurance directive; and excessive safety reporting. In the study, 

however, the laboratory managers did not provide specific examples 

of burdensome safety requirements or criteria that could be used for 

making a determination of what is burdensome.19

 

18On January 18, 2011, the President issued Executive Order 13563, Improving 

Regulation and Regulatory Review, to ensure that federal regulations seek more 

affordable, less intrusive means to achieve policy goals and that agencies give careful 

consideration to the benefits and costs of those regulations. Exec. Order No. 13,563, 76 

Fed. Reg. 3821 (Jan. 21, 2011).

For example, the 

19National Laboratory Directors Council, NLDC Prioritization of Burdensome Policies and 

Practices, (May 31, 2011). The study discussed a list of 18 policies and practices 

identified as the most burdensome by senior managers at each of DOE’s 18 national 

laboratories. The four safety-related burdensome policies included: (1) excessive 

oversight through a “piling on” of audits and assessments without clear risk prioritization, 

coordination, or value; (2) unnecessary requirements in DOE’s Worker Safety and Health 

Program, which establishes the requirements for a worker safety and health program that 

reduces or prevents occupational injuries, illnesses, and accidental losses, among other 

things, under 10 C.F.R. § 851; (3) maintaining directives that add no value, such as the 

quality assurance order, and become audit-bait for overseers; and (4) requiring 

unnecessary reporting on safety and other issues.

DOE Sought to Enhance 

Productivity and Reduce 

Costs but Did Not First 

Analyze Burden or Costs 

of the Original 

Requirements
 

Page 12 GAO-12-347 Reform of DOE Safety Directives

senior laboratory official who led the study could not provide us 

examples of specific safety requirements that were burdensome from 

the survey data collected from the laboratories’ managers. The official 

also could not provide an explanation of how burdensome 

requirements affected productivity or costs or how changes to them 

would be an improvement.

• In response to the concerns of several senior contractor and federal 

staff in NNSA that DOE’s nuclear safety requirements may be 

burdensome or overly prescriptive, NNSA launched a study to 

determine the strength of these concerns. In April 2011, as a result of 

the study, NNSA reported that the original requirements did not place 

an undue burden on the contractors.20

In terms of productivity, DOE officials indicated that productivity 

improvements from reducing burdensome requirements will be achieved. 

For example, several senior DOE officials told us that increases in 

productivity would result from raising the threshold at which a nuclear 

facility, such as a facility treating radioactive waste, would be required to 

undergo a rigorous review process before starting up to ensure it will 

operate safely. This review process involves federal staff review of a 

contractor’s detailed set of facility startup procedures, contractor 

preparation of a detailed plan to correct any deficiencies found during that 

review, and preparation of a detailed report indicating how any 

deficiencies were resolved. This rigorous review was previously required 

whenever any facility’s operations were restarted, even after routine 

maintenance. Under the reform effort, this level of review is now only 

required for facilities and activities posing a higher risk, such as starting 

up a newly constructed nuclear facility, and not required for facilities and 

activities posing lesser risk, such as restarting facilities after routine 

maintenance. According to two officials from DOE’s Office of Health, 

Safety, and Security, the revised requirement will help free up federal 

resources to focus on higher-risk activities, such as the startup of a newly 

The study found that senior 

contractor managers considered that DOE nuclear safety 

requirements provided a sound framework to safely operate nuclear 

facilities. These managers noted, however, that DOE had not clearly 

communicated its safety requirements, which resulted in uneven 

implementation of these requirements across NNSA’s sites.

 

20NNSA, Improving Nuclear Safety Requirements—Discussions with NNSA and 

Contractor and Site-Office Management (Washington, D.C.: Apr. 14, 2011).
 

Page 13 GAO-12-347 Reform of DOE Safety Directives

constructed nuclear waste processing facility, instead of lower-risk 

activities, which are the responsibility of the contractor to manage safely.

DOE did not analyze the costs of the original requirements or attempt to 

quantify how revising or eliminating requirements would reduce costs. 

DOE officials told us that cost savings are expected as a result of having 

a more streamlined, clear, and nonduplicative set of requirements. 

However, according to DOE officials, the department had not developed 

estimates of the cost savings it expected. According to DOE’s Associate 

Deputy Secretary, the department has launched an initial study of 

selected directives to determine how changes to these directives have 

impacted mission work, schedule, and costs, among other things.

Moreover, it is not clear whether the reform’s benefits will exceed the 

costs of implementing the revised directives, as DOE’s reform effort is 

likely to add costs in the short term. Specifically, several officials at DOE’s 

Hanford Site told us that contractors will have to perform cost-impact 

analyses prior to implementing the revised directives in their contracts. 

These officials estimated that it can cost $20,000 to $50,000 to conduct 

this type of analysis for each revised directive.

As we have previously reported, high-performing organizations typically 

follow four key practices to ensure management improvement initiatives 

are successfully implemented and achieve their intended benefits.21

These practices include: (1) establishing clearly defined goals, (2) 

developing an implementation strategy that sets milestones and 

establishes responsibility, (3) establishing results-oriented outcome 

measures early in the process, and (4) systematically using resultsoriented data to evaluate the effectiveness of the initiative and make 

additional changes where warranted. Table 1 describes characteristics of 

these four key practices, as identified by us and others, including DOE.

 

21GAO, Contract Reform: DOE Has Made Progress, but Actions Needed to Ensure 

Initiatives Have Improved Results, GAO-02-798 (Washington, D.C.: Sept. 13, 2002).

DOE Did Not Determine 

the Potential Benefits of 

Its Reform Effort by 

Establishing Clear Goals 

and Performance 

Measures
 

Page 14 GAO-12-347 Reform of DOE Safety Directives

Table 1: Four Key Practices of Management Improvement Initiatives 

Key practices Characteristics of key practices

Clearly defined goals • Goals are targeted levels of performance, expressed as 

tangible, measurable objectives against which achievement 

can be compared.

• Good goals should, among other things, be understandable 

and expressed in simple, clear terms so as to avoid 

misinterpretations or vagueness.

Implementation strategy • Strategy sets milestones, assigns roles and responsibilities, 

describes key tasks, and establishes timelines for the 

implementation of the reform.

• Strategy provides a guideline for near-term, as well as 

longer-term, implementation of the initiative to ensure that 

the long-term goals of the initiative are achieved.

Outcome measures • Measures assess the results of a program activity or effort 

compared to its intended purpose.

• Good performance measures, among other things, reflect 

results, not the activities used to produce results; relate 

directly to a performance goal; are practical and easily 

understood by all; and provide a benefit that exceeds the 

cost. 

Effectiveness evaluation • The evaluation uses results-oriented measures and 

supporting performance data to assess the effectiveness of 

an initiative and to identify any necessary changes, 

corrective actions, or follow-up actions to better achieve the 

underlying goals or objectives of the initiative.

Source: GAO analysis of prior GAO reports, DOE documents, and Office of Management and Budget guidance.

DOE did not completely follow these key practices to assess benefits 

when revising or planning for the implementation of the department’s 

safety directives. Specifically:

• Clearly defined goals. DOE’s stated goals—enhancing productivity 

and reducing costs while maintaining safe operations—are defined so 

generally that they do not lead to the development of tangible, 

measurable objectives against which achievement can be compared. 

For example, the goal of reducing costs does not specify those safety 

areas where DOE believes savings can be achieved. Moreover, 

because the goals are so general, DOE site office and contractor 

officials expressed concern about the lack of effective communication 

about what the reform effort is trying to achieve. For example, some 

NNSA officials at the Nevada National Security Site told us that the 

goals of the reform effort are unclear. Without clear goals that are 

objective, measurable, and effectively communicated to its sites, DOE 

will find it difficult to fully assess whether the reform effort is making 

progress toward achieving its intended results.
 

Page 15 GAO-12-347 Reform of DOE Safety Directives

• Implementation strategy. DOE developed a near-term implementation 

strategy for its reform effort—which included how safety directives 

would be revised—but did not develop a long-term strategy on how 

those revised directives would be implemented. For near-term 

implementation, DOE developed a project management plan, which 

focuses on the process to revise the directives but not on how to 

implement most of them. In the plan, DOE identifies priority actions 

and milestones to be achieved; establishes a process for the 

directives reform; and assigns responsibility for leading and managing 

the directives reform to DOE’s Office of Health, Safety, and Security. 

DOE’s implementation strategy, however, did not provide further 

information on how these changes would be implemented over the 

long term at DOE’s sites. According to DOE officials, it is up to each 

program office within DOE to determine how best to implement the 

revised directives.22

• Outcome measures. DOE has not developed results-oriented 

outcome measures for productivity, cost, or safety under its reform 

effort. Instead, DOE’s reform effort has focused on output-oriented 

measures, such as the number of directives cancelled or revised, and

not on outcome measures, such as specific improvements in 

productivity or cost savings. DOE indicated that the reform is 

expected to result in more than a 50 percent reduction in the number 

of directives but has not explained how this reduction will improve 

productivity, reduce costs, or maintain or improve safety. DOE’s focus 

on output-oriented measures such as the number of directives 

reduced does not align with its own guidance on performance 

measures. DOE’s guidance states that there is a danger when 

performance measures become numerical quotas because the setting 

of numerical goals and quotas does nothing to accomplish process 

improvements.

DOE’s Office of Health, Safety, and Security, 

however, has developed an implementation strategy for changing its 

approach to independent oversight that details how these changes will 

be implemented at DOE’s sites.

23

 

22DOE has formal processes for incorporating directives revisions into existing contracts in 

its DOE Order 251.1C. This order, however, does not include milestones, specific tasks, 

or roles and responsibilities for implementing the revised safety directives.

For safety performance, DOE has measures that it 

uses to monitor safety problems at its sites. However, according to 

23DOE, Guidelines for Performance Measurement, DOE G 120.1-5 (Washington, D.C.: 

June 30, 1996).
 

Page 16 GAO-12-347 Reform of DOE Safety Directives

DOE officials, the department has not developed a plan showing how 

it could use these measures, if at all, to evaluate the benefits of its 

reform effort.

• Effectiveness evaluation. DOE did not develop a strategy for 

evaluating the effectiveness of its reform effort and therefore is not 

collecting the results-oriented performance data necessary to identify 

benefits achieved or areas where further changes are needed. To 

date, DOE officials have only provided anecdotes on the benefits the 

reform is expected to achieve. For example, in response to written 

questions we provided to the department, DOE’s Office of Health, 

Safety, and Security stated that it expects measurable productivity 

improvements because it significantly streamlined the requirements 

for contractor oversight systems, which provide information on safety 

performance and other management issues. Some officials at DOE 

sites we visited, however, stated that DOE’s reform effort may not 

produce any productivity or safety improvements and may have little 

impact on the way they conduct their work. For instance, DOE and 

contractor officials at DOE’s Hanford Site told us that, while they are 

still working on implementing the revised directives at their site, they 

have neither seen any changes in project safety performance, nor do 

they expect to see any changes in the future as a result of the reform 

effort. Additionally, as discussed previously, DOE has launched an 

initial study of selected directives to determine how changes to these 

directives have impacted mission work, schedule, and costs, among 

other things. However, without results-oriented performance data, it 

will be difficult for DOE to identify benefits achieved by the reform 

effort.

DOE’s reform effort did not fully address safety concerns that we, DOE’s 

Office of Inspector General, and the Safety Board have repeatedly 

identified in three key areas—(1) quality assurance, (2) safety culture, 

and (3) federal oversight. In each of these three areas, some changes 

that DOE has made to its safety directives may begin to address safety 

concerns, but other changes it made are potentially problematic.

DOE’s Reform Effort 

Did Not Fully Address 

Safety Concerns We 

and Others Have 

Identified
 

Page 17 GAO-12-347 Reform of DOE Safety Directives

Quality assurance entails ensuring that proper work processes and 

procedures are in place to ensure all work meets certain standards of 

quality. Such processes include correcting identified problems and 

following up to ensure that these actions are effective. As we, DOE’s

Office of Inspector General, and the Safety Board have reported in 20 

reports since 2001, DOE has experienced numerous quality assurance 

problems, ranging from improper documentation detailing quality 

assurance procedures to insufficient monitoring of actions to correct 

identified problems.

Under its reform effort, DOE revised a key quality assurance directive in 

April 2011 to update and clarify how the directive applies to facilities with 

and without nuclear materials as well as to encourage the use of industry 

quality assurance standards. Specifically:

• In its revised directive, DOE clarified responsibilities to help ensure 

that contractors at facilities without nuclear materials at DOE’s sites 

are better aware that they can tailor implementation of their quality 

assurance programs to their nonnuclear needs. According to DOE 

officials, because problems at nonnuclear facilities may pose different 

levels of risk than those at nuclear facilities, quality assurance 

programs can be more flexible at DOE’s nonnuclear facilities and 

sites.

• To support the reform effort’s goal of greater use of industry safety 

quality assurance standards, the revised directive includes a new 

requirement for contractors overseeing high-hazard nuclear facilities 

to use a uniform version of a quality assurance standard developed by 

the American Society of Mechanical Engineers. Previously, some 

sites were using different versions of the standard. As a result, 

according to DOE documents we reviewed, assessments of the 

quality assurance practices at DOE’s sites sometimes resulted in 

citations that did not concern safety issues but rather arose from 

differences in the way that the different versions of the quality 

assurance standard were written. By eliminating the use of multiple 

versions of the quality assurance standard, DOE believes it can save 

time and costs when doing assessments.

• The revised quality assurance directive now helps to clarify quality 

assurance requirements for DOE’s safety software, which is 

DOE Strengthened Its 

Quality Assurance 

Directive by Requiring 

Contractors to Follow 

Established Industry 

Standards, but Some

Problems Persist
 

Page 18 GAO-12-347 Reform of DOE Safety Directives

consistent with commitments DOE made in response to the Safety 

Board’s September 2002 recommendation to improve the quality of 

DOE’s safety software24 and our February 2011 recommendation to 

clarify specific quality assurance requirements for computer models 

used in environmental cleanup decisions.25

These revisions appear to have strengthened the directive, but it is not 

yet clear if they will fully address quality assurance problems, some of 

which continue. For example, DOE’s Office of Enforcement identified 

quality assurance problems following a June 2010 incident during which a 

worker was exposed to radiation after puncturing his hand with a sharp 

object contaminated with plutonium at DOE’s Savannah River Site. As a 

result, in July 2011, this office proposed a fine of $243,750 against the 

contractor. Furthermore, in June 2011, DOE’s Office of Inspector General 

reported that both the Livermore Site Office and the laboratory’s 

contractor lacked adequate quality assurance processes to ensure that 

corrective actions were effective.

DOE expects this 

clarification to improve the performance of software used on safetyrelated systems, according to DOE documentation we reviewed.

26 In the report, DOE’s Office of 

Inspector General recommended that the site office perform more timely 

inspections to verify that corrective actions had been instituted prior to 

closing the finding that led to the corrective actions. In addition, at a 

nuclear facility at NNSA’s Nevada National Security Site, NNSA found in 

August 2011 that the contractor had not effectively identified, controlled, 

or prevented the recurrence of quality assurance problems related to the 

installation and inspection of fire safety and other components in nuclear 

testing facilities, as required in nuclear safety regulations, and proposed a 

nearly $180,000 fine against the contractor.

 

24Defense Nuclear Facilities Safety Board, Recommendation 2002-1 to the Secretary of 

Energy: Quality Assurance for Safety-Related Software (Washington, D.C.: Sept. 23, 

2002).

25GAO, Nuclear Waste: DOE Needs a Comprehensive Strategy and Guidance on 

Computer Models that Support Environmental Cleanup Decisions, GAO-11-143

(Washington, D.C.: Feb. 10, 2011).

26DOE, Office of Inspector General, Implementation of Beryllium Controls at Lawrence 

Livermore National Laboratory, DOE/IG-0851 (Washington, D.C.: June 17, 2011).
 

Page 19 GAO-12-347 Reform of DOE Safety Directives

A strong safety culture includes the quality that health and safety are 

integrated into all work decisions so that workers and managers are 

better aware of and better implement safety practices, which helps to 

minimize accidents. DOE defines safety culture as an organization’s 

values and behaviors modeled by leadership and practiced by employees 

to strive to make the safe performance of work a priority. To promote a 

strong safety culture at its sites, DOE has federal regulations27 and a set 

of directives—collectively known as Integrated Safety Management—for 

implementing the department’s key safety management practices. These 

directives lay out high-level expectations and implementing methods for 

safety management and include several guides and manuals with 

suggested methods for implementing safety management practices. 

Many of these directives resulted from DOE’s response to October 1995 

and September 1998 recommendations by the Safety Board to establish 

clear and systematic processes for addressing and resolving safety 

issues and to establish clear lines of responsibility for safety.28

Nevertheless, DOE has experienced problems maintaining an effective 

safety culture at some of its sites, as we, DOE’s Office of Inspector 

General, and the Safety Board have repeatedly reported. Problems have 

included not following required safety practices, inadequate testing of key 

nuclear waste processing systems to ensure they operate safely, and not 

developing safety strategies for extremely hazardous events. For 

example, in October 2007, we identified weaknesses in the safety culture 

at DOE’s three nuclear research laboratories, and recommended that 

DOE strengthen safety management at its weapons laboratories and 

ensure that safety improvements are carried out in a systematic 

manner.29

 

27DOE’s regulatory requirements for promoting safety culture for contractors are contained 

in DOE’s acquisition regulation 48 C.F.R. § 970.5223-1, Integration of Environment, 

Safety and Health Into Work Planning, and Execution. The regulation requires that 

contracts provide for contractors to comply with all applicable laws and regulations. The 

original set of DOE’s Integrated Safety Management directives provided supplemental 

requirements and best practices for contractors to follow in order to implement a strong 

safety culture. 

DOE generally agreed with our recommendations, but it noted 

28Defense Nuclear Facilities Safety Board, Recommendation 1995-2 to the Secretary of 

Energy: Safety Management (Washington, D.C.: Sept. 28, 1998), and Recommendation

1998-1 to the Secretary of Energy: Integrated Safety Management at the Department of 

Energy (DOE) Facilities (Washington, D.C.: Sept. 28, 1998).

29GAO-08-73. 

DOE’s Revisions to Its 

Directives Were Intended 

to Strengthen Its Safety 

Culture, but the Safety 

Board Raised Concerns 

That Less Vigorous Safety 

Practices Could Result
 

Page 20 GAO-12-347 Reform of DOE Safety Directives

that, in the department’s view, the safety management systems DOE had 

in place adequately addressed safety culture issues and, as a result, the 

department took no further action to address those recommendations. In 

addition, in September 2009, DOE’s Office of Inspector General reported 

that fire fighters who respond to incidents at Los Alamos were not 

provided with enough opportunity to tour and become familiar with the 

site, which would impede response time in an emergency.30 Furthermore, 

in October 2009, the Safety Board reported that Los Alamos lacked a 

safety strategy to minimize the potential consequences of earthquakes to 

stored nuclear material and recommended actions to mitigate these 

potential consequences.31

Under its reform effort, DOE revised its Integrated Safety Management 

directives to attempt to strengthen the safety culture at its sites. For 

example, DOE’s revisions more clearly emphasized DOE and contractor 

senior management roles and responsibilities for building a strong safety 

culture at DOE’s sites. Specifically, the new directives lay out tasks that 

each level of management should complete, such as developing and 

maintaining safety documents, approving site office safety initiatives, and 

establishing safety expectations across DOE’s sites. These revisions 

address past issues, such as lack of clarity in roles and responsibilities for 

ensuring safety practices at DOE’s sites. In addition, DOE has 

undertaken several efforts aimed at improving safety practices across its 

sites. For example, the department has worked closely with a contractor 

group—Energy Facilities Contractors Group—to issue guidance on 

assessing and strengthening safety culture. In addition, DOE issued a 

new Integrated Safety Management guide in September 2011 to provide 

additional and extensive information to assist the programs in 

implementing integrated safety management requirements. Finally, in 

2011, DOE established its Nuclear Safety and Security Council, which 

advises the department’s senior management on nuclear safety issues 

with the aim to improve safety performance.

 

30DOE, Office of Inspector General, Fire Suppression and Related Services at Los 

Alamos National Laboratory, DOE/IG-0821 (Washington, D.C.: Sept. 11, 2009).

31Defense Nuclear Facilities Safety Board, Recommendation 2009-2 to the Secretary of 

Energy: Los Alamos National Laboratory Plutonium Facility Seismic Safety (Washington, 

D.C.: Oct. 26, 2009).
 

Page 21 GAO-12-347 Reform of DOE Safety Directives

However, some revisions DOE made to its Integrated Safety 

Management directives raised concerns with Safety Board officials that 

safety culture may be undermined. For example:

• When it revised its Integrated Safety Management directives, DOE 

removed language that required contractors to follow the directives 

and instead revised the directives to apply only to federal employees. 

This is because contractors already had to comply with the 

department’s acquisition regulations, which the Safety Board noted 

contain similar but less detailed requirements. According to Safety 

Board officials, because the acquisition regulation does not contain 

the specificity of the Integrated Safety Management directives, 

contractors may not implement the requirements as vigorously as they 

would if they had to follow the more specific practices in the original 

directives.

• Because DOE removed language for contractors to follow the 

department’s Integrated Safety Management directives, contractors 

will no longer need to consider best practices for implementing a 

safety culture based on lessons learned over the years that are 

integrated into the directives. Specifically, Safety Board officials stated 

that they are concerned that contractors will therefore overlook these 

lessons learned since the contractors are no longer required to follow 

the Integrated Safety Management directives.

It is also not clear how revisions to DOE’s Integrated Safety Management 

directives will affect safety culture problems that persist at DOE’s sites. 

For example, in June 2011, the Safety Board reported that workers at 

DOE’s Waste Treatment and Immobilization Plant at its Hanford Site 

hesitated to raise safety concerns for fear of management reprisal and 

recommended that the Secretary of Energy act to ensure a strong safety 

culture at the site.32 DOE’s Office of Health, Safety, and Security has also 

recently reported on continuing safety culture problems at the Waste 

Treatment and Immobilization Plant.33

 

32Defense Nuclear Facilities Safety Board, Recommendation 2011-1 to the Secretary of 

Energy: Safety Culture at the Waste Treatment and Immobilization Plant (Washington, 

D.C.: June 9, 2011).

Furthermore, DOE’s Office of 

33DOE, Office of Health, Safety, and Security, Independent Review of Nuclear Safety 

Culture at the Hanford Site Waste Treatment and Immobilization Plant Project

(Washington, D.C.: October 2010).
 

Page 22 GAO-12-347 Reform of DOE Safety Directives

Enforcement issued a notice of violation in September 2011 to the 

contractor at DOE’s Separations Process Research Unit site in 

Niskayuna, New York, after a building demolition accident potentially 

exposed at least 100 employees to low-level radioactive contamination in 

September 2010. DOE’s Office of Enforcement found that the accident 

was tied to the contractor’s failure to consistently use safe work practices 

at the site and management’s failure to assess work processes to ensure 

a safe working environment.

We and others have reported on DOE’s problems overseeing contractors’ 

performance. These problems have ranged from the department not 

ensuring that it had sufficient resources to perform oversight at its sites to 

not consistently applying such oversight. For example, in October 2008, 

we reported that DOE’s authority to impose civil penalties on contractors 

for violating nuclear safety requirements had not reduced some recurring 

safety problems, and we recommended that DOE increase its 

independent oversight presence at DOE’s sites to provide more frequent 

observations to facilitate enforcement actions.34

In response to our recommendations, and under its reform effort, DOE 

has changed its approach to conducting independent oversight that is 

reflected in its revised oversight directives. For example:

• DOE has placed greater emphasis on having its Office of Independent 

Oversight staff review safety design documents, which lay out the 

safety systems for facilities at DOE’s sites, before their construction. 

Our October 2008 report noted that lack of oversight meant that these 

documents did not receive an independent review and therefore the 

safe operation of newly constructed facilities at DOE’s sites could not 

be reasonably assured. In response to our recommendations and 

under its reform effort, DOE’s Office of Independent Oversight staff 

now review the safety design documents before the facility is 

constructed, rather than after it is built, and when the facility 

undergoes major modification.

 

34GAO, Nuclear Safety: Department of Energy Needs to Strengthen Its Independent 

Oversight of Nuclear Facilities and Operations, GAO-09-61 (Washington, D.C.: Oct. 23, 

2008).

DOE Clarified Roles and 

Responsibilities for Its 

Oversight of Contractor 

Activities, but Its Reform 

May Result in Weakened 

Federal Oversight
 

Page 23 GAO-12-347 Reform of DOE Safety Directives

• DOE implemented a new approach to oversight that designates 

headquarters staff responsibility for oversight at key sites, such as 

DOE’s Hanford and Savannah River sites and its Idaho National 

Laboratory. These “site leads” monitor and assess all aspects of a 

site’s operations in order to assist the Office of Independent Oversight 

in planning assessment activities. According to Office of Independent 

Oversight officials, under the site lead approach, oversight staff now 

visit a site several times per year rather than approximately once 

every 3 years under the previous approach. These officials said that 

they believe this change will result in more frequent reviews at these 

key sites, enabling them to catch potential safety problems earlier.

However, some of the revisions DOE made to its oversight directives 

under its reform effort raise concerns about the department’s ability to 

effectively execute independent oversight. According to DOE’s 

independent oversight directive, independent oversight is an integral part 

of DOE’s ability to help ensure the effectiveness of DOE and contractor 

safety performance. However, some of DOE’s revisions place 

accountability for key oversight functions with the site offices and 

contractors, which may reduce confidence in an independent oversight 

process. For example:

• DOE revised its oversight approach to give site office, rather than 

Office of Independent Oversight staff, increased responsibility for 

managing actions to correct problems raised in independent 

assessments. Previously, issues identified during Independent 

Oversight assessments had to be addressed with a formal corrective 

action plan submitted to and tracked by the Office of Independent 

Oversight. Under the reform, site offices have responsibility for 

determining which issues will be formally addressed and monitored, 

and which problems are dealt with without the need for a formal plan. 

According to some Office of Independent Oversight officials, under 

this revised approach, independent oversight staff try to limit the 

concerns raised during assessments to higher priority issues in order 

to better ensure these receive site management attention. Site office 

determinations of whether issues required more formal contractor 

responses may be influenced by the fact that the site offices also have 

responsibility for keeping costs under control and work on schedule.

• In giving greater responsibility to the site offices, DOE has allowed 

them to use staff from the Office of Independent Oversight to help 

assess contractor performance. In addition, Office of Independent 

Oversight staff must now coordinate their assessment activities with 

site office management in order to maximize the use of resources. 
 

Page 24 GAO-12-347 Reform of DOE Safety Directives

This potentially raises concerns about whether Office of Independent 

Oversight staff will be sufficiently independent from site office 

management. Furthermore, Safety Board officials told us that the 

coordination requirement could reduce the effectiveness of Office of 

Independent Oversight assessments because surprise “drop-in” 

assessments would be lost, allowing site office and contractor staff to 

prepare ahead of the assessment. We have raised similar concerns in 

the past regarding the independence of DOE’s oversight, including 

concerns that the department’s focus on providing program offices a 

greater role in overseeing contractor oversight resulted in weakening 

independent review.35

Even after DOE’s oversight directives were revised, effective oversight of 

contractor activities continues to be a problem for DOE. For example, in 

June 2011, DOE’s Office of Inspector General reported that the Livermore

site office was not sufficiently overseeing the contractor to ensure that 

corrective actions were fully and effectively implemented.36 In September 

2011, DOE’s Office of Enforcement proposed a fine of $412,500 against 

the Separations Process Research Unit contractor in Niskayuna, New 

York, due, in part, to oversight inadequacies during the September 2010 

accident discussed earlier in this report. Moreover, the Office of 

Enforcement proposed a $150,000 fine in early October 2011 against the 

Idaho National Laboratory contractor, in part, because of inadequate 

management oversight that resulted in the tipping over of a hoisting rig 

loaded with 7,800 pounds.

DOE’s reform effort was driven by a belief that some requirements in its 

safety directives have placed excessive burdens on its contractors and 

that revisions would give contractors more flexibility in operating safely. 

The elimination of potentially burdensome, duplicative, and costly 

requirements that offer little or no contribution to improved safety is a 

worthy goal. If high levels of safety could be assured at DOE’s sites while 

unnecessary requirements were eliminated, then DOE’s reform effort 

would be considered a success. However, DOE did not first determine 

whether the directives it planned to revise were indeed burdensome or 

 

35GAO-09-61. 

36DOE, Office of Inspector General, Implementation of Beryllium Controls at Lawrence 

Livermore National Laboratory, DOE/IG-0851 (Washington, D.C.: June 17, 2011).

Conclusions
 

Page 25 GAO-12-347 Reform of DOE Safety Directives

costly. DOE also does not have results-oriented outcome measures to 

help the department gauge the effectiveness of its effort. Simply counting 

the number of directives revised or eliminated does not indicate the 

benefit of the reform on productivity and safety performance at DOE’s 

sites. Safety should not be measured by the amount of paper that is 

saved but by actual improvements in safety performance across the 

department.

Before embarking on management reforms, high-performing 

organizations (1) set clear goals, (2) develop an implementation strategy 

that sets milestones and establishes responsibility, (3) establish resultsoriented outcome measures, and (4) use results-oriented data to evaluate 

the reform’s effectiveness and make additional changes where needed. 

However, DOE did not fully follow these practices to assess the costs and 

benefits of revising its safety directives. Furthermore, our discussions with 

DOE and contractor officials at DOE’s sites indicate that there is some 

question about the benefits the reform effort can actually achieve. It is 

also unclear how revising safety directives will address past and recurring 

safety concerns with quality assurance, safety culture, and federal 

oversight of contractor activities that we and others have identified over 

the years. Many of the directives DOE revised were originally developed 

to correct problems in these areas. In revising these directives, DOE 

could be undermining hard-won progress over the years in safety 

performance at its sites. DOE has not effectively communicated with its 

site officials or its contractors about the overall goals of the reform effort, 

how progress will be measured, and whether benefits of the reform will 

exceed the costs involved with revising directives. In addition, changes to 

DOE’s oversight directives raise concerns about the ability of DOE’s 

Office of Independent Oversight staff to provide a critical review of safety 

at DOE’s sites that is independent from DOE site office and contractor 

staff, a concern we have raised in the past. As a result, it is unclear 

whether DOE’s reform effort will result in actual productivity or safety 

improvements at its sites.
 

Page 26 GAO-12-347 Reform of DOE Safety Directives

To help ensure that DOE’s reform of its safety directives results in 

improved productivity and safety at its sites, we recommend that the 

Secretary of Energy take the following four actions prior to fully 

implementing revisions to its directives across all of the department’s 

sites:

• systematically analyze the costs and benefits associated with 

implementing the revised safety directives to ensure that the costs do 

not exceed the benefits that the department expects to achieve;

• provide DOE’s sites and contractors with a plan that details (1) the 

reform effort’s goals, (2) the effort’s long-term implementation 

strategy, (3) results-oriented outcome measures, and (4) how DOE 

will use results-oriented data to evaluate the reform’s effectiveness 

and to determine whether additional changes are needed;

• ensure that the plan developed for DOE’s sites and contractors 

identifies how the reform effort will help address past and recurring 

safety concerns with quality assurance, safety culture, and federal 

oversight of contractor activities; and

• clearly define the oversight roles and responsibilities of DOE’s Office 

of Independent Oversight staff to ensure that their work is sufficiently 

independent from the activities of DOE site office and contractor staff.

We provided DOE with a draft of this report for its review and comment. In 

its written comments, DOE generally agreed with our recommendations 

and noted that it will use the report to build on its commitment to 

continually improve its approach to safety management. However, DOE 

commented that it had significant concerns with the accuracy of the 

report’s findings and the validity of its conclusions.

Specifically, DOE commented that it never assumes its existing directives 

are perfect and cannot be improved. Instead, DOE stated that its 

management principles require it to constantly evolve, engaging with its 

employees, contractors, and stakeholders to recognize impediments and 

work to mitigate them. We agree with DOE and, as our draft report noted, 

the elimination of potentially burdensome, duplicative, and costly 

requirements that offer little or no contribution to improved safety is a 

worthy goal. Our draft report also clearly described the process DOE

followed and the involvement of its employees; contractors; and 

stakeholders, such as the Safety Board. However, in our view, it is not 

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation
 

Page 27 GAO-12-347 Reform of DOE Safety Directives

possible to identify impediments and work to mitigate them without first 

determining whether and how existing requirements are burdensome. As 

our draft report stated, an April 2011 NNSA study found that DOE’s 

nuclear safety requirements did not place an undue burden on the 

contractors. Instead, NNSA reported that these requirements provided a 

sound framework to safely operate nuclear facilities. Officials we spoke 

with at some of DOE’s sites also told us that they lacked sufficient data to 

determine whether the safety requirements the department was revising 

were burdensome. We agree that continuous improvement to remove 

impediments is beneficial, but DOE did not determine whether its safety

directives were, in fact, impediments prior to revising them.

In addition, DOE’s letter provided information on the roles of its Office of 

Health, Safety, and Security and noted that its oversight and regulatory 

enforcement is independent from line management, guaranteeing the 

office’s autonomy without potential conflicts of interest. Our draft report 

clearly described the roles and responsibilities of DOE’s Office of Health, 

Safety, and Security and its Office of Independent Oversight. However, 

some of DOE’s revisions to its directives place accountability for key 

oversight functions with DOE site offices and contractors, which may 

reduce confidence in an independent oversight process. For example, as 

we noted in our draft report, Office of Independent Oversight staff must 

now coordinate assessment activities with site office management in 

order to maximize the use of resources. Safety Board officials told us that 

the coordination requirement could reduce the effectiveness of 

assessments because surprise “drop-in” assessments would be lost, 

allowing site offices and contractor staff to prepare ahead of the 

assessment. This problem echoes similar concerns we have raised in the 

past regarding the independence of DOE’s oversight, including that the 

department’s focus on providing program offices a greater role in 

overseeing contractor oversight resulted in weakening independent 

review.

DOE also enclosed a longer summary of its concerns with the draft 

report’s findings and conclusions. DOE’s letter, summary, and our 

detailed responses are reproduced in appendix II. DOE also provided 

technical comments, which we incorporated as appropriate.
 

Page 28 GAO-12-347 Reform of DOE Safety Directives

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of to the appropriate 

congressional committees; the Secretary of Energy; the Director, Office of 

Management and Budget; and other interested parties. In addition, the 

report will be available at no charge on the GAO website at 

http://www.gao.gov. 

If you or your staff have any questions regarding this report, please contact 

me at (202) 512-3841 or aloisee@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. Key contributors to this report are listed in appendix III.

Gene Aloise

Director

Natural Resources and Environment
 

Page 29 GAO-12-347 Reform of DOE Safety Directives

List of Requesters

The Honorable Fred Upton

Chairman

The Honorable Henry A. Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Cliff Stearns

Chairman

Subcommittee on Oversight and Investigations

Committee on Energy and Commerce

House of Representatives

The Honorable Joe Barton

House of Representatives

The Honorable Michael C. Burgess

House of Representatives
Appendix I: Scope and Methodology

Page 30 GAO-12-347 Reform of DOE Safety Directives

To examine how the Department of Energy (DOE) revised safety 

directives under its reform effort, we reviewed DOE documents describing 

the directives review process, including the March 2010 Safety and 

Security Reform Plan, the June 2010 Project Management Plan, and the 

September 2010 HSS Requirements Framework and Systems Approach: 

Integrating Requirements Framework and Overview. We also reviewed 

documents used to revise safety directives, including justification 

memorandums and crosswalks between the original directives and their 

revisions. We also reviewed comments to directive revisions that were 

submitted to the department’s directives review system. This review 

system—called RevCom—is an online system that disseminates 

proposed revisions to DOE federal and contractor staff for their review 

and comment on the revisions’ content, relevance, applicability, accuracy, 

impact, and implementation cost. We interviewed officials at DOE 

headquarters, including officials in DOE’s Office of Health, Safety, and 

Security and the National Nuclear Security Administration (NNSA), about 

the directives review process. In addition, we visited the Kansas City 

Plant in Kansas City, Missouri; the Nevada National Security Site in Las 

Vegas, Nevada; the Lawrence Livermore National Laboratory in 

Livermore, California; and the Hanford Site near Richland, Washington 

state; and interviewed DOE and contractor officials at those sites to 

determine how the safety directives and oversight reform affected the 

sites and contractors, if at all. Each of these sites is in different stages of 

implementing revised directives, from full implementation of revised 

directives at the Kansas City Plant to revised directives not yet 

implemented at the Lawrence Livermore National Laboratory. We also 

interviewed officials at other federal regulatory agencies, including the 

Nuclear Regulatory Commission and the Department of Labor’s Office of 

Occupational Health and Safety, to gain an understanding of the process 

of changing safety requirements and federal regulations. We reviewed 

comments on proposed revisions to DOE’s safety directives made by the 

Defense Nuclear Facilities Safety Board (Safety Board)—which was 

created by Congress to independently assess safety conditions and 

operations at defense nuclear facilities at DOE’s sites and interviewed 

Safety Board officials about those changes. We also interviewed officials 

from the American Society of Industrial Standards to determine how 

industry standards are developed.

To examine the benefits DOE hoped to achieve through its reform effort, 

we reviewed the reform documents mentioned previously, among others. 

We interviewed officials at DOE headquarters, including the Associate 

Deputy Secretary of Energy and staff from the Office of Health, Safety, 

and Security, to discuss how DOE intended to gauge the success of its 

Appendix I: Scope and Methodology
Appendix I: Scope and Methodology

Page 31 GAO-12-347 Reform of DOE Safety Directives

reform effort. We also interviewed officials with NNSA to discuss the DOE 

reform effort as it affected NNSA’s simultaneous governance and 

oversight reform effort. NNSA’s effort involves revising the agency’s 

business model to, among other things, place more reliance on 

contractor’s self-oversight through its contractor assurance systems.

Furthermore, we visited the Kansas City Plant, the Nevada National 

Security Site, Lawrence Livermore National Laboratory, and the Hanford 

Site and interviewed DOE site office and contractor officials about the 

2010 reform, site performance measures, expected productivity 

improvements, and whether cost savings were anticipated. To identify 

and develop best practices criteria for managing improvement initiatives 

and performance measures, we reviewed our prior work, DOE guidance 

on managing improvement initiatives and performance measures, and 

documentation on performance measures and performance evaluation by 

industry groups such as the Energy Facility Contractors Group. We then 

compared these best practices criteria to DOE’s documents describing its 

reform effort, including the March 2010 Safety and Security Reform Plan, 

the June 2010 Project Management Plan, and the August 2010 Program 

Plan for Enhancing Independent Oversight of Nuclear Safety, in order to 

determine how these best practices criteria were applied to these 

documents. We also verified this information by speaking with DOE 

officials about these best practices criteria to obtain their perspectives on 

how these criteria were applied to the reform effort. To identify other 

safety performance measures DOE uses to monitor safety performance 

at DOE’s sites, we reviewed DOE’s Office of Health, Safety, and Security 

worker safety performance reports and data, as well as performance 

measures, performance data, and performance evaluation plans provided 

to us by site office and contractor officials during our site visits. We did 

not validate these data, but we did examine the reasonableness of these 

data based on information in our prior work and DOE reports and 

concluded that these were sufficient for purposes of our report. We also 

interviewed officials from the Safety Board on issues pertaining to 

performance measures and performance evaluation.

To examine the extent to which DOE’s reform effort will address concerns 

we and others identified, we reviewed reports over the past 10 years by 

GAO, DOE’s Office of Inspector General, and the Safety Board that 

contain recommendations related to safety and oversight issues at the 

department. To identify the safety-related concerns of these report 

recommendations, we conducted a content analysis of the 

recommendations. Specifically, we developed categories for identifying 

safety-related concerns—including quality assurance, nuclear safety, 

worker safety, and oversight—using DOE’s HSS Requirements 
Appendix I: Scope and Methodology

Page 32 GAO-12-347 Reform of DOE Safety Directives

Framework and Systems Approach: Integrating Requirements Framework 

and Overview document. After discussions with our methodologist and a 

review of DOE safety directives, we combined the nuclear safety and 

worker safety categories under the category of safety culture. Two 

analysts independently reviewed the report recommendations and coded 

them into the three categories. In cases where differences between the 

two reviewers regarding the coding of the recommendations into these 

safety-related categories were found, all differences were resolved 

through reviewer discussion. To determine how DOE’s reform effort 

addressed past safety concerns, we reviewed key safety directives, 

crosswalks between the previous version of the directive and the current 

version, comments provided on those changes from DOE staff and 

contractors, and comments provided by the Safety Board. We also visited 

and interviewed staff at the Kansas City Plant, the Nevada National 

Security Site, Lawrence Livermore National Laboratory, and the Hanford 

Site to determine how the reform effort was affecting their day-to-day 

operations and strategies to address past concerns on-site. We also 

interviewed DOE officials, including at the Office of Health, Safety, and 

Security, as well as Safety Board officials.

We conducted this performance audit from February 2011 through April 

2012 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. 
Appendix II: Comments from the Department 

of Energy

Page 33 GAO-12-347 Reform of DOE Safety Directives

Appendix II: Comments from the Department 

of Energy

Note: GAO comments 

supplementing those in 

the report text appear at 

the end of this appendix
Appendix II: Comments from the Department 

of Energy

Page 34 GAO-12-347 Reform of DOE Safety Directives
Appendix II: Comments from the Department 

of Energy

Page 35 GAO-12-347 Reform of DOE Safety Directives

See comment 3.

See comment 2.

See comment 1.
Appendix II: Comments from the Department 

of Energy

Page 36 GAO-12-347 Reform of DOE Safety Directives

See comment 7.

See comment 6.

See comment 5.

See comment 4.

See comment 4.
Appendix II: Comments from the Department 

of Energy

Page 37 GAO-12-347 Reform of DOE Safety Directives

See comments 11-13.

See comment 10.

See comment 9.

See comment 8.
Appendix II: Comments from the Department 

of Energy

Page 38 GAO-12-347 Reform of DOE Safety Directives

See comment 14.

See comment 1.

See comment 13.

See comment 12.

See comment 11.
Appendix II: Comments from the Department 

of Energy

Page 39 GAO-12-347 Reform of DOE Safety Directives

See comment 14.

See comment 14.
Appendix II: Comments from the Department 

of Energy

Page 40 GAO-12-347 Reform of DOE Safety Directives

See comment 14.
Appendix II: Comments from the Department 

of Energy

Page 41 GAO-12-347 Reform of DOE Safety Directives

The following are GAO’s comments on the Department of Energy’s (DOE) 

letter dated April 9, 2012.

1. DOE is incorrect that the draft report did not identify any significant 

flaws in the revised directives that resulted from the department’s 

safety reform effort. On the contrary, the draft report discussed 

concerns that the Defense Nuclear Facilities Safety Board (Safety 

Board) and we had with revisions to DOE’s Integrated Safety 

Management and independent oversight directives. In addition, DOE 

is confident that the directives will, among other things, effectively 

support mission requirements in a safe and efficient manner. In our 

view, however, DOE cannot demonstrate that the reform effort will 

result in benefits because it failed to develop outcome-based 

performance metrics.

2. Our draft report clearly described the role of the Safety Board in 

DOE’s safety reform effort, including the Safety Board’s concerns with 

DOE’s revisions to its Integrated Safety Management directive. 

However, contrary to DOE’s comment, Safety Board officials with 

whom we spoke stated that, during the reform process, they had 

expressed concerns about some of the changes DOE made to its 

safety directives, including its Integrated Safety Management and 

independent oversight directives. The Safety Board staff indicated that 

they did not believe those original concerns had been fully addressed 

and that they continue to have concerns about some of the changes 

made. Our draft report discussed these concerns, particularly as they 

relate to independent oversight.

3. Our draft report did not suggest requiring the department to seek 

public comment when revising its internal directives. Instead, our draft 

report clearly stated that DOE is not required to obtain the public’s 

views on its internal directives. However, we did note that officials at 

NRC and OSHA—federal agencies with significant experience in 

nuclear and worker safety, respectively—told us that obtaining a wide 

range of comments on proposed revisions can be very helpful in 

developing quality requirements that balance cost with benefits and 

assist them to build support for the changes. We revised our report to 

further emphasize that DOE is not required to obtain public comments 

when making changes to its internal directives. However, we maintain 

that obtaining a wide range of comments from a variety of 

stakeholders is beneficial.

GAO Comments
Appendix II: Comments from the Department 

of Energy

Page 42 GAO-12-347 Reform of DOE Safety Directives

4. DOE agrees that it did not conduct an analysis of the costs and 

benefits of its requirements prior to revising them, stating that such an 

approach would be inconsistent with the department’s approach to 

safety and to its management principles. In our view, DOE’s 

comments indicate that the department’s priority when revising its 

directives was to act quickly rather than to use the key practices of 

high-performing organizations when undertaking management 

improvement initiatives. As our draft report noted, high-performing 

organizations set clearly defined goals that are targeted levels of 

performance, expressed as tangible, measurable objectives against 

which achievement can be compared. DOE did not do this—as DOE 

itself notes in its comments—opting for speed instead of 

effectiveness. We maintain, as our draft report noted, that simply 

counting the number of directives revised or eliminated does not 

indicate the benefit of the reform on productivity and safety 

performance at DOE’s sites and that safety should not be measured 

by the amount of paper that is saved but by actual improvements in 

safety performance. In our view, when it comes to rigorous safety 

requirements, the speed of a reform effort is far less important than 

the effectiveness of the reform.

5. DOE states that its safety reform resulted in more concise safety 

directives with requirements that are clearer and add value in 

protecting its workers and the public, and that the results are 

consistent with the goals established by the Deputy Secretary for the 

safety reform effort. As our draft report noted, however, one of the 

goals expressed by the Deputy Secretary in his March 2010 

memorandum announcing the reform effort was that “measurable 

productivity improvements” would result from reducing burdensome 

safety requirements. Because DOE made no attempt to determine 

whether these requirements were burdensome—which DOE itself 

acknowledges in its comments (see comment 4)—and has no 

outcome-oriented metrics to assess the performance of the safety 

reform effort, there is no way for the department to demonstrate that 

measurable productivity improvements will result from its revisions to 

its safety directives.

6. DOE’s comment that it does not measure success by the number of 

directives eliminated is not supported by the evidence. For example, 

the Deputy Secretary’s March 2010 memorandum announcing the 

reform effort stated that the reform was expected to result in more 

than a 50 percent reduction in the number of directives. Furthermore, 

in numerous meetings, DOE officials cited examples of the 

accomplishments of the safety reform effort. In particular, during a 
Appendix II: Comments from the Department 

of Energy

Page 43 GAO-12-347 Reform of DOE Safety Directives

November 2011 meeting, the Associate Deputy Secretary of Energy 

provided us with a copy of DOE’s fiscal year 2011 “Management and 

Operational Excellence Performance Results” that cited the 

elimination of more than 1,650 pages from DOE directives, the 

cancellation of 22 directives, and the revision of 26 other directives as 

an accomplishment of the reform effort.

7. Our draft report did not assert that inadequate directive requirements 

caused a variety of performance weakness at DOE sites over the last 

several years. Our point was not that inadequate safety directives 

caused these weaknesses, but that DOE’s revisions to these 

directives did not correct these weaknesses. We agree with DOE that 

safety performance problems are often not related to deficiencies in 

requirements, but rather in the implementation of the requirements. In 

our view, this increases the importance of ensuring directives are 

adequately implemented rather than spending inordinate time and 

staff energy revising those directives to eliminate “burdens” that have 

not been clearly defined.

8. DOE is correct that safety management and safety culture are 

different, but related, concepts. Nevertheless, as DOE itself 

acknowledges in its comments, the department has used the revisions 

to its Integrated Safety Management directives as one means to 

further clarify and strengthen expectations and requirements for safety 

culture. For example, our draft report stated DOE revised its 

Integrated Safety Management directives to, among other things, 

attempt to strengthen safety culture at its sites by more clearly 

emphasizing DOE and contractor senior management roles and 

responsibilities for building a strong safety culture at DOE’s sites. 

Nevertheless, as our draft report noted, Safety Board officials raised 

concerns that some of these changes—in particular the removal of 

language that required contractors to follow the directives and 

allowing them to follow similar but less detailed requirements in DOE’s 

acquisition regulations—could weaken safety culture at DOE’s sites. 

However, to address DOE’s concerns that the report does not 

adequately acknowledge the department’s efforts to improve safety 

culture, we revised the report to add additional examples of recent 

DOE safety culture improvement initiatives.

9. DOE stated that it has been the department’s long-standing practice 

to coordinate oversight activities with line organizations to ensure 

adequate planning and that this coordination is not a change from 

previous order expectations. However, the revised order states that 

“Independent Oversight appraisal activities must be coordinated with 
Appendix II: Comments from the Department 

of Energy

Page 44 GAO-12-347 Reform of DOE Safety Directives

affected DOE line management and staff offices to promote efficient 

and effective use of resources.”1 The previous order that the revised 

order replaced did not contain similar language. The previous order 

only required coordination between its oversight activities and DOE’s 

sites on the development of corrective actions to any deficiencies 

found.2

10. We revised the report to discuss the establishment of the Nuclear 

Safety and Security Council.

Although both orders note that independent oversight 

activities must be independent of all DOE elements that have line 

management responsibilities for safety and security programs, Safety 

Board officials with whom we spoke stated that they were concerned 

that this revision would result in surprise “drop-in” assessments being 

lost, allowing site office and contractor staff to prepare ahead of the 

assessment.

11. As DOE itself acknowledges in its comments (see comment 4), the 

department did not analyze the costs and benefits of its requirements 

prior to revising them. Therefore, we maintain that the draft report’s 

title is accurate.

12. Our draft report discussed in detail the process DOE followed in 

revising its directives, including the line-by-line review of each safety 

directive and its consultations with Safety Board staff, and we 

therefore made no changes to the report in response to this comment.

13. Our draft report noted that DOE has measures that it uses to monitor 

safety problems at its sites. However, the department has not been 

able to demonstrate how it could use these measures, if at all, to 

evaluate the benefits of its reform effort, nor has it developed other 

outcome-based metrics that could also be used. In our view, this is 

not consistent with one of the Deputy Secretary’s goals for the reform 

effort—namely, that measurable improvements in productivity would 

result from the elimination of burdensome requirements while 

maintaining safety. Because DOE never defined “burdensome” 

through an analysis of costs and benefits and never developed 

 

1

DOE, Independent Oversight Program, DOE Order 227.1 (Washington, D.C.: Aug. 30, 

2011).

2

DOE, Independent Oversight and Performance Assurance Program, DOE Order 470.2B 

(Washington, D.C.: Oct. 31, 2002).
Appendix II: Comments from the Department 

of Energy

Page 45 GAO-12-347 Reform of DOE Safety Directives

outcome-based measures of the performance of the safety reform 

effort, we are left with merely DOE’s assurances that improved 

productivity and safety performance will result rather than objective 

and verifiable data that could adequately demonstrate improvement.

14. We acknowledge DOE’s acceptance of our recommendations and will 

monitor the department’s implementation of them.
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 46 GAO-12-347 Reform of DOE Safety Directives

Gene Aloise, (202) 512-3841 or aloisee@gao.gov

In addition to the individual named above, Ryan T. Coles, Assistant 

Director; Pamela Davidson; Carlos Gomez; Nancy Kintner-Meyer; Cheryl 

Peterson; Kevin Remondini; and Carol Herrnstadt Shulman made key 

contributions to this report.

Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 47 GAO-12-347 Reform of DOE Safety Directives

2012 Annual Report: Opportunities to Reduce Duplication, Overlap and 

Fragmentation, Achieve Savings, and Enhance Revenue. 

GAO-12-342SP. Washington, D.C.: February 28, 2012.

National Nuclear Security Administration: Observations on NNSA’s 

Management and Oversight of the Nuclear Security Enterprise. 

GAO-12-473T. Washington, D.C.: February 16, 2012.

Excess Uranium Inventories: Clarifying DOE’s Disposition Options Could 

Help Avoid Further Legal Violations. GAO-11-846. Washington, D.C.: 

September 26, 2011.

Nuclear Material: DOE’s Depleted Uranium Tails Could Be a Source of 

Revenue for the Government. GAO-11-752T. Washington, D.C.: 

June 13, 2011.

Nuclear Waste: Disposal Challenges and Lessons Learned from Yucca 

Mountain. GAO-11-731T. Washington, D.C.: June 1, 2011.

DOE Nuclear Waste: Better Information Needed on Waste Storage at 

DOE Sites as a Result of Yucca Mountain Shutdown. GAO-11-230. 

Washington, D.C.: March 23, 2011.

Nuclear Waste: DOE Needs a Comprehensive Strategy and Guidance on 

Computer Models that Support Environmental Cleanup Decisions. 

GAO-11-143. Washington, D.C.: February 10, 2011.

Nuclear Waste: Actions Needed to Address Persistent Concerns with 

Efforts to Close Underground Radioactive Waste Tanks at DOE’s 

Savannah River Site. GAO-10-816. Washington, D.C.: 

September 14, 2010.

Recovery Act: Most DOE Cleanup Projects Appear to Be Meeting Cost 

and Schedule Targets, but Assessing Impact of Spending Remains a 

Challenge. GAO-10-784. Washington, D.C.: July 29, 2010.

Department of Energy: Actions Needed to Develop High-Quality Cost 

Estimates for Construction and Environmental Cleanup Projects. 

GAO-10-199. Washington, D.C.: January 14, 2010.

Nuclear Waste: Uncertainties and Questions about Costs and Risks 

Persist with DOE’s Tank Waste Cleanup Strategy at Hanford. 

GAO-09-913. Washington, D.C.: September 30, 2009.

Related GAO Products
Related GAO Products

Page 48 GAO-12-347 Reform of DOE Safety Directives

Department of Energy: Contract and Project Management Concerns at 

the National Nuclear Security Administration and Office of Environmental 

Management. GAO-09-406T. Washington, D.C.: March 4, 2009.

Nuclear Waste: DOE Lacks Critical Information Needed to Assess Its 

Tank Management Strategy at Hanford. GAO-08-793. Washington, D.C.: 

June 30, 2008.

Hanford Waste Treatment Plant: Department of Energy Needs to 

Strengthen Controls over Contractor Payments and Project Assets. 

GAO-07-888. Washington, D.C.: July 20, 2007.

Nuclear Waste: DOE Should Reassess Whether the Bulk Vitrification 

Demonstration Project at Its Hanford Site Is Still Needed to Treat 

Radioactive Waste. GAO-07-762. Washington, D.C.: June 12, 2007.

Hanford Waste Treatment Plant: Contractor and DOE Management 

Problems Have Led to Higher Costs, Construction Delays, and Safety 

Concerns. GAO-06-602T. Washington, D.C.: April 6, 2006.

Nuclear Waste: Absence of Key Management Reforms on Hanford’s 

Cleanup Project Adds to Challenges of Achieving Cost and Schedule 

Goals. GAO-04-611. Washington, D.C.: June 9, 2004.

Nuclear Waste: Challenges to Achieving Potential Savings in DOE’s 

High-Level Waste Cleanup Program. GAO-03-593. Washington, D.C.: 

June 17, 2003.

Nuclear Waste: Department of Energy’s Hanford Tank Waste Project—

Schedule, Cost, and Management Issues. GAO-RCED-99-13. 

Washington, D.C.: October 8, 1998.

(361270)
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