U.S. Department of Energy 

Office of Inspector General 

Office of Audit Services 

Audit Report 

Fire Protection Deficiencies at Los 

Alamos National Laboratory 

DOE/IG-0816 June 2009 
Department of Energy 

Washington, DC 20585 

June 23, 2009 

MEMORANDUM FOR THE SECRETARY 

 FROM: Gregory H. Friedman 

 Inspector General 

SUBJECT: INFORMATION: Audit Report on "Fire Protection 

 Deficiencies at Los Alamos National Laboratory" 

BACKGROUND

The Department of Energy's Los Alamos National Laboratory (Los Alamos) maintains some of 

the Nation's most important national security assets, including nuclear materials. Many of Los 

Alamos' facilities are located in close proximity to one another, are occupied by large numbers 

of contract and Federal employees, and support activities ranging from nuclear weapons design 

to science-related activities. Safeguarding against fires, regardless of origin, is essential to 

protecting employees, surrounding communities, and national security assets. 

On June 1, 2006, Los Alamos National Security, LLC (LANS), became the managing and 

operating contractor for Los Alamos, under contract with the Department's National Nuclear 

Security Administration (NNSA). In preparation for assuming its management responsibilities 

at Los Alamos, LANS conducted walk-downs of the Laboratory's facilities to identify preexisting deficiencies that could give rise to liability, obligation, loss or damage. The walkdowns, which identified 812 pre-existing fire protection deficiencies, were conducted by 

subject matter professionals, including fire protection experts. 

While the Los Alamos Site Office has overall responsibility for the effectiveness of the fire 

protection program, LANS, as the Laboratory's operating contractor, has a major, day-to-day 

role in minimizing fire-related risks. The issue of fire protection at Los Alamos is more than 

theoretical. In May 2000, the "Cerro Grande" fire burned about 43,000 acres, including 7,700 

acres of Laboratory property. Due to the risk posed by fire to the Laboratory's facilities, 

workforce, and surrounding communities, we initiated this audit to determine whether preexisting fire protection deficiencies had been addressed. 

RESULTS OF AUDIT

Our review disclosed that LANS had not resolved many of the fire protection deficiencies that 

had been identified in early 2006:

• Of the 296 pre-existing deficiencies we selected for audit, 174 (59 percent) had not 

been corrected; and, 

• A substantial portion of the uncorrected deficiencies, 86 (49 percent) were considered 

by the walk-down teams to be significant enough to warrant compensatory actions until 
2 

the deficiency was corrected or was tracked to closure through implementation of 

corrective actions. 

Further, we found that 32 of the significant deficiencies had been closed by the previous Los 

Alamos contractor, prior to LANS assuming responsibility for operation of the Laboratory, 

even though the deficiencies had not been corrected. 

A fire protection expert provided technical support during the audit. 

As an example of uncorrected problems, LANS had not resolved, by performing periodic tests, 

a deficiency identified in 2006 regarding a kitchen hood fire suppression system in a facility 

located within the Los Alamos Neutron Science Center. Such systems are required to be tested 

twice a year by the National Fire Protection Association standard, a standard that had been 

adopted by Department of Energy under DOE Order 420.1B. Yet, in 2006, the LANS walkdown team recognized that this system had not been inspected since May 2004 and noted that 

deficient suppression systems could result in significantly high levels of property damage and 

loss. After we brought this issue to management's attention on February 6, 2009, LANS 

officials stated that the Laboratory would correct this deficiency. 

As with the problems involving the fire suppression system, we observed that LANS had not 

always corrected life safety deficiencies involving building exits at one of its primary facilities. 

This included providing a secondary emergency exit for a building with occupants on multiple 

floor levels. LANS had removed personnel from the third floor and improved the sprinkler 

system of the facility, but it had still not provided a secondary exit for personnel on the second 

floor by the time we completed our review. NNSA has since stated that this fire protection 

issue will be completely addressed by relocating personnel from the second floor. 

Perhaps most serious, our testing revealed that a number of deficiencies were formally closed 

even though actual corrective action had not been completed. Notably, we observed that action 

had not been taken to resolve a recommendation to replace a fire alarm panel found to be 

unreliable. After the walk-down was conducted but prior to contract transition, the former 

contractor closed the recommendation in its action tracking database even though the panel had 

not been replaced. The walk-down team had categorized the fire alarm system as requiring 

replacement since it had been modified many times, was old and obsolete, and had very limited 

available spare parts. In fact, the walk-down team concluded that the panel "...must be 

considered to be unreliable and should have a very high priority for replacement." 

We concluded that the uncorrected fire protection deficiencies identified by the LANS walkdown team had not been properly resolved because the Department's Site Office had not 

effectively administered the Los Alamos contract. Specifically, the Site Office had not ensured 

that LANS and the former Los Alamos contractor made the necessary improvements to correct 

identified fire protection deficiencies nor had it validated the efficacy of corrective actions. 

Further, the Site Office had not established expectations for LANS to correct deficiencies, 

including properly structured contract incentives to achieve that goal. 

Absent strong fire protection leadership by Federal officials, LANS had not fully evaluated the 

most significant deficiencies identified by the walk-down team to determine whether they had 
3 

been corrected or if additional actions were needed. In particular, LANS had not tracked nor 

verified that corrective actions had actually been taken to remedy deficiencies. 

We noted that the Defense Nuclear Facilities Safety Board, in a December 2008 report to the 

NNSA Administrator, expressed concerns regarding the progress made in resolving protection 

issues at Los Alamos. Specifically, the Board reported that inadequate staffing of Los Alamos' 

fire protection function had impeded progress in correcting previously identified fire protection 

issues, including timely completion of required inspections and maintenance of fire protection 

equipment. 

The failure to correct fire protection deficiencies increased the risk of injury or loss of life. 

Further, there are increased risks associated with fire-related events, such as the release of 

hazardous or radiological material. If such an event were to occur, not only would the safety 

and health of employees and the public be impacted but the environment could be damaged as 

well. Accordingly, we made a number of recommendations to help improve fire protection at 

Los Alamos. 

As part of our continuing focus on safety, the Office of the Inspector General is also currently 

conducting an inspection to determine whether fire suppression and related services for Los 

Alamos National Laboratory are assured through agreements with Los Alamos County. 

MANAGEMENT REACTION

Management disagreed with conclusions, specifically, regarding the potential impact of the fire 

protection deficiencies. However, Management expressed its agreement with the proposed 

corrective actions and recommendations, and, during the course of audit field work, informed 

the audit team of corrective actions that it planned to take. As noted in the report, despite its 

stated disagreements with the audit conclusions, after we pointed out unresolved deficiencies 

both contractor and NNSA officials initiated action to reassess and/or correct individual fire 

protection problems. NNSA's completed and planned actions, when combined with our 

recommendations to adequately incentivize contractor performance, should, if completely 

implemented, help reduce the health, safety, and property risks associated with fire protection 

weaknesses at the Los Alamos National Laboratory. 

Attachment 

cc: Deputy Secretary 

 Administrator, National Nuclear Security Administration 

 Chief of Staff 

 Manager, Los Alamos Site Office 
AUDIT REPORT ON FIRE PROTECTION DEFICIENCIES AT LOS 

ALAMOS NATIONAL LABORATORY ___ 

TABLE OF 

CONTENTS 

Los Alamos Fire Protection

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

Recommendations and Comments....................................................................................6 

Appendices 

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

2. Prior Reports .............................................................................................................11 

3. Management Comments ...........................................................................................12 
LOS ALAMOS FIRE PROTECTION 

____________________________________________________________________________ 

Page 1 Details of Finding

Fire Protection Los Alamos National Laboratory (Los Alamos) had not 

Deficiencies corrected a majority of the pre-existing fire protection 

deficiencies identified by Los Alamos National Security, 

LLC (LANS), in 2006. We reviewed a sample of 296 of 

812 fire protection deficiencies identified by LANS prior to 

assuming management of the Laboratory from the 

University of California, the previous management and 

operating contractor. Although the LANS walk-down 

teams had not provided a detailed risk assessment of 

identified fire protection deficiencies, they did identify 

deficiencies that they considered to be significant. We 

evaluated the status of those deficiencies, with the support 

of a Los Alamos fire protection expert, and determined that 

174 deficiencies (59 percent) had not been corrected, 

despite having been identified between March and April 

2006. These deficiencies were located in a variety of areas, 

including nuclear and chemical facilities, office buildings, 

and other facilities containing hazardous materials. 

Notably, we determined that: 

• Eighty-six of the 174 uncorrected deficiencies (49 

percent) were considered significant enough by the 

walk-down team to require either compensatory 

action or tracking until the deficiency was corrected 

because they represented areas of non-compliance 

with fire protection standards and requirements; 

and, 

• Even though they had not actually been corrected, 

32 of the significant deficiencies had been closed by 

the previous Los Alamos contractor prior to LANS 

assuming responsibility for the Laboratory. 

Our examination disclosed that even though they had been 

identified more than two years prior to the commencement 

of our review, LANS had not taken action to address many 

significant deficiencies. For example, LANS had not: 

• Tested a kitchen hood fire suppression system 

(located within the Los Alamos Neutron Science 

Center) in over four years. Such systems are 

required to be tested twice a year by the National 

Fire Protection Association (NFPA) standard, a 

standard that had been adopted by Department of 

Energy Order 420.1B. In 2006, the LANS walkdown team recognized that this system had not been 

inspected since May 2004 and noted that deficient
 

____________________________________________________________________________ 

Page 2 Details of Finding 

systems could result in significantly high levels of 

property damage and loss. After we brought this issue to 

management's attention on February 6, 2009, LANS 

officials stated that the Laboratory would correct this 

deficiency. 

• Provided a secondary exit for the Administration 

Building in Technical Area-16. This three story office 

building had only a single exit stairwell from the second 

and third floors. The 2006 LANS walk-down team 

identified the absence of an additional exit stairwell as a 

significant life safety deficiency. The team also noted 

that the absence of a second exit violated a NFPA 

requirement that a facility's design must allow occupants 

to promptly escape. In 2007, LANS removed all 

personnel from the third floor and made modifications to 

the sprinkler system. The National Nuclear Security 

Administration (NNSA) management indicated that this 

fire protection issue will be completely addressed by 

relocating personnel from the second floor, an action that 

it planned to complete in the near term. 

Fire Protection Deficiencies Reported as Closed Were Not 

Corrected

At the time of our observation, a LANS subject matter expert 

verified that 32 of the significant deficiencies classified as "Issue 

Closed" in a stand-alone database, developed to track preexisting conditions, remained uncorrected. Our testing revealed, 

for example, that the contractor responsible for managing the 

Laboratory prior to LANS had closed the deficiencies even 

though corrective actions had not been completed or were 

ineffective. In particular, the former Los Alamos contractor had 

not: 

• Replaced a fire alarm panel that the walk-down team 

found to be unreliable. The alarm panel was located in a 

facility that housed and processed plutonium. Plutonium 

is a nuclear material that will burn and which, if not 

handled properly, has the potential to reach nuclear 

criticality and/or contaminate the site and workforce. 

The walk-down team had categorized the fire alarm 

system as requiring replacement since it had been 

modified many times, was old and obsolete, and had 

very limited available spare parts. In fact, the walkdown team concluded that the panel "...must be 

considered to be unreliable and should have a very high 
 

____________________________________________________________________________ 

Page 3 Details of Finding 

priority for replacement." While LANS located spare 

parts for the system after it assumed responsibility for 

management, it had not replaced the system as 

recommended by the walk-down team. NNSA 

management acknowledged that the alarm panel is 

antiquated but considered it functional and reliable, 

contrary to the walk-down report finding. NNSA 

management also stated that Los Alamos had secured 

and qualified an inventory of spare parts and will repair 

or replace the system if reliability deteriorates. Finally, 

NNSA plans to replace the part in the future. Actions 

that NNSA undertook after we notified it of problems 

with the fire panel are promising, and if fully 

implemented, should help resolve a significant weakness 

in the plutonium processing facility which this panel 

protects/monitors. 

• Corrected impediments to the effective operation of 

sprinklers in a facility within the Los Alamos Neutron 

Science Center. The LANS walk-down team observed 

that curtains and valances obstructed the flow of 

sprinklers and also noted that missing ceiling tiles could 

delay the operation of the sprinklers. The team 

recommended the removal of the curtains and valances 

and replacement of tiles. As a result of our audit, LANS 

created a work order in February 2009 to correct this 

deficiency. Similar to other actions taken after our field 

audit work was finished, officials told us that the work to 

address this problem had been completed. 

• Provided fire protection to an enclosed structure within a 

technical shop that the walk-down team determined was 

not protected by the existing sprinkler system. LANS 

officials told us that as a result of our audit work, it plans 

to take corrective actions in this area.

Contract The Los Alamos Site Office (LASO) had not 

Administration and effectively administered the Los Alamos facility operation 

Project Management contract to ensure that the fire protection deficiencies were 

corrected. Further, LANS did not follow its own requirements 

for project management related to correcting fire protection 

deficiencies. 

Contract Administration

Although safety is one of the Department of Energy's priorities, 

LASO had not ensured that fire protection deficiencies were 
 

____________________________________________________________________________ 

Page 4 Details of Finding 

corrected. LASO had not required either LANS or the previous 

Los Alamos managing contractor to validate the status of the fire 

protection deficiencies and it had not verified the status of those 

deficiencies. Further, LASO had not effectively used 

Performance Based Incentives (PBIs) to establish expectations 

for LANS to correct fire protection deficiencies identified in 

2006. Specifically, LASO had not provided incentives related to 

the 2006 deficiencies until 2008. At that time, it established an 

expectation that LANS develop a milestone schedule for closure 

or other disposition of all fire protection deficiencies expected to 

cost $50,000 or more. According to NNSA, LANS has 

developed such a schedule but had limited success in resolving 

the identified deficiencies. NNSA recognized that it had limited 

success during 2008 in correcting fire protection deficiencies 

and carried forward the PBI for correcting the deficiencies into 

Fiscal Year (FY) 2009. 

Deficiency Resolution Efforts

LANS had not fully evaluated the most significant fire 

protection deficiencies, those requiring compensatory action or 

tracking until closure, to determine whether they had been 

corrected or if additional actions were needed. In particular, 

LANS had not verified that corrective actions had actually been 

taken to remedy deficiencies. According to Laboratory officials, 

the former Laboratory contractor reportedly addressed the 

deficiencies identified by the walk-down team. However, 

LANS had not verified that the deficiencies identified as 

resolved by the former contractor had actually been corrected. 

Further, LANS had not tracked 68 of the 86 significant 

deficiencies in either its maintenance management system 

(PassPort) or the Los Alamos Issues Tracking System (LIMTS). 

According to officials, when LANS assumed responsibility for 

the Laboratory, the deficiencies in the former contractor's 

action/tracking database were transferred into either PassPort 

and/or LIMTS. We noted that 18 of the significant deficiencies 

were tracked in either PassPort and/or LIMTS at the start of our 

audit. However, LANS did not capture all outstanding 

deficiencies in PassPort or LIMTS when it transferred the 

deficiencies. For example, we determined that LANS had not 

transferred 42 significant deficiencies that were identified in the 

former contractor's tracking database as requiring corrective 

actions. As a result of our audit, LANS entered and began to 

track an additional 20 deficiencies in PassPort and/or LIMTS. 

Finally, LANS officials told us that they had resolved six 

deficiencies that had not been tracked in either system. 
 

LANS also could not demonstrate that it had always allocated 

resources or developed projected completion dates for fire 

protection deficiencies. LANS officials told us that based on 

issues identified during our review they had initiated actions to 

correct a number of deficiencies. LANS officials, however, 

could not always identify the funding allocated to correcting the 

deficiencies and the schedule established for completing the 

corrective actions. 

Consistent with our findings, we also noted that the Defense 

Nuclear Facilities Safety Board reported to the Administrator, 

NNSA, in December 2008, that inadequate staffing of Los 

Alamos' fire protection function had impeded progress in 

correcting previously identified fire protection issues. Problem 

areas included timely completion of required inspections and 

maintenance of fire protection equipment. 

To its credit, LANS plans to implement a number of important 

actions based on the results of our audit. In particular, LANS 

plans to: 

• Direct Facility Operation Directors to document the 

disposition of all significant walk-down issues (after 

rescreening) and verify that each has been properly 

closed or is being tracked in LIMTS; 

• Perform a management self-assessment, with the results 

tracked in LIMTS, on the efficacy of action taken to 

disposition fire protection deficiencies; 

• Conduct a corporate oversight assessment of LANS 

management of its fire protection deficiencies; 

• Ensure that PBIs on fire protection will be met in 

FY 2009; and, 

• Evaluate existing fire protection program performance 

metrics to determine if they are sufficient. If they are 

not, revise or augment them as necessary to provide 

sufficient visibility to support priority decisions. 

Potential Impacts The failure to correct a majority of fire protection deficiencies 

increased the risks of injury or loss of life had a fire occurred at 

Los Alamos. If such a fire did occur, and was not quickly 

suppressed, there could be a risk that hazardous or radiological 

____________________________________________________________________________ 

Page 5 Details of Finding 
 

material could be released, continuity of operations disrupted, 

and a loss of structures and components. Ensuring that known 

fire protection deficiencies are promptly and properly resolved 

would help ensure that employee safety and health is protected, 

the impact on the public is minimized, and that damage to the 

environment is prevented or minimized. 

RECOMMENDATIONS To help ensure that fire protection deficiencies are 

corrected, we recommend that the Manager, Los Alamos Site 

Office: 

1. Structure PBI's that establish the clear expectation that 

LANS correct existing fire protection deficiencies; and, 

2. Verify the efficacy of LANS' corrective actions, 

including those previously reported as closed. 

Additionally, we recommend that the Manager, Los Alamos Site 

Office, ensure that LANS: 

3. Establish funding plans and schedules for correcting all 

significant fire protection deficiencies; 

4. Track the status of the individual highly significant fire 

protection deficiencies; and, 

5. Validate the efficacy of corrective actions before closing 

the deficiency. 

MANAGEMENT Management agreed with the recommendations and stated that 

COMMENTS actions that have been taken or that are being implemented 

are providing confidence in the programmatic and management 

structure and are in the best interests of the NNSA. Management 

also noted that the deficiencies identified in this report were not 

nuclear safety issues which are its primary focus. 

Further, management stated that LANS had corrected a notable 

number of the high-significance and moderate-significance fire 

protection deficiencies that were identified during the walkdowns that were conducted from March through April 2006. 

Management did not agree, however, with the stated conclusions. 

Management indicated that the issues raised in the report arose 

from weaknesses in institutional issues and corrective action 

management that existed in June 2006. Management stated that, 

at that time, Los Alamos lacked a program to manage, prioritize,

________________________________________________________________________________ 

Page 6 Recommendations and Comments
 

and address these types of deficiencies in a manner that 

considered the multiple relevant factors, including but not 

limited to the potential mission impact, the available resources, 

and the risk to the public. 

Finally, management stated that it will initiate actions to verify 

the efficacy of LANS' corrective actions, ensure that LANS 

tracks the status of individual highly significant deficiencies, 

and ensure that LANS validates the efficacy of corrective 

actions before closing the deficiencies. NNSA also asserted that 

current PBIs establish a clear expectation that LANS correct 

existing fire protection deficiencies and ensure that LANS 

establishes funding plans and schedules for correcting all 

significant fire protection deficiencies. 

MANAGEMENT Management's comments and corrective actions taken or initiated 

REACTION are generally responsive to our recommendations. While we 

acknowledge that the fire protection deficiencies were not 

nuclear safety issues, the failure to correct fire protection 

deficiencies increased the risks of injury or loss of life if a fire

occurred at Los Alamos. If not extinguished quickly, a fire at or 

near facilities we tested could also potentially result in the 

release of radiological material. These issues were of such 

significance that, at the time of transition of Los Alamos 

management from the previous contractor to LANS, the LANS 

Transition Manager committed to develop Corrective Action 

Plans that addressed causal factors for the deficiencies, prioritize 

the deficiencies based on their significance and impact, identify 

resources needed to correct the deficiencies, and establish a 

schedule for completing corrective actions. 

Management's acknowledgement that Los Alamos lacked a 

program to manage deficiencies is not inconsistent with our 

report. Management's observation, in fact, provides additional 

insight regarding reasons for the failure to monitor and promptly 

resolve fire protection deficiencies, many of which lingered for 

nearly three years after discovery. 

We are encouraged that NNSA agreed to initiate action in 

response to our recommendations. We remained concerned, 

however, that NNSA plans to take no additional action regarding 

contractor performance incentives. As previously noted, current 

PBIs place an emphasis on deficiencies that are expected to cost 

$50,000 or more rather than addressing deficiencies based on 

significance. We noted that LANS did not include all 

significant fire protection deficiencies on the list it prepared in 

________________________________________________________________________________ 

Page 7 Comments
 

________________________________________________________________________________ 

Page 8 Comments

response to the PBIs, such as the uninspected kitchen hood fire 

suppression system. As noted in the LANS walk-down report, 

the deficiency could result in high levels of property damage 

should the system fail.
Appendix 1 

____________________________________________________________________________ 

Page 9 Objective, Scope, and Methodology

OBJECTIVE The objective of our audit was to determine whether 

pre-existing fire protection deficiencies had been corrected. 

SCOPE This audit was performed between December 2007 

and April 2009 at Los Alamos National Laboratory and the 

Los Alamos Site Office, located in Los Alamos, New 

Mexico. 

METHODOLOGY To accomplish the audit objective, we: 

• Reviewed applicable Laws, Departmental orders, 

other Departmental guidance, and contracts; 

• Analyzed prior Office of Inspector General and 

Defense Nuclear Facilities Safety Board reports; 

• Reviewed and analyzed internal Los Alamos 

guidance; 

• Reviewed compliance with the Government 

Performance and Results Act of 1993; 

• Selected a sample of 296 of the 812 fire protection 

deficiencies from a stand-alone database and with 

the aid of a fire protection subject matter expert 

performed visual observations. Los Alamos 

selected the subject matter expert, a member of the 

Laboratory's Fire Protection Group, to assist us in 

reviewing the fire protection deficiencies; and, 

• Interviewed key contractor personnel. 

We conducted this performance audit in accordance with 

generally accepted government auditing standards. Those 

standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a 

reasonable basis for our findings and conclusions based on 

our audit objective. We believe that the evidence obtained 

provides a reasonable basis for findings and conclusions 

based on our audit objective. The audit included tests of 

controls and compliance with laws and regulations 

necessary to satisfy the audit objective. Because our 

review was limited, it would not necessarily have disclosed 

all internal control deficiencies that may have existed at the 

time of our audit. We assessed performance measures
Appendix 1 (Continue) 

____________________________________________________________________________ 

Page 10 Objective, Scope, and Methodology

established under the Government Performance and Results 

Act of 1993 and found that Los Alamos had not instituted 

specific performance measures related to correcting preexisting fire protection deficiencies until 2008. We 

determined that computer-processed data from the standalone database was integral to meeting the objectives of 

this audit. We verified the accuracy of data contained in 

the database as it related to our audit objective by visual 

inspections of corrected and uncorrected deficiencies. 

Management waived an exit conference. 
Appendix 2 

____________________________________________________________________________ 

Page 11 Prior Reports 

PRIOR REPORTS

OFFICE OF INSPECTOR GENERAL REPORTS

• The Department of Energy's Wildland Fire Planning and Preparation Efforts 

(DOE/IG-0760, March 2007). This report found that wildland fire mitigation 

activities had either not been performed or were not completely effective. In 

addition, it was determined that contractor officials did not always adhere to 

established wildland fire planning and mitigation guidance. Specifically, contractors 

had not used risk-based principles to prioritize mitigation efforts and had either 

omitted or not adequately considered other items specified in Federal policy and 

Departmental guidance when developing fire protection plans. Further, Federal 

officials had not always actively monitored contractor wildland fire protection 

programs, coordinated protective efforts, or validated the effectiveness of contractor 

fire mitigation activities. 

OTHER REPORTS

• The Defense Nuclear Facilities Safety Board's Staff Issue Report, Fire and 

Emergency Response Capabilities for Defense Nuclear Facilities at Los Alamos 

National Laboratory, December 8, 2008. This report found weaknesses in Los 

Alamos' capability to respond to a fire or other emergency in the unique hazard 

environments associated with nuclear facilities. The report concluded that 

weaknesses resulted from the failure to implement long-standing recommendations 

made in 1995 and 2004 needs assessments. The report also found that staffing 

shortages may be hindering needed improvements in Los Alamos' fire protection 

program. 

• The Defense Nuclear Facilities Safety Board's Staff Issue Report, Fire Protection at 

Los Alamos National Laboratory, April 29, 2005. This report found a number of 

issues regarding weaknesses in the fire protection program at Los Alamos National 

Laboratory. Paramount among these issues was the lack of a formal plan to address 

the baseline needs assessment for fire and emergency services and the lack of a longterm contract for these services with Los Alamos County. The Board acknowledged 

the National Nuclear Security Administration's completion of a cooperative 

agreement for fire and emergency services with Los Alamos County. However, the 

Board remained concerned about the outlook for aligning those services with the 

unique capabilities required to meet the fire protection needs of the Laboratory. The 

report further indicates that there are weaknesses in the current capability to respond 

to a fire or other emergency event in the unique hazard environments associated with 

defense nuclear facilities at the Laboratory. This situation is a direct result of the 

failure to implement long-standing recommendations made in the 1995 and 2004 

Baseline Needs Assessments, and is further evidenced by observations made and 

issues identified by Los Alamos National Security, LLC during recent emergency 

exercises. The report also found that staffing shortages may be hindering needed 

improvements to the Laboratory's fire protection program. 
Appendix 3 

 May 21, 2009 

MEMORANDUM FOR George W. Collard 

 Assistant Inspector General 

 for Performance Audit 

FROM: Michael C. Kane / S / 

 Associate Administrator 

 for Management and Administration 

SUBJECT: Comments to Draft Fire Deficiencies Report; Proj. No. 

A08LA010; IDRMS No. 2007-04684 

The National Nuclear Security Administration (NNSA) appreciates the opportunity to 

review the Inspector General’s draft report, Fire Protection Deficiencies at Los Alamos 

National Laboratory. Due to the risk posed by fire to the Los Alamos National 

Laboratory’s (LANL) facilities, workforce, and surrounding communities, we understand 

that this audit was initiated to determine whether pre-existing fire protection deficiencies 

had been corrected. 

NNSA agrees with the recommendations that are being presented because quality 

assurance can always be strengthened. The actions that NNSA has taken or are being 

implemented are providing a level of confidence to NNSA’s programmatic and 

management structure and are in the best interests of the NNSA. 

NNSA does not agree, however, with the stated conclusions. The audit focused on 

pre-existing conditions identified by the Los Alamos National Security, LLC (LANS) 

field walk-downs conducted prior to contract transition in June 2006. The LANS duediligence walk-down report, issued in May 2006, identified about 3400 issues overall, of 

which 812 were related to fire protection. Particularly noteworthy, the fire protection 

issues flagged were not nuclear safety issues, since the walk-downs did not focus on 

nuclear-safety-credited systems; such systems are the primary focus of NNSA fire 

protection oversight. Furthermore, consistent with its purpose, the due-diligence walkdown report provided a triage of the issues but not a detailed risk analysis and risk 

prioritization for the issues. 

The issues raised by the auditors arise from weaknesses in institutional issue and corrective 

action management that existed in June 2006. At that time, LANL lacked a program to 

manage, prioritize, and address these types of deficiencies in a manner that considered the 

multiple relevant factors, including but not limited to the potential mission impact, the 

available resources, and the risk to the public. While the due-diligence walk-down report 

provided abundant symptoms of this problem, addressing only those 

________________________________________________________________________ 

Page 12 Management Comments 
2

Appendix 3 (Continued) 

symptoms would not address the problem and would not prevent recurrence. Since June 

2006, NNSA and LANS major focus has been to develop institutional issue management 

within the Contractor Assurance System, while also demonstrably improving the safety 

of the public, the workers, and the environment in all areas, including fire protection. 

NNSA will address the stated recommendations in the following manner: 

Recommendations 2, 4 and 5: Verify the efficacy of LANS’ corrective actions 

including those previously reported as closed. Ensure that LANS tracks the status of the 

individual highly significant fire protection deficiencies. Ensure that LANS validates the 

efficacy of corrective actions before closing the deficiency. 

-- NNSA Analysis: As of April 30, 2009, LANS has confirmed the valid and complete 

closure for 27 of the 30 high-significance fire protection deficiencies identified during 

the due-diligence walk-downs and has confirmed that the three such deficiencies that 

remain open are mitigated with compensatory measures. Similarly, LANL has 

confirmed that 138 of the 316 moderate-significance compliance issues have valid 

and complete closure, with the balance entered into and being managed within the 

LANL issue management system. LANS has separately provided comments on 

specific issues identified in the report. 

Several of the IG’s examples in this area warrant further discussion: 

• The Plutonium Facility fire detection and alarm panel is antiquated but considered 

currently functional and reliable, contrary to the walk-down report finding. 

LANL has secured and qualified an inventory of spare parts. If reliability 

deteriorates, LANL will repair or replace the system as a priority. Planned 

replacement is part of the TA-55 Reinvestment Project. 

• The fire protection issue associated with means of egress from the cited TA-16 

administrative building was partially addressed in 2007 by relocating personnel 

from the third floor and will be completely addressed by relocating personnel 

from the second floor in May 2009. 

To prevent recurrence, in 2007, LANS made improvements to the issue management, 

corrective action, and impairment control programs, and the comprehensive fire 

protection program (as required under the worker safety and health program under 10 

CFR 851). 

NNSA Action: As part of its programmatic fire protection oversight in FY 2009, the 

Los Alamos Site Office (LASO) will verify the efficacy of the closure of the 30 highsignificance fire protection deficiencies identified in the due-diligence walk-down 

report, as well as a sampling of the moderate-significance compliance deficiencies. 

Moving forward, the LASO and LANS will develop metrics to actively monitor the 

effectiveness of the LANS corrective action management system to ensure that issues 

________________________________________________________________________ 

Page 13 Management Comments 
3

Appendix 3 (Continued) 

are tracked and closed on a timely basis and that significant corrective actions are 

validated effective. Fire protection issues would be included in this overall program 

metric. 

Recommendations 1 and 3: Structure Performance Based Incentives (PBIs) that 

establish clear expectation that LANS correct existing fire protection deficiencies. 

Ensure that LANS establishes funding plans and schedules for correcting all significant 

fire protection deficiencies. 

-- NNSA Analysis: NNSA had such PBIs in 2008 but had limited success, based on 

the awarded fee (e.g., FY-08 PBI 11.4.1). In FY 2009, NNSA has PBIs that 

emphasize resolving legacy fire protection issues, including submitting a prioritized 

list, a plan and schedule for execution, and evidence of completion of scheduled 

activities; NNSA also has subjective PBIs that are based on performance on 

commitments and demonstrated continuous improvement in the fire protection 

program (FY 2009 PBI 7.7.1, PBI 16.5, PBI 16.7). Overall, LASO believes that, 

while individual omissions may exist in the program, the LANS fire protection 

program is demonstrating continuous improvement. Attachment A further discusses 

NNSA perspective. 

NNSA Action: In accordance with 10 CFR 851 and 10 CFR 830, which are 

enforceable under the Price Anderson Amendments Act, NNSA expects LANL to 

correct fire protection deficiencies that affect worker safety and nuclear safety. 

NNSA will continue to assess the contractor’s performance in implementing the fire 

protection program, which includes planning, funding, and correcting fire protection 

deficiencies. Current PBIs meet the intent; therefore, NNSA considers this action 

complete. 

In addition to the above comments, NNSA is also attaching technical comments 

(Attachment B) for the IG’s consideration. 

If you have any questions concerning this response, please contact Cathy Tullis, Acting 

Director, Policy and Internal Controls Management. 

Attachments 

cc: Revitization Manager, Los Alamos Site Office 

 David Boyd, Senior Procurement Executive 

 Karen Boardman; Director, Service Center 

________________________________________________________________________ 

Page 14 Management Comments 
IG Report No. DOE/IG-0816

CUSTOMER RESPONSE FORM 

The Office of Inspector General has a continuing interest in improving the usefulness of 

its products. We wish to make our reports as responsive as possible to our customers' 

requirements, and, therefore, ask that you consider sharing your thoughts with us. On the 

back of this form, you may suggest improvements to enhance the effectiveness of future 

reports. Please include answers to the following questions if they are applicable to you: 

1. What additional background information about the selection, scheduling, scope, or 

procedures of the inspection would have been helpful to the reader in understanding 

this report? 

2. What additional information related to findings and recommendations could have 

been included in the report to assist management in implementing corrective actions? 

3. What format, stylistic, or organizational changes might have made this report's 

overall message more clear to the reader? 

4. What additional actions could the Office of Inspector General have taken on the 

issues discussed in this report which would have been helpful? 

5. Please include your name and telephone number so that we may contact you should 

we have any questions about your comments. 

Name Date ________________

Telephone Organization 

When you have completed this form, you may telefax it to the Office of Inspector 

General at (202) 586-0948, or you may mail it to: 

Office of Inspector General (IG-1) 

Department of Energy 

Washington, DC 20585 

ATTN: Customer Relations 

If you wish to discuss this report or your comments with a staff member of the Office of 

Inspector General, please contact Judy Garland-Smith (202) 586-7828. 
The Office of Inspector General wants to make the distribution of its reports as customer friendly 

and cost effective as possible. Therefore, this report will be available electronically through the 

Internet at the following address: 

U.S. Department of Energy Office of Inspector General Home Page 

http://www.ig.energy.gov

Your comments would be appreciated and can be provided on the Customer Response Form.