DEFENSE NUCLEAR FACILITIES SAFETY BOARD 

August 30, 2013 

MEMORANDUM FOR: Steven Stokes, Acting Technical Director 

FROM: Jonathan Plaue, DNFSB Site Representative 

SUBJECT: LLNL Activity Report for Week Ending August 30, 2013 

This is the Site Representative’s final weekly report from LLNL prior to reassignment at the Los 

Alamos National Laboratory (LANL). 

Conduct of Operations: Last month, the laboratory contractor issued a lesson learned to the 

Department of Energy’s database (LL-2013-LLNL-13) regarding the acid eruption event at Site 

300 that significantly injured two workers. The lesson learned indicated that a vague scope of 

work and lack of information on how or when to add chemicals hindered the ability of subject 

matter experts to identify hazards and effective controls. The lesson learned further indicated the 

need to define work scope in a step-by-step manner and produce work instructions that ensure 

personnel performing the work understand the controls to ensure safe work accomplishment. 

The Site Representative notes that at the institutional level, the contractor has interpreted the 

requirements in Department of Energy Order 422.1, Conduct of Operations and applied industry 

best practices in a manner such that nuclear facility workers are rarely required to utilize a 

written procedure to accomplish programmatic activities. Instead, these workers utilize 

Operational Safety Plans (OSPs). The scopes of work for the OSPs do not typically include stepby-step task definition or provide work instructions as indicated by the lesson learned. Certain 

contractor line managers are now considering revising criteria to identify the need to use 

technical procedures–the Site Representative encouraged this positive action, particularly in light 

of the lesson learned and LANL’s ongoing criticality safety and conops issues. 

Plutonium Facility: Livermore Field Office (LFO) and contractor personnel recently reached 

agreement on the path forward for a new ion exchange separation activity involving plutonium238. LFO noted several issues with the OSP for this activity, including vague scope of work and 

inadequate hazards analysis and control. To address the issues, the contractor developed a 

chemical process flow diagram to improve the specificity of chemical conditions, hazards, and 

controls throughout the process. The contractor will use the flow diagram and a work permit to 

refine steps necessary for process development under the existing approved OSP. Once refined, 

management intends to capture this information in a technical work procedure, which will be 

used for steady-state processing.

LFO emphasized consideration of the hazard and associated controls for radiologicallycontaminated puncture wounds in the annual update of the safety basis currently under review 

(see weekly report dated March 29, 2013). In response, the contractor submitted a safety basis 

with new mitigative measures associated with the radiation protection program, such as wound 

evaluation and decontamination (e.g., excision or chelation). The only preventive control targets 

safe storage of sharp items. The Site Representative notes that identification and implementation 

of additional preventive controls could minimize the potential for puncture wounds on several 

activities with known sharps hazards (e.g., use of tool guards on machining activities). Based on 

this feedback, facility management is investigating the use of additional tooling guards.