Nuclear and Worker Safety: Actions Needed to Determine the Effectiveness of Safety Improvement Efforts at NNSA's Weapons Laboratories
Published: 2007-10-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Federal officials, Congress, and the public have long voiced concerns about safety at the nation's nuclear weapons laboratories: Lawrence Livermore, Los Alamos, and Sandia. The laboratories are overseen by the National Nuclear Security Administration (NNSA), while contractors carry out the majority of the work. A recent change to oversight policy would result in NNSA's relying more on contractors' own management controls, including those for assuring safety. This report discusses (1) the recent history of safety problems at the laboratories and contributing factors, (2) steps taken to improve safety, and (3) challenges that remain to effective management and oversight of safety. To address these objectives, GAO reviewed almost 100 reports and investigations and interviewed key federal and laboratory officials.
section_title: What GAO Found
paragraphs: The nuclear weapons laboratories have experienced persistent safety problems, stemming largely from long-standing management weaknesses. Since 2000, nearly 60 serious accidents or near misses have occurred, including worker exposure to radiation, inhalation of toxic vapors, and electrical shocks. Although no one was killed, many of the accidents caused serious harm to workers or damage to facilities. Accidents and nuclear safety violations also contributed to the temporary shutdown of facilities at both Los Alamos and Lawrence Livermore in 2004 and 2005. Yet safety problems persist. GAO's review of nearly 100 reports issued since 2000 found that the contributing factors to these safety problems generally fall into three key areas: relatively lax laboratory attitudes toward safety procedures, laboratory inadequacies in identifying and addressing safety problems with appropriate corrective actions, and inadequate oversight by NNSA site offices. NNSA and its contractors have been taking some steps to address safety weaknesses at the laboratories. Partly in response to continuing safety concerns, NNSA has begun taking steps to reinvigorate a key safety effort--integrated safety management--originally started in 1996. This initiative was intended to raise safety awareness and provide a formal process for employees to integrate safety into every work activity by identifying potential safety hazards and taking appropriate steps to mitigate these hazards. NNSA and its contractors have also begun taking steps to develop or improve systems for identifying and tracking safety problems and the corrective actions taken in response. Finally, NNSA has initiated efforts to strengthen federal oversight at the laboratories by improving hiring and training of federal site office personnel. NNSA has also taken steps to strengthen contractor accountability through new contract mechanisms. Many of these efforts are still under way, however, and their effect on safety performance is not clear. NNSA faces two principal challenges in its continuing efforts to improve safety at the weapons laboratories. First, the agency has no way to determine the effectiveness of its safety improvement efforts, in part because those efforts rarely incorporate outcome-based performance measures. The department issued a directive in 2003 requiring use of a disciplined approach for managing improvement initiatives, often used by high-performing organizations, including results-oriented outcome measures and a system to evaluate the effectiveness of the initiative. Yet GAO found little indication that NNSA or its contractors have been managing safety improvement efforts using this approach. Second, in light of the long-standing safety problems at the laboratories, GAO and others have expressed concerns about the recent shift in NNSA's oversight approach to rely more heavily on contractors' own safety management controls. Continuing safety problems, coupled with the inability to clearly demonstrate progress in remedying weaknesses, make it unclear how this revised system will enable NNSA to maintain an appropriate level of oversight of safety performance at the weapons laboratories.

section_title: Letter
paragraphs: The National Nuclear Security Administration (NNSA) oversees three  weapons laboratories—Lawrence Livermore, Los Alamos, and Sandia  national laboratories—to help carry out its missions of nuclear weapons  stewardship, environmental cleanup, and scientific and technical research.  The sensitive research conducted at these laboratories involves the  handling of radioactive and hazardous materials, such as plutonium, and  radioactive wastes that, if not handled safely, could cause nuclear  accidents or expose the public and the environment to heavy doses of  radiation. The weapons laboratories 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. Although  the consequences of such accidents could be less severe than one  involving nuclear materials, they could also lead to long-term illness,  injury, or even deaths among workers or the public.
NNSA relies on contractors and subcontractors to perform day-to-day  operations at each site. To promote laboratory and worker safety, NNSA’s  primary approach has been to require its contractors to follow federal  safety laws and Department of Energy (DOE) requirements, including  policies, orders, and standards, by incorporating these requirements into  the contracts. DOE requirements address safety both in nuclear operations  (nuclear safety) and in maintaining health and safety of laboratory  workers (worker safety). NNSA site offices located at the laboratories are  responsible for direct oversight of the contractors, including monitoring  contractor-generated data on safety-related incidents and observing daily  work activities in the facility. A recent change in DOE policy places more  responsibility on the contractor for having a reliable system of  management controls, including those addressing safety, and focuses  NNSA oversight efforts on high-hazard activities.
Over the years, federal officials, Congress, and members of the public have  expressed concerns about safety problems and weaknesses at the  weapons laboratories. The Defense Nuclear Facilities Safety Board (Safety  Board), which was created by Congress to provide an independent  assessment of safety conditions and operations at defense nuclear  facilities, held a series of eight public hearings starting in 2002 to address  concerns with DOE’s approach to ensuring safety—including at NNSA’s  weapons laboratories—and in 2004 recommended that the department  take a number of steps, such as strengthening the federal oversight role, in  an effort to improve safety at these facilities. In addition, more than a  dozen congressional hearings have addressed management problems at  Los Alamos National Laboratory, including a May 2005 hearing that raised  questions about the laboratory’s ability to manage safety issues.
In this context, you asked us to examine NNSA’s safety performance at the  three weapons laboratories. This report discusses (1) the recent history of  safety problems that have occurred at the weapons laboratories and  contributing factors, (2) steps NNSA and its contractors have taken to  improve safety management, and (3) challenges that remain to effective  management and oversight of safety performance at the weapons  laboratories.
To address these issues, we reviewed federal laws and regulations  describing safety requirements for nuclear safety and for worker safety  and health. We also reviewed DOE policies and procedures regarding  safety management. We reviewed relevant reports issued since 2000  evaluating safety issues at the three weapons laboratories, including  accident investigations, inspections by DOE’s Office of Independent  Oversight and Performance Assurance, reviews by NNSA’s Chief of  Defense Nuclear Safety, and reviews by the Safety Board. We also  discussed the safety problems and contributing factors with  representatives from these organizations, as well as with DOE and NNSA  headquarters officials. In addition, we visited the three weapons  laboratories and met with NNSA officials and contractors to discuss safety  management and safety problems at the laboratories and to determine  what steps NNSA and contractors were taking to address these issues.  Appendix I describes our scope and methodology in more detail. We  performed our work in accordance with generally accepted government  auditing standards, which included an assessment of data reliability, from  September 2006 through September 2007.
subsections: section_title: Background
paragraphs: NNSA carries out the department’s nuclear weapons research missions at  three weapons laboratories—Lawrence Livermore, Los Alamos, and  Sandia national laboratories. These three laboratories have primarily a  science and technology mission, which focuses on maintaining the  nation’s nuclear weapons stockpile; preventing nuclear proliferation; and  furthering basic scientific knowledge in chemistry, structural biology, and  mathematics. In addition to their primary mission, the three laboratories  perform work for other federal agencies, such as supporting homeland  security efforts, and they coordinate research efforts with DOE’s Office of  Science national laboratories in areas such as climate change and  nanotechnology. In support of these various missions, contractors at the  laboratories may carry out major construction projects, as well as projects  to clean up radioactive and hazardous wastes from decades of producing  materials or components for nuclear weapons.
NNSA relies heavily on contractors to carry out its work, making effective  federal oversight crucial to accomplishing its missions. At each of the  laboratories, about 100 NNSA staff at the site office have responsibility for  overseeing the work performed under contract by thousands of contractor  employees. The contractors, in turn, may subcontract out major portions  of their work, especially in mission-support areas such as constructing and  maintaining facilities. Although NNSA has no direct relationship with  these subcontractors, it is ultimately responsible for ensuring that all  work, whether done by the prime contractor or its subcontractors, is  performed in a manner consistent with the contract, including with all  requirements for nuclear and worker safety.
NNSA’s contracts for the three laboratories generally provide for  reimbursing contractors for allowable costs plus an additional fee. The  total fee available to the contractors may include a base, or fixed, amount  that is guaranteed and an “at-risk” amount that is tied to performance  measures in the contract. To help strengthen accountability, the  department established a new contract provision in 1999 that allows it to  reduce the fee otherwise earned if a contractor does not meet certain  environmental, safety, and health performance standards.
DOE regulations and directives set forth requirements for ensuring that  nuclear facilities are operated safely to protect workers and the public.  NNSA’s primary approach to ensuring nuclear and worker safety is to  incorporate these regulations and directives into contracts. These rules  require contractors to develop and maintain documentation that  (1) describes the work to be performed; (2) evaluates all potential hazards  and accident conditions; (3) contains appropriate controls, including  technical requirements, that will eliminate or minimize the risk of hazards;  and (4) delineates procedures and practices for operating the facilities  safely. This documentation is commonly referred to as the facility’s  documented safety basis. In addition, DOE regulations require that  radiation doses to workers at DOE facilities be maintained within  prescribed limits.
NNSA’s laboratories and facilities, with few exceptions, are not regulated  by the Nuclear Regulatory Commission or by the Occupational Safety and  Health Administration. Instead, DOE and NNSA provide internal oversight  of the three weapons laboratories at several different levels. NNSA  provides direct oversight of the laboratories and the contracts through its  site offices. In addition, NNSA headquarters staff offices, such as the  offices of Defense Programs and Nuclear Nonproliferation, provide  funding and program direction to the site offices. DOE’s Office of  Enforcement and Office of Independent Oversight and Performance  Assurance (now called the Office of Environment, Safety and Health  Evaluations) and NNSA’s Chief of Defense Nuclear Safety and Senior  Advisor for Environmental Safety and Health also provide oversight of  laboratory activities to ensure nuclear and worker safety. Finally, the  Safety Board, an independent oversight organization created by Congress  in 1988, provides advice and recommendations to the Secretary of Energy  to help ensure adequate protection of public health and safety at all of the  department’s defense nuclear facilities, including those at the three  weapons laboratories. As part of its independent oversight, the Safety  Board has full-time representatives at the Los Alamos and Lawrence  Livermore laboratories to work with the NNSA site offices and to observe  contractor work activities at the site’s nuclear facilities.
section_title: Long-standing Management Weaknesses Contribute to the Laboratories’ Persistent Safety Problems
paragraphs: From 2000 through 2007, the three NNSA weapons laboratories have been  troubled by persistent safety problems, including accidents and violations  of nuclear safety rules designed to protect laboratory employees and the  public. Our review of nearly 100 internal and external safety reviews since  2000 found that factors contributing to safety problems stemmed largely  from weaknesses in NNSA’s management of safety issues at the weapons  laboratories—weaknesses that leave the laboratories vulnerable to  continued, and potentially serious, safety problems.
subsections: section_title: Accidents and Violations of Nuclear Safety Rules Persist at All Three Weapons Laboratories
paragraphs: From 2000 through 2007, nearly 60 accidents or near misses—each serious  enough to be investigated—have occurred at the three NNSA weapons  laboratories. The accidents have included radiation exposures, inhalation  of toxic vapors, electrical shocks, and injuries during construction  projects or maintenance activities. Fortunately, no one has been killed, but  many of these accidents have resulted in serious worker injuries or facility  damage. (Appendix II lists the major accident investigations at the three  weapons laboratories since 2000.) For example:  In 2000, seven workers at a Los Alamos plutonium-processing and - handling facility received significant doses of radiation from plutonium  released into the air from a faulty unit, known as a glovebox, that shields  people working with radioactive materials. When plutonium is inhaled, it  can damage cells or raise a person’s risk of getting cancer. In this incident,  a technician was trying to determine why the glovebox system was not  operating properly; seven other workers were in the room at the time. As  the technician was working, a fitting in the system leaked plutonium into  the air, setting off alarms. Although the eight workers left the room at  once, at least four of them were exposed to radiological releases much  higher than the allowable annual exposure limits set in regulation, raising  their cancer risk. The workers were provided immediate treatment.
An internal DOE accident investigation found a number of factors behind  this accident—which, because of the number of workers involved and the  potential radiological doses, ranked among the top 10 worst radiological  intake accidents in 41 years of data gathering by DOE and its predecessor  agencies. These contributing factors included inadequate design and  configuration of the glovebox and its auxiliary systems, lack of  communication between workgroups tasked with maintaining different  parts of interconnected systems, weaknesses in the technician’s training,  and informal operations in the plutonium-handling facility. Moreover,  according to the investigation report, the Los Alamos Laboratory had  apparently failed to apply lessons learned from previous contamination  releases in the same facility—including a similar event 2 years before,  involving the same glovebox and some of the same people.
In 2002, at another Los Alamos unit, liquid chlorine dioxide formed  unexpectedly during an experiment and then exploded, sending debris  into the air with enough force to destroy the fume hood where the  experiment was taking place and to knock out pieces of wall, ceiling, and  concrete. One of the two researchers present during the experiment  noticed a rapid rise in temperature in the experimental apparatus, and  both researchers fled the room seconds before the explosion, thus  averting serious injury or death. According to an independent investigation  of this accident, the experiment was changed to use 100 percent chlorine  gas instead of 4 percent chlorine gas, a change that warranted a formally  changed hazard control plan; yet only informal evaluations, without  adequate analyses, review, or authorization, were done. As a result, the  researchers failed to recognize the potential for formation of liquid  chlorine dioxide and carried out the altered experiment inside a vessel  that could not withstand the high pressure of the unanticipated liquid  chlorine dioxide. According to the investigation report, this accident  represents a case in which division management, line management, and  workers had not adequately evaluated or ensured implementation of  existing safety requirements.
In 2003, an accident at a construction site on the New Mexico campus of  Sandia National Laboratories seriously injured two ironworkers who were  part of a crew of three installing a steel stairway in one building’s open  stairwell. As the crew was hoisting and positioning a stair section near the  top of the stairwell, a temporary hoisting beam slipped and fell; it struck  the first worker’s hardhat on its way down and crushed his foot before  hitting the ground. Other parts of the hoisting apparatus also collapsed,  cutting another worker’s shin and knocking over a third worker. The first  worker was hospitalized for a week; the second worker required six  stitches to close the wound on his leg; the third worker escaped injury.  The accident investigation report stated that neither the installation of the  temporary hoisting beam nor the lifting of the stair section conformed to  safety requirements. The report further noted that lack of clarity in safety  requirements and poor communication between NNSA’s Sandia site office,  project management, and subcontractors contributed to this preventable  accident.
Since 2000, Los Alamos and Lawrence Livermore have also been cited a  total of eight times for violating nuclear safety rules. These rules are  intended to protect workers and the public from nuclear hazards,  including unintended nuclear explosions and radiation exposure, and  under federal law, DOE has the authority to impose fines, or civil  penalties, on contractors that violate them. In general, the rules (1) require  analyses of work to be performed in a nuclear facility so as to identify  potential hazards and operate the facility at an acceptably low level of risk  and (2) spell out controls needed to ensure the safety of workers and the  public. The eight citations levied since 2000 against Los Alamos and  Lawrence Livermore laboratories have carried total penalties of nearly  $4 million for violations of a number of nuclear safety requirements by,  for example:  failing to test safety equipment, such as fire-alarm systems, before  beginning work to ensure proper operation;  failing to follow protective procedures for handling radioactive materials; failing to label areas that contained high levels of radiation; illegally storing radioactive waste in a facility that lacked proper operating  documentation; and failing to maintain proper documentation for the safe operation of nuclear  facilities.
In addition to accidents serious enough to warrant formal investigation  and violations of nuclear safety rules, the three laboratories have  experienced a number of less serious accidents and near misses. For  example, from 2004 to mid-2007, the three laboratories have reported 97  worker injuries serious enough to require off-site medical attention and  more than 150 electrical and mechanical near-miss incidents where  serious injury could have occurred. Other reviews have also raised  concerns about safety at the laboratories. In 2004, for instance, DOE’s  Office of Independent Oversight and Performance Assurance and the  Safety Board both raised concerns about safety management at Lawrence  Livermore Laboratory’s plutonium-handling facility, including concerns  over the adequacy of fire-suppression and ventilation systems in case of an  accident.
At both Los Alamos and Lawrence Livermore laboratories, such persistent  safety problems (combined with concerns about security at Los Alamos)  ultimately resulted in the temporary closure, or stand-down, of certain of  the laboratories’ facilities. On July 16, 2004, the director of Los Alamos  Laboratory suspended all laboratory operations, except those specifically  designated as critical, to address safety and security concerns. The  ensuing 10-month shutdown cost taxpayers an estimated $121 million to  $370 million in lost productivity. Similarly, on January 15, 2005, the  director of Lawrence Livermore Laboratory suspended all programmatic  work at the site’s plutonium-handling facility, largely because of numerous  unresolved safety issues and failure to address these issues adequately.  The facility did not return to full operation for 16 months. During the  stand-downs, both laboratories conducted comprehensive investigations  into the causes of the numerous safety and security problems and found  hundreds of deficiencies in both areas, which ranged from muddled lines  of authority to overly complex and unclear safety policies and procedures  to inadequate documentation and training.
Despite the stand-downs, however, all three laboratories have continued  to experience accidents warranting formal investigation, as well as  violations of nuclear safety rules. For example, of the nearly 60 accidents  investigated at the three weapons laboratories since 2000, 15 of them have  occurred since the stand-downs. In addition, Los Alamos and Lawrence  Livermore have both been cited for nuclear safety violations since the  stand-downs were declared. Accidents included the following:  In 2005, a worker at Los Alamos received and opened a package  containing radioactive material delivered from another Los Alamos site  and unknowingly contaminated himself, his clothing, and things he later  touched; the contamination was not detected for 11 days. The shippers  assumed the receiver would know that radiological contamination was  possible and would act accordingly, and they did not test the package for  contamination before shipping. The receiver, in contrast, assumed the  package was uncontaminated because he had not been alerted otherwise.  When the worker left that day, he was not screened for potential  contamination because the room he was working in was not designated as  a radiological control area. Over the next days and weeks, the worker  unwittingly spread contamination to his home, to relatives’ homes in  Kansas and Colorado, and to other locales at Los Alamos. In addition, he  handled some otherwise nonradioactive parts, which also became  contaminated and were shipped to Pennsylvania. The officials  investigating this accident found a number of failures to follow safety  procedures, unverified assumptions, and undocumented requirements;  according to their report, “all of the accident’s causal factors were well  established” before the accident.
In 2006, an electrician working alone on a project to replace rooftop air  conditioners at Lawrence Livermore missed a step while climbing a ladder  mounted on the building. The worker fell and sustained multiple fractures  of his wrist, shoulder, and pelvis, along with other injuries; he was  hospitalized for nearly a month. The officials investigating this accident  explicitly stressed the “significance of this seemingly simple accident—a  worker slipped and fell from a ladder” because workers frequently climb  similar ladders, the potential consequences of a fall are serious, and  remedies—from ladder design to worker training—are straightforward  and easy to put in place.
Other safety problems have also occurred since the stand-downs. For  example, the three laboratories have reported 33 electrical shock incidents  since 2005. In one case at Los Alamos, two employees operating a  generator-powered winch received electrical shocks on multiple occasions  over a 4-day period without stopping work to report the shocks; the winch  then malfunctioned, and the employees reported the shocks. At Sandia, a  subcontractor employee received an electrical shock requiring the  attention of paramedics after touching a “hot” screw on a 120-volt  receptacle he was testing.
section_title: Long-standing Management Weaknesses Leave Sites Vulnerable to Continued Safety Problems
paragraphs: In our review of nearly 100 safety studies—including accident  investigations and independent assessments by the Safety Board and  others since 2000—we found that factors contributing to safety problems  stemmed largely from weaknesses in how NNSA manages safety at the  weapons laboratories. These contributing factors generally fall into three  key areas:    A relatively lax attitude toward safety procedures. Accident  investigations and other reviews of the weapons laboratories have  repeatedly found an informal or lax attitude toward safety. Specifically,  reviews have cited weaknesses such as (1) laboratory management that  does not consistently and effectively emphasize the importance of working  safely and following prescribed safety procedures, (2) employees who rely  on their own expertise and knowledge of work hazards rather than  following safety procedures, and (3) subcontractors who understand and  implement safety procedures inadequately. The Safety Board and others  have cautioned that such lax safety attitudes—including employees’  reluctance to question potential safety problems or inadequate leadership  insistence on safety—create an environment where workers become  complacent, and accidents occur. At the Los Alamos plutonium-handling  facility, multiple accidental releases of airborne plutonium since 1996— including the 2000 incident involving seven workers and another one in  2003 involving the same group of employees in the same facility—led the  investigators of the 2003 accident to conclude that “the organizational  safety culture has evolved to one of complacency towards safety such that  workers and managers fail to respect the hazards present in the  workplace, and risks to workers are accepted without understanding the  magnitude of those risks.” Study after study has highlighted the informality  of laboratory operations and the lack of emphasis on safety throughout,  from division management levels to individual worker levels. As a result of  lax attitudes over the years, the laboratories have repeatedly failed to  prevent what many reports and reviews regard as preventable accidents  and near misses.
Weaknesses in identifying safety problems and taking appropriate  corrective actions. Fundamental weaknesses in the laboratories’ ability to  accurately identify and fully understand safety problems and take  appropriate corrective actions have hindered safety performance. Many  reviews have cited (1) an inability to learn from past incidents, (2) a lack  of rigorous self-assessments by the laboratories to identify problems, and  (3) a failure to develop appropriate or timely corrective actions to mitigate  these problems as factors contributing to recurring accidents. Several  investigations stressed that accidents could have been prevented had  lessons from previous accidents been learned and properly applied.
Inadequate oversight by NNSA site offices. Many reviews have pointed  out continuing deficiencies in federal oversight of the laboratories,  including that oversight was insufficiently formal or documented (for  example, that roles and responsibilities for safety were not clearly and  consistently delineated). Such weaknesses have been exacerbated by staff  shortages at the site offices, specifically, (1) unfilled positions resulting in  too few staff available to serve as NNSA’s eyes and ears at the laboratories  and (2) shortages in staff with adequate technical expertise. For example,  positions for critical senior nuclear safety officials at both the Lawrence  Livermore and Los Alamos site offices went unfilled for more than a year.
These safety evaluations have repeatedly indicated that key management  weaknesses have contributed to the laboratories’ continuing safety  problems and that accidents could have been prevented had weaknesses  been properly addressed. Together, these safety evaluations indicate that  unless corrected, the weaknesses create conditions that leave the  laboratories vulnerable to continued—and potentially more serious— safety problems.
section_title: NNSA and Contractors Have Been Taking Some Steps to Address Management Weaknesses
paragraphs: Steps taken by NNSA and its contractors include on-site efforts to address  weaknesses in three key areas, as well as mechanisms to hold contractors  more accountable for safety.
subsections: section_title: Steps Taken at the Laboratories Include Efforts in Three Key Areas
paragraphs: NNSA and its contractors have been taking steps intended to address  weaknesses in three key areas: safety culture, systems for identifying and  correcting safety problems, and federal oversight:    Safety culture. Since at least 2006, NNSA and its contractors have been  taking steps to reinvigorate NNSA’s key safety improvement effort, called  integrated safety management. Launched in 1996, integrated safety  management was designed to respond to concerns raised by the Safety  Board about the lack of formal, standardized procedures throughout DOE  for ensuring that hazardous activities were carried out safely. The effort  was intended to raise safety awareness and provide a formal process for  employees to integrate safety into work activities by requiring employees  to (1) define the scope of work, (2) analyze the hazards associated with  that scope of work, (3) develop and implement hazard controls to address  possible safety issues, (4) perform work within those controls, and  (5) provide a feedback system for continuing to improve safety. This  program aims to instill in every individual at the laboratories a sense of  responsibility for working safely.
Despite the program’s longevity and the soundness of the concepts behind  integrated safety management, many safety reviews have stated that the  program has not been fully or successfully implemented. In the decade  since it began, NNSA and laboratory contractors have developed policies  and procedures under program guidelines, but the laboratories have been  unable to ensure that managers and employees consistently follow these  policies and procedures in their work. Many of the accident and other  reports we examined specifically cited ineffective implementation of  integrated safety management at NNSA’s laboratories as a key factor  contributing to the accidents.
To remedy these recognized shortcomings, NNSA is revising its guidance  to clarify integrated safety management requirements, and the laboratories  have been taking various steps to reemphasize the principles of integrated  safety management. First, according to laboratory officials, the laboratory  directors have publicly stressed safety by, for example, at Sandia making  unannounced monthly visits to different laboratory units to observe  operations firsthand. At Lawrence Livermore, the laboratory director  holds monthly performance reviews requiring his associate directors to  report on specific safety metrics for their division. Second, several  hundred managers and employees at all three laboratories have undergone  training on why accidents happen and how to prevent them, in part  through better communication and teamwork. In addition, Los Alamos and  Sandia site office officials told us, the laboratories have been hiring staff  from contractors at other DOE sites or from other programs where  adherence to safety procedures has been more consistent, a move they  believe will help shift the safety culture at the laboratories.
Identifying safety problems and taking corrective actions. NNSA and its  contractors at the laboratories have been taking steps to better identify  safety problems and appropriate corrective actions. For example,  Lawrence Livermore has created a new process in which teams of workers  and managers annually review and assess implementation of work  practices to identify deficiencies in safety procedures or other  opportunities to improve safety. Sandia has also begun to standardize its  annual self-assessment process for identifying safety and other problems,  although officials told us that the new approach cannot yet provide  consistent and useful information across laboratory divisions.
Two laboratories (Los Alamos and Sandia) have also created new  processes and computer systems for managing safety issues. Previously,  reviews found deficiencies in processes for assigning and tracing  accountability for safety problems. Both laboratories now have  management boards that review identified safety issues and assign  responsibility for those issues to individual managers, who must analyze  and address the identified problems. To complete the process, individual  managers must sign off on the fixes they have directed and either have the  issue re-reviewed by the assigning board or have independent verification  that the corrective action was completed.
Further, the laboratories and site offices have begun using new software  systems to help them track safety issues. Specifically, Los Alamos and  Sandia have been improving their electronic management systems for  tracking safety deficiencies and associated corrective actions, and two of  the site offices, at Sandia and Lawrence Livermore, are using new  integrated software systems intended to help the site offices track safety  issues at the labs and document oversight efforts. Previously, this  information was stored in multiple systems across the labs and site offices,  which made it more difficult to track overall safety efforts.
NNSA site office oversight. The site offices have initiated efforts to  address concerns about inadequate federal oversight by instituting more- formal oversight procedures, seeking to fill vacant positions, and providing  additional training. The site offices at Lawrence Livermore and Sandia  have revised their operating procedures and documentation on staff  responsibilities, qualifications of technical staff, and schedules for  evaluating laboratory operations. Los Alamos and Lawrence Livermore  site officials told us they have begun to fill vacant positions, including  hiring a senior nuclear safety expert at Lawrence Livermore who directly  advises the site office manager. The site offices told us that they have  also been formalizing their process to provide training related to general  scientific and technical expertise, applicable regulations, contract  administration, and safety management.
Many of these efforts are still under way, however, and their effect on  safety performance is not clear.
section_title: Additional Steps Target Contractor Accountability for Safety Performance
paragraphs: To hold its contractors more accountable for safety performance, NNSA  has incorporated into its contracts at Los Alamos and Sandia new contract  mechanisms that provide for additional fee or contract extensions for  meeting annual safety and other goals. Under the new contract  incentives, contractors can earn substantially larger fees—or, in the case  of Sandia, a one-year contract extension as well—if they improve safety  performance. At Los Alamos, incentive fees are offered for improving  safety documentation and decreasing rates of illness and injury, for  example. In 2005, Sandia had the opportunity to earn the 1-year extension  but could not do so, primarily because of safety problems. NNSA officials  we spoke with were hopeful that these contract incentives would foster  greater accountability but said that improvements could take years to  achieve. Moreover, officials expressed concern that incentives to reduce  accidents could actually lead to underreporting, rather than actual  reductions in the number of accidents.
NNSA also is expecting to hold contractors more accountable through a  newly implemented regulation—referred to as the “851 rule”—that  requires contractors to follow worker safety requirements and imposes  penalties for violations. Promulgated in response to a 2002 congressional  requirement, and similar to nuclear safety regulations, the worker safety  regulation (effective as of February 2007) encourages contractors to  report violations of worker safety requirements and provides for DOE’s  Office of Enforcement to levy civil penalties carrying monetary fines up to  $70,000 per day. As of September 2007, DOE had not yet levied any fines  against its contractors.
section_title: NNSA Faces Fundamental Challenges to Effective Management and Oversight of Safety at Weapons Laboratories
paragraphs: NNSA faces two principal challenges in its continuing efforts to improve  safety at the nation’s weapons laboratories. First, the agency has no way to  determine the effectiveness of its safety improvement efforts, in part  because those efforts rarely incorporate outcome-based performance  measures. Second, concerns have arisen over the agency’s shift in its  oversight approach to rely more heavily on contractors’ own safety  management controls.
subsections: section_title: NNSA Has No Way of Determining the Effectiveness of Its Safety Improvement Efforts
paragraphs: NNSA does not have effective outcome-based performance measures that  would enable it to evaluate the impact of individual improvement  initiatives on safety performance. When asked what impact integrated  safety management has had on safety performance, for example, NNSA  and contractor officials at the laboratories described positive trends in  measures such as illness and injury rates. However, in a December 2005  report reviewing NNSA’s implementation of integrated safety management  at seven of its sites, including the weapons laboratories, the Safety Board  noted that, although the illness and injury rates had been declining, the  number of serious accidents, nuclear safety enforcement actions, and  other safety occurrences had not declined. According to the Safety Board,  this evidence indicated that the integrated safety management program  had not reduced the number of serious safety problems, and the Safety  Board suggested that NNSA develop a way to evaluate the effectiveness of  integrated safety management. Yet effective performance measures were  not included in the action plan to revitalize integrated safety management;  rather, the planned actions were primarily process-oriented, such as  developing new policies or manuals or providing additional training. The  few measures that were included in the plan focused on, for example,  defining annual performance measures in contracts or increasing the use  of measures related to repeated incidents, with no indication of how these  measures might help gauge effectiveness.
We have found that NNSA and its contractors have not consistently  managed safety improvement efforts using a disciplined approach  incorporating substantive outcome measures and a system to evaluate its  efforts’ effectiveness. Such an approach, often taken by high-performing  organizations, generally includes four key elements: (1) defining clear  goals, (2) developing an implementation strategy that sets milestones and  establishes responsibility, (3) establishing results-oriented outcome  measures to gauge progress toward the goals, and (4) using results- oriented data to evaluate the effectiveness of the effort and making  additional changes where warranted. We have previously recommended  that DOE develop and use this systematic approach in future improvement  efforts. In response to this recommendation, the department issued a  directive (DOE Notice 125.1) in October 2003 that adopted these  principles. In February 2004, we reported on challenges at Los Alamos  and Lawrence Livermore national laboratories, including problems with  ensuring the safe operations of nuclear facilities and recommended that  NNSA include in its contracts for the two laboratories a requirement that  the contractors manage future improvement efforts in accordance with the  October 2003 directive, to better ensure that its efforts are effective.  Nevertheless, we found little indication that either NNSA or the  contractors have been using the systematic approach specified by the  October 2003 directive, and the approach in the directive has not been  incorporated into the laboratory contracts.
Rather than following the recommended systematic approach, the safety  improvement efforts described by NNSA and its contractors echo previous  attempts while continuing to lack useful measures of effectiveness.  Specifically, the laboratory contractors have been providing managers and  workers with additional safety training, but the contractors have not  instituted any systems to evaluate whether the trainees have put into  practice what they have been taught. In another example, the laboratories  have changed their systems for tracking identified safety problems and the  corrective actions taken to address those problems. But these systems still  measure whether corrective actions were completed and completed on  time, rather than how effective the actions were in addressing underlying  weaknesses. What outcome-based measures do exist to evaluate safety  performance—specifically, accident, illness, and injury rates—consider  just part of the safety situation and do not address underlying management  weaknesses that allow these incidents to recur. In short, NNSA has no  objective way of determining whether improvement efforts are effective,  whether these efforts will correct long-standing safety problems, or  whether reduced accident rates are merely coincidental. Without stronger  performance measures, NNSA and its contractors have no way of knowing  whether the time and money invested in their improvement initiatives have  actually resulted in safer laboratories.
Given the persistent nature of safety problems at the laboratories, it  appears that either the identification of the underlying causes or the  corrective actions taken have been inadequate. A crucial step in the  October 2003 directive is to fully understand problems and their  underlying causes so that corrective actions will be effective. Yet over the  past decade, NNSA and laboratory contractors have developed corrective  action plans that were essentially reactive—responding to findings and  recommendations from one or another internal or external report— without consistently taking the next step of identifying deeper, systemic  weaknesses and taking steps to mitigate these weaknesses. Moreover, for  at least two of the weapons laboratories, neither the safety problems nor  the efforts to correct them are new. As we reported in February 2004,  NNSA had put into place contract mechanisms and requirements to  address known problems in areas including nuclear safety. Although this  effort was intended to strengthen management and federal oversight of  nuclear safety at Los Alamos and Lawrence Livermore, most of the  measures included in the contracts were aimed at establishing processes  or developing plans. In reports issued as recently as 2007, the Safety Board  and others have again raised similar concerns about safety management  weaknesses and suggested that NNSA and its contractors have not fully  understood the safety problems or their underlying causes and have not  identified and implemented the appropriate corrective actions. It thus  appears likely that agency efforts will continue to be disjointed, and  incidents and vulnerabilities could continue.
section_title: Weaknesses in Federal Oversight Raise Concerns about NNSA’s Decision to Rely More Heavily on Contractors’ Management Controls
paragraphs: NNSA has revised its laboratory contractor oversight policy to rely more  on the contractors’ own systems of management controls to identify and  correct safety problems. We and others have expressed concerns in the  past, however, about these changes to its oversight policy and the  increased emphasis and reliance on the contractors’ systems of  management controls. In its draft policy of August 2003, NNSA proposed  relying more on contractor assurance systems and self-assessments to  identify and correct problems in all areas of operations, including safety.  NNSA would then use a risk-based approach to its oversight, tailoring the  extent of federal oversight to the quality and completeness of the  contractor’s assurance system and the extent to which NNSA could rely on  the contractor’s system to identify and correct problems effectively. In our  February 2004 report, we acknowledged the potential benefits of a risk- based approach to federal oversight, but we also raised concerns about  NNSA’s ability to effectively carry out this approach while successfully  meeting its responsibility for safety. Furthermore, we recommended that  NNSA retain sufficient independent federal oversight of contractors’  activities to fulfill its responsibilities for protecting workers, the public,  and the environment. In addition, the Safety Board, in a series of public  meetings in late 2003 and early 2004, expressed concerns about NNSA’s  proposed oversight policy and stressed that NNSA should not delegate  responsibility for the inherently high-risk area of operations at its nuclear  facilities. The Safety Board was concerned about both the adequacy and  the quality of federal oversight; it was also concerned that the contractors’  systems of management controls had yet to be proven effective.
In response to these concerns, NNSA revised its oversight policy to outline  how contractors’ systems of management controls, federal line  management oversight, and independent reviews would work together to  ensure effective operations, including safety. To specifically address the  Safety Board’s concerns about high-hazard operations, the revised policy  requires additional, and more rigorous, federal oversight of nuclear  facilities and other high-hazard operations. The departmentwide oversight  policy’s stated objective is to ensure that contractor assurance systems  and federal oversight programs are comprehensive and integrated for all  aspects of operations essential to mission success. According to the  policy, contractor assurance systems should identify and address program  and performance deficiencies and opportunities for improvement, provide  the means and requirements to report deficiencies, establish and  effectively implement corrective and preventive actions, and share lessons  learned across all aspects of operations.
Regardless, NNSA lacks a cohesive implementation strategy for how it will  maintain appropriate levels of oversight of its laboratory contractors’  safety performance under this revised policy. At the site offices, oversight  consists of a collection of activities, such as observations of work  activities and reviews of contractor data, but it is not clear how these  activities will fit into NNSA’s overall oversight structure. Furthermore, the  NNSA site offices lack their own clear goals for improving oversight but  instead equate improved oversight to ensuring that the contractors meet  contract goals and annual performance measures. For example, at the  Lawrence Livermore site office, the goals and outcomes for fiscal year  2007 included (1) ensuring that the contractor completes all required  nuclear facility safety documentation, (2) ensuring that lessons learned  from the 2005 plutonium facility stand-down are implemented at the  laboratory’s other nuclear facilities, and (3) ensuring that the contractor  implements the new worker safety rule. Yet these three goals and  outcomes are still geared more toward process rather than safety  improvements and are generally activities that the contractor should  already have completed. Specifically, one of these goals—ensuring that the  contractor completes all required nuclear facility safety documentation to  identify the potential nuclear hazards and mitigation plans to protect  workers, the public, and the environment—has been part of Lawrence  Livermore’s contract requirements since 2001. Yet the laboratory had  nuclear facilities that lacked completed safety documentation until  September 2007.
Furthermore, no clear criteria or results-oriented outcome measures exist  for determining when a contractor assurance system is mature and reliable  enough for NNSA to depend on the contractor for identifying and  correcting safety problems. Without such measures, NNSA has no  assurance that contractors can and will effectively identify and correct  safety problems. In line with what we reported 3 years ago, we continue  to believe it is premature for NNSA to rely so heavily on the contractors to  maintain laboratory safety. Given the perennial safety problems at the  laboratories, coupled with NNSA’s and contractors’ continued inability to  clearly demonstrate progress in remedying weaknesses, it is unclear how  this revised system will enable NNSA to maintain an appropriate level of  oversight of safety performance at the weapons laboratories.
section_title: Conclusions
paragraphs: The NNSA weapons laboratories, which conduct important but potentially  dangerous research, have experienced persistent safety problems despite  years of effort to make the laboratories safer. Although dozens of reviews  since 2000 have repeatedly highlighted significant safety management  problems at the laboratories, and NNSA and contractors have been taking  steps aimed at improving safety, many of the steps appear to be revision or  repackaging of earlier efforts, with few new approaches to correcting  underlying problems. A key shortcoming may be that—despite a DOE- wide directive requiring that improvement initiatives include results- oriented outcome measures—neither NNSA nor its contractors have  developed performance measures suitable for assessing the effect, if any,  of safety improvement efforts on identified safety weaknesses. As a result,  NNSA has no assurance that the resources expended on safety  improvement efforts will successfully remedy fundamental weaknesses or  strengthen laboratory safety. Furthermore, we remain concerned about  NNSA’s recent shift to relying more on contractors to police themselves at  a time when the laboratories remain vulnerable to safety problems,  including accidents. We and others have raised concerns that although  effective oversight of laboratory safety requires a strong, qualified federal  presence, federal oversight remains problematic. Until contractors at the  weapons laboratories can demonstrate improved safety performance, and  until their efforts to address underlying management weaknesses are  effective, our misgivings remain about NNSA’s ability to maintain effective  independent oversight. As the responsible owner of these weapons  laboratories, NNSA must be able to demonstrate that it is carrying out  sufficient independent federal oversight of contractors’ activities to fulfill  its responsibilities for protecting the health and safety of workers, the  public, and the environment. Unless NNSA addresses these fundamental  challenges and adopts a more structured and disciplined approach to  improvement efforts and federal oversight, the weapons laboratories will  continue to be vulnerable to safety problems and potentially serious  consequences.
section_title: Recommendations for Executive Action
paragraphs: To strengthen safety management and oversight at the nation’s weapons  laboratories, we recommend that the Secretary of Energy direct the  Administrator of NNSA to take the following four actions:    Ensure that safety improvement initiatives comply with DOE Notice 125.1,  which requires, in particular, that improvement initiatives be carried out in  a systematic manner, with effective performance measures based on  outcomes, not process.
Negotiate with the weapons laboratories to include in their contracts a  requirement that safety improvement initiatives be managed in a manner  consistent with the best practices of high-performing organizations, as  defined in accordance with the framework established in DOE Notice  125.1.
Ensure that as NNSA implements its proposed oversight and contractor  assurance policy, it develops a clear plan and specific measures that  enable it to (1) determine when a contractor’s assurance system is  sufficiently mature and reliable to identify and address safety problems at  the weapons laboratories effectively and (2) retain sufficient independent  federal oversight of safety to fulfill its responsibilities associated with  protecting workers, the public, and the environment.
Report annually to Congress on progress toward making the weapons  laboratories safer, including the status and effectiveness of safety  improvement initiatives, using outcome-based performance measures.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to NNSA for its review and comment. In  written comments, NNSA’s Associate Administrator for Management and  Administration stated that NNSA generally agreed with the report and its  recommendations. NNSA’s written comments on our draft report are  included in appendix IV.
While generally agreeing with the facts in our report and its corresponding  recommendations, NNSA sought to provide additional context in which  our findings could be viewed. Specifically, NNSA stated that it believes  that, given the numbers of employees, the period of years covered, and the  high-hazard work that is performed at these laboratories, safety at the  laboratories has been impressive. NNSA suggests that the ladder incident  we describe does not exemplify lax safety. Yet this view overlooks the fact  that even an accident as simple as a ladder fall can result in serious  personal injuries. NNSA’s own accident investigation report stressed the  “significance of this seemingly simple accident” because the consequences  can be serious, and the remedies are relatively easy to put into place.  Furthermore, we cited a number of examples illustrating the range and  severity of accidents at the laboratories, including major radiation  exposures. We remain concerned that such safety incidents are symptoms  of more pervasive problems.
NNSA also stated that, contrary to our criticism of its oversight of the  weapons laboratories, it believes that oversight of safety at the  laboratories is excellent. NNSA offers as evidence the existence of safety  evaluations performed by its offices and other DOE offices. While we  agree that reports by NNSA’s offices and other DOE offices are useful, our  report focused on oversight at the NNSA site office level. In fact, NNSA’s  safety evaluations themselves point out the same long-standing concerns  about the adequacy of NNSA site office oversight. In addition, NNSA  pointed to a decrease in its illness and injury rates at the weapons  laboratories as evidence of the effectiveness of federal oversight of safety  at the weapons laboratories. We acknowledge in the report that NNSA and  its contractors described recent positive trends in safety measures such as  illness and injury rates. We remain concerned about relying solely on this  measure as evidence of improved safety performance because a number of  factors could affect these rates, including instances of underreporting. In  addition, illness and injury rates are not useful in indicating performance  in nuclear safety, where a single accident can carry serious consequences  not only for workers but for the public at large. Finally, as we stated in our  report, a December 2005 Safety Board report noted that, although illness  and injury rates had declined, the number of serious accidents and nuclear  safety enforcement actions had not declined. We continue to believe that  until NNSA adopts a more disciplined approach to improvement efforts  and federal oversight—an approach that incorporates meaningful  performance indicators—the laboratories cannot assure that safety  improvement efforts have been effective or will be sustained.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  date of this letter. At that time, we will send copies of this report to the  Secretary of Energy; the Administrator, NNSA; and appropriate  congressional committees. We will also make copies available to others on  request. In addition, the report will be available at no charge on the GAO  Web site at http://www.gao.gov.
If you or your staff have any questions on this report, please contact me at  (202) 512-3841 or Aloisee@gao.gov. Contact points for our Office of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine the safety problems that have occurred at the weapons  laboratories and contributing factors, we reviewed documents, including  federal laws and regulations describing safety requirements for nuclear  safety and for worker safety and health, Department of Energy (DOE)  policies and procedures regarding safety management, and about 100  relevant reports issued since 2000 evaluating safety issues at the three  weapons laboratories: Lawrence Livermore, Los Alamos, and Sandia  national laboratories. Reports included inspections or reviews of the  weapons laboratories by DOE’s Office of Independent Oversight and  Performance Assurance, the National Nuclear Safety Administration’s  (NNSA) Chief of Defense Nuclear Safety, the Defense Nuclear Facilities  Safety Board (Safety Board), and our past reports. Reports also included  all type A and type B accident investigation reports for the three weapons  laboratories and, when possible, any contractor-led accident  investigations. We also reviewed all enforcement actions for violations of  nuclear safety rules taken against the laboratories by DOE’s Office of  Enforcement. We reviewed the factors these reports identified as  contributing to safety problems and categorized them into three key areas,  using an analytical tool developed in consultation with our methodologist.  We also analyzed safety performance data provided by DOE, specifically,  safety incident data contained in DOE’s Occurrence Reporting and  Processing System and Computerized Accident/Incident Reporting  System. We determined that these data were sufficiently reliable for the  purposes of this report. We discussed the safety problems and  contributing factors, as well as our categorization of them, with  representatives from DOE’s Office of Independent Oversight and  Performance Assurance, NNSA’s Chief of Defense Nuclear Safety and  Senior Advisor for Environmental Safety and Health, and the Safety Board,  as well as with DOE and NNSA headquarters officials. In addition, we  visited the three weapons laboratories and met with NNSA officials and  contractors to discuss the factors we identified as contributing to safety  problems at the laboratories.
To identify the steps NNSA and its contractors have taken to improve  safety management and address underlying management weaknesses, we  reviewed agency documents, including implementation plans; laboratory  contracts; and, to the extent it was available, documentation on safety  improvement initiatives. We also interviewed officials at the three  laboratories and NNSA site offices to discuss efforts taken by NNSA and  the laboratories to improve safety and to more specifically address the  areas of concern we identified. We also discussed efforts to improve safety  performance with independent experts, including officials from DOE’s  Office of Enforcement and representatives from the Safety Board.
To determine the challenges that remain to effective management and  oversight of safety performance at the weapons laboratories, we reviewed  and analyzed relevant GAO reports on safety issues at the laboratories;  recommendations made, if any; steps taken in response, if any; and issues  remaining. We reviewed relevant DOE, NNSA, and contractor documents,  including DOE policies and orders, site office strategies and plans,  laboratory contracts, and annual evaluations of contractor performance.  We also discussed challenges with DOE and NNSA officials; contractor  officials; and independent experts, including officials from the Safety  Board.
We performed our work in accordance with generally accepted  government auditing standards, which included an assessment of data  reliability, from September 2006 through September 2007.
section_title: Appendix II: List of Key Safety Evaluations
subsections: section_title: Los Alamos National Laboratory
paragraphs: Department of Energy, National Nuclear Safety Administration. Type B  Accident Investigation of the Americium Contamination Accident at the  Sigma Facility, Los Alamos National Laboratory, New Mexico, July 14,  2005. Washington, D.C.: January 2006.
Department of Energy, Office of Security and Safety Performance  Assurance. Inspection of Environment, Safety, and Health Programs at  the Los Alamos National Laboratory. Washington, D.C.: November 2005.
Department of Energy, National Nuclear Safety Administration. Type B  Accident Investigation of the Acid Vapor Inhalation on June 7, 2005, in  Technical Area 48, Building RC-1, Room 402, Los Alamos National  Laboratory. Washington, D.C.: June 2005.
Tarantino, Frederick A., et al. LANL Investigation of a Laser Eye Injury.  LA-UR-04-6229. Los Alamos, New Mexico: Los Alamos National  Laboratory, 2004.
Department of Energy, National Nuclear Safety Administration. Type B  Accident Investigation of the August 5, 2003, Plutonium-238 Multiple  Uptake Event at the Plutonium Facility, Los Alamos National  Laboratory, New Mexico. Washington, D.C.: December 2003.
Hargis, Barbara, et al. Unanticipated Formation and Explosion of Liquid  Chlorine Dioxide in a Parr Reaction. LA-CP-02-206. Los Alamos, New  Mexico: Los Alamos National Laboratory, 2002.
Department of Energy, Office of Security and Safety Performance  Assurance. Inspection of Environment, Safety, and Health Programs at  the Los Alamos National Laboratory. Washington, D.C.: 2002.
Department of Energy, National Nuclear Safety Administration. Type B  Accident Investigation of the Mineral Oil Leak Resulting in Property  Damage at the Atlas Facility, Los Alamos National Laboratory, New  Mexico. Washington, D.C.: March 2001.
Department of Energy, National Nuclear Safety Administration. Type A  Accident Investigation of the March 16, 2000, Plutonium-238 Multiple  Intake Event at the Plutonium Facility, Los Alamos National  Laboratory, New Mexico. Washington, D.C.: July 2000.
section_title: Lawrence Livermore National Laboratory
paragraphs: Department of Energy, Office of Health, Safety and Security. Inspection of  Environment, Safety, and Health Programs at the Lawrence Livermore  National Laboratory. Washington, D.C.: May 2007.
Department of Energy, National Nuclear Safety Administration. Type B  Accident Investigation of the July 31, 2006, Fall from Ladder Accident  at the Lawrence Livermore National Laboratory, Livermore, California.  Washington, D.C.: October 2006.
Department of Energy, Office of Security and Safety Performance  Assurance. Inspection of Environment, Safety, and Health Programs at  the Lawrence Livermore National Laboratory. Washington, D.C.:  December 2004.
Department of Energy, National Nuclear Safety Administration. Type B  Accident Investigation Board Report of the June 2002 High Radiation  Dose to Extremities in Building 151, Lawrence Livermore National  Laboratory, Livermore, California. Washington, D.C.: Department of  Energy, October 2002.
Department of Energy, Office of Security and Safety Performance  Assurance. Inspection of Environment, Safety, and Health Programs at  the Lawrence Livermore National Laboratory. Washington, D.C.: July  2002.
section_title: Sandia National Laboratories
paragraphs: Department of Energy, Office of Security and Safety Performance  Assurance. Inspection of Environment, Safety, and Health Programs at  the Sandia National Laboratories. Washington, D.C.: 2005.
Department of Energy, National Nuclear Safety Administration. Type B  Accident Investigation of the March 20, 2003, Building 752 Stair  Installation Accident at the Sandia National Laboratories, New Mexico.  Washington, D.C.: Department of Energy, April 2003.
Department of Energy, Office of Security and Safety Performance  Assurance. Inspection of Environment, Safety, and Health Programs at  the Sandia National Laboratories, New Mexico. Washington, D.C.: 2003.
section_title: Other Key Safety Reports
paragraphs: Defense Nuclear Facilities Safety Board. Safety Management of Complex,  High-Hazard Organizations. DNFSB/TECH-35. Washington, D.C.:  December 2004.
Defense Nuclear Facilities Safety Board. Integrated Safety Management:  The Foundation for a Successful Safety Culture. DNFSB/TECH-36.  Washington, D.C.: December 2005.
section_title: Appendix III: Enforcement Actions at NNSA Weapons Laboratories, 2000 through September 2007
paragraphs: Significant multiple deficiencies in work control, quality  improvement, and radiation protection resulting in exposure of eight  employees to airborne radioactive material (estimated to be 1 of 10  worst radiological exposures over past 41 years). Failure to  address long-standing deficiencies at an additional nuclear facility,  which should have been identified and corrected during routine  assessments and reviews.
Management failures leading to establishing and operating an  unauthorized nuclear facility for 5 years by storing radioactive  waste in a facility without a safety evaluation and necessary  controls. Failure of management processes, including oversight  and assessments to identify inventory of nuclear materials that  required analysis and controls.
Numerous work process and radiological control violations resulting  in exposure of workers to radioactive material and contamination of  facility. Numerous failures to follow nuclear safety requirements  and repeated work and radiological control deficiencies. Long- standing weaknesses in recognizing and addressing nuclear safety  deficiencies.
Significant work control deficiencies resulting in two workers  receiving greater than annual allowed doses of radioactive material  and exposure of five workers to toxic vapors. Severity levels  increased because of long-standing nature of underlying problems  and failure of management assessments and controls to identify or  correct such problems.
Fifteen separate violations of nuclear safety rules, which reflect  continuing safety performance deficiencies over past several years.  Deficiencies in work controls and quality improvement. Lack of  fundamental improvements noted since stand-down of facilities.
Failure to adequately address or take steps to correct  programmatic weaknesses previously identified in maintaining and  adhering to documents that form the safety basis for nuclear  facilities. Failure to perform work using established controls over  work processes.
Radiation protection deficiencies resulting in significant radiological  overexposure to one worker. Inadequate radiological controls and  failure to implement a required hazard assessment.
Long-standing and repeated failures to effectively track and correct  radiological program deficiencies. Significant failure of  management to properly oversee the correction of repeated  problems. Weaknesses in determining underlying causes and  corrective action plans.
section_title: Appendix IV: Comments from the Department of Energy
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the individual named above, Janet E. Frisch, Assistant  Director; Carole Blackwell; Timothy Bober; Candace Carpenter; Ellen W.  Chu; Doreen Eng; Daniel Feehan; Nancy Kintner-Meyer; Thomas Laetz;  Mehrzad Nadji; Omari Norman; Keith Rhodes; Rebecca Shea; and William  R. Swick made contributions to this report.
section_title: Related GAO Products
paragraphs: Department of Energy: Consistent Application of Requirements Needed  to Improve Project Management. GAO-07-518. Washington, D.C.: May 11,  2007.
National Nuclear Security Administration: Security and Management  Improvements Can Enhance Implementation of the NNSA Act. GAO-07- 428T. Washington, D.C.: January 31, 2007.
National Nuclear Security Administration: Additional Actions Needed  to Improve Management of the Nation’s Nuclear Programs. GAO-07-36.  Washington, D.C.: January 19, 2007.
DOE Contracting: Better Performance Measures and Management  Needed to Address Delays in Awarding Contracts. GAO-06-722.  Washington, D.C.: June 30, 2006.
Stand-down of Los Alamos National Laboratory: Total Costs Uncertain;  Almost All Mission-Critical Programs Were Affected but Have Recovered.  GAO-06-83. Washington, D.C.: November 18, 2005.
Department of Energy: Further Actions Are Needed to Strengthen  Contract Management for Major Projects. GAO-05-123. Washington, D.C.:  March 18, 2005.
National Nuclear Security Administration: Key Management Structure  and Workforce Planning Issues Remain As NNSA Conducts Downsizing.  GAO-04-545. Washington, D.C.: June 25, 2004.
Department of Energy: Mission Support Challenges Remain at Los  Alamos and Lawrence Livermore National Laboratories. GAO-04-370.  Washington, D.C.: February 27, 2004.
Contract Reform: DOE’s Policies and Practices in Competing Research  Laboratory Contracts. GAO-03-932T. Washington, D.C.: July 10, 2003.
Nuclear Security: NNSA Needs to Better Manage Its Safeguards and  Security Program. GAO-03-471. Washington, D.C.: May 30, 2003.
Department of Energy: Status of Contract and Project Management  Reforms.GAO-03-570T. Washington, D.C.: March 20, 2003.
Contract Reform: DOE Has Made Progress, but Actions Needed to Ensure  Initiatives Have Improved Results. GAO-02-798. Washington, D.C.:  September 13, 2002.
Nonproliferation R&D: NNSA’s Program Develops Successful  Technologies, but Project Management Can Be Strengthened. GAO-02-904.  Washington, D.C.: August 23, 2002.
Nuclear Security: Lessons to Be Learned from Implementing NNSA’s  Security Enhancements. GAO-02-358. Washington, D.C.: March 29, 2002.
Department of Energy: NNSA Restructuring and Progress in  Implementing Title 32. GAO-02-451T. Washington, D.C.: February 26,  2002.
Department of Energy: Fundamental Reassessment Needed to Address  Major Mission, Structure, and Accountability Problems. GAO-02-51.  Washington, D.C.: December 21, 2001.
National Laboratories: Better Performance Reporting Could Aid  Oversight of Laboratory-Directed R&D Program. GAO-01-927.  Washington, D.C.: September 28, 2001.
Nuclear Security: DOE Needs to Improve Control Over Classified  Information. GAO-01-806. Washington, D.C.: August 24, 2001.
Department of Energy: Follow-Up Review of the National Ignition  Facility. GAO-01-677R. Washington, D.C.: June 1, 2001.
Department of Energy: Views on Proposed Legislation on Civil Penalties  for Nuclear Safety Violations by Nonprofit Contractors. GAO-01-548T.  Washington, D.C.: March 22, 2001.
Nuclear Weapons: Improved Management Needed to Implement Stockpile  Stewardship Program Effectively. GAO-01-48. Washington, D.C.:  December 14, 2000.
National Ignition Facility: Management and Oversight Failures Caused  Major Cost Overruns and Schedule Delays. GAO/RCED-00-141.  Washington, D.C.: August 8, 2000.
Department of Energy: Views on Proposed Civil Penalties, Security  Oversight, and External Safety Regulation Legislation. GAO/T-RCED-00- 135. Washington, D.C.: March 22, 2000.
Nuclear Security: Security Issues at DOE and Its Newly Created  National Nuclear Security Administration. GAO/T-RCED-00-123.  Washington, D.C.: March 14, 2000.
Department of Energy: Views on DOE’s Plan to Establish the National  Nuclear Security Administration. GAO/T-RCED-00-113. Washington,  D.C.: March 2, 2000.
Nuclear Security: Improvements Needed in DOE’s Safeguards and  Security Oversight. GAO/RCED-00-62. Washington, D.C.: February 24,  2000.
Department of Energy: Need to Address Longstanding Management  Weaknesses. GAO/T-RCED-99-255. Washington, D.C.: July 13, 1999.
Nuclear Weapons: DOE Needs to Improve Oversight of the $5 Billion  Strategic Computing Initiative. GAO/RCED-99-195. Washington, D.C.:  June 28, 1999.
Department of Energy: DOE’s Nuclear Safety Enforcement Program  Should Be Strengthened. GAO/RCED-99-146. Washington, D.C.: June 10,  1999.
National Laboratories: DOE Needs to Assess the Impact of Using  Performance-Based Contracts. GAO/RCED-99-141. Washington, D.C.: May  7, 1999.
Department of Energy: Key Factors Underlying Security Problems at  DOE Facilities. GAO/T-RCED-99-159. Washington, D.C.: April 20, 1999.