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. 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. 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.