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Safety Culture, Incidents, and Issues at LANL and in particular LANL's Plutonium Facility (PF-4)
updated 10 Jun 2025

Related news media & documents

The following is a collection of key correspondence between the Defense Nuclear Facilities Safety Board (DNFSB), the Department of Energy (DOE), & the National Nuclear Security Administration (NNSA)

Seismic, Criticality, and other Safety Issues

2025

2024

  • Jun 7, 2024: skin contamination event in the Plutonium Facility. Two workers were performing a walkdown to support isolating water from the decontamination shower that overflowed and spread contamination in March (see 3/15/2024 report).
  • Mar 15, 2024: Last Thursday, workers accidentally placed a piece of equipment that had been removed from a laboratory room on the pressure plate for a decontamination shower. The shower actuated and water flowed until it overflowed the shower berm, migrated into a contaminated pump room, and started seeping through the walls and floors into adjacent rooms and the basement

2023

  • NA--LASO-LANL-TA55-2023-0014 - Hand Injury from Door, May 4, 2023 (ORPS)
  • NA--LASO-LANL-TA55-2023-0015 - Los Alamos Fire Department Responds to PF-4 For Dropbox Fire Alarm Activation, May 2, 2023 (ORPS)
  • NA--LASO-LANL-TA55-2023-0008 - Plenum Cooldown Activation - fire suppression water flowing into PF-4 basement, Mar 13, 2023
  • NA--LASO-LANL-TA55-2023-0012 - Los Alamos Fire Department Responds to Technical Area-55-4 for Hand Injury, Feb 21, 2023
  • NA--LASO-LANL-TA55-2023-0010 - Safety Significant Component Degradation: Facility Control System Inoperable, Feb 14, 2023
  • NA--LASO-LANL-TA55-2023-0005 - Discovery of Uncontrolled Hazardous Energy During Electrical Work on Power Panel in PF-4, Feb 3, 2023
  • NA--LASO-LANL-TA55-2023-0004 - Small Fire in a Nuclear Facility Dropbox, PF-4, Jan 9, 2023

2022

  • NA--LASO-LANL-TA55-2023-0006 - Process Deviation Resulting in Documented Safety Analysis Non-Compliance, PF-4, Dec 13, 2022
  • NA--LASO-LANL-TA55-2023-0003 - Management Concern: Unauthorized Removal of Lockout/Tagout Device, PF-4, Nov 16, 2022
  • NA--LASO-LANL-TA55-2022-0012 - Technical Safety Requirement (TSR) violated, Flammable Gas Analysis performed in "Cold Standby" mode, Sep 22, 2022
  • NA--LASO-LANL-TA55-2022-0015 - Failure to Follow a Hazardous Energy Control Process, PF-4, Sep 15, 2022
  • NA--LASO-LANL-TA55-2022-0013 - Safety Significant Structure, System or Component Degradation: Ventilation Loss of Differential Pressure, PF-4, Aug 31, 2022
  • NA--LASO-LANL-TA55-2022-0011 - Potential Process Deviation - SNM container not stored correctly, Aug 16, 2022
  • GAO: LANL Contractor Improving in Safety and Other Areas but Still Faces Challenges, GAO-22-105412, Jun 2022
  • NA--LASO-LANL-TA55-2023-0001 - Two potentially energized Capacitors Discovered Following Down-sizing, PF-4, May - Sep 2022
  • NA--LASO-LANL-TA55-2022-0007 - Performance Degradation of PF-4 North Side Ventilation System, Mar 29, 2022
  • NA--LASO-LANL-TA55-2022-0004 - Employee Received Electrical Shock While Unplugging Monitor, PF-4, Feb 15, 2022
  • NA--LASO-LANL-TA55-2022-0002 - Skin Contamination Detected on Employees During Glovebox Operation, PF-4, Jan 7, 2022
  • DNFSB review, LANL Onsite Transportation Safety, Jan 6, 2022

2021

  • DNFSB ltr, Conceptual Design LANL LAP4, Nov 24, 2021
  • NA--LASO-LANL-TA55-2021-0020 - Confinement System LCO not Entered While Performing Work on Ventilation System, Oct 19, 2021
  • NA--LASO-LANL-TA55-2021-0018 - Skin Contamination Detected on Employee's Hands after Performing Analysis of Actinide Material in a Microscopic Laboratory, PF-4, Aug 3, 2021
  • NA--LASO-LANL-TA55-2021-0014 - Safety Significant Structure System or Component Degradation: Facility Control System Failure, PF-4, Jun 29, 2021
  • NA--LASO-LANL-TA55-2021-0011 - Safety Significant Structure, System, or Component Degradation: Discovery of Waste Drum with Filter Corrosion, PF-4, Jun 10, 2021
  • DOE Office of Enterprise Assessments: Triad National Security, LLC Nuclear Criticality Safety Program at LANL, May 2021
  • NA--LASO-LANL-TA55-2021-0010- Worker Sustains Metacarpal Fracture When Wind Gusts Unexpectedly Shut Shipping Container Door on His Hand, PF-4, Apr 15, 2021
  • NA--LASO-LANL-TA55-2021-0009 – Safety Class Safety Significant Component Degradation: Discovery of Damaged SAVY Container, PF-4, Apr 8, 2021
  • NA--LASO-LANL-TA55-2021-0006 - Skin and Personal Clothing Contamination Identified Resultant of Glovebox Machining Operations, PF-4, Mar 3, 2021
  • NA--LASO-LANL-TA55-2021-0005 - Fire Department Response to Sparks Observed in Glovebox during Waste Handling Activities, PF-4, Feb 26, 2021
  • NA--LASO-LANL-TA55-2021-0004 - Material Move Results in a Documented Safety Analysis Noncompliance and a Critical Safety Infraction, PF-4, Feb 11, 2021
  • NA--LASO-LANL-TA55-2021-0003 - Employee Tripped and Fell on a Single-Fork Pallet Jack Fracturing Right Hand, PF-4, Jan 12, 2021

2020

2019

2018

2017

2016

2015

2014

2013

  • DNFSB report on status of significant unresolved safety issues - design & construction of DOE's defense nuclear facilities, Dec 26, 2013
  • DNFSB LANL WSR: PF-4 seismic & criticality safety, Dec 13, 2013
  • NNSA ltr to DNFSB re: pause in programmatic operations due to criticality safety concerns in PF-4, Dec 6, 2013
  • DOE says alternate analysis of PF-4 seismic risks will be done in Dec, Nuclear Weapons & Materials Monitor, Sep 6, 2013
  • DNFSB Fourth Annual Report to Congress: Summary of Significant Safety-Related Infrastructure Issues, Oct 30, 2013
  • DOE Dep. Sec. Poneman ltr to DNFSB, Sep 3, 2013
  • NNSA ltr to DNFSB re: PF-4 criticality safety controls, Aug 15, 2013
  • DNFSB response to DOE Sec. Moniz, re:Public and Worker Protection for a Seismic Collapse Scenario at PF-4, Jul 17, 2013
  • DNFSB Staff Report re: LANL Criticality Safety Program, Jul 2, 2013
  • DOE Sec. Chu ltr to DNFSB , Mar 27, 2013
  • DOE NNSA ltr re: TA-55 Conduct of Operations & Criticality Programmatic Pause, Jan 26, 2013
  • DNFSB ltr to DOE Sec. Chu re: PF-4 seismic accident scenarios, Jan 3, 2013
  • Jul 5: Based on direction from the Laboratory Director, fissile material operations at the Plutonium Facility remain paused this week.
  • Jun 28: On Thursday, the Laboratory Director paused programmatic activities at the Plutonium Facility. The pause was directed based on issues identified during procedural and criticality safety reviews and findings from recent assessments. The Director communicated to all LANL personnel the importance of ensuring procedures and operational processes are being executed appropriately. Additionally, the memorandum emphasized the importance for employees to raise concerns and for leaders to take action on those concerns. The Principal Associate Director for Weapons Programs and the senior management team have been tasked to evaluate the way work is executed and to determine what process and procedure improvements are needed as well as determining a path forward to continuous improvement. Individual operations at the Plutonium Facility will be resumed once necessary updates and enhancements have been achieved.
  • Jun 21: LANL paused operations in a facility glovebox based on concerns identified by the field office criticality safety subject matter expert. The current location of tape demarking a pass through lane in the glovebox would not allow compliance with criticality safety limit approval controls. Because the pass through lane has not been used recently, no criticality safety infraction was declared. Plutonium Facility personnel are pursuing a path forward to correct the situation and resume operations, and are developing a lesson learned package.
  • Jun 7: LANL continues to evaluate fissile material procedures and operations in the room where operations were recently paused (see 5/24/13 and 5/31/13 weeklies). As part of the review this week, Plutonium Facility workers identified two containers stored in a safe that do not comply with criticality safety limits. Appropriate actions were taken to secure the room, inform criticality safety personnel, and conduct a critique. The criticality safety limit approval includes an operational requirement that container outside diameter be greater than 6.5-inches to protect spacing assumptions in the criticality safety evaluation. This requirement is also identified on the posting. During the critique, operators noted that they were focused on the mass limits when storing items in the safe. A criticality safety infraction was declared for two containers that were identified with an outer diameter of less than 6.5-inches.
  • May 31: Operations remain paused in the room where the Board’s staff identified a criticality infraction during their recent on-site criticality safety review (see 5/24/13 weekly). Operators, engineers, criticality safety and facility operations personnel are walking down each operation within this room to ensure that the criticality safety controls are clearly understood and adequately captured in procedures and postings. Additionally, the walkdowns are being used to verify that procedures can be followed as written and reflect the work as it is actually performed.
  • May 24: Over the past week the Plutonium Facility has experienced a number of criticality safety infractions and process deviations. Several of these issues were self identified and conservative action was taken to respond, critique, and develop corrective actions. However, these infractions and deviations indicate potential conduct of operations and Criticality Safety Evaluation (CSE) issues that emphasize the need for LANL to continue criticality safety improvements.  During a system walkdown, the Board’s staff identified material located within a workstation that was not allowed by the CSE. This infraction was due, in large part, to inconsistent understanding of criticality safety requirements regarding the boundaries of the workstation and failure to follow good work practices as prescribed in the CSE. Because this is one of multiple infractions that have occurred in this particular room over the past few months (including inconsistent interpretation of requirements between facility and criticality safety personnel), operations have been paused in this room while operators and criticality safety personnel ensure limits specified in CSEs and postings are clear and well understood.  A criticality control mass limit was exceeded in a vault location. Workers identified that two containers intended to be stored in certain locations had been inadvertently swapped when initially moved to the vault. This transposition resulted in one location exceeding the mass limit prescribed in the CSE.  A process deviation occurred when liquid level was discovered in a trap tank sight glass for a wet vacuum system. Liquid is not normally expected to be located in this portion of the system. The CSE requires that if liquid is discovered that the source be located and the liquid be returned to the source. The source of the liquid has yet to be determined and the liquid could not be returned to its source regardless due to the system configuration. During review of this issue, Plutonium Facility personnel identified that the system configuration differed from the CSE description.  During an extent of condition review, liquid was identified in another wet vacuum trap tank sight glass. The source of this liquid has yet to be determined as well. Plutonium Facility – Personnel Contamination: A Plutonium Facility worker was identified with skin contamination after removal of a temporary foam plug used during a glovebox pressure test. Nasal smears following the discovery of contamination were positive. The foam plug was installed over an existing temporary plug that had been installed more than a decade ago but was not sufficiently airtight to allow the pressure test to pass. During this activity, the two plugs adhered to each other such that when the new plug was removed the old plug was removed as well resulting in the spread of contamination. Facility management is conducting an extent of condition review to determine whether additional “temporary” plugs are being used as contamination boundaries.
  • Apr 19: Operators identified two General Purpose Heat Source (GPHS) items contained in a Plutonium Facility glovebox that were bulging due to an apparent internal pressure build-up. The encapsulated GPHS is credited in the safety basis with providing safety-class confinement (damage ratio of zero) for heat source-plutonium (HS-Pu). When discovered, facility management declared the bulging heat source items inoperable, entered a limiting condition for operation based on the potential for exceeding glovebox material limits, and recalculated the inventory in the glovebox using a damage ratio of one (accounting for all of the HS-Pu). The recalculation showed that no material limits were violated. Facility and program personnel are evaluating the history of the bulging items and have entered the new information process as they develop their plan to resolve the over-pressure condition.
  • Mar 29: This week, the Associate Director for Plutonium Science and Manufacturing (ADPSM) directed completion of a 90 minute safety pause over the next week for First Line Managers and team leaders to cover radiological contamination issues. There has been a noticeable increase in skin and laboratory contamination events over the last few months (including three continuous air monitor alarms this week). The safety pause will communicate some of the causes involved in these events along with actions and expectations for improving the current trend. In addition to the safety pause, ADPSM is emphasizing self-monitoring, housekeeping, glove breach issues, and the sharps program to improve Plutonium Facility radiological performance.
  • Feb 8: This week, Plutonium Facility management declared a Potential Inadequacy of the Safety Analysis (PISA) based on failure to capture criticality safety controls associated with facility transfer carts in the safety basis. LANL had previously declared a criticality safety infraction when containers that were too small to be restrained by an interference plate were identified on these carts, which defeated the control in the criticality safety limit approval (see 1/18/13 weekly). During investigation of the infraction, LANL noted that the criticality safety documents specified the transfer cart controls for inclusion in the safety basis consistent with requirements in DOE-STD-3007 and site procedures; however, no action had been taken to capture these controls in the safety basis. Facility management declared a PISA on Tuesday and terminated normal operations in the facility to remove criticality safety postings and segregate these carts. Following these actions, the Plutonium Facility was returned to normal operations; however, lack of these carts significantly impacts the ability to move nuclear material in the facility. LANL is pursuing safety basis changes to appropriately capture the criticality safety controls and return the carts to service.
  • Jan 18: Based on questions from site office personnel, a criticality safety infraction was identified in the Plutonium Facility when workers placed containers on a cart that were too small to be restrained by an interference plate. This plate is designed to ensure containers remain in their location during a seismic event as required by the criticality safety limit approval (CSLA). During the critique of the event it was determined that controls that were identified as safety significant in the CSLA were not elevated to the safety basis documents as would have been appropriate. In response to this discovery, the New Information process has been entered and use of the carts has been suspended until appropriate criticality safety controls are implemented.

2012

  • DNFSB Report to Congress, Status of Significant Unresolved Issues DOE's Design & Construction Projects, Dec 24, 2012
  • DNFSB Third Annual Report to Congress: Summary of Significant Safety-Related Infrastructure Issues, Oct 31, 2012
  • DOE Dep. Sec. Poneman ltr to DNFSB, Sep 28, 2012
  • DNFSB ltr to DOE Dep. Sec. Poneman, Jul 18, 2012
  • DNFSB ltr to NNSA Admin. D'Agostino re: Documented Safety Analysis, Jun 18, 2012
  • DNFSB Staff Report, Documented Safety Analysis and Post-Seismic Accident Consequences, May 8, 2012
  • NNSA Dep. Admin. for Def. Prog. Cook ltr to DNFSB, Jan 30, 2012
  • Dec 7: Two criticality safety related issues were identified at the Plutonium Facility this week. On Monday, workers identified liquid in a glovebox used to stage plutonium metal and oxide. Appropriate immediate actions to back-off and contact the operations center were taken. Operations personnel with criticality safety staff input developed a path forward to remove the materials from the glovebox and address the liquid. Subsequent investigation indicates that the liquid came from a legacy liquid cooling system associated with a furnace. The furnace and cooling system have not been used in over a decade; however, the system was not removed or placed out-of service such that a limited amount of liquid remained in the system. Other similar legacy furnaces are being evaluated as a part of the extent of condition review for this issue. Also this week, Plutonium Facility personnel identified approximately 450 grams of plutonium oxide holdup that was released into two gloveboxes during replacement of glovebox HEPA filters. These HEPA filters are used as housekeeping filters (i.e. not credited as a safety component) in the glovebox ventilation system. The filters are replaced as needed but the replacement periodicity varies depending on the operation in the glovebox and is not rigorously controlled. For the gloveboxes in question, there is a significant amount of plutonium oxide processing that has been performed for several years, however, the informal installation dates identified for one of the filters was 1991. Currently, the criticality safety evaluation for operations in these gloveboxes excludes evaluation of the filter because only limited contamination is expected. As part of the corrective actions, criticality safety will determine if additional evaluation is required. Plutonium Facility management is also pursuing an extent of condition review for other housekeeping filters, re-evaluating the program for filter replacement, and will determine if periodic non-destructive assay is appropriate for these type filters.
  • Oct 19: This week, Plutonium Facility management declared a Potential Inadequacy in the Safety Analysis (PISA) based on criticality safety concerns for vault rooms B and I. These rooms had been operating under a Justification for Continued Operations (JCO) since 2007 because criticality safety evaluations included a neutron poison (boron) with inadequate documentation that the boron was present. Without the poison, criticality safety controls were not adequate to prevent criticality under all normal and credible abnormal conditions. In September, LANL completed a new criticality safety evaluation that did not include the boron and exited the JCO; however, a separate calculation for the interaction between floor and drawer locations was identified this week that assumes the presence of boron. Plutonium Facility management suspended operations and entered mode 2 for these vault rooms pending resolution of the PISA. Identification of this issue was prompted by questions from site office personnel.
  • Sep 7: This week, LANL concluded that the Potential Inadequacy of the Safety Analysis (PISA) identified last week based on the results of the static non-linear analysis did represent an Unreviewed Safety Question. LANL is preparing an Evaluation of the Safety of the Situation for submittal to the site office for this issue. The static non-linear analysis has also been communicated to the peer review team. LANL personnel will be meeting with this team later this month to discuss the results and any peer review comments.
  • Aug 31: On Wednesday, Plutonium Facility management declared a Potential Inadequacy of the Safety Analysis (PISA) based on static non-linear seismic analysis of the Plutonium Facility. The results indicate that the probability of failure for certain structural components do not meet the performance goals identified in the safety basis. LANL will evaluate this information using the Unreviewed Safety Question process to determine the safety basis impact and the need for additional controls.
  • Aug 17: This week, Plutonium Facility management declared a Potential Inadequacy of the Safety Analysis (PISA) based on structural/seismic issues with shelves and racks in two vault rooms. During performance of the In-Service Inspection (ISI) for design features in the vault, the system engineer identified a number of missing and loose bolts and screws. During evaluation of these issues, the system engineer identified that the SAFER seismic analysis of four vault rooms was not consistent with the actual field configuration. Subsequent seismic evaluations identified structural issues in two rooms that represent a PISA and need to be resolved. Three locations in these two rooms will require minor structural upgrades to resolve this issue. Plutonium Facility management is also reviewing the SAFER analyses to determine why these issues were not identified during the seismic review.
  • Aug 10: On Thursday, Plutonium Facility management declared two Potential Inadequacies of the Safety Analysis (PISAs) associated with the 2011 Documented Safety Analysis (DSA) post seismic accident scenario. The first PISA is associated with the potential for a post-seismic fire in the facility basement. As part of the DSA evaluation, LANL performed a probabilistic analysis to determine the likelihood of a fire following a seismic event based on historical information. The evaluation identified a probability of a post-seismic fire per facility square foot. When using this value for the Plutonium Facility, the DSA only used the laboratory area and did not include the basement area. The second PISA is associated with the leak path factor used for the accident scenario. The software calculation used as the technical basis for the leak path factor included material involved in both a spill and a fire that provides an integral result; however, the DSA uses different leak path factors for the contribution from a fire and spill. Both of these issues were identified by the Board’s staff during a review of the DSA earlier this year and communicated to NNSA by Board letter on June 18, 2012.
  • Jul 13: On Tuesday, a Plutonium Facility worker was discovered to have alpha contamination on his left wrist (2,000 dpm) and wrist watch (10,000 dpm) after performing maintenance activities in an Automated Recovery and Integrated Extraction System (ARIES) glovebox. After completion of maintenance activities for the day, the worker alarmed the hand and foot monitor when exiting the room. The responding radiological control technician identified the personnel contamination, contamination on the personal protective equipment of another worker and contamination in the room. Appropriate actions were taken to respond to the personnel contamination and to isolate the lab room. Plutonium Facility procedures require workers to monitor their hands and arms for contamination after removal from glovebox gloves. The particular glovebox where the maintenance was being performed is equipped with two newer cordless contamination monitoring devices. During the critique for this event, it was identified that these cordless probes are powered by a capacitor that maintains power for a limited time after being removed from the charging cradle on the glovebox. Workers for this maintenance activity had removed the probe and placed it on a nearby table to perform hand monitoring after exiting from the glovebox and were not aware that the probe would become de energized and inoperable if not returned to the cradle. LANL management is developing corrective actions and plans to communicate a complex-wide lessons learned to ensure other sites are aware of the limitations for this type of cordless contamination monitor.
  • Apr 12: The Plutonium Facility safety basis credits a TSR-level material at risk (MAR) limit of 7500 g Weapons-Grade Pu (WG-Pu) equivalent for individual containers outside of gloveboxes. Plutonium Facility personnel use a software program called MAR Tracker to perform this and other required MAR limit surveillances in the facility. This week, a system engineer discovered an error in MAR Tracker that caused only a small subset of applicable facility containers (roughly 1700 out of 13000 containers) to be checked during the required annual MAR surveillance. This week, facility management declared a TSR violation based on this discovery. In response to this TSR violation, normal operations have been terminated and the Plutonium Facility has been placed in Standby Mode. Facility personnel have revised the surveillance procedure to allow compliance with container MAR limits to be verified manually, rather than automatically using MAR Tracker, and teams of individuals are working to perform surveillances on all 13000 applicable containers. To date, fifteen containers, all housed in the facility’s vault, have been identified with contents that exceed the MAR limit of 7500 g WG-Pu equivalent. The MAR Tracker error was introduced during software development. To perform surveillances, MAR Tracker imports data from the laboratory’s Material Control and Accountability (MC&A) inventory database. The MAR Tracker error resulted from a miscommunication between software developers and security personnel over how to recognize inventory data that corresponded to containers in the MC&A database.
  • Feb 10: On Tuesday, Plutonium Facility personnel discovered a leak in the safety class fire suppression system when operators observed water on the floor of a laboratory room used for pit manufacturing. Upon discovery, personnel isolated the affected portion of system piping, entered the applicable TSR Limiting Condition for Operation and instituted a fire watch. The system was repaired, confirmed to be operable and returned to service by the end of Tuesday. The leak developed at an elbow joint in the fire suppression system piping. The failed joint fitting was installed during system modifications performed in 2005. Preliminary evaluation of the failed fitting suggested a hairline crack may have developed due to over-tightening of the tapered threaded connection during installation. Results of more detailed metallurgical evaluation are pending. In response to this event, facility management has directed engineering personnel to develop a plan to inspect system piping and components as part of an extent of condition review. The extent of condition inspections will focus on other components that were installed during the 2005 system modification, but will also involve a sampling of older components.
  • Jan 27: This week, Plutonium Facility management declared a TSR violation based on the failure to perform a required In-Service Inspection (ISI) on a safety significant design feature. The Plutonium Facility safety basis requires the use of credited containers for all operations that could produce molten plutonium metal. These containers provide a confinement barrier for molten plutonium in the event of a process or furnace upset. Recently, Plutonium Facility personnel discovered an infrequently used process that creates molten plutonium metal. The containers used in this process are made of the correct material for molten plutonium processing, but the containers had not been subjected to the applicable ISI as required by the TSR.

2011

  • DNFSB Public Hearing & Meeting in Santa Fe, NM, Nov 17, 2011
       – Transcript #1 Plutonium Facility Seismic Safety, and Emergency Preparedness and Response
       – Transcript #2
  • DNFSB Second Annual Report to Congress: Summary of Significant Safety-Related Infrastructure Issues, Sep 30, 2011
  • NNSA deliverables in answer to DNFSB recommendation 2009-2, Jun 28, 2011
  • NNSA deliverable 5.4.2 of Implementation Plan for DNFSB Recommendation 2009-2, LANL Plutonium Facilily Seismic Safety, Apr 1, 2011
  • NNSA Implementation Plan (IP) deliverable 5.4.1 for DNFSB's Rec 2009-2, LANL Plutonium Facility Seismic Safety, Jan 31, 2011
  • NNSA Implementation Plan (IP) deliverable 8.6.5 for DNFSB's Rec 2004-2, Ventilation systems in DOE complex, Jan 12, 2011
  • Dec 23: In August, a troubling criticality safety infraction occurred at the Plutonium Facility that increased management concern over criticality safety and conduct of operations and highlighted the pressing need to address shortcomings and improve performance in these areas. In the August event, a researcher, who was a certified fissionable material handler (FMH), wanted a photograph of the results of a recent plutonium casting operation. The FMH accessed material in a glovebox that he was not authorized or released to work in and violated posted criticality safety limits by taking plutonium metal rods from two separate material locations and bringing them together in a single location. During this evolution, a second certified FMH entered the area and recognized the plutonium mass in the glovebox location significantly exceeded posted limits. The two certified FMHs then violated requirements for dealing with criticality safety infractions by re-accessing the affected glovebox and moving the rods back to their original locations.
  • Sep 23: Las Conchas Wildfire: Last week, the site office transmitted the Las Conchas Wildfire Final Emergency Report to NNSA-Headquarters consistent with the requirements in DOE Order 151.1C, Comprehensive Emergency Management System. The fire began on Sunday, June 26th at approximately 1300 roughly 12 miles southwest of LANL. An Operational Emergency was declared on Monday, June 27th due to a small (approximately 1 acre) fire on laboratory property that was quickly extinguished. LANL transitioned from an Operational Emergency to recovery mode on Friday, July 1st after the threat from the fire had been sufficiently mitigated. As a noteworthy practice, the report identifies lessons learned and corrective actions developed after the 2000 Cerro Grande fire that included execution of a wildland fire management plan, construction of a new Emergency Operations Center (EOC), formalized training of Emergency Response Organization personnel, establishment of a 24/7 Emergency Operations Support Center and development of an enhanced drill and exercise program. The report identified opportunities for improvement in the areas of communication, management and staffing, EOC infrastructure, access control and accountability. The site office also reviewed the event and identified opportunities for improvement associated with LASO and DOE-Headquarters performance. The site office is developing a performance-based incentive for FY12 to drive improvements in the identified areas.
  • Aug 19: A criticality safety infraction was declared last Thursday when a plutonium overmass condition was identified in a facility glovebox. In order to take pictures of several cast plutonium items in a glovebox, a plutonium worker removed the items from two separate slip lid containers in two different mass locations. The worker then collocated of the all items to take a picture. This resulted in a total mass that exceeded the criticality safety limit. An angle iron spacing delimiter that is a criticality safety engineered feature was also moved from its required location and used to prop up the items for the photographs. A second plutonium worker entered the area and recognized the overmass condition. The first worker then moved the items back to their original location. This action is not consistent with criticality safety expectations and procedures, which require workers to back off and contact criticality safety personnel. Workers in the lab room were notified of the issue and the room was evacuated and facility management was notified. Subsequent evaluation by criticality safety personnel concluded that the current position of the items (i.e. after the worker returned the items to the separate locations inside slip lid containers) was safe and consistent with criticality safety requirements. During the subsequent critique, additional issues with regard to the process for authorizing work (the glovebox owner was not aware the activity) and timely and complete notifications were identified. Recognizing the significance of this event, Plutonium Science and Manufacturing Directorate management plan to pause work on Monday morning to conduct an all-hands briefing followed by breakout sessions at the group level to discuss the briefing and lessons learned. The brief will focus on conduct of operations, criticality safety requirements, work authorization and lessons learned from this and other criticality safety issues. Management will authorize individual group activities to resume after this training is complete. All Plutonium Facility personnel will be required to complete this training prior to being authorized to perform work.
  • Jul 1: The laboratory was closed this week due to the Las Conchas wildland fire. LANL declared an operational emergency on Monday, June 27th, and the Emergency Operations Center was activated and declared operational. Only one small (less than one acre) spot fire occurred on LANL property and was extinguished within one hour. All nuclear operations were suspended this week and nuclear facilities were placed in a safe-stable configuration with the exception of the Radioactive Liquid Waste Treatment Facility (RLWTF), which did perform low level waste processing operations this week to maximize lag storage space should an extended outage at RLWTF be required. As of Friday, the Las Conchas fire has burned over 100,000 acres and is only 3% contained; however, the threat to LANL property and nuclear facilities has been significantly reduced by extensive firefighting efforts, preventative burns and fire breaks. During the week, LANL also performed extensive fire mitigation activities throughout the laboratory to reduce fuel sources (especially around Area G). Based on the reduction in threat to laboratory from the fire on Friday afternoon, LANL terminated the operational emergency and transitioned to recovery operations mode. On Friday, the LANL emergency director approved the recovery plan that includes facility walkdowns (including the nuclear facilities) over the weekend by the Facility Operations Directors (FODs) to determine facility status and habitability. Restart of the laboratory will be phased over two days with management and programmatic walkdowns and restoration of site services on the first day. Provided there are no significant facility issues identified by the FOD or programmatic walkdowns, LANL will reopen to all personnel on the second day. Beginning the phased restart of the laboratory is dependent on repopulation of the Los Alamos town site.
  • Jun 24: This week, Plutonium Facility Management declared a TSR violation based on a failure to comply with an operational restriction associated with the facility’s cement silo appurtenance. SAFER project analysis concluded that if the silo is filled with cement above a certain level, it could fail in a seismic event and adversely impact the confinement integrity of the safety class building structure. In conjunction with JCO completion and submittal, Plutonium Facility management committed to implement an operational restriction to control the amount of cement in the silo to less than one-fourth capacity. To protect this operational restriction, operations personnel physically locked out a bucket hoist mechanism that they believed was the only means to add cement to the silo.
  • Apr 15: This week, LANL declared a Potential Inadequacy of the Safety Analysis (PISA) based on preliminary seismic evaluation results that indicate an increased likelihood of structural failure in some locations during postulated seismic events. In 2007, the Probabilistic Seismic Hazard Analysis for Los Alamos was updated and indicated increased seismic hazard for LANL facilities. A Justification for Continued Operations (JCO) for nuclear facilities was approved by the site office while the Seismic Analysis of Facilities and Evaluation of Risk (SAFER) project was initiated to evaluate the impact of the increased hazard. The SAFER evaluation of all LANL nuclear facilities except the Plutonium Facility was completed last year. The Plutonium Facility analysis has been ongoing and is now expected to be complete in May including independent peer review and resolution of comments. Currently, SAFER preliminary results have identified nine Plutonium Facility issues where the anticipated seismic demand may exceed the structural capacity during the design basis seismic event. The potential failures may invalidate safety basis assumptions related to the facility’s leak path factor in the 2008 Documented Safety Analysis (DSA), which is scheduled to be fully implemented within two months, and may impact assumptions in the yet to be approved 2010 DSA. As a part of the PISA declaration, LANL has identified a compensatory measure to develop and implement an emergency operating procedure to isolate the facility’s exhaust stacks during certain seismic accident conditions to eliminate a potential unfiltered material release path that could result from two of the newly identified failure modes. The PISA is expected to result in an unreviewed safety question and safety basis personnel are developing an evaluation of the safety of the situation. Plutonium Facility management noted that facility upgrades to resolve these issues are being evaluated.
  • Apr 1: This week, Plutonium Facility management declared a TSR violation based on the discovery that the material form of some plutonium items stored in two vault rooms does not comply with criticality safety requirements specified in a Justification for Continued Operations (JCO). Vault rooms B and I have been operating under a JCO since 2007 when laboratory personnel found that criticality safety limits for locations in these rooms were not adequate to prevent criticality under all normal and credible abnormal conditions. Criticality safety controls in the current JCO revision only provide approved material limits for plutonium metal and oxide items. On Monday, Plutonium Facility vault operators recognized that 22 plutonium residues and 9 plutonium compounds are currently stored in vault rooms B and I, in violation of JCO controls that only allow metal and oxide forms.
  • Jan 7: This week, Plutonium Facility management declared a PISA related to two types of safety class controls used to contain 238Pu-enriched Heat Source Plutonium (HS Pu). Certain completed heat source assemblies and robust containers for storing bulk HS-Pu oxide are credited in the Plutonium Facility DSA to survive the most severe accident scenarios postulated for the facility. Because these safety class assemblies and containers are credited to survive bounding accident conditions without releasing their contents, the HS-Pu they contain does not count toward facility MAR limits. Facility personnel recently discovered that analyzed temperatures for glovebox fires exceed the temperatures that the safety class assemblies and containers are credited to survive. This discovery resulted in the PISA declaration. In response, facility management instituted a compensatory measure to begin counting the HS-Pu material inside the safety class assemblies and containers against glovebox MAR limits and to ensure all affected gloveboxes contained less than their allowed limits. Longer term, facility personnel intend to reevaluate the safety basis approach for analyzing and crediting these safety class controls.

2010

  • DNFSB report on "Summary of Significant Infrastructure Issues at Operating Defense Nuclear Facilities," Sep 10, 2010
  • "Implementation Plan for DNFSB Recommendation 2009-2, "Los Alamos National Laboratory Plutonium Facility Seismic Safety," Jul 13, 2010
  • NNSA's response to DNFSB ltr re: documented safety analyses, Jun 30, 2010
  • Letter from DOE to DNFSB re: Rec 2009-2, "Los Alamos National Laboratory Plutonium Facility Seismic Safety," Feb 2, 2010
  • Nov 26: This week, facility management declared a TSR violation based on an NNSA Facility Representative discovery that a TSR-level surveillance to ensure compliance with material-at-risk limits had been performed without inspecting all required material locations. Currently implemented Plutonium Facility TSRs require the quantity of 238Pu-enriched heat source plutonium (HS-Pu) stored in each of the 60 locations in the vault water bath to be checked for compliance with approved limits on a quarterly basis. The limit on HS-Pu in vault water bath locations was derived to ensure the thermal loading from the total quantity of high-activity HS-Pu does not overwhelm the heat removal capability of the vault water bath leading to a rise in water temperature and eventual boiling.
  • Nov 19: This week, Plutonium Facility management declared a potential inadequacy of the safety analysis (PISA) related to 238Pu-enriched heat source plutonium (HS-Pu) items. This PISA involved the discovery of issues with several different classes of sealed HS-Pu items in the facility. In mid-October, the Plutonium Facility cognizant system engineer for container systems identified a family of sealed HS-Pu items used as calibration standards that presented a potential over-pressurization concern. Although subsequent analysis demonstrated that pressures inside these standards would not exceed acceptable limits, an extent of condition review identified roughly 100 other sealed HS-Pu items that required evaluation for over-pressurization hazards. By this week, walkdown evaluations had discovered several sealed items that presented potential over-pressurization hazards, including one item that appeared to be slightly bulged. These discoveries prompted the PISA and immediate actions to place affected items in a safe configuration either by overpacking them in credited containers with a filtered vent or by introducing them into gloveboxes.
  • Nov 5: Last Thursday, Plutonium Facility personnel lost control of radiological contamination during an operation to bagout material from a glovebox. The event occurred when one operator dropped a container to another waiting operator down an interface tube leading to the bagout port. When the container reached the second operator, the force caused his hand to pull down on the bagout assembly enough for the bag to detach from the glovebox port and breach the confinement boundary. Operators successfully re-secured the bag to the glovebox port with tape, and exited the area after continuous air monitors (CAMs) began alarming in their room. CAMs later alarmed in two adjacent rooms. The two operators and their attending Radiological Control Technician had contamination on their personal protective equipment and one operator had roughly 1100 dpm of alpha contamination on his skin. Nasal smears taken after all affected personnel doffed their respirators showed no detectable activity. This week, facility personnel performed a controlled re-entry to secure the bagged containers and decontaminate affected areas. The design of the glovebox bagout port appeared to play a role in this event. Unlike most bagout ports found in the facility, this port lacks an engineered feature, such as a lip or raised nub, to help secure the bagout assembly to the port and prevent slipping. Also, this port included a long interface tube that required one operator to drop the container about 18 inches before it could be received and controlled by the other operator. Facility management has suspended all bagouts from gloveboxes with similar features until corrective actions can be developed and implemented.
  • Jun 4: Plutonium Facility: The Plutonium Facility Documented Safety Analysis (DSA) that was approved by NNSA in 2008 and is currently being implemented by LANL identified a suite of planned safety improvements that include seismic upgrades to a population of ‘high risk’ gloveboxes. The DSA criteria for high risk included gloveboxes that contain ignition sources or greater than 10 kg of material at risk. Because these glovebox upgrades play a key role in the facility’s existing seismic safety strategy, the NNSA Safety Evaluation Report (SER) that approved the 2008 DSA included a Condition of Approval to accelerate the schedule for glovebox seismic upgrades such that all high risk gloveboxes meet performance category 3 seismic requirements by the end of 2011. LANL uses this commitment for future glovebox seismic upgrades to reduce the mitigated dose consequence for a seismically-induced spill scenario by a factor of 10 (i.e. a damage ratio of 0.1 is credited). LANL intended to use Phase 2 of the line item TA-55 Reinvestment Project (TRP2) to complete seismic upgrades for all high risk gloveboxes. However, the expected cost of seismic upgrades to individual gloveboxes has risen from an original estimate of about $80,000 per glovebox to a current estimate of approximately $850,000. Concurrent with this order of magnitude cost increase, LANL personnel completed a comprehensive facility survey and identified 157 high risk gloveboxes, roughly twice as many as originally expected. The current scope of TRP2 would upgrade a total of 40 gloveboxes through 2014. LANL has not yet clearly defined the strategy and schedule for performing required seismic upgrades for the large population of remaining high risk gloveboxes that will not be addressed by TRP2.
  • May 14: This week, facility management declared a potential inadequacy of the safety analysis (PISA) based on the recognition that hazards may not be fully analyzed for four metallic heat source plutonium (HS-Pu) items currently stored in shelf locations in the facility’s vault. These Pu-238 enriched items were made in the late 1990’s to support a programmatic activity that is now complete. One item contains greater than 100 grams of HS-Pu sealed in a welded inner container that is overpacked in a container with a filtered vent. The other three items, believed to involve small quantities of HS-Pu, are welded in sealed sample vials that are not contained in filtered overpacks.
  • Mar 26: LANL has completed the 3rd phase of the 2008 DSA implementation effort at the Plutonium Facility including completion of Implementation Verification Reviews. In February, the site office approved extending the implementation period for this DSA from the end of March to the end of May. In the 4th and final phase of implementation, LANL will complete actions to achieve a safety class fire suppression system for non-seismic fire scenarios. The final phase also includes implementation of controls on material-at-risk and transient combustible loading, as well as, several safety management programs (e.g., fire protection and glovebox transient combustible programs) and safety design features (e.g., glovebox support stands). The site office continues review of the Plutonium Facility’s 2009 DSA annual update submittal.
  • Feb 26: This week, LANL declared a Potential Inadequacy in the Safety Analysis (PISA) based on a potential issue with the safety class ceiling armor for the Isotope Fuel Impact Test (IFIT) facility. The ceiling armor is designed and implemented to prevent a projectile from breaching the facility (projectiles are gas propelled in the vertical direction). The technical safety requirements note that the armor is designed to withstand a projectile with speeds up to 200 m/s; however, there are no safety class controls that protect this assumption (e.g., a relief valve that would limit the maximum projectile velocity is installed but is not credited as safety class).
  • Jan 22: This week, LANL responded to the December site office direction on improving seismic safety at the Plutonium Facility (site rep weekly 1/8/10). LANL proposes completion of several improvements this fiscal year including the following: 1) complete 100% design of seismic electrical interlocks (August) 2) implementation of ignition source control (March) 3) installation of 6 robust safes (August) 4) testing of existing containers to establish a defensible damage ratio during a fire (September) 5) seismic evaluation of fire suppression and ventilation systems (September) and 6) fire-barrier assessment (July). LANL also identified material at-risk reduction goals for the Plutonium Facility. For weapons grade plutonium, the laboratory plans to repackage into robust containers or ship off-site 200 kg (Pu-239 equivalent) of material. For heat source plutonium, LANL plans to overpack the roughly 100 remaining non-safety class Russian Product Containers by the end of June.

2009

  • DNFSB recommendation 2009-2 addressing seismic safety at LANL's Plutonium Facility (PF-4), Oct 26, 2009
  • NNSA ltr re: PDSA & Safety Strategy of CMRR facility, Apr 21, 2009
  • DNFSB review of CMRR nuclear safety design strategy & safety-class & safety-significant systems, Mar 30, 2009
  • Dec 11: This week, the NNSA site office transmitted to NNSA Headquarters (NA-10) a document describing the seismic safety posture of the Plutonium Facility.
  • Nov 6: A backfit analysis on the Plutonium Facility Active Confinement Ventilation System was recently completed to evaluate gaps and recommend actions to upgrade the system from safety significant to safety class.
  • Oct 30: Programmatic operations in the Plutonium Facility remain suspended as a result of the recent discovery that portions of the facility’s fire suppression system cannot deliver the minimum required flow density of fire water. A Justification for Continued Operations (JCO) has been approved by the NNSA site office that would allow programmatic operations to resume in most areas after compensatory measures to reduce combustible loading have been implemented.
  • Oct 23: Programmatic activities at the Plutonium Facility remain suspended pending implementation of Justification for Continued Operations controls associated with flow density issues for the fire suppression system.
  • Oct 16: On Tuesday, a general evacuation alarm caused by a Criticality Alarm System (CAS) signal, a loss of all facility ventilation and failure of the Facility Control System (FCS) occurred at the Plutonium Facility. The CAS alarm was subsequently identified to be erroneous and troubleshooting efforts were able to restore ventilation and FCS after approximately 3 hours. The facility was in standby mode during this event due to previously identified issues with the fire suppression system and, therefore, limited personnel were in the facility. During the event, personnel responded appropriately to alarms/announcements and evacuated the facility. Subsequent activities this week have focused on investigation into the cause of the event and reentry and evaluation of the facility condition. One laboratory room was identified to have some spread of contamination based on a continuous air monitor alarm.
  • Oct 9: As discussed last week, the Plutonium Facility remains in standby mode pending resolution of operability issues associated with the fire suppression system. This week, LANL submitted a Justification for Continued Operations (JCO) to the NNSA site office that would allow a return to normal operations for most of the facility with specific compensatory measures for the affected areas (i.e. the areas that do not meet the safety basis requirement for flow density).
  • Oct 2: On Wednesday, facility management declared the fire suppression system inoperable based on recent hydraulic calculations that conclude the system does not achieve the water density coverage required in the safety basis (0.19 gpm/ft2). Facility activities were placed in a safe and stable condition to support a transition to standby mode, which was accomplished Wednesday afternoon, consistent with the Technical Safety Requirements (TSRs). To support upgrading the classification of the fire suppression system from safety significant to safety class, LANL performed a system adequacy analysis (backfit analysis) in 2008.
    Also this week, personnel found a surface-contaminated legacy item in an unposted area outside of the Plutonium Facility proper (i.e. PF-4) during an extent of condition walkdown performed in response to a recent contamination event and worker uptake at CMR (site rep weekly 9/18/09). Plutonium Facility management established a systematic and thorough inspection plan for uncontrolled auxiliary areas that could contain contaminated legacy items that are not appropriately marked or labeled. This inspection process included opening locked drawers that have not been accessed for many years. In one locked drawer, personnel found legacy radiation sources in an unmarked container. One of these radiation sources was found to have removable americium contamination. Upon discovery of the contamination, appropriate actions were taken to exit the room, post the area and develop a recovery plan with support from radiation protection personnel. The management decision to undertake a broad extent of condition review to identify problematic legacy items in unexpected locations led to the isolation and elimination of this previously unknown and uncontrolled hazard.
  • Sep 18: This week, Plutonium Facility management declared a TSR violation when an unvented transuranic waste drum was discovered by an NNSA facility representative in the Plutonium Facility basement. This is the third discovery of an unvented container in the facility basement over the past seven months that has resulted in either a TSR violation or declaration of a potential inadequacy of the safety analysis. All three situations were identified by NNSA facility representatives. In this case, the legacy unvented drum had been re-categorized from low level waste to transuranic waste in January based on new assay data, but the drum had not been labeled or re-barcoded to indicate this change. In response to this event, facility procedures and processes are being revised to ensure safety basis and compliance implications are evaluated when the status of a waste container changes from low level to transuranic. Also, facility management has directed the conduct of a thorough and rigorously documented extent of condition review that will assess all containers in all applicable areas of the Plutonium Facility.
  • Sep 4: This week, a Technical Safety Requirement (TSR) violation was declared when an NNSA facility representative discovered a loose round sheet in the facility basement that indicated required TSR-level surveillances of HEPA filter differential pressures had not been completed. Plutonium Facility operations center personnel were aware of the missing record for these rounds, but incorrectly believed that their existing review and verification process would have contemporaneously identified and corrected any required rounds that had not been completed. Corrective actions have been identified to strengthen control, accountability, and review of multi-page round sheets.
  • Aug 28: As part of the Documented Safety Analysis approved in December 2008, LANL committed to a series of engineered and administrative control upgrades to improve the safety posture of the facility. A near-term cornerstone of site plans to reduce the consequences of challenging accident scenarios, such as a post-seismic fire, is to seismically upgrade glovebox stands, as part of the line item TA-55 Reinvestment Project. The site office SER included a Condition of Approval to accelerate seismic upgrades for select, high-priority gloveboxes to be completed by the end of FY11. However, during this week’s Integrated Nuclear Planning workshop, it was reported that these priority upgrades would be delayed rather than accelerated due to line item funding issues.
  • Jul 3: The site office approved a justification for continued operation (JCO) this week that provides the safety basis to allow movement, handling and radiography of non-safety class heat source plutonium containers. The JCO includes compensatory measures that will be implemented as specific administrative controls to limit the time non-safety class containers will be removed from the vault water bath and subject to increased temperatures due to self heating.
  • Jun 26: Three drum-sized containers staged in the Plutonium Facility basement were recently recognized to be unvented. These legacy containers hold plutonium that is in contact with hydrogenous material. This configuration could result in hydrogen gas being produced via radiolysis, which over time could create a flammable environment inside in the unvented container. Facility management declared a potential inadequacy of the safety analysis (PISA) because it is not clear that this type of hydrogen deflagration hazard is analyzed in the facility safety basis. The affected containers have been cordoned off and an isolation area has been established around them. This situation has parallels to a PISA declared in March involving the discovery of an unvented legacy transuranic waste container that had also been staged in the Plutonium Facility basement for many years. B
  • Jun 12: This week, LANL submitted for NNSA review and approval a justification for continued operations (JCO) that would remove existing operational restrictions that prohibit removal of non-safety class heat source plutonium containers from the vault water bath.
  • Jun 5: This week, a criticality infraction was declared at the plutonium facility when a plutonium metal sample was identified in a glovebox that was only analyzed and posted for plutonium oxide. Following evaluation by criticality safety engineering, the material was removed from the glovebox. The metal sample was originally placed in the glovebox several years ago in compliance with criticality safety requirements at that time. The glovebox limits were subsequently changed to require oxide only; however, presence of the metal sample that did not comply with the revised limit was not identified at that time.
  • May 29: This week, a criticality infraction was declared at the plutonium facility when a plutonium metal sample was identified in a glovebox that was only analyzed and posted for plutonium oxide. Following evaluation by criticality safety engineering, the material was removed from the glovebox. The metal sample was originally placed in the glovebox several years ago in compliance with criticality safety requirements at that time. The glovebox limits were subsequently changed to require oxide only; however, presence of the metal sample that did not comply with the revised limit was not identified at that time.
  • Apr 17: This week, the Plutonium Facility returned to Operations mode after LANL personnel completed a re-evaluation of all unreviewed safety question (USQ) screens and determinations performed for the facility since January.
  • Apr 10: The plutonium facility fire suppression system is being upgraded from safety significant to safety class as a part of the on-going safety basis implementation. In accordance with a site office Safety Evaluation Report condition of approval, LANL recently submitted a gap analysis for this system against National Fire Protection Association standards 13, 25 and 72. LANL notes that despite identified non-compliant conditions, the fire suppression system is able to meet its credited safety function.
  • Mar 27: This week, prompted by concerns raised by the staff, Plutonium Facility management declared a potential inadequacy of the safety analysis (PISA) and implemented a series of compensatory measures related to the transportation, storage and protection of non-safety class (non-SC) heat source plutonium (HS-Pu) containers. About 200 non-SC containers holding a significant quantity of HS-Pu are stored in the Plutonium Facility’s safety class vault water bath (VWB). The VWB is relied on to prevent overpressurization of non-SC HS-Pu containers by keeping them fully covered with water to remove heat generated by intense radioactive decay. This week, facility personnel discovered that the process, hazards and controls associated with transporting non SC HS-Pu containers from the VWB to laboratory rooms and staging these containers in rooms on the laboratory floor are not adequately described and evaluated in the DSA. As a result, even though non-SC containers being transported or staged are subject to the same stresses from internal heat generation as the non-SC containers in the VWB, they did not benefit from the protection of a safety class control to prevent overpressurization. These discoveries resulted in the declaration of a PISA.
  • Mar 6: This week, LANL declared a potential inadequacy of the safety analysis (PISA) based on the presence of an unvented transuranic waste container in the facility that may pose hazards that are not analyzed in the safety basis. In late 2007, this roughly 2' x 2' x 4'metal waste container, which was long thought empty, was assayed and found to be holdjng contents that included gram quantities of plutonium. Upon discovery, the contail1er was entered into the facility waste item database and operators partially removed the container lid under a radiological work pennit in an attempt to characterize the unknown contents. A bagged metal cylinder was observed and when contamination was detected on the outside of the bag, the container lid was restored. The container remained in this state until an NNSA facility representative noticed the container was not vented and notified facility management of a potential safety basis concern.
  • Feb 27: A criticality safety infraction was declared recently when an oveDJlass condition was discovered in a glovebox. Last week, operators moved a plutonium part from a casting glovebox into a machining glovebox that still contained metal turnings from a previous operation. The machining glovebox had separate criticality safety ljmits for approved metal shapes and plutonium metaL The casting operators mistakenly believed that the higher mass limit for approved metal shapes applied to tllis material move; however, since the machining glovebox already contained metal turnings from a different part, the plutonium metal1imit should have been applied. Once the part was moved, the aggregate mass of plutonium in the glovebox was roughly 11 0% ofthe posted limit for plutonium metal. Machining operators recognized the overmass condition the next day and responded appropriately. Upon consultation with the Nuclear Criticality Safety Group, facility personnel corrected the overmass condition. This infraction was binned in the lowest significance category.
  • Feb 20: LANL recently completed a backfit analysis on the Plutonium Facility fire suppression system, which was upgraded from safety significant to safety class in the recently approved Documented Safety Analysis. The backfit analysis concluded that the system could meet its safety function for operational fire events (i.e. fires that are not seismically induced) but recommended actions that could significantly improve reliability. The analysis also identified a vulnerability associated with a lack of redundant risers but concluded the system could perform its safety function based on overall system reliability estimates. A project plan to address gaps identified in the backfit analysis and other system evaluations is being developed.
  • Jan 9: This week, a glovebox glove breach occurred while an operator was perfonn.ing housekeeping activities in a heat source plutonium (i.e. Pu-238) glovebox. To prepare a glass condenser tube to be removed as waste, an operator applied tape to the outside of the tube, broke the glass with a blunt tool, then folded the broken tube over to redl!Ce its size. Post-evolution monitoring found contamination in excess of two million disintegrations per minute on the palm of the operator's inner glove. The inner glove was intact and nasal smears showed no indication of an uptake. An integrated work document (JWD) provided activity-level work control for the glass breaking and handling po11ion of this operation. Although one section of the IWD cans for protective leather or Kevlar gloves to be used over the glovebox gloves 'as necessary,' the section identifying required personnel protective equipment (PPE) and the IWD's procedural steps clearly require the use of protective over-gloves and puncture resistant inner gloves. The operator was not wearing either of these two required pieces of PPE dllli11g the glass breaking and handling operation, nor was the evolution performed .in accordance with the procedural steps in the IWD. The breached glovebox glove is being removed for examination in an attempt to determine the direct cause of the event. Even if the broken glass is detem1ined not to have breached the glovebox glove, this event stlll highlights a case where an operation involving latent sharps in a high hazard environment was performed without appropriate controls in spite of the significant attention that has been focused recentJy on safe handling of sharps inside gloveboxes. ln response, facility management has suspended all glass breaking and handling operations by the affected group and has commjtted to developing a single procedure for use in all glass breaking and handling operations in the facility. Tl:lls new procedtLre will be incorporated into the glovebox worker training process.

2008

  • DNFSB Staff Report, Documented Safety Analysis for PF-4, Apr 8, 2008
  • Nov 14: This week, a criticality safety infraction was declared when an item containing roughly 2900g of material was discovered in a vault location with a criticality safety limit of2500g. This item was shelved in January 2007 and the direct cause of the jnfraction could not be determiJ1ed. However, this event did highlight an opportunjty to improve the robustness of vault operating procedures. Currently, an operator is reqt1ired to perfom1 a hand calcttlation to ensure that an item will comply with the criticality safety limits of its intended vault location prior to shelving. To reduce the probability ofhumaJl error causing criticality safety infractions, the relevant vault procedure will be revised to require independent verification of the calculation and criticality safety limit compliance. Next week, the Plutonittnl Facility will begin a nominal outage period that will continue through December. Unlike last year's outage, on-going progran1matic work in the Plutonium Facility will not be suspended. Although the demand to perform programmatic operations during the outage period is expected to be low, a full stand-down was deemed not to be required based on the assertion that concurrent programmatic work would not impact the ability to accomplish outage objectives. These objectives include: • implementing upgrades to the facility control system, • replacing credited HEPA filters, • labeling equipment associated wiU1 the ventilation and instrument air systems, • performing system walkdowns to support technical baseline reconstitution, and • establishing a warehouse in the basement for controlled staging of safety class and safety significant equipment and components.
  • Oct 3: This week, the LANL accident investigation team issued their fmaJ report on the recent Plutonium Facility contaminated puncture wound. The team concluded that an undetected metal spur left on a part during a machining operation penetrated the worker's personal protective equipment and punctured the worker's hand. The following three judgments of need (JONs) were identified: LANL should require specific procedures for machining and cutting hard metals (e.g., stainless steel) that identify appropriate hazards and controls; LANL should require part inspection and 11lltigation of sharps hazards after each cutting or machining operation; and LANL should develop remote and automatic metal handling, cutting, and machirTing techniques to reduce worker exposure to potential puncture hazards. A separate team is scheduled to develop a corrective action plan based on these JONs by the end of October (site rep weeklies 8/29/08, 8/22/08, 8/15/08).
  • Sep 19: This week facility personnel recognized a condition where 3 uncredited containers bearing Pu-238 were incompletely submerged in the vault water bath. Compensatory measures stemming from a 2006 potential inadequacy of the safety analysis (PISA) and positive unviewed safety question (USQ) require uncredited containers to be fully submerged. The control derived to ensure this condition is satisfied relates to maintaining the water in the vault water bath above a certain level. However, the water level control was based on assumptions associated with container dimensions and storage configurations. These assumptions were not protected and operators were nol aware that certain container sizes and storage configurations could defeat the intent ofthe control. As a result, the water level was maintained at the prescribed level, but this did not prevent uncredited containers from being stored in an incompletely submerged state. Upon recognition of this situation, facility management remediated the condition, reengaged the PISA process and revised the ineffective compensatory measures associated with the legacy PISA.
  • Aug 29: The laboratory accident investigation continued this week, with the team focused on personnel and management interviews and timeline development. ln addition to the on-going investigation, a number of other efforts to evaluate glovebox safety and glovebox glove integrity are progressing. These include the LANL effectiveness evaluation for corrective actions associated with the January 2007 puncture wounds; an evaluation of glovebox glove breaches at the Plutonium Facility; and an assessment of Glovebox Glove Integrity Program implementation. These parallel efforts are being performed under the auspices of several different laboratory organizations, but appear to be analyzing different facets of the same problem. As such, upon completion of these activi ti es, there may be value in having a single entity collect and review the results, consolidate .identified issues, and coordinate an integrated response (site rep weeklies 8/22/08, 8/15/08, 7/18/08).
  • Aug 22: The Deputy Laboratory Director has formally chartered a team to investigate the glovebox glove puncture event that occurred last Wednesday and resulted in a contaminated wound. The scope of the investigation, wbich began this week, is to collect relevant facts and detennine the causes of the glove puncture. The charter also specifically tasks the team to evaluate the following: • adequacy of activity hazard ana.lysis and control identification for glovebox operations, • work controls and procedures relevant to the associated activity, and • training and qualification of the involved workers on relevant work controls and procedures. A causal analysis and accompanying report are due to the Deputy Director by September 251h and corrective actions to address the causal factors are due by October 24th (site rep weekly 8/t5/08). Plutonium Facility: In response to the puncture event, Plutonium Facility management suspended all metal cutting and machining operations. The facility has developed a review and release process to ensure controlled resumption of suspended operations. For a given operation, the process evaluates the types of metals involved, the potential for sharp pieces or turnings to be produced, and the extent to wbjch cut pieces or turnings need to be handled. Operations that pose a puncture risk based on these factors are subjected to more rigorous review requirements, including a process walkdown involving appropriate safety subject matter experts. Multiple levels of management approval are required to release an operation once it has been reviewed and controls have been verified as adequate. Few of the roughly 80 suspended metal cutting and machining operations have been released to date.
  • Aug 15: On Wednesday, an operator punctured his band while performing a stainless steel cutting operation in a glovebox. Operators and radiological control personnel took appropriate action to respond to the injury and transport the injured operator to the on-site Occupational Medical Facility. Initial wotmd counts wer:e positive; however, subsequent medical efforts were able to remove a smaLl metal sliver and significantly reduce tbe wound contamination. Based on initial investigation, the Integrated Work Document (IWD) included the puncture hazard and controls were identified. In particular, the IWD required use of puncture resistant gloves for this activity. The pre-job brief included a discussion of this hazard and controls. In addition to the fir:st line manager and other operators in the area, two members from the effectiveness evaluation team for the January 2007 contaminated puncture wound corrective actions were in the area and observing the activity. Personnel observing the activity noted that the procedure and controls (including puncture resistant gloves) were followed by the operator. This particular cutting operation with stainJess steel creates a rough edge that appears to have breached the operator's glove. Based on the injury sustained by the operator, it appears that the controls identified may not be adequate. All machining activities at the Plutonium Facility have been suspended pending causal analysis of this event. ln addition, the Director has requested that a formal investigation be performed.
  • Jul 18: Glovebox Safety: Recently, LANL began an effectiveness evaluation ofthe corrective actions associated with the puncture wounds that resulted in intemal contamination inearly-2007. The review plan includes evaluation of institutional actions but will maintain a specific focus on the safety of glovebox operations. The evaluation team is developing guidance cards with specific Jines of inquiry for line managers who will perform parts of the evaluation. In addition, the institutional evaluation team will perform an independent verification for a subset of the line management evaluations. Field activities are expected to be complete in August. Several other reviews of glove box safety issues are also on-going, including a management evaluation of glove breaches over the last two years and an assessment of the Plutonium Facility glove integrity program.
  • Jul 4: While attempting to open a taped slip-lid container using a screwdriver, a:n operator inadvertently punctured the glove-box glove and an interior glove. The screwdriver did not lacerate the operator's hand but resulted in 15,000 dpm alpha contamination on his innermost cotton glove liner. Subsequent discussions with the operator indicated that the taped container did not have tabs (as expected) to facilitate removing the tape nor was the screwdriver the appropriate tool for tape removal. The operator was also not aware ofprevious similar incidents (e.g., the January 2007 contaminated puncture wounds) or the associated con·ective actions. Based on this infom1ation, faciLity management met with first Line managers to discuss methods of ensuring that lessons learned and corrective actions are adequately disseminated down to the worker level. In addition, the facility is using this event to re-emphasize the use of appropriate tools and the need to pause work when unexpected conditions are identified (site rep weeklies 1/19/07, 1112/07).
  • Jun 27: Last week, facility personnel discovered that safety-class seismic bracing had been improperly removed from a g.love box. The bracing is credited to prevent glove box toppling and release ofPu-238-doped material in a seismic event. Given this discovery, LANL declared a TSR v.iolation based on a significant breakdown of the configuration management program. The credited bracing was removed for a glove box modification project that began over a year ago under a design change package (DCP), but was never completed. When the project was abandoned, the bracing was not reinstalled and the DCP remained open. The glove box was being used to stage weapons-grade Pu when the discrepant condition was found. An annual in-service inspection (lSI) of the glove box and its bracing was performed in May 2008; however, a scientist who did not use a required system drawing when performing the ISI, inappropriately noted the bracing as satisfactory. ln response to this event, the faci lity operations director (FOD) suspended Pu-238 and Pu-238-doped material operations until appropriate portions ofthe ISI could be re-performed to verify credited bracing was intact and operable on other glove boxes. Personnel performing ISis must now be approved by the FOD. An action plan to remove the weapons-grade Pu from the affected glove box is in development. Finally, facility persmmel are working on a process to screen and tri.age the hundreds of legacy DCPs that remain open to identify and address other latent vulnerabilities.
  • Apr 25: On Thursday, an inadequately controlled fumace operation caused a glove-box window to crack during post-maintenance testing on two clamshell-type fumaces. After testing the first fw-nace, an operator opened the clamshell to allow the unit to cool. Then, intending to test the second fumace, the operator inadvertently re-energized the first furnace that remained in an open configuration. This furnace, which is not interlocked to preclude operation when the clamshell is open, ran unattended for a period of time causing the glove-box window to crack due to thermal insult. Personnel de-energized the furnace when they returned to the area and observed the damage. No nuclear matetial was present and ambient glove-box temperature did not exceed the alarm threshold.
  • Apr 4: Last week, operators were conducting normal plutonium operations in two furnaces and post-modification function-testing on a third furnace that was in an abnormal configuration that heated the glove-box more than normal. In this condition, rising ambient glove-box temperature exceeded the thermal detector setpoint of 190• F, prompting an alarm. Personnel exited to the corridor and upon assessment of the situation made a conscious decision to re-enter the room to de-energize the 3 operating furnaces in the alarmed box. There was no damage or material release. The Fire Department responded. Follow-up investigation identified issues with the configuration management of over-temperature controls for furnace operations: some interlocked over-temperature alarms were found to be disabled; over-temperature set-points were higher than necessary; and the abnonnally-configured furnace was operating without one of its normally-installed temperature sensors. In response to this event, facility management has suspended all furnace operations. Identified corrective actions include evaluating, baselining, and formalizing configuration control for alarm status and set-points for all furnace controllers; and establishing formal pre-operational checks to ensure proper equipment configuration and system line-ups. Operating groups must present corrective actions to a board that wi11 evaluate their adequacy and approve resumption (site rep weekly 3/28/08).
  • Mar 28: On Thursday, TA-55 had a valid glove-box over-temperature alarm during a furnace operation that resulted in a fire department response. Tbe facility appears to have responded appropriately and is critiquing the event and the response next week.
  • Feb 15: On Wednesday, a deflagration occurred in two electrical cabinets in a pump house (PF~ 1 0) when an operator pressed a button to start an electrical fire pump. The cause was a natural gas leak elsewhere at TA-55; natural gas migrated down an electrical conduit to the cabinets and ignited when the button was pressed. In response, TA-55 isolated natural gas until the leak was found and patched Wednesday night. There were no injuries and no impact on nuclear operations. Visible damage is limited to bowing ofthe cabinet doors. TA-55 will conduct full diagnostics before returning affected equipment to service and is investigating the cause of the leak.
  • Jan 11: Pursuant to 10 CFR 820.8(b), Special Report Orders, NNSA has directed LANL to submit a report within 90 days on the causes and the corrective actions for the CMR and TA-55 contaminated puncture wounds of January 2007.

2007

  • Selected Defense Nuclear Facilities Safety Board (DNFSB) Background Regarding Criticality Safety at Los Alamos National Laboratory (LANL), LASG, Oct 8, 2007
  • DNFSB Staff Report re: Design, Functionality, & Maintenance of Safety Systems at LANL, Aug 31, 2007
  • DNFSB Staff Report re: Nuclear Criticality Safety (NCS) implementation in PF-4 vault, Aug 6, 2007
  • Update of the Probabilistic Seismic Hazard Analysis (PSHA) and Development of Seismic Design Ground Motions at the Los Alamos National Laboratory, May 25, 2007
  • Overview on Brookhaven National Laboratory (BNL) Assessment of Seismic Analysis Methods for Deeply Embedded NPP Structures, Apr 2007
  • LANL Investigation Report: Investigation of Two Separate Worker Injuries and Resultant Internal Contamination, LA-UR-07-1305, Feb 23, 2007
  • Numerous Infrastructure and Safety Deficiencies Impact Plutonium Pit Production at Los Alamos National Laboratory (LANL), Feb 20, 2007
  • Dec 28: In September, due to emergent concerns with vault limits, LANL committed to reviewing criticality safety limits for 520 unit operations in the Plutonium Facility (TA-55) before the operations resumed. As of last week, per the LANL database, 218 operations have entered the review process (42 %); 188 have been accepted or have had actions approved (36 %); 64 have been recommended for release (12 %); and 32 have been released, based on criticality safety evaluations done since April2006 (6 %). While the fraction released is low, the scope is sufficient to allow significant operations to proceed, including: sampling, staging, pyro-chemistry, casting, machining, roasting, blending, drop-box transfers, and container welding; many of these will resume next month.
  • Dec 14: On Monday, two electricians working on the switchgear upgrade project shorted two wires that, unbeknownst to them, were energized. This led to a partial power loss in half the building, including partial loss of continuous air monitoring. Because ofthe upgrade project, the facility is not in a normal lineup; while attempting to restore power, operators took actions that led to a near-complete power loss in that half of the building, including loss of lab-room ventilation (Zone 2). Next, because of changing air pressure, ventilation in the other half of the building was secured. Throughout the event, the facility ensured primary confinement by maintaining glove-box exhaust ventilation (Zone 1); personnel also took appropriate actions, including orderly exit from the facility.
  • Nov 23: TA-55 is in the middle of a major switchgear upgrade project. Last Tuesday (11113), to save two days of production, project personnel deviated from their design change package and unsuccessfully attempted to switch from the primary feed to the alternate feed before work was completed on the latter; they safely stopped work when the Ops Center could not confirm both feeds were operational.
  • Nov 9: TA-55 continues to struggle with infrastructure challenges. This week, TA-55 experienced issues with its paging system and chlorine detection system. Both ofthese safety significant systems are antiquated and require upgrades or replacement (site rep weekly 7/20/07).
  • Nov 2: Nuclear Infrastructure: TA-55 is probably LANL's best maintained nuclear facility, but at current funding levels, sub-standard practices persist. For example, TA-55 does not have a proactive maintenance and surveillance program for radioactive liquid systems; they rely on radiological control indicators to identify leaks after they occur. Facility personnel have spent the last week tracking down the source of one such leak for one glovebox line and discovered another leak in the process. TA-55 lacks sufficient staffing and resources to implement such programs. The LANL Director's Assessment recognized the base issues: TA-55 operations are not being performed to modem nuclear standards, and TA-55 is not supported in a manner commensurate with its national importance. Other issues - such as the recent concerns on criticality safety, fissile material handler certification, and safety system operability- will likely recur until resolving the base issues becomes an institutional priority (site rep weeklies 1015107, 9121107, 8131107, 8117107, 7127107, 7120107, 6122/07, 312107).
  • Oct 12: TA-55 (PF-4) starts a two-week outage Monday, Oct 15th; a second outage is planned for December. Initial focus is on walk-downs, condition assessments, and drawing updates for some safety-related systems (e.g., ventilation, instrument air, chlorine, steam, wet-vacuum, and acidic waste). Other priorities include certifying fissile material handlers, implementing an integrated plan-of-the-day, and continuing criticality safety reviews. While these initial outages may be uneven, the outage approach should lay a framework for continuously improving TA-55 infrastructure.
  • Oct 7: The following are noteworthy: • LANL has proposed a new TA-55 safety basis to replace the 1996 facility safety analysis report and the 2005 interim technical safety requirements; if approved, LANL estimates it will take a year to implement within the current budget. • LANL has issued a report on the June Director's Assessment; the report has about 100 findings and basically concludes that TA-55 is not supported in a manner commensurate with its national importance; that operations are not being performed to modem nuclear standards; and that work is done safely primarily due to the collaboration and experience of personnel. • TheTA-55 confinement boundary was systematically extended this week to include the tunnel, which is being modified to support nuclear material radiography. • TA-55 is considering splitting the upcoming outage, with the first phase starting on Oct 14th; this takes advantage ofthe current pause in fissile material operations and would permit some operations in November (site rep weeklies 9/7/07, 8/24/07, 6/22/07, 6/15/07).
  • Sep 28: LANL has met its milestone of fabricating 10 QA-accepted pits in FY-07.
  • Sep 7: TA-55 is planning an outage from Nov 5th through the end ofthe year, focused on formality of operations, configuration management, condition assessments, procedure standardization, system improvements, etc.; some limited operations would continue (Pu-238, MOX).
    TA-55 is declaring a potential inadequacy of the safety analysis (PISA) and is suspending fissile material moves into two vault rooms unless the moves are reviewed by the LANL criticality safety group; material moves out of the rooms are unrestricted. While related, this is a different problem and affects different rooms than those reported last week.
  • Aug 24: Operationally, TA-55 resumed pit manufacturing activities last Friday.
  • Jun 8: This week, NNSA certified (i.e., diamond stamped) a W-88 pit made by LANL. The last certified pit was made by Rocky Flats and was delivered in 1989.
  • Mar 9: On Jan 17th, a TA-55 machinist scratched his wrist on a lathe bit while donning a cotton glove over a glove-box glove. Per their training, personnel evacuated the room, and a radiological control technician assisted the machinist in donning a respirator before he withdrew his arms from the glove box. The machinist was deconned and taken to LANL medical within two hours. The wound count slightly exceeded the guidance level for chelation, which began after 5 hours. Treatment continued for 2 days. Since the activity was close to the skin's surface, it was readily excised and eliminated.
  • Feb 9: The Plutonium Facility has resumed more than 90% of glovebox operations after standing down in mid-January in response to a contaminated injury that punctuated a string of less-severe glove breaches (see site rep weekly 1/19/07). TA-55 management took actions to identify and address worker safety issues associated with glovebox work and instituted a deliberate process for resuming operations. These actions included mandatory use of more puncture-resistant inner gloves; execution of formal walkdowns to identify and eliminate or otherwise better control hazards; temporary use of an independent safety observer for certain operations with a higher potential of injury; and plans for periodic walkdowns for certain operations deemed to have high potential risk.
  • Jan 19: • On Wednesday (1117), a TA-55 pit machinist was scratched and became contaminated while working in a glovebox; the wound count is positive; TA-55 has curtailed pit manufacturing work and is reviewing operations. CMR and TA-55 are also re-examining their glovebox glove integrity programs, which have weaknesses but are a key component in several facilities (e.g., WCRR) for worker radiological safety.

2006

  • Dec 15: Weaknesses in theTA-55 electrical distribution system leave the facility vulnerable to power loss from even minor grid transients. Nineteen transient events have impacted the facility over the past six months, ten of which led to significant operational interruptions. These events cause unplanned interruption of hazardous work; they adversely affect the operability of facility safety systems, particularly confinement ventilation; and while the transient lasts milliseconds, orderly recovery typically takes about 2 hours. Near-term, the facility is pursuing installation of a power conditioner and/or capacitor bank to reduce sensitivity to short duration transients. Longer-term, planned switchgear upgrades are intended to automatically transfer key loads to a backup diesel generator when offsite power is interrupted or lost (site rep weeklies 10/13/06, 4/2/04).
  • Nov 17: Thursday afternoon (11/16), TA-55 curtailed work in PF-4 and personnel performed an orderly exit after acidic liquid backed up from the closed transuranic acid waste line into two pump rooms and then seeped into three adjacent rooms. As a precaution, LANL emergency response and hazardous material organizations responded. TheTA-55 spill response team reentered and determined that the chemical hazard was minimal and the radiological hazard was readily manageable. The spill (estimated at 10 gal) was cleaned up, and normal operations resumed Friday. These small pump rooms are normally controlled as contamination and airborne radioactivity areas; they have a history of radiological and material condition issues that TA-55 is investigating.
  • Nov 10: TA-55 has increased operating tempo and is close to demonstrating a six pit per quarter surge capacity, either this quarter or next. Longer term, LANL intends to accelerate and complete a legacy pit production run by FY -09, then shift to building a Reliable Replacement Warhead (RRW) demonstration unit in 2010 and a first production unit in 2012. The maintenance tempo has also increased for upgrading equipment and is moving to an extended-hour work schedule, likely requiring extended-hour infrastructure support (e.g., site emergency services).
  • Sep 15: In 1996, the Board's staffnoted that TA-55 lacked standard electrical analyses that are essential to ensuring personnel safety, as well as safe and reliable power (ref: Board letter and staff report 12/5/96). fu 1997, LANL had a subcontractor complete these calculations. However, it seems little was subsequently done with the subcontractor's recommendations. LANL is now updating key analyses and expects them to be done in November; it's advisable for LANL to also fully and expeditiously evaluate the associated vulnerabilities and address the prior recommendations.
  • Aug 18: TA-55 has declared that the interim technical safety requirements are fully implemented, although NNSA and LANL have not closed on the prior reported issues (site rep weekly 7/28/06). TA-55 has also lost power and ventilation a half-dozen times since June 1st, causing PF -4 evacuation; NNSA is still reviewing a March AB package for improving ventilation reliability.
  • Jul 7: on Thursday (7/6), TA-55 personnel self-reported a criticality safety infraction, which led to a brief suspension of operations on Friday; such infractions are a recurring issue and the subject of a lab corrective action plan {site rep weekly 3110/06); • last Tuesday (6/27), the Sigma Complex (TA-3-66) received a potential internally contaminated package from TA-55 that was not what was expected; there are parallels to the Am-241 contamination event of a year ago, also the subject of a corrective action plan (site rep weeklies 2/3/06, 5/31/06); • LANL has postponed their readiness assessment for starting up more trailers on theTA-55 safeguarded trailer pad because findings from the startup of the first trailer a year ago remain open (site rep weeklies 7/8/05,10/7/05). A common theme here, which applies lab-wide, is the continuing need for followup on known issues and corrective actions.
  • Jun 16: Last Friday (6/9), a KSL worker sustained first and second degree burns on one hand due to a malfunction of a soldering torch; he was working under a glove-box in a Pu-238 lab room and was wearing cotton anti-Cs and rubber gloves. KSL suspended work using this type of torch and is investigating the event, including the personal protective equipment requirements.
  • Jun 9: TA-55 has declared a potential inadequacy in the safety analysis (PISA) for Pu-238 residues in higher-loaded containers because of the potential for hydrogen generation ifthe residues are hydrogenous and the potential for acid generation if the bagging is polyvinyl chloride.
  • Jun 2: LANL has a substantial legacy inventory throughout, particularly in TA-18, the plutonium facilities (TA-55, CMR), and waste storage (TA-54 Area G). This inventory drives the . public and worker risks from LANL nuclear operations; it has nearly saturated storage for some facilities; its timely disposition affects not only safety but the lab's national security mission. Several ofLANL's highest-consequence postulated nuclear accident scenarios involve transuranic waste stored at Area G, which is near capacity. TA-55 appears near capacity, pending more trailer startups on the safeguarded trailer pad, a temporary solution. It has unmitigated scenarios with calculated off-site consequences similar to Area G's. The highest involve Pu-238lab room fires, exacerbated by an uncertain degree ofbuilding confinement. TA 55 has hundreds of grams of Pu-238 residues, some intermixed with combustibles in poor containers within gradually degrading plastic bags, stored in the room that was contaminated in Aug 2003; these conditions are similar to those assumed going into the worst-case accident scenarios. TA-55 also has roughly 4,000 items in non-robust containers; these constitute a handling risk for the worker (e.g., the Dec 2005 vault contamination), and they could fail during a major accident. While TA 55 is pursuing more robust packaging, radiochemical stability is an issue, and processing has been postponed due to TA-50's transuranic liquid waste treatment problems. TA-55 would like to dispose of more residues, including the Pu-238 residues, with minimum handling and processing. This would likely require an unprecedented degree of coordination between NNSA, DOE-EM, LANL, and the WIPP contractor to establish optimum waste acceptance criteria, and a safe and efficient program.
  • Mar 3:It is unclear how LANL's confinement analyses address scenarios with Pu outside glove-boxes. TA-55 has about 10,000 items; 60% are in standard cans that may be thermally limited; 40 % are in weaker non-standard cans; 9 % have additional risk attributes; and 1 % are an elevated risk and have been moved to a glove-box or over-packed. Relatedly, TA-55 has deconned and down-posted the vault from a contamination area; respirators are still required when handling non-standard cans.
  • Feb 10: Vault recovery from the Dec 19th contamination event continues (site rep weekly 1113/06). TA-55 is moving suspect containers out of the vault and into glovebox lines for inspection and repackaging. This week, work slowed when one bulged inner can and one rusted-to failure inner can were discovered and when concerns were raised on potentially pyrophoric contents in other cans; these represent abnormal conditions that warrant special attention. In other areas, a PF-4 evacuation drill last Thursday (2/2) revealed issues in emergency response and in drill simulation and control; the drill was complicated by contamination found on clothing for two PF -4 workers. TA-55 also reported last week that a sliding door between two glove-boxes fell and momentarily pinned a worker's gloved hand without injuring the worker; as a result, TA-55 is looking for those systems that need frequent repair and that should be placed in a routine scheduled maintenance program.
  • Jan 13: Thursday evening (1/12), LANL placed TA-55 in standby (Mode 2) and established a 2 hour roving fire watch due to suspected failure of a 17-year-old fire alarm system component that is no longer made. Last year, NNSA designated this system as safety-significant as one of the compensatory measures for the confinement strategy issue. LANL plans to eventually replace the system as part of the TA-55 reinvestment project. On Friday (1/13), NNSA approved LANL's proposed path-forward, which involves modifying the system and testing at least one alarm device in each of the roughly 200 zones before removing the fire watch and returning to operations.
  • Jan 6: TA-55 continues to radiologically characterize and to plan recovery from the Pu-239 contamination released into the vault on Dec 19`h (site rep weekly 12/23/05). Initial dose estimates for personnel involved are low (e.g., 10 - 50 mrem CEDE range, which is two orders of magnitude below the annual federal limit). Material movements outside glove-boxes remain restricted. Based on contamination surveys and radiographs, the source appears to be an archival oxide sample from the early 1980s; the sample was packaged in a plastic screw-lid jar within a plastic bag, both within a taped, slip-lid can; the inner jar and bag failed, releasing powder into the can; the vinyl tape around the lid circumference then possibly failed, causing the release. TA-55 has triple-bagged this container and another similar container, but records indicate that there could be several dozen similar containers in the vault, including about a dozen that are near-identical. Some of these containers were on a list to be repackaged near-term as part of LANL response to Board Recommendations 94-1/00-1, but clearly this effort needs higher priority. A recovery plan is expected to be available next week.

2005

  • Dec 23: Monday morning, nine workers promptly evacuated the TA-55 vault following a continuous air monitor (CAM) alarm; appropriate immediate actions were taken, including securing the scene. The release was predominantly Pu-239. Five workers had positive nasal smears (-90 dpm max); three workers had contamination on gloves or booties consistent with later floor surveys (20k dpm max). Initial dose estimates should be available in January.
  • Jul 29: On Monday, LANL determined that a staff member in the Sigma Complex (TA-3-66 – a radiological facility) had become contaminated with Am-241 eleven days earlier while unpacking vials of uranium nitride from TA-55. During the period that contamination was undetected, the employee unknowingly spread contamination both in the facility and off-site, including his home. LANL is pursuing surveying and decontamination activities both on and off-site, including surveying the nearly two hundred people who work in Sigma and their work-spaces. As of Thursday, about a dozen people were placed on special bioassay monitoring; initial bioassay results should be available in mid-August. LANL has secured affected areas and is initiating an investigation.
  • Mar 11: This week, work has commenced on the recovery of Room 201B, which was contaminated with Pu-238 in August 2003 (site rep weekly, 2/4/2005). The contamination resulted from a breached residue can and led to a Type B uptake event. The current clean-up phase includes over-packing approximately 180 Pu-238 residue cans into filtered plastic bags and completing room decontamination. To date, 38 of the residue cans have been bagged (20%). Execution of the next phase of recovery, which entails over-packing the bagged residue cans into Type A 55 gallon drums with an additional filtered plastic drum lining, is contingent on a laboratory readiness review and is expected to begin in mid-April. This progress is encouraging and completion of these activities will significantly reduce the risk-profile at TA-55.
  • Feb 25: Based on bioassays, TA-55 has identified four individuals who may have received possible Pu-238 uptakes while working in a Pu-239 lab room last June (site rep weekly 12/10/05); some gloveboxes in the room have legacy Pu-238 contamination. The most-recent dose estimates have central tendencies below 5 Rem CEDE. The estimates tend to decrease during followup bioassays. The sequence of events is as follows. In June 2004, one of 52 fixed-head air samples in the room was high. A glove-box glove was found with a pin-hole leak. Nine employees working in the room submitted special bioassays. In July, another employee self-identified he had been in the room and submitted a kit. In December, bioassay results became available; reasons for the delay are being addressed. Initial results for the self-identified employee were high but dropped during followup sampling. Upon further review, TA-55 identified 28 people who were in the room during the week of the high fixed head sample. Initial bioassay results from this larger set have identified three other individuals who may have received a Pu 238 uptake. Detailed radiological surveys in the room have identified a capped copper vent line that had a small amount of loose Pu-238 contamination, which may or may not be the cause; the line runs under a glove-box line and is connected to Zone 1 ventilation. Other than the delay in bioassay analyses, LANL appears to have followed their procedures in responding to this event; however, the sparce workplace indicators (e.g., no positive nasal swipes) and the apparent lack of motive force to spread contamination are curious.

2004

  • May 3, 2004: DNFSB Staff Report, Status of Safety Bases at Los Alamos National Laboratory, (LANL has 26 nuclear facilities. Includes list of LANL's 17 HC-2 nuclear facilities).
  • Apr 16, 2004: NNSA has rejected a backward-looking Unreviewed Safety Question Determination involving cleanup of the room contaminated with Pu-238 last August. NNSA identified weaknesses in the 7-year-old final safety analysis report and could not verify that controls are adequate to address hazards in the room. It’s unclear right now what the implications of this are on the cleanup effort and on addressing the large inventory of Pu-238 residues in the room. TA-55 has clarified its strategy for resuming Pu-238 operations curtailed last fall because of concerns about residues stored in containers outside gloveboxes (site rep weekly 3/19/04). Residues are not to be removed and stored outside gloveboxes until after NNSA has approved a process hazard analysis and LANL has finalized associated hazard control plans and work instructions. Residues declared as waste may be removed from gloveboxes following existing waste handling procedures.
  • Jan 16, 2004: Integrated Safety Management (ISM): Last September, 5 workers in the Plutonium Facility (TA-55) were exposed to highly toxic vapors while soldering a rerouted coolant line in a poorly ventilated anti-contamination tent. The event and conclusions of a thorough LANL accident investigation have been previously reported (site rep weeklies 10/3/03, 12/5/03), but they warrant further consideration. Even though there had been months of planning, the workers had no forewarning of possible toxic hazards. One of their first indications of a problem was when they observed spraying liquid from a line that they thought had been purged. They continued to work. Their first warning was when they experienced respiratory distress after heating piping joints for about 5 minutes. Per the LANL report, if they had not immediately evacuated the tent, there could have been serious injuries, including possible fatalities. During the investigation, LANL identified multiple breakdowns. Some were driven by conflicting safety controls. Others resulted from mis-communication, misunderstandings on responsibilities, and reliance on conversation or other records over work-site walk-downs. For example: Due to radiological control and waste minimization concerns, the workers were wearing flammable coveralls and latex gloves while working with the acetylene torch, counter to their flame permit. This has some similarities to conditions that resulted in a fatality at Oak Ridge K-25 in 1997. In that case, the worker’s vision was more obstructed, and he was working alone. During the actual work, the workers expressed conflicting concerns on when to operate the ventilation blower – considering the potential for contamination spread vs the need for air flow during hot work. Even then, the controls in place did not include local task exhaust recommended by the coolant Material Safety Data Sheet when applying heat. The tent was an informal addition to the work package, and the hazards it presented were not evaluated. It may have amplified the toxic vapor concentration by an order of magnitude. There were multiple opportunities by various organizations to identify the chemical hazards during the planning phase, but they did not engage appropriate subject matter experts. They did not realize how ill-informed they were on the hazards, and incorrectly identified the hazards on multiple work package forms. Since no chemical hazards were identified, the workers believed that all the hazards had been identified and removed. The LANL report includes a gap analysis of the event against the new integrated interim work controls being implemented (site rep weekly 10/31/03). It concludes that these new work controls could conceivably have prevented the accident, but they must be strengthened. The site rep believes that these new controls are the most positive actions that have taken place here to improve worker safety during the last two years. This event and LANL’s subsequent investigation strongly reinforce the needs for full implementation and continued improvement in LANL work control.
  • Jan 9, 2004: TA-55 began decon of the room contaminated by Pu-238 last August (site rep weekly 8/8/03). The job was planned and the work released via the new interim work control process. Controls selected are appropriate. Workers were instructed to inspect containers before moving them. TA-55 still needs to complete a Unreviewed Safety Question (USQ) before removing containers for access to decontaminate the cages. Relatedly, DOE Office of Enforcement plans in early February to conduct an on-site investigation into the contamination event.

2003

  • Dec 19, 2003: NNSA released this week the Type B investigation report on the 8/5/03 Pu-238 contamination event. The report identifies the direct cause as an airborne release from a degraded package containing cellulose material (i.e., cheesecloth) and Pu-238 residues. The root causes were (1) the LANL division failed to balance management attention and resources between accomplishing the programmatic mission and providing an appropriate level of protection for the workers handling Pu-238; (2) DOE, NNSA, and LANL failed to adequately evaluate and understand the magnitude of the worker safety risks that they have accepted for the activities conducted by the Pu-238 Group; (3) DOE, NNSA, and LANL managed DNFSB Recommendations 94-1/00-1 as projects for addressing legacy materials storage rather than as an effort to mitigate potential hazards to workers. The failed package had been stored in the room since 1996, and was a can-bag-can configuration as previously described (site rep weekly 8/8/03). Chemical, radiolytic, and thermal decomposition of the contents and packaging caused the inner can and plastic bag to fail. Corrosion of the outer can appears to have caused the breathable seams to seal, allowing gas to build up. Simple handling of the package was sufficient to dislodge the corrosion and allow contamination to vent to the room. The failure mechanisms for all 3 “barriers” can occur simultaneously and independent of each other. The failure was similar to previous container failures that have been the subject of well-known reports since 1994.
  • Aug 29, 2003: The NNSA Type B investigation on the 8/5/03 Pu-238 contamination event continues. The suspect containers have been relocated to a glovebox line and planning for non-destructive examination is underway. The moveable cage holding the containers in the affected room has been restored to comply with authorization basis seismic requirements (i.e., cage is closed and chained to the wall). Last Monday (8/18/03), one crafts worker had positive nasal smears after contamination was found in the torso area of his anti-Cs, and the worker has been put on prompt bioassay. The worker had been engaged in dismantling equipment in a Pu-239 glovebox and was using leather gloves over the glovebox gloves while cutting, a best practice. Upon investigation, contamination (400k dpm alpha, 1k - 4k dpm removable) was found on the small window between the gloves.
  • Aug 8, 2003: On Tuesday, a continuous air monitor alarmed in a Pu-238 waste storage and management room while two workers were inventorying containers. The two workers evacuated and were found to have high facial, hair, and skin contamination and high nasal swipes (2,500 dpm max - nasal swipes).
  • Jul 3, 2003: Last week, a Pu-238 worker had contamination found and removed from a fingernail. Contamination was then found in two glovebox gloves in use less than a year. In an unrelated event, an airborne release occurred in one room, traced to a glovebox door actuator leak.
  • Jun 20, 2003: Last Thursday, two TA-55 workers had skin contamination as a result of a glovebox glove failure in Pu-239 aqueous operations. The workers discovered the contamination when they frisked their hands and feet at the lab room exit. Radcon personnel responded and controlled the room. One worker had a positive nasal smear. One fixed head air sample was elevated (16 DAC-hrs). The two workers were decontaminated and placed on diagnostic bioassay. This is similar to other recent events (site rep weeklies 5/23/03, 6/6/03, 6/13/03). Because of recent glove failures, TA-55 management curtailed non-essential glovebox work. TA-55 has approximately 7,000 pairs of glovebox gloves and recognizes that they constitute the weakest link in its glovebox confinement system – an engineered control. There is a high reliance on administrative controls, particularly proper frisking at the glovebox after removing hands from the gloves.
  • Jun 13,2003: On Tuesday, TA-55 reported another failed glovebox glove in the Pu-238 operations (see last week’s report). The worker discovered the failed glove while monitoring his surgeon gloved hand after closing an interconnecting spool-piece door between two gloveboxes. Radcon responded and detected in excess of 1M dpm on the worker’s left gloved hand. Like last week, the room was evacuated and controlled. Subsequent investigation identified this was an older glove (installed in October 2000). All fixed head samples in the room were elevated. The one at the workstation with the failed glove read 1065 DAC-hrs (daily sample). There were no continuous airborne monitoring alarms, and no skin contaminations. One worker had an elevated nasal smear. The 5 affected workers are being placed in diagnostic bioassay. On Wednesday, the site rep toured the space with LANL and a DOE facility rep. It appears that this glove failed by being mechanically pinched. A piece of glove was visible, wedged in the threads of the spool-piece door closure. Because of repeated glove failures, TA-55 has started an investigation to determine if there are any common causes between the Pu-238 related failures. This appears necessary but insufficient. LANL recognizes that the gloves are the weakest link in the safety-significant glovebox confinement system. LANL thoroughly investigates each failure, and periodically has pursued means to reduce failures. The site rep believes LANL could be well-served by implementing a continuous improvement effort for glovebox gloves and glovebox operations to minimize these failures,
  • Jun 6, 2003: On Tuesday, TA-55 reported a high fixed head air sample reading (53 DAC-hrs weekly sample) in a room that was subsequently found to have a small nearby area of removable contamination. LANL is investigating what work was recently performed in this room. Also on Tuesday, a worker opened a container of Pu-238 via a glovebox glove and then discovered contamination on one of his surgeon’s gloves. RadCon personnel responded. After personnel surveys, the room was evacuated and controlled. Subsequent investigation identified a relatively new glove with a tear (installed in April). Two local fixed head air samples were elevated (max: 472 DAC-hrs daily sample), but there were no skin contaminations, and nasal swipes were negative. The 5 affected personnel are being placed on diagnostic bioassay. The site rep observes that there was a similar Pu-238 glove tear in January (site rep weekly 1/17/03).
  • May 23, 2003: On Tuesday, TA-55 had a low-level personnel contamination event when replacement heater elements were moved from one room to another via an introduction hood, glovebox lines, and the trolley system. The source remains to be determined. Seven glove box gloves in two different rooms had contamination but were apparently intact.
  • Mar 7, 2003: Two pipe fitters received a possible inhalation dose, based on positive nasal smears (37 dpm alpha max), and had skin contamination (500 dpm alpha max). This resulted when they opened a leaking steam condensate line for repair with insufficient radiological controls. The workers were in one pair of anti-c’s but without respirators. The work authorization did not require respirators, a Radiological Work Permit (RWP), or assign radcon coverage. During work planning, the assumption was made that no contamination was present – based on no detectable activity in leaked water and no contamination found when the system was last opened, which was more than a year ago. This system is in the PF-4 basement near the ceiling and connected to a lab room. NNSA and LANL recognize it should have been treated as potentially contaminated, Feb 22, 2003.
  • Jan 17, 2003: Last Wednesday, a worker was opening an inner container of Pu-238 in a glovebox using vise grips and “felt” the outer container grab the glovebox glove. The worker observed a spot on the glove, closed his fist, and alerted others.

2002

  • Sep 20, 2002: DNFSB Staff Report, PF-4 ventilation shut down for calibration, second time in two months TA-55 has had to rely on passive filtration mode for confinement due to a minor evolution.
  • Jul 5, 2002: Last Thursday, personnel inadvertently dropped a double-contained can of plutonium oxide during a bag-out operation. While the can remained intact, the dispersed contamination from the can’s surface was sufficient to set off continuous airborne monitors (CAMs) in several rooms, leading 15 people to evacuate these rooms to the corridor. Two individuals had low-level positive nasal smears (i.e., anticipate minimal health consequences); also: Last Friday, PF-4 (plutonium operations) had a partial loss of ventilation when five fan motors tripped during maintenance on the control system.
  • The DOE's Pit Production Project, DOE/IG-0551, Apr 2002
  • Mar 22, 2002: Contamination control in TA-55 may warrant increased attention, particularly in the process chemistry area. Last Friday, an elevated weekly fixed head airborne sample was reported for one room in this area. The site rep understands that this has been traced to a single particle on the sample, possibly dispersed by nearby maintenance in a normally inaccessible raceway. On Saturday, workers in another room were conducting a radiological survey and discovered a brown spot where a line attaches to the top of a glovebox. Workers measured 0.5 million dpm alpha on a wet cheesecloth that had been swiped over the brown spot, and they left the room. There were bootie contaminations from this event but no continuous airborne alarms. Nasal smears were negative. Workers subsequently covered the dark spot, decontaminated and surveyed the room, and released it for operations. There may be similarities between these events and those reported in site rep weekly 12/14/01.
  • Mar 15, 2002: On Wednesday, an alpha contamination event occurred in TA-55 that led to CAM alarms, two personnel with positive nasal smears, and one with skin contamination. Bioassay results are forthcoming. The event occurred when an employee removed copper vacuum tubing from a plastic waste bag and began cutting out lead-solder fittings so that the tubing would not need to be disposed of as mixed waste.

2001

  • Dec 14, 2001: Recently, there have been several contamination events in the aqueous processing operations, including one skin contamination. Several of the events are attributed to service-life failures.
  • Aug 24, 2001: TA-55 identified a high reading on a fixed head air sampler in one room, indicating an airborne release and uncontrolled spread of contamination. Access to the room was controlled pending resolution. Thirteen people have been requested to submit bio-assay samples to determine if they received an uptake. At this time, the source appears to be a mechanical seal on a glove-box vacuum pump.

2000

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1996

1990
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