LANL Improving Nuclear Safety and Operations

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LosA amos NATIONAL LAaORATORY

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Official Correspondence FormName : U1101915

Title: SO:32CK-374635: LANL Improving Nuclear Safety and Operations

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....10/13/2011eceived: \0

....01Addressee C. McMillanName:Originator: K. Smith, LASOAction Item Provide LASO a comprehensive report by 11/30/2011Descri ption:~ c t i o n DueDate: 11/30/2011Responsiblefor Action: Search Anderson. Charles EResponsible PADOPffice:Distribution: Charles F. McMillanRichard A. Marquez

Isaac E. Richardson II IICarl BeardSteve K. ShookRoland B. KnappMatthew W. Hardy

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Charles E. AndersonJoseph M. OrtegaChris CantwellInez Valdez IDonna L. BaileyChristopher A. James

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UNITED STATES GOVERNMENT DEPARTMENT OF ENERGYNational Nuclear Security Administration

Los Alamos Site Officememorandum Los Alamos, New Mexico 81544DATE: SEP 1 6 201'

REPLY TOATTN OF: Kevin W. SmithSUBJECT : Los Alamos National Laboratory - Improving Nuclear Safety and Operations

TO: Charles F. McMillan, Director, Los Alamos National Security, LLC, MS-A I 00Reference:1. Contract Number DE-AC52-06NA25396, Los Alamos National Security, LLC and

the Department of Energy, National Nuclear Security Administration2. Contract Number DE-AC52-06NA25396, Los Alamos National Security, LLC andtue Department of Energy, National Nuclear Security Administration (NNSA),Section I, "Contract Clauses", Clause H- I, "Redefining the Federal/ContractorRelationship to Improve Management and Performance"3. Contract Nwnber DE-AC52-06NA2S396, Los Alamos National Security, LLC and

the Department of Energy, National Nuclear Security Administration (NNSA),Section I, "Contract Clauses", Clause H-2, "Performance Direction"

Los Alamos Site Office (LASO) acknowledges the rigorous and self-critical na ture oftwo recent Los Alamos National Security, LLC, (LANS) assessments: one involves theWaste Disposition Project (WDP) nuclear operations; the other involves the PlutoniumFacility (PF-4) criticality safety program. These assessments, along with input frommultiple other sources, helped to codify LASO's view on the need to address a number ofreoccurring issues now and improve the laboratory's nuclear safety and operations. Theyare : The PF-4 criticality safety, conduct of operations, and configuration management

safety programs are either incompletely implemented or ineffectively implemented solhat they can be sustained. Also, a few operations in PF-4 have less criticality safetymargin lhan other operations and are highly reliant on mature, effective conduct ofoperations to ensure worker safety.

WDP has deficiencies in credited safety management programs and safety systems.LANS has attempted to address these deficiencies several times in the past, but thefixes have not been pennanent .

These two sets of facility-specific issues indicate problems that continue to occur and thatwarrant near-tenn actions and a sustained improvement plan. Examples of suchproblems that LASO has observed include: lOadequate processes for self-identifying andsustainably addressing issues ; inadequate work package planning; not identifying all jobhazards; inadequate closure of issues; lack of system, engineering processes, and safetybasis knowledge; inability to execute procedures as wri tten ; workers accepting

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- 2 SEP 1 6 2DIfinadequate procedures or no t following procedures; and managementJsupervisory actionsthat rationalize the status quo rather than identifying root causes and fixing the problems .Collectively, these problems indicate that the level-or-maturity of both the Laboratory' scontractor assurance system (CAS) and its nuclear safety culture does not yet consistentlymeet expectations . Th e special and unique aspects of the Laboratory's mission and itsnuclear operations require a q\.,cstioning attitude to be cultivated , nuclear safety to becontinuously examined, self discovery to be valued, and organizational learning to beembraced . These key elements of a strong nuclear safety culture are not consjstentlypresent Competency in integrated safely management also needs to be improved.Therefore, Jdirect you to take the fonowing inunediate and longer term actions :Immediate actions: Evaluate the adequacy and implementation of criticality safety controls for the PF-4

operations that have less-than-typical safety margin, identified by federal staffreview; report to LASO within 7 days of receipt of this letter of the additional actionsthat bave been taken to either secure or fully ensure the safety of these operations.

Evaluate the WDP safety system operability issues identified in recent federal reports;take approp riate actions, including critiquing and repor ting.

Assess whether PF-4 and WD P safety management programs are adequate to meetthe intent of the safety bases for continued operations without compensatorymeasures.

Provide LASO a status repor t on the above within three weeks of receipt of thismemorandum

Longer term, sustainable, actions : Eva lua te , in detail, the PF4 and WDP issues identified in thls leller and from other

internal and external sources, including assessments, occurrence reports, technicalsafety requirement violations, FCA reports, CAS metrics, and lessons learned.

Detennine deficiencies, causal factors, extent-of-condition across the site, anddevelop a comprehensive corrective action plan and provide it to LASO.

Provide LASO specifLc commitments for improving nuclear safety and operations inFiscal Year 20 12

Establish a suite o f perfonnance (CAS ) me trics and leading indicators that can bejoi ntl y used by LASO and LANS to track Ule improvements in the quality of nuclearoperatioIlS

Provide LASO a comprehensive report on planned actions and the suite ofperfonnance tracking metTles by November )0 , 2011.If the Contractor believes the Performance Direction vio)ates Co ntract No. DE -AC5206NAJS3% Cause H-2 enlltled "P erfoonance Direction," the Contractor shall suspendimplementation of the Performance Di rection and promptly nOli fy the Los A lam os SiteO ffi ce (LASO) Contracting Officer of il s reasons for believing thai the Performance


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- J SP 1 6 201:DirectIOn '!iolates this clause. Oral notl[lC;allorl (0 tile COnlrar;tlng Office, shall beconfirmed 111 writing within ten calenda r da ys of the Oidl notification To contact th


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4 . SEP 1 f, ZOU

cc: ! . Rjchardson, DD LR., LA. 'S, MS-A 00 C. Beard , PADOPS, LANS , \1S -A P Henry, PADCAP, LANS, MS-A i \3 P.WWP , LANS, MS-A A Bishop PADSTE, LANS . )\1S -B 2 I j T. Wallace, PADGS , '.,ANS MS- J-.U5 Records Ce nte r, LASO Off:cia'l Contract F ib LAS'. SO 32CK-174G35
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LANL Improving Nuclear Safety and Operations