Earlier this week the DOE released its Accident Investigation Report on the Radiological Release Event at the Waste Isolation Pilot Plant. The report is a prodigious effort in the just over two months since the event. It is also a serious indictment of DOE’s management of WIPP and arguably, the DOE itself. There is however a significant flaw in the investigation and report: the investigators were kept on too tight a leash. Itemization of failures, particularly pervasive failures, without pursuing how and why they occurred is not sufficient. It also highlights the essence and value of systems analysis - identifying the fundamental dynamics that produced the failures and solutions that change those dynamics.
At first blush the issuance of yet another report on safety issues and safety management performance at a DOE facility would hardly merit a rush to the keyboard to dissect the findings. Yet we believe this report is a tipping point in the pervasive and continuing issues at DOE facilities and should be a call for much more aggressive action. It doesn’t take long for the report to get to the point in the Executive Summary:
“The Board identified the root cause of Phase 1 of the investigation of the release of radioactive material from underground to the environment to be NWP’s and CBFO’s management failure to fully understand, characterize, and control the radiological hazard.” [emphasis added] (p. ES-6) NWP is Nuclear Waste Partnership, the contractor with direct management responsibility for WIPP operations, and CBFO is the Carlsbad Field Office of the DOE.
To complete the picture the investigation board also found as a contributing cause, that DOE Headquarters oversight was ineffective. So in sum, the board found a total failure of the management system responsible for radiological safety at the WIPP.
Interestingly there has been a rather muted response to this report. The DOE issued the report with a strikingly neutral press release quoting Matt Moury, Environmental Management Deputy Assistant Secretary, Safety, Security, and Quality Programs: “The Department believes this detailed report will lead WIPP recovery efforts as we work toward resuming disposal operations at the facility.” And Joe Franco, DOE’s Carlsbad Field Office Manager: “We understand the importance of these findings, and the community’s sense of urgency for WIPP to become operational in the future.”* (We note that both statements focus on resumption of operations versus correction of deficiencies.) New Mexico’s U.S. Senators Udall and Heinrich called the findings “deeply troubling” but then simply noted that they expected DOE management to take the necessary corrective actions.** If there is any sense of urgency we would think it might be directed at understanding how and why there was such a total management failure at the WIPP.
To fully appreciate the range and depth of failures associated with this event one really needs to read the board’s report. Provided below is a brief summary of some of the highlights that illustrate the identified issues:
- Implementation of the NWP Conduct of Operations Program is not fully compliant with DOE policy;
- NWP does not have an effective Radiation Protection Program in accordance with 10 Code of Federal Regulations (CFR) 835, Occupational Radiation Protection;
- NWP does not have an effective maintenance program;
- NWP does not have an effective Nuclear Safety Program in accordance with 10 CFR 830 Subpart B, Safety Basis Requirements;
- NWP implementation of DOE O 151.1C, Comprehensive Emergency Management System, was ineffective;
- The current site safety culture does not fully embrace and implement the principles of DOE Guide (G) 450.4-1C, Integrated Safety Management Guide [note: findings consistent with findings of the 2012 SCWE self assessment results]; and DOE oversight of NWP was ineffective;
- Execution of CBFO oversight in accordance with DOE O 226.1B was ineffective; and
- As previously mentioned, DOE Headquarters (HQ) line management oversight was ineffective. (pp. ES 7-8)
Many of the specific deficiencies cited in the report are not point in time occurrences but stem from chronic and ongoing weaknesses in programs, personnel, facilities and resources.
Losing the Scent
As mentioned in the opening paragraph we feel that while the report is of significant value it contains a shortcoming that will likely limit its effectiveness in correcting the identified issues. In so many words the report fails to ask “Why?” The report is a massive catalogue of failures yet never fully pursues the ultimate and most relevant question: Why did the failures occur? One almost wonders how the investigators could stop short of systematic and probing interviews of key decision makers.
For example in the maintenance area, “The Board determined that the NWP maintenance and engineering programs have not been effective…”; “Additionally, configuration management was not being maintained or adequately justified when changes were made.”; “There is an acceptance to tolerate or otherwise justify (e.g., lack of funding) out-of-service equipment.” (p. 82) And that’s where the analysis stops.
Unfortunately (but predictably) what follows from the constrained analysis are equally unfocused corrective actions based on the following linear construct: “this is a problem - fix the problem”. Even the corrective action vocabulary becomes numbingly sterile: “needs to take action to ensure…”, “needs to improve…”, “need to develop a performance improvement plan…”, “needs to take a more proactive role…”.
We do not want to be overly critical as the current report reflects a little over two months of effort and may not have afforded sufficient time to pull the string on so many issues. But it is time to realize that these types of efforts are not sufficient to understand, and therefore ultimately correct, the issues at WIPP and DOE and institutionalize an effective safety management system.
* DOE press release, “DOE Issues WIPP Radiological Release Investigation Report” (April 24, 2014) Retrieved May 5, 2014.
** Senators Udall and Heinrich press release, “Udall, Heinrich Statement on Department of Energy WIPP Radiological Release Investigation Report” (April 24, 2014). Retrieved May 5, 2014.