Plutonium Facility PF4 at Los Alamos National Laboratory. Photo Courtesy LANL

BY MAIRE O’NEILL
maire@losalamosreporter.com

Jill Hruby, the Department of Energy Undersecretary for Nuclear Security and Administrator for the National Nuclear Security Administration has issued a preliminary notice of violation (PNOV) to Triad National Security, LLC citing five Severity Level II violations linked to four nuclear safety events between February and July 2021 at the Los Alamos National Laboratory Plutonium Facility PF4.

A DOE investigation into the facts and circumstances associated with the four events alleges multiple violations of DOE nuclear safety requirements by Triad National Security, LLC, the management and operations contractor for LANL. The events were summarized as follows:

On February 11, 2021, fissionable materials placed in an area contrary to the criticality safety posting exceeded criticality safety mass-control requirements.

On March 3, 2021, a glove breach released radioactive contamination resulting in skin contamination of three workers.

On March 31, 2021, an over-filled water bath resulted in flooding of a vault containing fissionable materials.

Lastly, on July 19, 2021, a water tank for the wet vacuum system in LANL’s PF4 overflowed into the negative pressure chilled cooling water (NPCCW) tank, which then flowed into the glovebox ventilation system that supplies multiple rooms and gloveboxes containing fissionable materials.

DOE provided Triad with an investigation report dated August 3, 2022 and convened an enforcement conference with Triad representatives on October 27, 2022 to discuss the report’s findings and Triad’s response. The report noted deficiencies in

• Work processes
• Management processes
• Quality improvement to violations related to causal analyses and corrective actions
• Criticality safety requirements

NNSA grouped and categorized the violations as five Severity Level II violations. Severity Level II violations represent a significant lack of attention or carelessness towards responsibilities of DOE contractors for the protection of public or worker safety, which could if uncorrected potentially lead to an adverse impact on public or worker safety at DOE facilities.

In consideration of the mitigating factors NNSA calculated a civil penalty (prior to reduction for contract fee reduction) of $571,187, however partially in response to the violations associated with these events, NNSA Los Alamos Field Office withheld some $1,486,640 of the available award fee for Goal 5, which was “Mission enablement for FY 2021”. As a result NNSA has elected to exercise discretion and proposes no civil penalty for the five violations cited in the PNOV.

Under Work Processes, the document says contrary to the requirements, Triad failed to perform work consistent with the approved instructions, procedures or other appropriate needs. Specific examples include:

On February 11, 2021, Triad did not verify that the fissionable material placed in a drop box complied with the criticality safety posting as required. As a result, the material in the drop box violated the criticality safety posting mass limits.

On March 2, 2021, Triad deviated from procedural requirements and did not perform a self-monitoring evaluation after each withdrawal from the gloves and that consequently Triad did not recognize that a glove had breached and that a worker had contamination on their hands. As a result the worker spread contamination to surfaces, personal protective equipment, personal clothing and the skin of some workers in the room.

On March 31, 2021, Triad did not execute a step of a round sheet procedure to inform the Operations Center that the vault water bath required filling. Furthermore during filling of the water bath, Triad deviated from the approved procedural steps by blocking open a spring-loaded valve therefore bypassing its safety feature. This ultimately caused water to overflow onto the vault floor because the worker was not present to close the valve.

On July 19, 2021, Triad did not implement all the required procedures which meant that work was specifically delegated to workers that did not meet the qualification standards for filling the tanks. Because the workers were not qualified for the task they did not manipulate valves in the proper sequence after filling the tank nor did they complete the required notifications to the Operations Center upon completion of the activity so that the Operations Center could respond appropriately to alarms. These errors resulted in one of the valves being misaligned allowing water to inadvertently enter the ventilation system.

Collectively these non-compliances constitute a Severity Level II violation. The base civil penalty is $123,500. Mitigated civil penalty (prior to adjustment fee reduction) $77,187 with no civil penalty (as adjusted).

Under Management Processes, Triad was criticized for failing to properly schedule or provide sufficient resources to accomplish work in PF4 safely and efficiently. Specific examples in the PNOV include:

On March 3, 2021, Triad did not provide sufficient resources for a lapping operation that ultimately resulted in a glove breach and the contamination of three workers. In this incident, one individual was assigned four roles including glovebox operator, escort, working person in charge and trainer. Additionally while the individual was lapping, the glovebox pressure was fluctuating, adding an equipment challenge for the individual to resolve. With all these responsibilities and distractions, self-monitoring was not performed when the individual exited the glovebox. The glove breached at some point during the operation, contaminating the individual. The contamination subsequently spread through contact to two other nearby workers before being detected.

On March 31, 2021, Triad did not provide sufficient resources for completing facility rounds and surveillances to account for actual equipment and facility conditions. On this day, an equipment operator was required to complete multiple time-sensitive rounds which were complicated by the degraded facility condition (including a leaking vault water bath pump seal necessitating daily filling of the water valve). In addition the operator assisted another operator in completing a surveillance that required two people. In planning that surveillance, Triad did not account for the additional workload on equipment operators resulting from access restrictions to the room (due to the presence of certain materials).  Because Triad did not provide sufficient resources to accomplish the work safely in accordance with procedures, the equipment operators were overtasked and developed workarounds to complete the work. One of the workarounds was to block open a spring-loaded valve to the re-filled water bath, causing the bath to overfill and flood the vault room.

On July 19, 2021, Triad did not provide sufficient resources for completing facility rounds, refilling a wet vacuum sealed water tank (which ultimately overflowed to the NPCCW system, resulting in the flooding of a glovebox) and other operational activities to account for equipment status and facility conditions. On this day, the PNOV states that an equipment operator was required to complete multiple time-sensitive rounds while also completing tasks to support ongoing activities in the facility. One of these tasks involved refilling a wet vacuum seal water tank located in a radiologically contaminated room. The activity required a full set of anti-contamination clothing and a respirator which requires a considerable amount of time to don and doff. Maintenance work was also occurring on the same day on a pump located in the same room. The PNOV says the operator couldn’t complete rounds in that room during maintenance because the room couldn’t accommodate maintenance personnel as well as the operator. Because Triad didn’t provide sufficient resources to accomplish the work safely and in accordance with procedures, the operator was overtasked and asked an unqualified maintenance worker to refill the wet vacuum seal water tank. The maintenance worker was not qualified to perform this task and thus did not complete all of the steps (e.g. closing the ball valve) leading to the flooding of the glovebox ventilation system, a glovebox and several rooms, the PNOV states.

With regard to Quality Improvement issues, the report states that Triad failed to identify and correct quality problems in a manner that effectively prevented recurrence and that were consistent with the “hierarchy of controls”.

Although Triad acknowledges the “inherent uncertainty of human performance” causal analysis prepared by Triad routinely focuses on human errors rather than on the conditions that make those errors more likely.  Consequently, Triad’s corrective actions focus more on preventing employees from making mistakes than on making more effective and longer changes to engineering controls. Examples given in the PNOV were:

With the March 3, 2021 skin contamination event, Triad didn’t adequately identify the causes to allow effective and sustainable correction of weaknesses in performance. The causal analysis attributed the root cause to human error and ineffective management and did not prioritize deficiencies in engineering controls over deficiencies in administrative controls. For example the causal analysis identified the operator’s lack of self-monitoring (an administrative mitigation control) and not the actual glove breach. As a result the causal analysis focused on personnel actions rather than on engineered control deficiencies, contrary to the hierarchy of controls when determining the root causes of events. One of the root causes identified by Triad is that the operator did not establish a method for ensuring inspection of the gloves before exiting the glovebox gloves. However the cause and reason for the damage to the gloves (i.e. an abrasive surface that the glove was rubbing against were not fully evaluated. The deficiencies in the corrective action Triad identified – reinforcing procedural adherence and training – are not likely are not likely to be effective in preventing recurrence.

The report states that with the March 13, 2021 incident, Triad didn’t adequately identify the causes of the vault bath flooding event to allow effective and sustainable correction in the weakness in performance. The causal analysis attributed the root causes to inadequate resources and ineffective management supervision but did not fully consider deficiencies in engineering controls, except to recognize that ongoing nuisance alarms obscured operations personnel from recognizing the vault water leak indicator alarm. The causal analysis did not consider ergonomic deficiencies in the manual operation of the valve used to refill the tank. According to worker interviews, manipulation of the valve required operators to maintain a contorted position while holding open a stiff actuator for approximately 15 minutes. The causal analysis did not explore the potential effect of this ergonomic shortcoming on operation actions and the decision to defeat the automatic closing functionality.

In the July 19, 2021 event the report states that Triad didn’t adequately identify the causes of the glovebox flooding event to allow effective and sustainable correction of weaknesses in performance. The causal analysis attributed the root causes to inadequate implementation of conduct of operations and inadequate implementation of corrective actions from a similar event in 1990. The causal analysis report states that the event was exacerbated by the challenges of performing work in the particular pump room and that these challenges were not previously known to Triad. However Triad was notified if many of these challenges as multiple facility service requests had been submitted during Triad’s tenure to improve the equipment and conditions in the room but Triad did not take actions on those requests. The corrective actions for the 1990 event included installation of overfill and air eliminator lines on the equipment in the room. These corrective actions were not completed and Triad didn’t identify the deficiency until the July 19, 2021 event revealed it. Triad had several opportunities to identify this deficiency.

The PNOV also took issue with how Triad addressed Criticality Safety Requirements.

Triad has 30 days from the issuance of the PNOV to provide a written response. If Triad’s reply waives the right to contest the PNOV, the notice will become the Final Order. In the response, corrective actions that have and will be taken to avoid further violations should be delineated with completion dates in DOE’s Non-Compliance Tracking System.