DNFSB/TECH-10
The author wishes to acknowledge the efforts of Steve Krahn in organizing this paper and providing significant technical input. Substantial technical assistance was also provided by Wayne Andrews and Timothy Dwyer; additional assistance was provided by Ralph Arcaro, Cynthia Miller, Matthew Moury, Daniel Ogg, Robert Warther, and outside experts Lieutenant General Kenneth Cooper, USA, (Ret.), Captain John Drain, USN (Ret.) and Rear Admiral Ralph West, Jr., USN (Ret.). Special thanks is also extended to the Board's General Counsel, Mr. Robert Anderson.
While the facts presented herein are a matter of records, the views and summary expressed are those of the author; they are not to be construed as representing the views of other Defense Nuclear Facilities Safety Board Members.
Introduction
Background
Discussion
Major Impediments to Resolving the Problem
Summary
List of Appendices
Reference
In 1995, the Defense Nuclear Facilities Safety Board (Board) reported to Congress as follows:
"In each of its first four annual reports, the Board recognized the most important and far-reaching problem affecting the safety of DOE [Department of Energy] defense nuclear facilities is the difficulty in attracting and retaining personnel who are technically qualified to provide the management, direction, and guidance essential for safe operation of DOE defense nuclear facilities. It remains the most critical problem today.<1>
In establishing the Board, in 1988, Congress indicated that it was well aware of this problem. Thus, the Senate Conference Report that accompanied the Board's enabling legislation stated:
"The Board is expected to raise the level of technical expertise in the Department substantially . . . .<2> [Emphasis added]
While improvements of an incremental nature have been made by the DOE as a result of Board actions, they are very far from having changed the level of technical expertise "substantially." In all DOE organizations responsible for safety of defense nuclear facilities, there remains a serious lack of sufficient numbers of DOE personnel who are technically qualified. This applies at Headquarters and in the field in both line and oversight organizations. Moreover, as discussed below, the prospects of improvement appear dim unless the Secretary and senior DOE managers make a firm commitment to solve the problem and give personal, priority attention to following through on that commitment.
The focus of this report is on two inseparable matters: (1) the number of DOE technical personnel who are fully qualified for their safety responsibilities and (2) safety at defense nuclear facilities. There is no representation in this report that DOE does not have adequate numbers of personnel assigned to DOE organizations responsible for safety at these facilities. The Board has no direct responsibility to determine the adequacy of the total numbers in these organizations -- only that there be enough who are fully qualified technically to assure safety. The Board's responsibility does not extend to other matters except where such matters affect safety. Thus, for example, it includes reliability insofar as it affects safety, but not beyond.
The report does not discuss the possible future of the DOE about which there has been conjecture. Irrespective of what changes may or may not be made, there is one imperative requirement; it is that the government should have among its employees the technical and managerial expertise capable of assuring protection of public and worker health and safety at its defense nuclear facilities and that it be suitably organized to do so. This need exists today and is not being met in the full degree needed. This problem requires correction urgently; the imperatives of safety will not wait on other organizational arrangements.
There is, however, one possible change that requires a brief discussion in the context of safety -- namely regulation. A DOE advisory committee recently recommended to the Secretary that its defense nuclear facilities be subjected to a greater degree of external regulation than now applies to them.<3> Implementation of this recommendation would not alter the need for DOE to build up the full "in-house" technical capability that is called for in this report.
The technical personnel problem described in this report has persisted generally for several decades throughout the nuclear programs of DOE and its predecessor organizations, the Energy Research and Development Administration (ERDA), and the Atomic Energy Commission (AEC). Attention has been called to the problem repeatedly -- most intensively in the aftermath of the nuclear accidents at Three Mile Island and Chernobyl. The roots of the problem are deep-seated; so much so that they go back to the very origins of the AEC.
The AEC was "born decentralized," matching the strong convictions of its first chairman, David Lilienthal. It had a very small headquarters organization and large government organizations in the field, at sites like Oak Ridge, Richland, and Savannah River. The technical aspects of programs and activities were, for the most part, handled by the AEC's laboratories and industrial contractors. Government organizations confined their activities mostly to contractual, budgetary, and administrative matters. The tradition of this division of functions has tended to endure, with a few significant exceptions, through the decades to the present.
As a result of this division of functions, the succeeding government organizations in AEC, ERDA, and DOE did not build up the cadres of strong technical capability "in-house" to the degree needed to provide effective technical line management direction and guidance. Lacking this essential capability, the DOE has not performed effectively as a knowledgeable and "demanding customer" (Appendix A) for the technical aspects of laboratory and contractor performance.
This deficiency in capability is especially important regarding the protection of public and worker health and safety at defense nuclear facilities and activities. Two successive Secretaries of Energy have acknowledged their personal responsibility that such protection be provided.<4>,<5> Yet the DOE organizations to which safety authorities have been delegated, in both Headquarters and field, do not have sufficient resources of technical personnel to exercise such authorities effectively. This deficiency has been consistently cited in comprehensive studies of DOE performance (Appendix B). For example, in a 1987 report, a committee of the National Research Council stated:
"The committee concludes that the Department, both at headquarters and in its field organizations, has relied almost entirely on its contractors to identify safety concerns and to recommend appropriate actions, in part because the imbalance in technical capabilities and experience between the contractors and DOE staff is of sufficient magnitude to preclude DOE from comprehensive DOE involvement in the operation of the production reactors. The committee recommends that the Department acquire and properly assign the resources and talent necessary to ensure that safe operation is being attained.<6>
The managerial approach by DOE that was called for in this recommendation is opposed by individuals within DOE and its laboratories and contractors. The opposition is so influential and has persisted so long that it requires discussion. In the most fundamental terms, those who object to government direction, guidance, and oversight, appear to desire a laissez faire relationship between the government and laboratories and contractors. They discount the value of the government providing technical direction, guidance, and oversight for organizations comprised of highly competent, carefully chosen professionals. The objections to such government activity take several forms and are based on misconceived convictions that: (1) it tends to stifle imagination and initiative; (2) it is counterproductive to have the actions of bright professionals (i.e., contractor and laboratory) questioned by those of presumably lesser intellectual endowments and experience (i.e., in government); and (3) it is uneconomical.
Those who object emphasize the overall safety record of DOE's nuclear weapons program to date, but they fail to note that the program has operated for decades with restrictions on the release of information. Thus, the public was seldom made aware of safety-related problems encountered or of conditions inimical to safety that ought not to have been allowed to exist. For example, there have been major fires at DOE plutonium processing facilities.<7> Some of these events have either gone unreported to the public, or have been explained in significantly less detail than would have been required if the veil of secrecy had been removed. One could speculate that these accidents could have had a significant impact upon the nuclear weapons program had they been fully examined with complete objectivity and in the public domain.
Safety-related problems have persisted into the 1990s. For example, the Board's Staff has made several careful reviews of the technical procedures being used by contractor personnel at Pantex in disassembling nuclear weapons. The procedures, while based on those provided by the weapons laboratory personnel, who are the technical experts for weapon operations, were being changed by personnel at Pantex without having the changes reviewed and approved by the weapons laboratory. This is unacceptable in a nuclear program. As the Board stated in Recommendation 93-1, Standards Utilization in Defense Nuclear Facilities,<8> "There are certain basic principles that apply to the handling of nuclear materials regardless of their form." One of these "basic principles" is that all changes to safety-significant procedures should be thoroughly reviewed and approved by the designated technical authority. Moreover, many reports sent by the Board to DOE regarding the nuclear weapons program provide vivid examples that are counter to the opinion that highly-qualified professionals, no matter how well-intentioned and dedicated, can be allowed to conduct nuclear weapons operations without independent, technically-qualified checks on the processes and procedures involved. The safety of activities involving nuclear weapons requires the government to act as a demanding customer, fully-qualified technically to assure that nuclear safety of the highest order is being achieved.
In 1988 the Secretary recognized the pitfalls of letting the contractors and laboratories operate as they had been and began to take corrective action. Reacting to the report issued by the National Research Council,<9> DOE formed the Advisory Committee on Nuclear Facility Safety (ACNFS). The goal of the ACNFS was to provide a degree of independent safety oversight within the Department. Moreover, in that same year, Congress also took action and passed legislation that established the Board to provide external safety oversight of the DOE's defense nuclear facilities and activities.
The Board began operation in late 1989, with the aforementioned admonition from Congress regarding raising the level of technical expertise within DOE. While subsequent actions by the Board and DOE have resulted in some improvements, they have been neither comprehensive nor sufficiently effective at promoting the safety culture changes necessary at DOE activities. The single most important safety problem at defense nuclear facilities is the lack of sufficient numbers of technically-qualified DOE personnel -- both at Headquarters and in the field.
It is important to take note of a significant and potentially instructive exception to all of the foregoing, namely, the naval nuclear propulsion program (also known as Naval Reactors, or NR). Since 1949, this program has been a joint effort by DOE (or its predecessors) and the Navy. A distinguishing attribute of NR is its strong headquarters organization that is comprised of civilians and a limited number of military personnel -- all of whom are line managers responsible and accountable to the program manager. They are led by a nuclear- experienced naval officer who is given long tenure as Director. All but a few of its personnel are engineers or scientists; these technical personnel have been carefully selected for excellence in academic performance and other attributes. Field activities are managed as virtual extensions of Headquarters; heads of field organizations have extensive experience at Headquarters prior to their appointment.
The NR organization, so constituted, provides strong technical direction and guidance based on close interaction with the ensemble of laboratories, industrial contractors, shipyards, and training establishments that comprise the program. Congress regarded its safety record as outstanding; independent reviews have substantiated this opinion.<10> Thus, the program was not placed under the cognizance of the Board. Even though DOE operates the program jointly with the Navy, there is little evidence that DOE has studied the program for lessons that might be applicable to DOE's other defense nuclear programs. For a discussion of the lessons to be learned regarding personnel matters, see Appendix C.
Principles Which Should Shape DOE Technical Personnel Needs
There are three large organizations in DOE Headquarters with key responsibilities for the safety of defense nuclear facilities: two are line organizations; one headed by the Assistant Secretary for Defense Programs (DP) and the other headed by the Assistant Secretary for Environmental Management (EM). As line organizations, it is their responsibility to achieve safety. The third organization is headed by the Assistant Secretary for Environment, Safety and Health (EH). Its safety responsibilities are to: (1) independently confirm that safety is achieved by the line management organizations, (2) develop safety standards, and (3) provide "technical assistance" to line organizations concerning governmental, safety, and health matters (note that in providing such assistance there is a danger of compromising DOE EH effectiveness in making objective safety assessments of line performance). Supplementing these Headquarters organizations are many field organizations representing DOE to government-funded laboratories and contractors at the sites. The functions of these DOE field organizations are of a line character, that is, they are supposed to be assuring that safety is achieved.
Each of the DOE organizations cited above must have appropriate levels of expertise "in- house" to provide technical guidance and direction to laboratories and contractors under their cognizance and to effectively assess the performance of the latter in technical dimensions as regards safety. To do this, technical capabilities of DOE personnel must be at a level generally commensurate with that of laboratory and contractor personnel. DOE itself has stated this in formal policy:
"A level of staffing and competence must be provided that is commensurate with discharging the responsibilities of the program . . . Organizations responsible for Department operations need to have . . . personnel who possess technical competence, commitment, discipline, and high standards of professional and personal excellence.<11>
Without an equivalent level of technical competence, DOE managers cannot effectively engage in technical dialogue with their laboratory and contractor counterparts. The greater the disparity in competence, the greater the technical ascendancy the latter will have over the DOE. In such an environment, it will be difficult, if not impossible, for DOE managers to negotiate effective agreements with their contractor counterparts on safety-related matters.
There is a need to address, more specifically, the level of DOE technical competence that must be achieved. The level should be geared to the degree of technical difficulty inherent in the technology being applied and with the potential severity of the adverse consequences on public and worker health and safety that can result from misusing the technology. This is consistent with the tailored approach to safety management discussed by the Board in two recent technical papers.<12>,<13> Generally, the potential for adverse consequences is most acute for activities involving nuclear weapons (such as their assembly, disassembly, and maintenance). Thus, DOE technical personnel responsible for such activities should have a first-class engineering or scientific education, thorough education and training in nuclear weapons technology, and experience in the practical application of such technology consistent with effective performance of their assigned duties.
Many doubt that it is realistic to expect that such a high level of qualifications can be achieved by DOE personnel. One rejoinder to such doubts has long been available in the NR program. Objective examination of the qualifications of all personnel, both civilian and military, in this program would provide a convincing demonstration that the criteria of excellence cited above are being met -- and have been met for decades. Until a serious and consistent attempt to meet them is made in DOE's defense nuclear complex, success in this area will continue to be limited at best.
Principles Which Govern DOE's Relationship with the Board
As will be made evident elsewhere in this report, compensation for many weaknesses and shortages among DOE technical personnel has been provided in recent years by bringing the technical competence of the Board and its staff to bear directly on the problems at issue. On the positive side, it has been highly advantageous that this capability has been available. On the other hand, there is need to recognize the serious adverse effects that could result from excessive DOE dependence on the Board's technical expertise. To be able to understand these effects, it is necessary to discuss some principles which govern the relationship between DOE and the Board. These principles have been discussed by the Board in its Annual Reports to Congress.
The first is that DOE has total responsibility for the safety of its facilities. DOE must have the technical competence, in substance and not merely in appearance, to carry out that responsibility without unduly relying on the independent oversight provided by the Board. The Board has no authority to assume or share the line responsibility that DOE has for safety. The Board's function is that of providing independent safety oversight from a position outside DOE. It is, by nature, a "back-up" function. By bringing its staff to bear directly on the DOE technical problems, however, the potential exists for the Board to lapse into an assumption of aspects of DOE's functions, both line and internal oversight. This is most likely to happen in areas where DOE is technically weakest. If so, it would be accompanied by the following effects that are adverse to safety in its larger dimensions: (1) DOE would no longer be in full control of safety; (2) the independent, external back-up status of the Board would be compromised and vitiated; and (3) specific DOE weaknesses would be "papered over" and the incentive to correct them removed or lessened. In short, inordinate application of Board capability to compensate for DOE technical weakness would serve to camouflage the DOE weakness and perhaps even compound and reinforce such a weakness.
Secondly, as a well-known aphorism states, "One cannot inspect safety or quality into an activity or product from the outside." As an outside organization, it is unrealistic to expect the Board either to inspect or to assess safety into DOE defense nuclear activities. Some very specific safety improvements have resulted due to the Board's activities. However, to be fully effective and enduring, changes must result from DOE "internalizing" Board recommendations and observations and applying them across the broad spectrum of its defense nuclear responsibilities. What is to be expected is that the Board's activity will spur similar, self-initiated actions on the part of DOE line and oversight organizations.
Evidence that a Problem Exists
As noted earlier, the Board has informed Congress, in each Annual Report issued to date, that the most important safety problem at DOE defense nuclear facilities relates to the number and qualifications of technical personnel. However, these forceful statements have not generated a commensurate degree of concern and attention in DOE and have not led to effective corrective action. In these circumstances, it is necessary to describe several matters that provide evidence that a safety problem exists. These matters will be described in summary form below. More detailed discussion is provided in appendices.
1. DOE has been slow in carrying out a set of Board recommendations that called for actions to remedy DOE technical personnel problems. In June 1993, the Board issued Recommendation 93-3, Improving DOE Technical Capability in Defense Nuclear Facilities Programs,<14> which provided a comprehensive set of recommendations to correct technical personnel problems within DOE. A key provision of the Recommendation is that, for each position requiring a technically qualified incumbent, a determination would be made both of the requirements for the position and of the qualifications of the incumbent; then the difference (or "delta") would be determined. Determination of these "deltas" is especially important. Objectively made, the determination will provide the following: (1) increased knowledge of the breadth and depth of the technical personnel problem on a comprehensive basis; (2) an understanding of the education and training that may be needed on an individual basis; (3) data for developing specific and general programs of education and training that may be required; and (4) a means for deciding which individuals cannot be upgraded to meet the requirements of their positions, and how to make out-placement provisions for them.
Implementation of these "delta determinations" is being initiated only now, three years after the Recommendation. While the determinations were to have been completed and remediation efforts commenced by December 1995, the "delta determination" process did not even begin until then. An important reason for this is that the preliminary steps adopted by DOE were not completed on schedule. One such step was to establish generic qualification standards for positions of varying types. At the site-specific and facility-specific level, many of these standards are still not completed. Until the "delta determinations" have been made, the Board cannot assess how objectively they have been made or whether effective corrective actions have been taken.
There are already indications that the initial DOE efforts to make these "delta determinations" may prove unacceptable. One indicator is that the sum of the qualification standard requirements (at the general, department-wide, and site-specific or facility-specific levels), once they are fully developed, may not be demanding enough, especially with regard to their technical content. Several standards are suspect for being too weak in their technical requirements; among the poorest are the important Technical Qualification Standards for the functional areas described as "Technical Manager" and "Project Management." These particular standards are simply not written to be technically oriented, and they should be. A second indicator is that the "delta determinations" are to be made by the same supervisors who, in many cases, have already either selected the incumbent for his or her position or otherwise have assessed him or her as well qualified. A third indicator is that the technical capabilities of many supervisors are suspect, and the Technical Qualification Program does not set higher standards for these individuals. Identifying these prospective difficulties and the measures to cope with them heightens the probability of further delays in making adequate and timely determinations.
When viewed as a whole, DOE's actions to implement Recommendation 93-3 to date are not accomplishing the overall goals of the Recommendation and have been uneven in quality and effectiveness. Taken together, these indications call into question DOE's resolve to address the shortcomings identified by the Recommendation.
2. DOE has been ineffective in carrying out the recommendations of a DOE internal staffing study of personnel needs in organizations under the Assistant Secretary for Defense Programs. More than a year and a half ago DOE made a commitment to the Board, as part of the Implementation Plan<15>
for Board Recommendation 93-6, Maintaining Access to Nuclear Weapons Expertise in the Defense Nuclear Facilities Complex,<16> to make an immediate study to determine the effect of the loss of personnel on the capabilities of the DP organization. Some eight months later, the final draft of the plan<17> stated the following:
The report went on to state that the need for additional personnel was acute in both the area of Nuclear Explosive and Weapons Safety, as well as the area of Nuclear Facility Safety. Regarding Nuclear Explosive and Weapons Safety, the report stated:
"[A] number of phenomena point to the need to increase current levels of nuclear explosive safety-related technical expertise . . .(1) the loss by early retirement of many of the most experienced personnel in the field; (2) the need for improvements in Nuclear Explosive Safety Study (NESS) technical input documentation; (3) the requirement for more rigorous selection, qualification, training, and certification of Nuclear Explosive Safety Study Group (NESSG) participating and reviewing personnel; and (4) the need to improve compliance with the relatively new requirement to incorporate more rigorous qualitative risk assessment methodologies into the Nuclear Explosive and Weapons Safety Program. All these factors support the immediate requirement for additional personnel resources with technical expertise in the field of nuclear explosive safety and related disciplines."<18>
When discussing Nuclear Facility Safety, the conclusions were similar. The report stated:
"[T]wo major areas of deficient performance were identified. The first is the slow pace of the Safety Analysis Report (SAR) Upgrade Program and the indifferent quality of the documents developed under the program. The second category of problems is the ongoing difficulties encountered in implementing and maintaining nuclear safety limits, such as Operational Safety Requirements (OSRs), Technical Safety Requirements (TSRs), administrative limits, etc. . . . Particular emphasis was placed on the SAR Upgrade Program, . . . which is hampered by a significant lack of safety analysis review capability within the Department. This has resulted in a number of adverse phenomena: (1) lack of an overall management understanding of the need for this vital safety documentation, and a subsequent drawing out of the schedule for completion thereof; (2) absence of a technically competent review capability for SARs and other safety-related documentation, resulting in further delays and the inability to perform adequate quality assurance; and (3) as a consequence of both of the above problems, inconsistent and inadequate technical direction being provided to contractors . . . significant and ongoing problems exist with implementation of new and existing safety and operating limits in the field. These problems can be directly tied to insufficient levels of talent in the DOE field organizations. Some of these problems include: (1) OSRs/TSRs for facilities that cannot be followed as written, . . . (2) the required periodicity for OSR/TSR surveillances is often not met; and (3) non- safety significant requirements are sometimes mixed in with safety significant requirements leading to a diminution of impact. These contingencies continue to persist because of insufficient numbers of qualified [DOE Facility Representatives] and inadequate levels of technical expertise for them to fall back on within the DP organization."<19> [Emphasis added]
Nearly a year has passed since DP completed its first draft of this staffing study and briefed the Board on its contents. Since then the Board has learned that DP has hired only eleven safety-related personnel (i.e., one person more than the original ten authorized by the Secretary); nowhere near the 30-40 additional FTEs noted earlier. Further, it required eight months for DOE to provide the Board with a formal copy of the DP Staffing Study, which was a deliverable under the Board's Recommendation 93-6. The Study delivered was couched as a proposal to DP and DOE management. To the Board's knowledge, it has not been formally accepted by either. These facts highlight DOE's lack of resolve in executing the findings of the study.
3. A large number of on-site assessments made by the Board's staff have shown a lack of technical qualifications among DOE personnel. Assessments made by the Board's staff at defense nuclear facilities often include evaluations of the qualifications of DOE personnel. Such assessments are then sent as trip reports to cognizant DOE officials. For example, in mid-1993 the Board apprised DOE of problems at the Amarillo Area Office (DOE-AAO) as follows:
" . . .there have been only modest advances in the program to identify appropriate training in the areas of nuclear engineering and nuclear safety required for Field Office and Area Office personnel and there is no plan to acquire that training and education. This condition is particularly apparent at the Amarillo Area Office where there is a relative lack of personnel with nuclear engineering experience and training.<20>
A year later the following further comments were made in a letter to the Secretary regarding the Amarillo Area Office:
"The Board wishes to call your attention to staffing deficiencies at the Amarillo Area Office ([DOE-]AAO) that are adversely affecting the performance of safety-related functions assigned that office."
"Even with these [vacant senior manager and engineering positions] filled, it is not evident that sufficient technical and management competence in middle management and staff at the [DOE-]AAO will be available to support the pace of activities at the site.<21>
It is pertinent to point out that the Amarillo Area Office is the DOE field office located at the Pantex plant where nuclear weapons are assembled and disassembled.
Prompted by these two reports, and constant pressure from the Board's Site Representatives, DOE-AAO did take action and a number of new facility representatives have been hired; a senior technical advisor to counsel the DOE-AAO Manager on technical matters has been hired, and a senior nuclear engineering professional has been hired, who has contributed substantially on safety-related matters at the site.
Another recent example is the Board's Recommendation 94-4, Deficiencies in Criticality Safety at Oak Ridge Y-12 Plant,<22> concerning criticality* safety and conduct of operations deficiencies at the Y-12 Plant in Oak Ridge, Tennessee. One portion of that Recommendation focussed on the performance of DOE site office personnel. Since the issuance of Recommendation 94-4, the DOE Oak Ridge Operations Office has taken significant measures to upgrade the technical expertise present at its Y-12 Site Office (DOE-YSO). Six new facility representatives have been hired and an experienced criticality safety specialist has been brought in to oversee contractor efforts in this important area.
Both the DOE-YSO and DOE-AAO examples clearly indicate that, where DOE managers make a personal commitment to increase the technical capability of their organizations, significant progress can be made. It is important to remember, however, that both of these instances of technically weak staffs were identified by the Board and its staff -- neither case was identified or acted upon by DOE itself. This failure is a technical competence issue in its own right.
Excerpts from Board's staff trip reports that address similar technical personnel problems at several other field offices are provided in Appendix D.
4. DOE managers were ineffective while hiring large numbers of technical personnel in 1994 and 1995. As noted earlier, Congress called on the Board to "raise the level of technical expertise in DOE substantially." DOE managers of defense nuclear organizations should, of course, have adopted this same objective in hiring personnel. They appear not to have done so in 1994, when DOE hired 950 individuals to fill positions in organizations responsible for defense nuclear activities. The Board's staff and its outside experts analyzed the qualifications of 445 of these "hires," using qualifications described by their resumes and other documents. They compared the qualifications of each with the requirements of the position for which the individual was hired. The result of such analyses showed a normal statistical distribution about a mean of only average capability for the population.
Closer examination of 1994 hires by grade level reveals another characteristic of the hiring process that was highly counterproductive with respect to raising the level of DOE technical expertise. If one examines the distribution of the sources of hires among grade levels, it is clear that in the higher grade levels (Senior Executive Service, GS-15, and GS-14), the most hires, by a very wide margin, were either promotions or lateral transfers within DOE (Figure 1). An increase in technical expertise was not achieved either by promoting individuals of marginal (average) capability or by transferring them from one position to another. Moreover, a valuable opportunity was lost. If DOE had used the opportunity to hire individuals of outstanding capability, the beneficial effects would have been twofold: (1) the individuals would have raised the level of technical expertise as reflected in individual contributions, and; (2) from positions of higher responsibility, they would have increased the effectiveness of existing cadres.
One is obliged to conclude that the DOE managers involved misused a large opportunity to "raise the level of technical expertise in DOE substantially" and, instead, augmented its numbers with those of average qualifications. The following are excerpts from the study made by the Board's Staff (Appendix E):
"DOE failed to take advantage of the unique opportunity this hiring authority provided to substantially raise the technical capabilities of the DOE staff.
· Overall DOE hiring practices did not result in hiring a significant number of technical personnel who were highly qualified; no excepted service personnel were hired. [Emphasis added.]
· The technical applicant screening process used by DOE in 1994 tended toward selection of minimally qualified candidates, selection of highly qualified candidates occurred with no greater frequency than that expected through a random process.
· The selection process for those technical individuals hired by DOE in 1994 did not adequately emphasize the quality of candidate technical education."
The data indicate that Board efforts to encourage DOE to raise the technical expertise of the Department through acquisition of technically qualified individuals were not effective in 1994. A briefing was given by the Board to the Assistant Secretary for Human Resources on the results of this study. Thus far, there has been no comment from DOE that questions the analysis, nor evidence that DOE itself has made a comparable study. Moreover, a subsequent analysis by the Board's Staff of 470 DOE hires covering the first three quarters of 1995 indicates that the level of competence is below, or at least no better than that for 1994.
Unfortunately, there is reason to doubt that the DOE managers understand the impact of their actions. For example, DOE's report to Congress on its 1994 activities includes the following:
"The Office of Environmental Management has aggressively pursued staffing 850 positions allocated to the field to support safe and efficient site operation. As of the end of December 1994, almost 600 of these positions had been filled from a qualified national pool. For positions at the GS-15 level or higher, a process was developed which involved the selecting official, field office Assistant Manager mostly affected by the position, and the appropriate Deputy Assistant Secretary in Headquarters. This process was approved by the Assistant Secretaries for Environmental Management and Human Resources as well as the Associate Deputy Secretary for Field Management. The Office of Environment, Safety and Health has filled 35 of their 100 new allocated positions. Most of these new hires will assist the contractor oversight function, and these personnel will be permanently stationed at 13 field locations.<23>
The impression created by this report is that DOE believes it has done well in increasing its technical competence for the future when, in fact, it has exacerbated an existing, serious problem.
5. DOE has relied on the Board to an inordinate degree for technical guidance and assistance. There are many ways in which DOE has done this. For example, DOE has: (1) failed to identify many safety problems and to initiate corrective actions before the Board had to call them formally to the attention of the Secretary; (2) demonstrated undue difficulty in planning and scheduling specific corrective actions in response to Board recommendations and safety-related initiatives, in general; and (3) has frequently had difficulty in carrying out agreed-upon actions on schedule.
By the end of calendar year 1995, the Board had issued 33 formal recommendations. Most of them addressed important safety problems of a broad or generic character; that is, they were either applicable to many facilities and activities, or should have been perceived by DOE as such. If DOE had identified these problems, and if it had begun to take responsible corrective action, then the Board, in most instances, would not have felt compelled to make a recommendation in the first place. Thus, a Board recommendation is a primary indication that DOE did not have the technical experience to recognize the problem identified, the technical personnel to correct it, or both. The problems that led to most Board recommendations were neither technically difficult nor managerially complex. Even a limited technical capability coupled with forceful management should have sufficed to recognize the need for corrective measures and set them in motion (Appendix F).
DOE has had difficulty in developing the Implementation Plans that the Secretary is required to submit to the Board for each Recommendation. For instance, Recommendation 90-2, Design, Construction, Operation and Decommissioning Standards at Certain Priority DOE Facilities,<24> which was issued in March 1990, called for DOE to do the following for high priority nuclear facilities and activities: (1) identify the applicable nuclear safety standards; (2) evaluate their adequacy; and (3) assess the extent to which they were implemented. This was not a difficult job from a technical perspective; yet, DOE made five unsuccessful attempts to develop an Implementation Plan before one was finally accepted by the Board. In the end, the Board found it necessary to provide DOE the assistance of its own Technical Director and General Counsel in order to get progress. It took more than four years to develop an acceptable plan.
The Implementation Plan for 90-2 has not been carried forward effectively for several reasons, which include, but go beyond lack of technical expertise. Simply put, DOE does not yet have the demonstrably adequate, standards-based safety program envisioned some six years ago. This has caused the Board to issue a follow-on to 90-2, Recommendation 95-2, Safety Management.<25> In 95-2 the Board noted that an important attribute of the integrated safety management program which DOE is now trying to put in place is that it establishes a clear need for DOE technical expertise even beyond that which the department now has "in-house." The inevitable result will further exacerbate the technical personnel problem.
6. Radiological protection as prime example of inadequate levels of technical expertise within DOE. Further evidence that a problem exists relates to Recommendation 91-6, Radiation Protection for Workers and the General Public at DOE Defense Nuclear Facilities,<26> which addresses the many deficiencies in DOE's radiation protection program. In a situation similar to that illustrated for Recommendation 90-2 above, DOE proved incapable of putting together an Implementation Plan acceptable to the Board, without the assistance of senior members of the Board's staff.
One provision of Recommendation 91-6 was that DOE establish a board of outside experts to review its radiation protection program. DOE established such a committee, led by Dr. John W. Poston, Sr., which reported the results of its study to DOE in January 1995.<27> The report drew important attention to the lack of technical expertise in radiation protection in DOE. The following excerpts relate to technical personnel problems:
Finally, almost a year after the Poston Committee submitted its report to DOE, the Board received a formal briefing of the DOE's Management Action Plan that responded to the Committee's recommendations. The proposed action plan did not adequately address or outline actions to be taken to eliminate staffing deficiencies concerning DOE personnel with radiological protection responsibilities.
Another review<29> of the numbers and quality of personnel in DOE's radiation protection program also revealed many deficiencies. The defense nuclear complex consists of at least 10 major and numerous minor sites around the country. To protect their workers and the public at these sites, DOE contractors employ more than 3400 radiation protection personnel (more than 1300 of them at the management or supervisory level).<30> DOE is attempting to manage this program with just 44 full-time positions at these 10 sites,<32>
though DOE recognizes this as unrealistic. A report by the Senior Radiological Protection Officer of DOE's Office of Oversight states that these 44 positions "represent an insufficient Federal resource . . . .<32>
The problem goes beyond that of numbers; it concerns quality also. As of mid-1995, the DOE Office of Oversight report showed that only four of DOE's 44-person site radiation protection staff have been certified by the American Board of Health Physics. These four individuals focus their activities at three DOE sites; therefore, most sites have no certified radiation protection professionals among the federal ranks. By contrast, DOE's contractors average about ten certified radiation professionals at each major site. Delving deeper into the qualifications of the 44 DOE personnel discloses an even bleaker picture. A sampling indicates that 17% of the DOE professional radiation protection staff do not have a college degree; another 17% have a bachelor's degree, but not in a technical major. Thus, the sampling suggests that a minimum of one-third of the DOE radiation protection program personnel do not have the strong educational background needed to cope effectively with the agency's problems.
Radiation protection is integral to protecting the health and safety of the public and workers. However, DOE does not presently have the technical expertise "in-house" to provide adequate technical direction for the radiation protection programs at its various sites. Ongoing and planned activities, such as processing radioactive wastes, decontaminating systems and facilities, and completing environmental restoration present the possibility for increased levels of radiation exposure unless rigorous "as low as reasonably achievable" (ALARA) practices are instituted. Such practices presuppose that an adequate level of radiation protection expertise exists within DOE.
There is no better or clearer example of DOE's inattention, or lack of dedication, to its responsibilities for providing adequate numbers of technically qualified personnel than this one in radiation protection, which is paramount to worker and public safety.
7. Summary. The above evidence points to a problem of major proportions regarding DOE technical personnel associated with defense nuclear activities. Since the problem concerns the safety of activities at defense nuclear facilities, this evidence should raise doubts of sufficient magnitude to bring about a thorough inquiry into the matter and the promptest possible corrective action.
Apparent Causes of the Problems
Many causes can be cited for the lack of sufficient numbers of fully qualified DOE technical personnel in defense nuclear facilities. Most are longstanding cultural problems. A substantial number are interrelated.
1. Disposition among DOE managers not to regard strong technical education and experience as essential. Board Members have, from time to time, discussed the technical personnel problem with DOE managers. These discussions have left the impression that many DOE managers believe that management qualifications are sufficient unto themselves to enable one to manage nuclear activities effectively, despite a lack of solid technical credentials. This belief has been discredited in the commercial nuclear power industry and in other mature nuclear programs. For example, an important effect of the establishment of the Institute of Nuclear Power Operation (INPO) has been to raise the level of technical competence among utility organizations that own and operate commercial nuclear power plants.
2. Some managers appear to believe that safety responsibilities, which accrue to DOE by law, can somehow be made to devolve upon laboratories and contractors. Because of a lack of technical competence, DOE technical managers have attempted to abdicate their safety responsibilities by allowing those responsibilities to be transferred to their laboratories and contractors. Belief in the efficacy of such an arrangement is the counterpart of the conviction that DOE managers of technical activities need not have strong technical credentials. An independent study of the National Research Council, in 1987,<33> criticized DOE for relying on laboratories and contractors as a substitute for DOE technical expertise. However, as pointed out elsewhere in this report, DOE policy seems to be to increase this dependence on laboratories and contractors in safety-related matters.
This DOE tendency is deeply ingrained; it represents a tradition of reticence with respect to providing authoritative technical direction to its laboratories and contractors and to holding them accountable to execute such direction, once provided. The tendency stems, in important part, from the disparity in technical capability between DOE and these contractor organizations. DOE Orders and standards are also often impacted, with the DOE role being described as "provide oversight;" which is open to broad interpretation varying from an active to a passive role.
3. Lack of understanding that, in nuclear activities, accidents of disastrous proportions can be triggered by incidents of seemingly small consequence. Many key DOE management personnel do not have technical education and experience. Therefore, they do not have a sufficiently developed understanding of how apparently small lapses in discipline of operations, departures from safety standards, and malfunctions of apparatus can often have serious safety consequences. The remedy for such deficient understanding is developed through reflection upon the two most recent large nuclear accidents, Three Mile Island and Chernobyl. Neither of these was caused by one large error -- both were the consequence of a number of minor failures, exacerbated by technical and management misjudgements. Managers who lack an appreciation for the major consequences that can result from minor deficiencies cannot adequately judge the impact of inadequately qualified technical personnel upon nuclear program activities.
4. Impediments to out-placing DOE personnel found deficient in technical qualifications. Within DOE it is generally regarded as extremely difficult to remove personnel whose background or performance is deficient. This opinion has been voiced to the Board by senior DOE officials on a number of occasions. With time, therefore, the number of poor performers increases. The problem becomes acute when a remedy of adding qualified personnel is foreclosed or circumscribed by budgetary constraints. A provision of Recommendation 93-3, and a premise of the DP Staffing Study<34> was that DOE would develop a method of addressing this problem. Now, some three years later, it appears DOE has done little about it.
5. Failure to heed the lessons learned from Three Mile Island. In the aftermath of Three Mile Island, the DOE conducted a comprehensive self-assessment of the safety of DOE nuclear reactors.<35> In the letter to the Under Secretary which forwarded the report, the chairman of the study committee wrote, "A paramount need is to increase the number of technically qualified personnel in both headquarters and field organizations." The report also recommended a study similar to that completed for reactor safety be made of the safety of DOE nonreactor nuclear programs. The recommended study, which presumably would have included defense nuclear facilities, was not made. DOE thus missed an opportunity, beginning in 1981, to systematically build up its technical manpower capabilities in nuclear programs to an appropriate level.
6. Failure to understand that the added costs of achieving excellence in the technical qualifications of personnel are relatively small. There are costs associated with maintaining technical cadres of individuals with high competence. They include potentially higher salaries, costs of formal education, costs of practical training, etc. Such costs will not seem worth the price to those for whom budgetary considerations transcend all others. However, these costs are not inordinate. For example, for the past two fiscal years, the Board's own educational and training expenses have been less than one percent of their obligations; yet this level of expenditure has permitted the Board to maintain a staff that is recognized as highly-qualified and continues to grow in educational qualification.
7. Unjustified confidence engendered by lack of serious weapons accidents to date. The lack of a significant number of weapons accidents to date in DOE nuclear activities contributes to an attitude that the status quo is sufficient to ensure against their happening in the future. This attitude is analogous to that in NASA's space program before catastrophes struck (such as Apollo One and Challenger), and in the commercial nuclear power program before Three Mile Island. Likewise, the numbers of significant incidents that might have become accidents at defense nuclear facilities have not been used as a countervailing measure to eliminate this attitude.
Few in DOE are now aware that there have been two major fires at the Rocky Flats Environmental Technology Site (previously called the Rocky Flats Plant) -- one in 1957 and the other in 1969.<36> The first fire started when metallic plutonium casting residues spontaneously ignited in a glove box. The fire spread to an exhaust filter plenum, consumed a considerable quantity of filter, and damaged the duct work and fan system. The fire burned for about a day. Plutonium was spread throughout most of the building and a portion was probably released through the exhaust system. The second fire started in a glove box in a plutonium foundry line. The fire burned for about six hours, spreading combustible material in several hundred interconnected glove boxes in the building. The damage to the building and equipment was extensive and the building was grossly contaminated with plutonium. The Atomic Energy Commission estimated that the financial loss for the damage to buildings and equipment, including the cost of decontamination, was about $1 million for the 1957 fire and $45 million for the 1969 fire.<37>
Other documented examples from DOE history include: detonations in shaping high explosives for nuclear weapons;<38> numerous criticality excursions in the processing of nuclear materials, one as recently as 1978;<39> and problems during nuclear weapons dismantlement that have led to facility contaminations that have yet to be restored.<40> Each of these occurrences was investigated by DOE (or its predecessor agencies) at the time, and corrective actions were taken. However, the continued occurrence of problems of this nature points to an ongoing need for an aggressive, technically competent DOE federal workforce.
8. Unwillingness by DOE personnel to look for guidance beyond defense nuclear programs. The programs that guard against accidents in defense nuclear activities such as assembly and disassembly of nuclear weapons should embody only the best methods of selecting, educating, and training personnel, the best technology, and the best management methods and techniques. It may be that laboratories and contractors systematically look beyond their own organizations to learn from others, but DOE organizations tend not to. As noted earlier, the NR program has had an outstanding record of safety for decades. The organization is especially well known for its success in selecting, educating, and developing government personnel (both military and civilian) who conduct the program. Key DOE officials have been repeatedly urged by the Board to study this program for lessons to be learned in technical management practice.
9. Difficulties of attracting technical expertise to DOE. A difficulty sometimes mentioned as contributing to the DOE technical personnel problem is that DOE has trouble attracting expertise. The problem has two aspects: DOE's poor reputation for hiring technical expertise and using it effectively, and the potentially limited supply of nuclear-trained personnel with the requisite qualifications.
There are many examples of government organizations effecting a major reform to develop excellent "in-house" technical talent. An especially relevant one is the major overhaul carried out by DOE's predecessor, the AEC, in its civilian nuclear power program. The demand for the overhaul came from the Joint Congressional Committee on Atomic Energy.<41> It was effected with the guidance and support of Commissioner Ramey and under the outstanding leadership and technical guidance and direction of Mr. Milton Shaw. A distinguishing feature of the revamped program was a highly competent "in-house" capability for technical management of a wide-ranging breeder reactor program that involved many laboratories, reactor plant manufacturers, architect-engineering firms, and utility companies. The government talent was assembled by aggressive recruiting, using high standards, notwithstanding the poor reputation of the AEC for technical competence in matters relating to reactor development.
AEC was competing with the commercial nuclear industry for talent during a period of high demand for the then-limited number of nuclear-qualified personnel. The difficulty today is no greater than it was then. Moreover, DOE is competing for expertise against these same kinds of organizations as AEC was. So, too, are government organizations like the Nuclear Regulatory Commission and the Board itself. Starting with no staff at all, the Board has assembled an outstanding one. As an indication of the Board's technical talent, 20% of the technical staff hold degrees at the Doctoral level and an additional 64% have Masters degrees. Moreover, most technical staff members (except interns) possess practical nuclear experience gained from duty in the nuclear weapons field, the commercial reactor industry or the U.S. Navy's nuclear propulsion program. The key to assembling such a highly qualified technical staff is senior management attention to the task. Acquisition, maintenance, education, and training of a highly qualified staff have been among the highest priorities, one to which Board Members have given close and continuous, personal attention. Board Members themselves review applications for employment. Board Members and the Technical Director interview each applicant seen as meriting such consideration. On several occasions senior Departmental managers have committed to applying similar effort and rigor to their recruitment programs.* The results achieved, to date, do not reflect such a commitment.
But there have been isolated successes, within DOE itself, as mentioned previously. It is particularly instructive to examine in more detail the case involving DOE-YSO. On September, 27, 1994, the Board issued Recommendation 94-4, Deficiencies in Criticality Safety at Oak Ridge Y-12 Plant.<42> The subject of the technical competence of Federal staffing at DOE-YSO was integral to this Recommendation, which stated, in part:
"(3) DOE should evaluate the experience, training and performance of key DOE and contractor personnel involved in safety-related activities at defense nuclear facilities within the Y-12 Plant to determine if those personnel have the skills and knowledge required to execute their nuclear safety responsibilities . . ." and
"(4) DOE take whatever actions are necessary to correct any deficiencies identified in (3) above in the experience, training, and performance of DOE and contractor personnel.<43>
The Board reiterated its concerns regarding technical staffing at DOE-YSO during a public meeting held at Oak Ridge in November of 1994.<44>
In response to these Board actions, the Manager of the Oak Ridge Operations Office negotiated with DOE Headquarters and was immediately granted permission to advertise and fill five safety-related positions. The Recommendation 94-4 Implementation Plan (IP)<46> committed DOE to follow up with detailed reviews of the staffing requirements in DOE-YSO. Within six months after the Board had issued this Recommendation, through a combination of nationwide advertising/hiring and DOE reassignments, DOE-YSO was able to add eight new, technically competent personnel. These personnel had extensive nuclear backgrounds and technical degrees -- clear indications of the type of personnel available if aggressive hiring measures are taken. In fact, the DOE-YSO Manager noted that the response to the nationwide advertisements placed in trade journals was overwhelming, and resumes from this effort have been provided to other field offices trying to fill safety-related positions.
Subsequent to these initiatives, a training assistance team (TAT) was formed in accordance with the Recommendation 94-4 Implementation Plan, visited Oak Ridge in August 1995, and evaluated the technical competence of key federal personnel supporting the Y-12 Plant. The TAT found the following:
"[T]he base level of key Federal personnel technical expertise and competency at the Y-12 Site has significantly increased since the September 1994 event."
"Needed technical expertise has been added to . . . Y-12 Site Office. Significant enhancements include the addition of Facility Representatives, improvements in technical support to the Facility Representatives, and improvements in communication of issues and concerns to the contractor.<46>
DOE-YSO's efforts to augment staff technical expertise are a good example of what can be accomplished when dedicated management utilizes all of the tools at its disposal. In the short space of seven months DOE-YSO, working with both DOE Headquarters and the Oak Ridge Operations Office, advertised, screened, and selected eight personnel. Probably most striking is the fact that DOE-YSO was able to almost double the number of technically degreed personnel in the office by filling these eight positions. These personnel changes did, in the words of the Board's tasking from Congress, increase their expertise "substantially."
10. Summary. From the above, it is evident that the difficulty in hiring technically competent personnel perceived by DOE does not hold up under serious scrutiny. DOE apparently has yet to learn that acquisition of nuclear expertise requires three things: (1) recognition by top management that it is needed, (2) high personnel standards, and (3) the willpower to consistently push personnel acquisition as a high priority issue. DOE management appears, based on the above, to have problems in all three areas.
Consequences of the Problem
There are many serious, adverse consequences of the lack of sufficient numbers of technically qualified DOE personnel who are responsible for the safety of its defense nuclear facilities.
1. DOE is unable to carry out its safety responsibilities. Without enough qualified personnel DOE is unable, with the degree of effectiveness necessary to protect public and worker health and safety, to do the following: provide technical guidance and direction to laboratories and contractors, develop safety standards, know whether laboratories and contractors have assigned fully competent personnel and are otherwise performing effectively. Simply stated, DOE cannot act as a knowledgeable and demanding customer who is fully qualified to require the laboratories and contractors to safely deliver the product and the performance for which they are being paid. DOE is forced to fall back into a relationship in which technical matters are left preponderantly in the contractors hands and into a reliance on external oversight by the Board. In matters of public safety, especially nuclear safety, this amounts to an abdication of responsibility.
2. DOE has resorted to the use of a surrogate to manage DOE contractors at the Rocky Flats Environmental Technology Site. For many years, the DOE and its predecessors proved unable to obtain effective safety performance from contractors at the Rocky Flats nuclear weapons plant. In 1995, DOE established a new contractor, Kaiser-Hill, at the site for the purpose of "integrating" the activities of other contractors there. This has the effect of interposing an additional layer of management between DOE and the contractors doing the work. It apparently presumes that DOE itself does not have the technical personnel needed to manage the site.
3. Sound safety management relationships are distorted among laboratories, contractors, DOE organizations, and the Board. Fundamental safety principles mandate that responsibility for achieving safety lie only with one organization -- the line organization, and that nothing should be allowed to vitiate that responsibility. This is fully consistent with the Secretary of Energy's own position, transmitted to the Board in response to a May 6, 1994, reporting requirement,<47> wherein DOE states,
"The fundamental principle governing safety management is that line management has full responsibility and authority for the safety of the facilities.<48>
Within DOE that line extends from the Secretary to the Assistant Secretaries, to the operations officers in the field, and on to the laboratories and contractors. A backup to the line is provided by an internal safety oversight organization under the Assistant Secretary for Environment, Safety and Health.
Properly manned and managed, these two types of DOE organizations taken together must become sufficient in and of themselves for protecting public health and safety. Because they were not, Congress established the Board and placed it outside the DOE. Referring back to earlier discussion of the Board's functions, the Board provides independent external oversight of safety at defense nuclear facilities. In effect, it provides a second layer of safety oversight. Assessing the performance of both the DOE line organizations and the DOE internal oversight organization, the Board makes recommendations to the Secretary or provides other assistance to correct safety deficiencies.
The Board assesses whether these DOE organizations maintain their independence from one another. If independence is compromised and DOE's internal oversight organization becomes a surrogate for DOE's line management, then the potential exists for the internal oversight organization to be assessing their own efforts and their function as a safety backup to line management is no longer being performed. This independence must be maintained, not only by the manner in which line management functions are assigned formally, but also by the manner in which organizations interact with one another. The most important threat to safety occurs when both the DOE line and internal oversight perform ineffectively. When these circumstances occur, they could result in Board actions whose effect is to compensate for DOE inaction or lack of competence. The interests of safety may well be served in that particular instance, but there are adverse effects such as: (1) the Board's action will conceal DOE weakness and thereby deprive DOE management of the opportunity to correct it; (2) the proper function of the Board as a second layer of safety oversight will have been compromised.
Two examples will illustrate the principles and problems involved -- one was encountered soon after the Board began operation and the other has lasted over a longer period. The Board's first Recommendation (90-1)<49> called attention to serious deficiencies in the training of operating personnel for the K-Reactor at the Savannah River Site. (It will be recalled that poorly trained operators contributed to the serious reactor accidents at Chernobyl and Three Mile Island.) It should have sufficed for the Board to make its Recommendation, which prescribed a clear course of corrective action in specific steps. However, DOE personnel were not competent enough to complete the tasks from there. Board Members, staff, and its outside experts had to devote extensive efforts to seeing that the contractor carried out the much needed operator training and qualification programs. With its small resources thus tied up at the Savannah River Site, the Board and its staff could not give as much attention to other sites as it otherwise might have.
Moreover, the Board soon discovered that DOE had not profited from the lesson it should have learned at K-Reactor. As other facilities at the Savannah River Site were being readied for operation, the Board repeatedly found it necessary to use its own personnel to make sure that operators were properly trained and qualified. The Board was spending too much time doing work that was DOE's responsibility, but which DOE was not doing due to a lack of qualified technical personnel.
The second example is the lack of technical expertise in radiological protection in the DOE Richland Operations Office at the Hanford Site (DOE-RL). In 1990 a DOE Tiger Team reported that "[d]ue to inadequate resources, DOE-RL health physics branch is not able to provide adequate oversight of contractor nuclear facilities.<50> [Emphasis added] This problem was among other major radiological protection problems identified by the team, "such as poor radiation protection practices and lack of disciplined operations, [which] have been identified in many ways and have been known for years.<51> These deficiencies have been repeatedly confirmed in assessments made on site by the Board's Staff. At least seven reports of the results were formally transmitted DOE by the Board between May 1992 to August 1995. In November 1995, a team from the Board's Staff again confirmed that the problems cited above continue.
It is clear from the above reports and from personal observations by both Board Members and the Board's staff that DOE-RL has not acquired sufficient numbers of well-qualified radiological protection personnel, nor have they properly motivated managers and supervisors to become actively involved with radiological work and safe work practices. Further, despite continuous acknowledgment that this problem exists, DOE's internal oversight organizations have been unable to force the line management organization to take effective corrective action. This has severely hindered the establishment of a work environment at the Hanford Site that properly recognizes radiological safety. Unless upgrading of technical competence at DOE-RL is aggressively pursued, a safety-conscious work environment fully prepared to cope with problems of radiation exposures will not be achieved.
On October 25, 1995, the DOE-RL Operations Office Manager acknowledged in a memorandum that "[m]ost contractor radiological engineers and radiological control technicians, and [DOE-]RL and contractor personnel do not possess sufficient education, experience, and training in the areas of health physics and radiological controls principles to effectively carry out their assigned responsibilities, without professional health physics support.<52> However, as of the end of 1995, no effective action had been taken to provide it. As a consequence, serious deficiencies continue to exist at the Hanford Site.
Among the points to be emphasized here is that even a large investment of Board resources will be unavailing if DOE lacks the will and the expertise to bring about corrective action. In the case of inadequate radiological expertise at DOE-RL, neither the line organizations in EM Headquarters and DOE-RL, nor internal safety oversight in EH, have carried out their responsibilities effectively.
Efforts to Correct the Problem
1. Recommendations that specifically target the personnel problem. The principal means that the Board has for effecting safety improvements is through the formal recommendations that it makes to the Secretary. By the end of 1995 it had made thirty-three. Of these, twelve included recommendations directed toward strengthening the technical capabilities of DOE personnel.
For example, the most recent Board Recommendation, 95-2, Safety Management, describes a specific problem of technical expertise and recommended action as follows:
"We recognize that the various DOE organizational units which may be delegated review and approval authority for S/RIDs [Standards/Requirements Identification Documents] and associated Safety Management Programs may not have enough individuals with qualifications in the technical specialties required to carry out effectively the streamlined process being recommended. This means that technical assistance may need to be retained from elsewhere to compensate for such personnel deficiencies where they exist. It also means that DOE may need to augment its own technical expertise so as not to be obliged to continue indefinitely to rely on technical assistance from outside DOE."
". . . Therefore, the Board recommends, that DOE:
5.Take such measures as are required to ensure that DOE itself has or acquires the technical expertise to effectively implement the streamlined process recommended.<55> [Emphasis added]
Pertinent personnel-related extracts from other Board recommendations are included in Appendix G.
As noted elsewhere, it is the practice of the Board to send DOE reports of assessments made by the Board's Staff and outside experts at DOE sites. Many of these have cited specific deficiencies among DOE personnel. Having evidence that these and other measures were not bringing about the corrective measures needed, the Board sent the Secretary Recommendation 93-3, which called for comprehensive actions across the full range of DOE technical personnel problems. DOE has taken a number of measures called for by its Implementation Plan for Recommendation 93-3; however, they have not brought about the results intended by the Board in issuing the Recommendation.
2. Excepted Service Authority. In particular, DOE's efforts to attract and retain highly technically competent scientists and engineers in response to this Recommendation have been unsuccessful. In a market of limited numbers of highly competent nuclear technology personnel, it has long been evident that government agencies have difficulty hiring and retaining such personnel under the Civil Service System. Thus, the AEC, ERDA, and the Nuclear Regulatory Commission (NRC) all were granted excepted service personnel authority to hire outside the Civil Service System. When the Board was formed, one of its early, high-priority actions, based on the above and other precedents, was to seek and acquire its own excepted service personnel authority from Congress -- it has proved essential for hiring outstanding technical staff.
DOE retained such authority in limited form (i.e., for 200 positions) when it succeeded ERDA, but made no effort to use it. Recognizing that DOE not only needed to use its existing statutory authority, but also needed to expand such authority, the Board recommended (as part of Recommendation 93-3) that DOE seek the necessary legislation. DOE accepted the Recommendation, but showed little initiative and interest in using the available excepted service personnel authority or in acquiring the legislation to expand this authority until prodded and assisted by the Board. Moreover, having acquired the authority for a total of 400 excepted service hires, DOE has been ineffective in using it.
This lack of initiative and interest by DOE in acquiring excepted service personnel authority and the failure to use it aggressively and effectively, when acquired, is an important element of the Department's overall failure to address the larger technical personnel problem at defense nuclear facilities. DOE's use of excepted service personnel authority was treated in more detail in a statement by the Board's General Counsel at a public meeting held by the Board on the subject of the DOE technical personnel problem on January 23, 1996 (Appendix H).
There are several impediments to the kind of far-reaching measures that are needed to resolve DOE's technical personnel problems.
1. Lack of understanding, experience, and personal involvement by upper echelons of DOE management. The fact that the technical personnel problem exists, after six years during which the Board has called frequent attention to it, is prime evidence of lack of top management involvement, beginning with the Secretary and proceeding on down at other levels. It is evident, notwithstanding the actions of the Board, that these DOE officials have not treated the matter as one of sufficient importance to merit their continued, personal attention. Without such direct, personal involvement, there is little hope that the problem can be corrected.
2. Failure to define safety responsibilities. When the Board began operations in 1989, the safety responsibilities of DOE Headquarters technical line managers were in the process of being strengthened to exercise greater control over DOE field organizations and contractors and to hold them to a higher standard of accountability for performance than they had been previously held to.<54> However, In April 1993, a new Secretary of Energy announced a major change for the DOE organization.<55> It was intended, among other things, to assign more responsibility and authority to the field and, therefore, away from Headquarters. In several later discussions with the Assistant Secretaries for Environment, Safety and Health and for Environmental Management, and the Associate Deputy Secretary for Field Management (whose position had been newly created by the reorganization), Board Members tried to find out what specific changes in safety responsibilities had been made. A key purpose of these repeated inquiries was to make sure that such responsibilities were defined, promulgated, and understood by the individuals and organizations involved. Having failed for almost a year to obtain the information sought, the Board was obliged to impose a reporting requirement on DOE. The Board's letter of May 6, 1994, stated:
"The Board recognizes that under your leadership the Department has been undergoing a major reorganization with respect to its management of defense nuclear facilities. This reorganization has affected the roles and responsibilities of the various offices responsible for nuclear safety at DOE, and extends to the contracting process as well as to line management and independent oversight assignments. To carry out its statutory duty, the Board must understand in detail how certain aspects of this reorganization affect the Department's programs for assuring public and worker safety, for minimizing risk to life and property, and for protecting the environment.<56>
On June 29, 1994, the Secretary sent a preliminary response and provided the Board with a newly- updated Manual of Functions, Assignments, and Responsibilities for Nuclear Safety (FAR Manual).<57> Updating this manual represented a step forward in providing the information needed. However, it required that many complementary actions be taken by the organizational units affected, as well as specific action to correct numerous discrepancies discovered in the FAR Manual by the Board's Staff. One of these actions was the issuance of DOE's response to the Board's May 6, 1994, reporting requirement. That response<58> provided a summary of DOE's approach to the management of safety, including the roles of line management, safety standards, technical competency, and independent internal oversight. However, implementation of the approach was inconsistent and often ineffective.
By September 1995, the FAR Manual was out-of-date, in part as a result of organizational changes. The Board brought this to the attention of the Secretary, who then directed the Assistant Secretary for Environment, Safety and Health to bring the manual up-to-date. Since this was not being accomplished, the Board again informed the Secretary of its continuing concern in December 1995. Again, the Secretary directed that corrective action be taken. As of now, there still has been little progress. Thus, over two and a half years after a major reorganization, which affected safety responsibilities at defense nuclear facilities, DOE still does not have in place clearly delineated safety responsibilities, especially as between Headquarters and field offices. This conflicts with well- established industry practice; for example, the applicable consensus standard states:
"Lines of authority, responsibility and communication for the operating and support organizations shall be established and defined. These relationships shall be documented and updated, as appropriate, in the form of organizational charts, functional descriptions of departmental responsibilities and relationships and job descriptions for key personnel positions or in equivalent forms of documentation."<59>
This confused situation in DOE represents a clear lapse of sound safety management as indicated by DOE's own policy. Until safety responsibilities are defined in detail, deploying technical manpower resources effectively will be difficult, if not impossible.
DOE's attempts to resolve the problems of assigning, defining, and engendering understanding of safety responsibilities are complicated by differing views as to where such responsibilities should lie. This difference in views especially affects the relationship between Headquarters and field organizations due to the continuous state of flux of the Orders and standards that they work by. Field organizations have had a long history of relative independence from subordination to Headquarters; thus, these differences are likely to be difficult to resolve. A recent effort to do so was led by an action group of senior Headquarters and field managers under the aegis of the Strategic Alignment Implementation Group. The results of the deliberations by the action group were reported to the Associate Deputy Secretary for Field Management in a memorandum dated June 22, 1995, from the Manager, Richland Operations Office. The document states that "The Strategic Alignment Team identified the need for clarity in roles, responsibilities, authority, and accountability between Headquarters [and] the operations offices . . . to improve coordination and eliminate duplication of work.<60> It offered a plan for doing so. However, the plan was submitted in draft form and, as far as the Board has been made aware, no action has been taken on it.
A chronology of the efforts by the Board to Require DOE to adequately define nuclear safety responsibilities is attached as Appendix I.
3. Misplaced organizational assignment of internal nuclear safety oversight. Under the major DOE reorganization announced in April 1993, the unit responsible for internal nuclear safety oversight (Office of Nuclear Safety), which had previously reported directly to the Secretary, was placed under the Assistant Secretary for Environment, Safety and Health. From the perspective of nuclear safety, it is believed that this change was imprudent for several reasons.
Given the large dimensions of the technical personnel problem, it should have been brought continually, forcefully, and directly to the attention of the Secretary by the internal oversight organization. The Secretary was being apprised repeatedly by external safety oversight (i.e., the Board) that the technical personnel problem was the single most important safety problem at defense nuclear facilities. It is not evident that internal safety oversight, now located under the Assistant Secretary for Environment, Safety and Health, was confirming this forcefully and continually to the Secretary and providing detailed supporting information. Moreover, as noted elsewhere, DOE has a serious lack of radiological protection personnel, a portion of it under the Assistant Secretary for Environment, Safety and Health, the organization to which the internal safety oversight unit reports. If this unit had been assigned directly to the Secretary, instead of to the Assistant Secretary, it would have been obliged to report to the Secretary that the Assistant Secretary was not correcting technical personnel deficiencies within the EH organization. The fact is, the Assistant Secretary for Environment, Safety and Health has an apparent conflict of interest in this specific area.
Also, the Assistant Secretary for Environment, Safety and Health has a clear responsibility for identifying the need for corrective action on the widespread technical personnel deficiencies in line organizations, both at Headquarters and in the field. Had internal safety oversight reported directly to the Secretary, one cannot be certain that reports of these deficiencies would have been made to the Secretary, but the organizational arrangement would certainly have provided the responsibility and hopefully the opportunity.
4. Advice of External Advisory Groups. On February 1, 1995, a report, alternative Futures for the Department of Energy's National Laboratories, was issued by Mr. Robert Galvin, Chairman, Secretary of Energy Advisory Board Task Force. Regarding DOE technical expertise, the report states:
"The root deficiency . . . is the absence of a sustained, high quality, scientific technical review capability at a high level within the DOE as well as a lack of leadership and poor management of the science/engineering-operational interface.<61>
Emphasis by the Task Force on this "root deficiency" should have proved helpful in bringing about corrective action to strengthen DOE technical expertise.
However, the report is likely to have a contrary effect. It has been perceived by many as warrant for the DOE to relax its efforts to strengthen its standards-based safety program. This is due to several negative comments made by the Galvin Report concerning DOE's management of the national laboratories. It describes DOE's management style as "excessive oversight and micromanage[ment].<62> An entire six-page appendix of the report was given over to anecdotal information regarding this perception of excessive oversight and micromanagement. The impression that is left with the reader of the report is that the DOE should leave management of these facilities to the contractors who operate them.
On balance, it appears that the Galvin Report will encourage those who seek a more laissez faire relationship between the DOE and its laboratories and, thus, hamper efforts to cause DOE to acquire the technical experience it needs.
Also, it is likely that the Report of the External Members of the Department of Energy Laboratory Operations Board, October 26, 1995 will have this same effect or will be used to hide from things that are too hard to do. In fact, the Deputy Secretary of Energy described the purpose of these external members to the House Science Committee as follows:
"They will help ensure that the Galvin Task Force report will not suffer the fate of many previous examinations of the DOE laboratories.<63>
Paralleling the Galvin Report, the report by the External Members states that:
"The Department should continue to identify and tackle excessive administrative burdens which it imposes on the laboratories . . .<64>
and targets,
" . . .four areas where dramatic reductions in the paperwork burden seem possible.<65>
One of these areas is compliance with environmental, safety, and health regulations.
The objective of reducing the administrative burdens on the laboratories is a commendable one. But, the interpretation being placed on it could cause the DOE to back away from constructive technical interactions with the laboratories and contractors, and also to weaken technical requirements that apply to safety at defense nuclear facilities.
5. Uncertainty about Department of Defense (DoD) involvement within DOE's weapons program. Military officers of the Armed Services have had an important role in managing the nuclear weapons program of the DOE since the program's inception. However, changes of significant proportions and implications have taken place with regard to the role of military personnel within DOE's nuclear weapons program. By using "within" it is intended to exclude the complex organizational and other matters in which both DOE and DoD are jointly involved in the nuclear weapons program and discuss only military officers assigned to DOE to perform DOE functions.
The Atomic Energy Act of 1946 established a Division of Military Application (DMA) and provided that it be headed by a general or flag officer (normally an O-8) who managed the AEC weapons program under the close, continuing direction of the General Manager and five AEC commissioners. Most of the General Managers had sound technical management credentials and many of the commissioners were either engineers or scientists of renown. The officers who headed DMA were highly-accomplished members of the Army's Corps of Engineers, all with outstanding academic credentials, graduate degrees in engineering and extensive engineering experience.
Most of the DMA technical staff were military officers from the Army, Navy, Marine Corps, and Air Force. Those with the best technical education tended to be Army Engineers and, in lesser numbers, naval officers with weapons-oriented postgraduate education. The assignments were considered attractive and career-enhancing. Special programs were established under which some officers received training in nuclear weapons technology at the DOE (then AEC) weapons laboratories.<66>
In recent years there appears to have been a progressive diminution in stature and responsibility of the senior-most officer assigned to weapons duties within DOE. For a number of years it was a "one- star" (O-7) position instead of a "two-star" (O-8), as it had long been. The attraction for military officers seems of late to have been closely associated with the fact that it offered the opportunity to meet the requirement of "joint-staff" duty. Also the length of the prescribed tour of duty appeared to have been shortened. The average tour length for the first five Directors of DMA was four years. For comparison purposes, during the six and a half years of the Board's existence, it has interacted with four different incumbents.
Concerned by the adverse effects on safety of these developments, the Chairman and another Board Member visited the Deputy Secretary of Defense in July 1994 and urged him to consider elevating the rank of the senior DMA military officer and extending the length of tour. The Deputy Secretary took action to return the rank to "two-star" (O-8) and made a tour extension to three years optional.<67> DOE itself did not take the initiative to enhance the importance of the assignment and was quite willing to accept a diminution of its importance.
In recent years there has also been an apparent dilution in the qualifications of other military officers assigned to DOE's nuclear weapons program; especially when compared to their counterparts in the early years of the program. One of the reasons has been that the nuclear weapons specialty has either ceased to exist or is regarded as "not career-enhancing." Also, the services are no longer encouraging graduate education aimed toward nuclear weapons as a specialty.<68> Another adverse factor might be the termination of the Military Research Associates (MRA) program under which young officers following a nuclear weapons career path could acquire experience at DOE's weapons laboratories working on weapons program assignments. During the years from 1953 to 1990, three hundred and twenty-one (321) individuals completed this program.<69> The Board expressed its concern on this issue in a letter to the Deputy Secretary of Defense which stated, in part:
"The Department of Defense's continuing attention to the selection of highly qualified individuals of sufficient stature and commitment to critical DOE Defense Programs positions will be an essential element in ensuring the continuing safety of the defense nuclear complex.<70>
The Board has no authority to ensure that there be DoD policies and programs which assure availability of officers of outstanding competence to the DOE weapons program. But it does have a responsibility to provide independent oversight of the DOE policies and practices by which officers assigned to safety responsibilities at defense nuclear facilities in DOE give assurance that they will be fully qualified.
It is not clear to the Board whether Congress has been kept informed of the conditions within the military services themselves which make it difficult for DOE to draw on the DoD for outstanding talent. To the extent that DOE cannot rely on the DoD to provide military officers of outstanding capability, it will need to make other provisions. But, DOE should ensure that the intent of Congress is not being altered with respect to the role of military officers in managing DOE's nuclear weapons program.
This paper has shown that the most important and far reaching problem affecting the safety of DOE defense nuclear facilities is the lack of sufficient numbers of personnel who are technically qualified to provide the management, direction and guidance essential for their safe operation.
This statement of the problem differs somewhat from that used by the Board in years past. The emphasis in previous statements was on DOE's " . . .difficulty in attracting and retaining personnel . . .<71> with the requisite technical qualifications. While this difficulty remains, it can no longer be called " . . .the most important and far-reaching problem affecting the safety of DOE defense nuclear facilities . . . .<72> The reasons should be readily apparent based on the data presented in this report. The more critical problem today is a lack of sufficient numbers of personnel who are technically qualified.
Despite repeated Board efforts to cause DOE to raise the level of technical expertise in the Department substantially, DOE progress to date has been inadequate. In order to invigorate its technical personnel, DOE must first establish a policy as regards the technical direction to be provided to its contractors. A DOE policy directive on this matter would clarify the situation; it should include direction with respect to: (a) the methods for providing technical direction (rules, orders, manuals, guides, etc.), (b) the appropriate level of detail, (c) the manner in which technical direction is provided (i.e., contractual nuances), (d) the mechanisms to assure that all important sources of input have been used (e.g., the field), and (e) the means by which contractor adherence to DOE technical direction and guidance will be monitored and assured.
The intent of the Board's Recommendation 93-3 was that the overall level of technical expertise in DOE be elevated. As shown above, this goal has, by and large, not been met. In order to invigorate the Recommendation 93-3 implementation process, DOE should perform several immediate "benchmarking" studies, that is, studies of other federal agencies that have consistently been able to attract and maintain highly competent technical and program management talent. The organizations used for this comparison should include, but not be limited to, the NR organization within DOE and the Navy's Strategic Programs (SP) organization, both of which have garnered consistent praise for their ability to accomplish complex technical assignments.<73> The report should include such recommendations, as deemed necessary, to achieve a comparably high level of "in-house" technical capability.
When these DOE studies are completed, the Board should review them and provide comments and/or recommendations deemed appropriate to the Secretary of Energy.
Given the lack of progress on the issue of improving the overall technical expertise of DOE, to-date, the Board should evaluate whether additional measures, either formal or informal, need to be taken. Such measures could range from providing informal assistance to DOE in identifying qualified candidates to making additional formal recommendations deemed necessary to remedy the situation and/or urging Congress to expand the Board's purview in areas associated with safety-related personnel in DOE.