Los Alamos National Laboratory Accident Investigation Board Corrective

Los Alamos National Laboratory Accident Investigation Board Corrective Action Plan Update to Regional Coalition of Los Alamos Communities Meeting Dave Nickless Environmental Management Los Alamos Field Office February 12, 2016

Investigation Reports q Phase 2 Accident Investigation Board (AIB) Report Issued April 16, 2015 • Local root cause: failure of Los Alamos National Security (LANS) to understand • and effectively implement the LANL Hazardous Waste Facility Permit and Carlsbad Field Office (CBFO) directed controls Systemic root cause: failure of National Nuclear Security Administration Los Alamos Field Office (NA-LA) and National Transuranic Program/CBFO to ensure that LANS had adequately developed and implemented repackaging and treatment procedures q Technical Assessment Team (TAT) Report Issued March 17, 2015 • • • DOE created an independent TAT to determine the mechanisms and chemical reactions that may have contributed to the failure of waste Drum 68660 Chemically incompatible contents of Drum 68660 from LANL in combination with physical conditions supported exothermic chemical reactions leading to a thermal runaway The consequent build-up of gases within the drum displaced the drum lid, venting radioactive materials 2

Corrective Action Plans (CAPs) q Phase 2 – 24 Conclusions and 40 Judgments of Need (JONs) • • • 5 JONs directed to EM-LA & NA-LA 16 JONs directed to LANS 1 JON directed to LANS and EM-LA & NA-LA q Overall CAP Approach • • DOE (EM Headquarters, CBFO, EM-LA, & NA-LA) and contractors (Nuclear Waste Partnership & Los Alamos National Security) established a set of integrated CAPs Accomplished by establishing Technical and Management Teams to develop a set of integrated corrective actions as a point of departure q Los Alamos DOE Field Office CAP Development • • • Established Senior Management Team to develop corrective actions Coordinated and integrated across EM-HQ, NNSA-HQ, CBFO, EM-LA and NA-LA and Field Office Contractors Final Los Alamos Field Office CAPs Approved on November 3, 2015 q Los Alamos DOE Field Office CAP Management • • • CAP Managers identified and assigned Integrated schedule developed to track status and actions CAPs under configuration control 3

Types of Corrective Actions at LANL Addressing Systematic Issues JON 14: Process Engineering/Change Control JON 32: Procedure Development JON 39: Safety Culture Improving Requirements Definition JON 9, 10: RCRA Requirements JON 13, 18: Remediated Nitrate Salt Technical Basis JON 19, 20, 21: Safety Basis Implementing Improvements JON 15, 16, 17: WCRRF Glovebox Procedure JON 38: Training and Qualification JON 38: Safety Basis Ensuring Compliance and Improving Oversight JON 22, 23, 24: Unreviewed Safety Question Process JON 38, 39: Contractor Assurance System and Quality Assurance JON 38: Safety Basis JON 3, 26, 27, 29: Oversight Numbers in red are JONs that are assigned to EM-LA and NA-LA. Numbers in black are JONs assigned to LANS. 4

LANL Corrective Action Plans q LANS – 17 JONs Resulting in 58 Actions: • 12 Address Systemic Issues (Process Engineering, Procedure Development & Safety Culture) • 23 Improve Requirements (RCRA, Nitrate Salt, Nuclear Safety) • 6 Implement Improvements in Procedures, Training and Qualification for Waste Packaging • 13 Compliance (Safety Basis, Contractor Assurance & Quality Assurance) • 4 Relate to obtaining DOE Approvals for Remediation of Nitrate Salt Waste (Stored at LANL) q EM-LA – 6 JONs Resulting in 33 Actions: • 33 Focused on Oversight, Training and Safety Culture q NA-LA – 6 JONs Resulting in 23 Actions: • 23 Focused on Oversight, Training and Safety Culture 5

Summary Status of Corrective Actions CAP ACTIONS ORGANIZATION Total Complete NA-LA 23 7 EM-LA 33 21 LANS 58 36 Total 184 96 Coordination Process q NA-LA coordinates actions with NA-HQ q EM-LA coordinates actions with EM-HQ q LANS coordinates with both EM-LA and NA-LA 6

CAP Implementation q Federal LANL CAP End-State • Documented Roles, Responsibilities, Accountabilities and Authorities between EM-LA, NA-LA and CBFO • Formalized Process for Performing Contractor Oversight • Qualified staff with Experience Commensurate with Responsibilities • Training/Qualification in-place for Oversight Positions • Safety Culture training provided to Managers and Employees • Improved Operational Envelope (i. e. : nuclear safety, RCRA and waste management programs) 7

Moving Forward q LANL Legacy Waste Missions • q Integration and coordination to meet waste management and disposal objectives Los Alamos Field Managers Are Engaged and Committed to Improving LANL Oversight • Collaboration and integration of waste operations is a top priority 8