[Federal Register Volume 79, Number 184 (Tuesday, September 23, 2014)]
[Notices]
[Pages 56779-56796]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-22510]


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DEFENSE NUCLEAR FACILITIES SAFETY BOARD

[Recommendation 2014-1]


Emergency Preparedness and Response

AGENCY: Defense Nuclear Facilities Safety Board.

ACTION: Notice, recommendation.

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SUMMARY: Pursuant to 42 U.S.C. 2286a(b)(5), the Defense Nuclear 
Facilities Safety Board has made a recommendation to the Secretary of 
Energy concerning the need to take actions to improve the emergency 
preparedness and response capability at the Department of Energy's 
(DOE) defense nuclear facilities.

DATES: Comments, data, views, or arguments concerning the 
recommendation are due on or before October 23, 2014.

ADDRESSES: Send comments concerning this notice to: Defense Nuclear 
Facilities Safety Board, 625 Indiana Avenue NW., Suite 700, Washington, 
DC 20004-2001.

FOR FURTHER INFORMATION CONTACT: Andrew L. Thibadeau at the address 
above or telephone number (202) 694-7000.

    Dated: September 17, 2014.
Peter S. Winokur, Ph.D.,
Chairman.

Recommendation 2014-1 to the Secretary of Energy

Emergency Preparedness and Response

Pursuant to 42 U.S.C. Sec.  2286d(a)(3)
Atomic Energy Act of 1954, As Amended
Dated: September 2, 2014
    The need for a strong emergency preparedness and response program 
to protect the public and workers at the Department of Energy's (DOE) 
defense nuclear facilities is self-evident. Design basis accidents 
resulting from natural phenomena hazards and operational events do 
occur and must be addressed. Consequently, emergency preparedness and 
response is a key component of the safety bases for defense nuclear 
facilities, as evidenced by its inclusion as a safety management 
program in the technical safety requirements for these facilities and 
in specific administrative controls that reference individual elements 
of emergency response. It is the last line of defense to prevent public 
and worker exposure to hazardous materials. One of the objectives of 
DOE's order on emergency preparedness and response (Order 151.1C, 
Emergency Management System) is to ``ensure that the DOE Emergency 
Management System is ready to respond promptly, efficiently, and 
effectively to any emergency involving DOE/[National Nuclear Security 
Administration (NNSA)] facilities, activities, or operations, or 
requiring DOE/NNSA assistance.'' The Defense Nuclear Facilities Safety 
Board (Board) believes that the requirements in this order that 
establish the basis for emergency preparedness and response at DOE 
sites with defense nuclear facilities, as well as the current 
implementation of these requirements, must be strengthened to ensure 
the continued protection of workers and the public.
    Problems with emergency preparedness and response have been 
discussed at Board public hearings and meetings over the past three 
years, as well as in Board site representative weekly reports and other 
reviews by members of the Board's technical staff. At its hearings, 
Board members have stressed the need for DOE to conduct meaningful 
training and exercises to demonstrate site-wide and regional 
coordination in response to emergencies. Board members have also 
encouraged DOE to demonstrate its ability to respond to events that 
involve multiple facilities at a site and the potential for several 
``connected'' events, e.g., an earthquake and a wildland fire at Los 
Alamos.
    On March 21, 2014, and March 28, 2014, the Board communicated to 
the Secretary of Energy its concerns regarding shortcomings in the 
responses to a truck fire and radioactive material release event at the 
Waste Isolation Pilot Plant (WIPP) in Carlsbad, New Mexico. The DOE 
Accident Investigation Board explored and documented these shortcomings 
in its reports. Many of the site-specific issues noted at WIPP are 
prevalent at other sites with defense nuclear facilities, as documented 
in the attached report.
    The Board has observed that these problems can be attributed to the 
inability of sites with defense nuclear facilities to consistently 
demonstrate fundamental attributes of a sound emergency preparedness 
and response program, e.g., adequately resourced emergency preparedness 
and response programs and proper planning and training for emergencies. 
DOE has noted these types of problems in reports documenting 
independent assessments of its sites and in its annual reports on the 
status of its emergency management system. The annual reports also 
noted a lack of progress in addressing these problems.
    The Board is concerned that these problems stem from DOE's failure 
to implement existing emergency management requirements and to 
periodically update these requirements. DOE has not effectively 
overseen and enforced compliance with these requirements, which 
establish the baseline for emergency preparedness and response at its 
sites with defense nuclear facilities. These requirements need to be 
revised periodically to address lessons learned, needed improvements to 
site programs, new information from accidents such as those at the 
Deepwater Horizon drilling rig and the Fukushima Dai-ichi Nuclear Power 
Plant, and inconsistent

[[Page 56780]]

interpretation and implementation of the requirements.
    Through its participation in DOE nuclear safety workshops in 
response to the events at the Fukushima Dai-ichi Nuclear Power Plant 
and its lines of inquiry regarding emergency preparedness and response 
at recent public hearings and meetings, Board members have been 
supportive of DOE's efforts to improve its response to both design 
basis and beyond design basis events. However, the Board believes DOE's 
efforts to adequately address emergency preparedness and response at 
its sites with defense nuclear facilities have fallen short as clearly 
evidenced by the truck fire and radioactive material release events at 
WIPP.
Background
    Technical planning establishes the basis for emergency preparedness 
and response at DOE sites with defense nuclear facilities. Technical 
planning includes the development of emergency preparedness hazards 
assessments, identification of conditions to recognize and categorize 
an emergency, and identification of needed protective actions. This 
basis is used to develop emergency response procedures, training, and 
drills for emergency response personnel. This basis leads to 
identification of resource requirements for emergency response, 
including facilities and equipment. Technical planning is also the 
basis for determining the scope and scenario of exercises and other 
assessments used to verify and validate readiness and effectiveness of 
emergency response capabilities at DOE sites with defense nuclear 
facilities.
    Hazards assessments form the foundation of the technical planning 
basis for emergency preparedness and response and provide the basis for 
the preparation of the procedures and resources used as personnel 
respond to emergencies. As cited in the attached report, the Board has 
observed that hazards assessments at many DOE sites with defense 
nuclear facilities do not (1) address all the hazards and potential 
accident scenarios, (2) contain complete consequence analyses, (3) 
develop the emergency action levels for recognizing indicators and the 
severity of an emergency, and (4) contain sufficiently descriptive 
protective actions. One example of incomplete hazards analysis that is 
endemic to the complex is the lack of consideration of severe events 
that could impact multiple facilities, overwhelm emergency response 
capabilities, and/or have regional impacts.\1\ This was a topic of 
discussion at the Board's public meeting and hearing on the Pantex 
Plant in Amarillo, Texas, on March 14, 2013, and on the Y-12 National 
Security Complex in Knoxville, Tennessee, on December 10, 2013.
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    \1\ Severe events include design basis and beyond design basis 
events. They also include operational and natural phenomena events.
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    At many DOE sites with defense nuclear facilities, the Board has 
observed, as cited in the attached report, that training on the use of 
emergency response procedures, facilities, and equipment is not 
adequate to fully prepare facility personnel and members of the 
emergency response organization. Similarly, drill programs are not 
adequately developed and implemented to augment this training.
    As part of their preparedness for emergencies, DOE sites with 
defense nuclear facilities have emergency response facilities such as 
Emergency Operations Centers and firehouses, and associated support 
equipment. The Board has observed that some emergency response 
facilities at DOE sites with defense nuclear facilities will not 
survive all potential accidents and natural phenomena events and, 
consequently, will be unable to perform their vital function of 
coordinating emergency response. As discussed in the attached report, 
many of these facilities will not be habitable during radiological or 
hazardous material releases. Equipment that is used to support 
operations of these facilities is frequently poorly maintained and may 
not be reliable during an emergency.
    The Board has also observed problems with DOE efforts to 
demonstrate the effectiveness of its planning and preparation for 
emergencies and its response capabilities. Exercises are used to 
demonstrate a site's capability to respond, and assessments are used to 
verify adequacy of planning and preparedness. As discussed in the 
attached report, exercises conducted at many DOE sites with defense 
nuclear facilities do not adequately encompass the scope of potential 
scenarios (i.e., various hazards and accidents) that responders may 
encounter. Some sites do not conduct exercises frequently enough or do 
not develop challenging scenarios. Many sites are not effective at 
critiquing their performance, developing corrective actions that 
address identified problems, and measuring the effectiveness of these 
corrective actions.
    DOE oversight is a mechanism for continuous improvement and is used 
to verify the adequacy of emergency preparedness and response 
capabilities at its sites with defense nuclear facilities. As cited in 
the attached report, the Board has observed that many DOE line 
oversight assessments are incomplete and ineffective, and do not 
address the effectiveness of contractor corrective actions. In 
addition, the Board has noted that the current scope of DOE independent 
oversight is not adequate to identify needed improvements and to ensure 
effectiveness of federal and contractor corrective actions.
    As observed recently with the emergency responses to the truck fire 
and radioactive material release events at WIPP, there can be 
fundamental problems with a site's emergency preparedness and response 
capability that will only be identified by more comprehensive 
assessments that address the overall effectiveness of a site's 
emergency management program. For example, emergencies can occur during 
off-shift hours, such as the radioactive material release event at WIPP 
that happened at approximately 11:00 p.m. on Friday, February 14, 2014. 
Overall effectiveness was the scope of DOE's independent assessments 
conducted prior to 2010. These assessments consistently identified 
problems with site emergency preparedness and response, and also sought 
continuous improvement of these programs. In 2010, DOE independent 
oversight transitioned to assist visits and did not conduct independent 
assessments. In 2012, DOE independent oversight returned to conducting 
independent assessments. However, these assessments are targeted 
reviews, currently only focused on the ability of the sites to prepare 
and respond to severe events. As a result, these independent 
assessments do not encompass all elements of emergency management 
programs and will not identify many fundamental problems.
Causes of Problems
    Based on an evaluation of the problems observed with emergency 
preparedness and response at DOE sites with defense nuclear facilities, 
the most important underlying root causes of these problems are 
ineffective implementation of existing requirements, inadequate 
revision of requirements to address lessons learned and needed 
improvements to site programs, and weaknesses in DOE verification and 
validation of readiness of its sites with defense nuclear facilities.
    The Board has observed at various DOE sites with defense nuclear 
facilities that implementation of DOE's requirements for emergency

[[Page 56781]]

preparedness and response programs varies widely. Therefore, the Board 
concluded that some requirements do not have the specificity to ensure 
effective implementation. For example, existing requirements for 
hazards assessments lack detail on addressing severe events. 
Requirements do not address the reliability of emergency response 
facilities and equipment. Requirements for training and drills do not 
address expectations for the objectives, scope, frequency, and reviews 
of effectiveness of these programs. Requirements for exercises do not 
include expectations for the complexity of scenarios, scope of 
participation, and corrective actions.
    Guidance and direction that address many of the deficiencies in 
these requirements are included in the Emergency Management Guides that 
accompany DOE Order 151.1C; however, many sites with defense nuclear 
facilities do not implement the practices described in these guides. 
DOE has not updated its directive to address the problem with 
inconsistent implementation. In addition, DOE has not incorporated the 
lessons learned from the March 11, 2011, earthquake and tsunami at the 
Fukushima Dai-ichi Nuclear Power Plant in its directive.\2\ These 
lessons learned need to be more effectively integrated into DOE's 
directive and guidance on emergency preparedness and response.
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    \2\ Lessons learned from this event that are applicable to DOE 
sites and facilities were discussed by DOE during its June 2011 
Nuclear Safety Workshop and published in its August 16, 2011 report, 
A Report to the Secretary of Energy: Review of Requirements and 
Capabilities for Analyzing and Responding to BDBEs, and its January 
2013 report, A Report to the Secretary of Energy: Beyond Design 
Basis Event Pilot Evaluations, Results and Recommendations for 
Improvements to Enhance Nuclear Safety at DOE Nuclear Facilities.
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    The Board also observed that DOE has not effectively conducted 
oversight and enforcement of its existing requirements. DOE oversight 
does not consistently identify the needed improvements to site 
emergency preparedness and response called for in its directive. When 
problems are identified, their resolution often lacks adequate causal 
analysis and appropriate corrective actions. When corrective actions 
are developed and implemented, contractors and federal entities 
frequently do not measure the effectiveness of these actions.
Conclusions
    The Board and DOE oversight entities have identified problems with 
implementation of emergency preparedness and response requirements at 
various DOE sites with defense nuclear facilities. The Board has also 
identified problems with specific emergency preparedness and response 
requirements. These deficiencies lead to failures to identify and 
prepare for the suite of plausible emergency scenarios and to 
demonstrate proficiency in emergency preparedness and response. Such 
deficiencies can ultimately result in the failure to recognize and 
respond appropriately to indications of an emergency, as was seen in 
the recent radioactive material release event at WIPP. Therefore, the 
Board believes that DOE has not comprehensively and consistently 
demonstrated its ability to adequately protect workers and the public 
in the event of an emergency.
Recommendations
    To address the deficiencies summarized above, the Board recommends 
that DOE take the following actions:
    1. In its role as a regulator, by the end of 2016, standardize and 
improve implementation of its criteria and review approach to confirm 
that all sites with defense nuclear facilities:
    a. Have a robust emergency response infrastructure that is 
survivable, habitable, and maintained to function during emergencies, 
including severe events that can impact multiple facilities and 
potentially overwhelm emergency response resources.
    b. Have a training and drill program that ensures that emergency 
response personnel are fully competent in accordance with the 
expectations delineated in DOE's directive and associated guidance.
    c. Are conducting exercises that fully demonstrate their emergency 
response is capable of responding to scenarios that challenge existing 
capability, including their response during severe events.
    d. Are identifying deficiencies with emergency preparedness and 
response, conducting causal analysis, developing and implementing 
effective corrective actions to address these deficiencies, and 
evaluating the effectiveness of these actions.
    e. Have an effective Readiness Assurance Program consistent with 
DOE Order 151.1C, Comprehensive Emergency Management System, Chapter X.
    2. Update its emergency management directive to address:
    a. Severe events, including requirements that address hazards 
assessments and exercises, and ``beyond design basis'' operational and 
natural phenomena events.
    b. Reliability and habitability of emergency response facilities 
and support equipment.
    c. Criteria for training and drills, including requirements that 
address facility conduct of operations drill programs and the interface 
with emergency response organization team drills.
    d. Criteria for exercises to ensure that they are an adequate 
demonstration of proficiency.
    e. Vulnerabilities identified during independent assessments.

Peter S. Winokur, Ph.D.,

Chairman

Recommendation 2014-1 to the Secretary of Energy

Emergency Preparedness and Response

--Findings, supporting data, and analysis--
    Introduction. In recent years, multiple high-visibility, high-
consequence accidents have occurred. On April 20, 2010, the Deepwater 
Horizon oil rig exploded and sank, resulting in a sea floor oil gusher 
flowing for 87 days and releasing about 210 million gallons of oil in 
the Gulf of Mexico. On March 11, 2011, an earthquake and tsunami struck 
the Fukushima Dai-ichi Nuclear Power Plant, resulting in equipment 
failures, and a subsequent loss of coolant accident, nuclear meltdowns, 
and releases of radioactive materials. Both accidents are examples of 
an initial event that cascaded into subsequent events. In both cases 
the facility operators, institutional managers, and emergency 
responders were not adequately prepared.
    The Defense Nuclear Facilities Safety Board (Board) has been 
concerned about whether (1) the Department of Energy (DOE) has provided 
adequate direction and guidance for emergency preparedness and response 
to severe events \1\ that could affect multiple facilities, lead to 
cascading effects, cause loss of necessary utilities and supporting 
infrastructure, and require coordination for offsite support; (2) DOE 
sites and facilities have implemented DOE requirements for emergency 
preparedness and response; (3) DOE, in its role as a regulator, has 
provided adequate oversight of site and facility emergency preparedness 
and response; and (4) DOE and its contractors are adequately trained 
and qualified, and are using drills and exercises effectively and as 
required. In general, the Board has been concerned about a culture of

[[Page 56782]]

complacency with respect to emergency preparedness and response.
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    \1\ Severe events include design basis and beyond design basis 
events. They also include operational and natural phenomena events.
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    These concerns about the emergency preparedness and response 
capabilities of DOE sites have been topics during recent Board public 
meetings and hearings at the Savannah River Site [1], Los Alamos 
National Laboratory [2], Pantex Plant [3], and Y-12 National Security 
Complex (Y-12) [4]. To address these concerns, members of the Board's 
staff conducted a review (1) to ensure DOE site emergency preparedness 
and response capabilities provide adequate protection of the public and 
workers; and (2) to provide feedback to DOE Headquarters and sites 
about improvements to complex-wide emergency management programs and 
site emergency preparedness and response. The objectives for the review 
included:
     Assessing individual DOE site emergency preparedness and 
response capabilities.
     Assessing DOE Headquarters efforts to provide 
comprehensive requirements and guidance, and to provide oversight and 
enforcement for conducting emergency management; specifically, recent 
efforts to improve site preparedness for severe events.
    As part of an effort to assess the overall ``health'' of emergency 
preparedness and response at DOE defense nuclear facilities, members of 
the Board's staff conducted programmatic reviews at DOE's National 
Nuclear Security Administration (NNSA) and Environmental Management 
sites, representing the various elements of the nuclear weapons complex 
(i.e., weapons design laboratories, production sites, and cleanup 
sites). These assessments included reviews of emergency management 
program documents (including policy documents, plans, hazard 
assessments, and procedures; findings and opportunities for improvement 
(OFIs) resulting from federal and contractor assessments; corrective 
actions to address findings and OFIs; exercise and drill packages, with 
their associated after-action reports; etc.); onsite programmatic 
reviews; reviews conducted using video conferencing facilities; reviews 
to follow up on the results of previous reviews; and observation of 
drills and exercises. In addition to reviewing emergency preparedness 
and response in general, the staff reviews also addressed the ability 
to prepare and respond to severe events (e.g., events that can affect 
multiple facilities, can cascade into additional events, and can 
overwhelm site resources).
    Historical Background. The Board has had a long-standing interest 
in the state of emergency preparedness and response at DOE sites that 
predates Deepwater Horizon and Fukushima. In the late 1990s, the Board 
issued a Technical Report [5] and a Recommendation [6] that led to 
improvements in emergency preparedness and response. However, the Board 
observed in the past several years that the momentum for continuous 
improvement has faded and that some sites have lost ground, failing to 
institutionalize improvements they had begun. The following section 
summarizes the Board's earlier engagement in improving emergency 
preparedness and response at DOE sites, and the fate of the resulting 
improvements.
    DNFSB Technical Report--In March 1999, the Board published 
Technical Report-21, Status of Emergency Management at Defense Nuclear 
Facilities of the Department of Energy. The reviews documented in that 
report were based on objective evaluation guidance promulgated by both 
DOE [7] and the Federal Emergency Management Agency [8]. Although the 
evaluations were based on observations at several facilities with 
widely diverse missions and operating characteristics, and the 
observations were made over an extended time, there were a number of 
observations that recurred. The following bulleted list is a direct 
quote of the Board's general conclusions regarding the status of 
emergency management in a DOE-wide context:
     Top-level requirements and guidance for DOE and contractor 
organizations involved in emergency management functions are well 
founded and clearly set forth in appropriate documents.
     Applicable requirements and guidance are applied 
selectively. In some cases, noncompliance is condoned on the basis of a 
faulty conclusion--either that a requirement ``doesn't apply here,'' or 
that a particular guidance element ``isn't mandatory.''
     A potentially serious problem exists at the DOE level, 
involving apparent misperceptions and questionable interpretations 
regarding the division of responsibility for: (1) Development and 
promulgation of emergency management requirements and guidance; (2) 
establishment, conduct, and supervision of emergency management 
programs; and (3) oversight and evaluation of performance. 
Responsibilities are set forth clearly enough in DOE Order 151.1, 
Comprehensive Emergency Management System (dated September 25, 1995) 
[9], but implementation could be made more effective with better 
cooperation among senior and mid-level managers in programmatic and 
staff offices [at DOE Headquarters] involved with emergency management 
matters. These conflicts, which also exist between DOE Headquarters and 
field elements, have been observed in other DOE contexts as well. All 
the involved organizations bear some degree of responsibility for these 
problems. This matter merits attention at the highest levels of DOE 
management.
     Deficiencies exist in emergency hazard analyses in one or 
more of the following areas:

--Thoroughness of hazard assessments performed as elements of emergency 
planning at defense nuclear facilities, particularly in addressing all 
nuclear and nonnuclear hazards with potential impact on ongoing nuclear 
operations.
--Verification and independent review processes used to ensure the 
completeness and accuracy of the parameters and analytical tools 
employed in hazard and consequence analyses, and identification of 
Emergency Classifications, Emergency Planning Zones, and Protective 
Action Recommendations.
--Integration of emergency hazard assessments with related 
authorization basis activities for identification and implementation of 
the controls necessary for effective accident response.

     In general, consequence assessment is weak all across the 
DOE complex. Observations have included use of inapplicable 
computational models and/or software that is limited with regard to the 
hazards and accident scenarios that can be simulated. There are too few 
qualified responders assigned to execute sophisticated computer 
modeling programs for downwind plots of likely radiation levels and/or 
contamination; at some sites this responsibility is vested in a single 
individual.
     At some sites and facilities, Emergency Action Levels are 
insufficiently developed and poorly implemented. Response procedures 
occasionally fail to address reasonably postulated incidents that could 
lead to an operational emergency, sometimes because hazard assessments 
were not sufficiently comprehensive or penetrating. In some cases, 
initiating conditions have not been recognized in sufficient detail to 
permit timely initiation of the appropriate emergency action.
     Responders are slow to classify emergencies and to 
disseminate

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appropriate Protective Action Recommendations, both in drills and 
exercises, and in actual events. In some cases, recommended actions 
have been inconsistent with the prevailing conditions; in others, 
communication of the recommendations has been confused and unclear, 
leading either to failure to implement suitable protective measures or 
to implementation of unnecessary measures.
     Members of emergency response organizations whose 
emergency response duties are in addition to their routine day-to-day 
responsibilities are generally provided only minimal training regarding 
the infrastructure, equipment, and procedures involved in emergency 
response. Most of the training they do receive is imparted on the job 
during periodic drills and exercises; little formal classroom training 
or one-on-one tutoring is conducted for this group of responders.
     Tracking of the resolution of weaknesses disclosed during 
drills and exercises, as well as those experienced during actual 
emergencies, is poor. Closure of these issues is, at best, informal, 
with almost no attention from senior DOE managers. As a result, many 
weaknesses do not get satisfactorily resolved, and repetition tends to 
ingrain them groundlessly as inevitable characteristics of emergency 
response that cannot be corrected.
    DNFSB Recommendation 98-1--On September 28, 1998, the Board issued 
Recommendation 98-1, Resolution of Issues Identified by Department of 
Energy (DOE) Internal Oversight [6]. Under this recommendation, the 
Board cited the need to establish a clear, comprehensive, and 
systematic process to address and effectively resolve the environment, 
safety, and health issues identified by independent oversight during 
the conduct of assessment activities. As a result, DOE established a 
disciplined process, clarifying roles and responsibilities for the 
identification of, and response to, safety issues; established clearer 
direction on elevating any disputed issues for resolution to the Office 
of the Secretary, if necessary; and established a tracking and 
reporting system to effectively manage completion of corrective 
actions, known as the ``Corrective Actions Tracking System.''
    DOE sent the Implementation Plan [10] for Recommendation 98-1 to 
the Board, which accepted the Implementation Plan in March 1999. As 
part of its implementation of this plan, DOE developed corrective 
actions to address the issues identified in Technical Report-21 and 
during DOE's assessments of emergency management programs. DOE used 
these corrective actions as case studies to demonstrate execution of 
its Implementation Plan. Initially, the Corrective Actions Tracking 
System addressed only emergency management issues.
    Evolution of DOE Oversight--After DOE identified serious problems 
in its security practices, the Secretary of Energy created the Office 
of Independent Oversight and Performance Assurance in early 1999 to 
consolidate security-related Department-wide independent oversight into 
a single office reporting directly to the Office of the Secretary of 
Energy. As a result of significant concerns with emergency management 
programs throughout the DOE complex, DOE created the Office of 
Emergency Management Oversight within the new organization. DOE 
incorporated the Office of Independent Oversight (which included the 
Office of Emergency Management Oversight) into the new Office of 
Security and Safety Performance Assurance in 2004, and then into the 
Office of Health, Safety and Security in 2006. The Office of Emergency 
Management Oversight began conducting oversight inspections in 2000.
    The Office of Emergency Management Oversight conducted evaluations 
of the emergency management programs at DOE's sites about every three 
years, in accordance with DOE Order 470.2A, Security and Emergency 
Management Independent Oversight and Performance Assurance Program 
[11], and DOE Order 470.2B, Independent Oversight and Performance 
Assurance Program [12].
    Initially, the evaluations focused on critical planning and 
preparedness of sites to classify the severity of emergency conditions 
and to initiate appropriate protective actions. The evaluations 
addressed the identification and analysis of hazards, consequence 
analysis, emergency action levels used to determine the classification 
of an emergency, and protective actions for the workers and public. The 
evaluations included limited scope performance tests to demonstrate 
effectiveness of the emergency response organization to execute these 
essential response actions. As the Office of Emergency Management 
Oversight observed improvement with the ability to determine and 
implement protective actions, it iteratively expanded the scope of the 
evaluations to include other elements of emergency preparedness, such 
as the adequacy of plans, procedures, emergency response organization, 
training, drill and exercise programs, and readiness assurance.
    The Office of Emergency Management Oversight documented the results 
of the evaluations, reviewed corrective action plans, and then followed 
up with an evaluation of the effectiveness of the corrective actions in 
the next year. The oversight resulted in progressive improvement in the 
emergency management programs at the DOE sites. The Board's staff 
limited its oversight of DOE's emergency management programs as a 
result of the rigor and effectiveness of the Office of Emergency 
Management Oversight.
    In 2009, in compliance with the new vision for the Office of 
Health, Safety and Security (HSS) [13], the Office of Emergency 
Management Oversight focused on assisting DOE line management with 
solving problems in the area of emergency management, versus 
independent oversight.\2\ In short, this focus included:
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    \2\ HSS was recently reorganized into two new offices, the 
Office of Independent Enterprise Assessments and the Office of 
Environment, Health, Safety and Security; however, the rest of this 
paper will reference HSS since that was its designation when the 
reviews referenced in this paper were conducted. Also note that the 
Office of Emergency Management Oversight, which subsequently became 
part of the Office of Safety and Emergency Evaluations, has become 
the Office of Emergency Management Assessments and is located in the 
Office of Independent Enterprise Assessments as part of this 
reorganization.
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     Providing mission support activities only at the request 
of DOE line managers.
     Defining activities in a collaborative fashion with 
cognizant site and Headquarters managers and staff, tailoring the 
activities to best meet identified needs.
     Developing mission support activity reports and similar 
products that have been specifically designed to provide the 
information requested by line management, and that do not include 
ratings or findings.

In addition to moving from an independent oversight mode to an assist 
mode, the Office of Emergency Management Oversight no longer tracked 
corrective actions.
    DOE began to consider its preparedness for beyond design basis 
accidents after the 2011 Fukushima accident. As a result, evaluation of 
emergency preparedness and response at DOE's sites and facilities 
received attention again. However, DOE limited its reviews to 
evaluations of severe events.
    DOE Response to Fukushima--In response to the March 11, 2011, 
earthquake and tsunami at the Fukushima Dai-ichi nuclear power plant, 
the Secretary of Energy issued a safety bulletin, Events Beyond Design 
Safety Basis Analysis, on March 23, 2011 [14]. This safety bulletin 
identified actions ``to evaluate facility

[[Page 56784]]

vulnerabilities to beyond design basis events at [DOE] nuclear 
facilities and to ensure appropriate provisions are in place to address 
them.'' The safety bulletin directed that these actions were to be 
completed for Hazard Category 1 nuclear facilities by April 14, 2011, 
and for Hazard Category 2 nuclear facilities by May 13, 2011.
    During June 6-7, 2011, DOE held a two-day workshop addressing 
preliminary lessons learned from Fukushima. This workshop included 
presentations from representatives of government agencies and private 
industry, plus breakout sessions to identify vulnerabilities associated 
with beyond design basis events, natural phenomena hazards, emergency 
management, and actions to address these vulnerabilities. Results from 
this workshop and the responses to the Secretary of Energy's safety 
bulletin were published by DOE in the August 2011 Nuclear Safety 
Workshop Report, Review of Requirements and Capabilities for Analyzing 
and Responding to BDBEs [15]. This report identified recommendations 
for near-term and long-term actions to improve DOE's nuclear safety. A 
September 16, 2011, memorandum [16] from the Deputy Secretary 
``directed the Office of Health, Safety and Security (HSS) to work with 
DOE's Nuclear Safety and Security Coordinating Council, and the Program 
and Field Offices of both DOE and the National Nuclear Security 
Administration, to develop a strategy to implement the recommended 
actions and report back to [the Deputy Secretary] by the end of 
September 2011.'' The memorandum also stated that the Deputy Secretary 
``expect[ed] all short-term actions identified in section 8.1 of the 
attached report [to] be completed by March 31, 2012, and all 
recommendations to be completed by December 31, 2012.''
    HSS issued an implementation strategy, Strategy for Implementing 
Beyond Design Basis Event Report Recommendation, in February 2012 [17]. 
The implementation strategy addressed all the recommendations in the 
August 2011 Workshop Report and proposed that guidance and criteria be 
piloted at several nuclear facilities prior to revising safety basis 
and emergency management directives. HSS conducted pilot studies at the 
High Flux Isotope Reactor at the Oak Ridge National Laboratory, the 
Waste Encapsulation Storage Facility (WESF) at the Hanford Site, the H-
Area Tank Farms at the Savannah River Site, and the Tritium Facility at 
the Savannah River Site [18, 19].
    One of the recommendations in the August 2011 Nuclear Safety 
Workshop Report was to update the emergency management directives by 
December 2012 with a focus on incorporating requirements and guidance 
for addressing severe accidents. The DOE Office of Emergency 
Operations, which is responsible for the development and maintenance of 
DOE requirements for emergency preparedness and response at its sites, 
developed draft guidance for planning and preparing for severe events 
as part of its response to lessons learned from Fukushima; however, it 
has not been able to incorporate this guidance in the emergency 
management directives. To date, none of these directives have been 
updated to reflect the lessons learned from the earthquake and tsunami 
at the Fukushima Dai-ichi nuclear power plant. In fact, the Office of 
Emergency Operations has not been able to update either the emergency 
management order (last revised in 2005) or the supporting guides (last 
revised in 2007) as part of its normal update and revision cycle. The 
Operating Experience Level 1 Document, Improving Department of Energy 
Capabilities for Mitigating Beyond Design Basis Events (OE-1), issued 
in April 2013 [20] does contain a summary of this guidance, but it does 
not drive action to implement this guidance.
    Review Approach. To address the Board's objectives, members of the 
Board's staff developed three questions that formed the foundation of 
its review of the state of emergency preparedness and response at DOE 
defense nuclear facilities:
    1. Does DOE provide facility workers, response personnel, and 
emergency management decision makers with adequate direction and 
guidance to make timely, conservative emergency response decisions and 
take actions that focus on protection of the public and workers?
    2. Does DOE provide adequate equipment and hardened facilities that 
enable emergency response personnel and emergency management decision 
makers to effectively respond to emergencies and protect the public and 
workers?
    3. Do the contractor assurance systems and DOE oversight provide an 
effective performance assurance evaluation of emergency preparedness 
and response?
    The staff review was supplemented by reviews of relevant DOE 
independent oversight assessments. Members of the Board's staff also 
made observations regarding the ability of various site emergency 
management programs to address severe events, and included observations 
of the response to the truck fire and radioactive material release 
events at the Waste Isolation Pilot Plant (WIPP).
    Observations. The following sections discuss observations made by 
members of the Board's staff as part of their review. Although the 
staff team made observations in numerous areas of emergency 
preparedness and response, the following sections address staff team 
observations that will have the most impact on improvements to 
emergency preparedness and response at DOE sites. The Technical 
Planning Documents, Training and Drills, and Exercises sections address 
the first review question. The Facilities and Equipment section 
addresses the second question. The Oversight and Assessments section 
addresses the third question. Some observations reflect problems with 
emergency management program requirements and guidance, including 
observations addressing: Problems with specific requirements, problems 
with implementation of guidance, and problems with oversight and 
enforcement of compliance with these requirements.
    Technical Planning Documents--Planning is a key element in 
developing and maintaining effective emergency preparedness and 
response. As required by DOE Order 151.1C [21], ``emergency planning 
must include identification and analysis of hazards and threats, hazard 
mitigation, development and preparation of emergency plans and 
procedures, and identification of personnel and resources needed for an 
effective response.'' DOE Guide 151.1-2, Technical Planning Basis [22], 
provides further clarification, highlighting in section 2.1 the need to 
document the technical planning basis used to determine ``the necessary 
plans/procedures, personnel, resources, equipment, and analyses [e.g., 
determination of an Emergency Planning Zone] that comprise'' an 
emergency management program.
    Hazard Assessments: Development of planning documents begins with 
identification and analysis of hazards and threats, which is then 
followed by the development of actions to mitigate the effects of these 
hazards and threats during an emergency. The Board's staff team 
observed that the quality of these documents varied widely among the 
DOE sites, also varying among contractors at a site. Specifically, the 
staff team observed that hazards assessments at many DOE sites do not 
address all the hazards and potential

[[Page 56785]]

accident scenarios,\3\ contain incomplete consequence analyses, do not 
develop the emergency actions levels (EALs) for recognizing indications 
and the severity of an emergency, and contain incorrect emergency 
planning zones. In addition, a few sites limited their hazards 
assessments to the bounding analysis in their documented safety 
analysis; as a result, the hazard assessments do not address less 
severe events warranting protective actions for the workforce, and do 
not address beyond design basis accidents.
---------------------------------------------------------------------------

    \3\ An EPHA does not have to analyze all the scenarios, but it 
does have to identify all possible initiating events and their 
impacts and analyze the results of all potential impacts (such as 
breaching a confinement barrier or causing an explosion or fire).
---------------------------------------------------------------------------

    For example, during its 2013 review of the emergency planning 
hazard assessments (EPHAs) for facilities at the Sandia National 
Laboratories (SNL) in New Mexico, the Board's staff team found that the 
EPHAs were incomplete. The EPHAs for SNL defense nuclear facilities 
included input parameters for consequence analyses, but did not include 
documentation of the calculation or the results [23-25]. Further, the 
SNL EPHAs did not document the derivation of, or basis for, the EALs 
[23-25]. The EPHA for the Pantex Plant did not address flooding as a 
potential operational emergency, even though flooding occurred on July 
7, 2010 [26-29]. The emergency responders for the radioactive material 
release at WIPP were unable to classify the event to identify needed 
protective actions because the hazard assessment did not evaluate a 
radiological release when the mine was unoccupied or when operations 
underground were not ongoing [30]. Although some sites have addressed 
natural phenomena events in their EPHAs, others have not. Overall, the 
sites do not address ``severe'' events that would affect multiple 
facilities or regional areas.
    Emergency Action Levels: During its review of EALs for various 
sites, members of the Board's staff found that EALs and protective 
actions in the EPHAs for defense nuclear facilities were often based 
only on the worst case design basis accidents and were too generic to 
be effective. When decision makers know that the release is less severe 
than the worst case accident, they may be reluctant to implement 
conservative protective actions, particularly those that involve the 
public. Therefore, it is important to analyze less severe accidents so 
that less extreme responses can be developed for use by decision 
makers. EALs were often event-based rather than condition-based (i.e., 
based on observable criteria or triggers). As a result, emergency 
response personnel would not be able to identify emergency conditions 
of various degrees of severity and, therefore, would not be able to 
select appropriate protective actions. In addition, many of the EPHAs 
did not contain specific observable criteria or triggers to determine 
the severity of a radiological or hazardous material release when a 
release is occurring.
    For example, the EALs for SNL were based on ``worst case events'' 
\4\ and were event-based only [23, 24, 25, 30]. As a result, emergency 
response personnel would be unable to classify emergencies at different 
degrees of severity (Alert, Site Area Emergency, and General 
Emergency), determine the required response, and determine the needed 
protective actions for the workers and public. The EALs lacked 
observable criteria or triggers such as stack monitor readings, the 
quantity of material involved, the degree that containment or 
confinement is compromised, and whether ventilation is operating. This 
failure to include measurable triggers in EALs was also observed by HSS 
in oversight reviews at other sites such as the Hanford Site [31].
---------------------------------------------------------------------------

    \4\ Although the SNL EALs do consider different quantities of 
material at risk for various activities, they represent the maximum 
quantities that could be used for those activities and thus do not 
consider the use of lesser quantities.
---------------------------------------------------------------------------

    In contrast, the staff observed that the WIPP EALs reference 
conditions, but only after observing an event (such as a vehicle 
accident or a fire on a vehicle). Thus, if a condition occurs that is 
not associated with an observable event that was analyzed in the EPHA 
(such as occurred during the February 14, 2014, radioactive material 
release), emergency response personnel would be unable to categorize 
and classify the event, and then implement appropriate protective 
actions [29, 32].
    Similarly, members of the Board's staff observed a wide variety of 
problems with EALs at other DOE sites. For example, at the Pantex 
Plant, EALs were predominantly event-based [33]. At Los Alamos National 
Laboratory (LANL), some EALs were based on bounding conditions similar 
to those in the documented safety analysis, and would not lead to the 
initiation of protective actions for accidents of a lesser degree [34, 
35]; while EALs that were condition-based assume that personnel are at 
work in the facility to observe the indicators [36].\5\ Similarly, at 
Lawrence Livermore National Laboratory (LLNL), EALs were also event-
based [37-39]. Some use indicators that were limited to consideration 
of the initiating event and did not consider the results of the event 
or the follow-on indicators (e.g., a confinement barrier is defeated, 
alarms are activated, and monitors indicate a release).
---------------------------------------------------------------------------

    \5\ For example, in the Weapons Engineering Tritium Facility 
(WETF) and Chemistry & Metallurgy Research Facility EPHAs [34, 35], 
the material at risk (MAR) for each scenario is the bounding limit 
in the technical safety requirements. As a result, none of WETF EALs 
are less than general emergencies when the ventilation is not intact 
and none of the Chemistry & Metallurgy Research EALs are less than a 
site area emergency.
---------------------------------------------------------------------------

    Protective Actions: Some sites default to a protective action of 
shelter-in-place no matter what the emergency may be. The Pantex Plant 
[33] and Savannah River Site [40-45] are two sites that use this 
default protective action extensively.\6\ There are some events in 
which the potential exposures would require an evacuation; however, 
some sites are sheltering-in-place initially until they recognize that 
conditions warrant evacuations. Therefore, a necessary evacuation could 
be delayed and result in unnecessary exposures. For emergencies with 
the potential for exposures requiring evacuation, sites may need to 
consider a more timely conservative protective action rather than wait 
for additional direction from decision makers.
---------------------------------------------------------------------------

    \6\ If the hazard from an emergency is an internal exposure 
hazard, then sheltering-in-place would be appropriate; however, if 
the release leads to an external exposure hazard, then sheltering-
in-place may not be acceptable and it may be important to evacuate 
personnel as soon as possible. Similarly, if the release is of short 
duration, sheltering-in-place may be appropriate; whereas, a long 
duration release with significant consequences might require early 
evacuation.
---------------------------------------------------------------------------

    Other sites do not provide sufficient description in their 
protective actions. Some sites implement shelter-in-place when the need 
is to take shelter in a structurally sound facility for a natural 
phenomenon hazard (such as an earthquake or tornado). Sites should have 
separate protective actions in response to a radioactive or hazardous 
material release versus protection from physical harm (e.g., falling 
debris, collapsing buildings, and missiles). Some sites have identified 
shelter (or take cover) and shelter-in-place (or remain indoors) to 
address these two categories of protective needs. This problem has been 
corrected in protective actions at the Savannah River and Hanford sites 
[46], but is still evident in protective actions at WIPP [32, 47] and 
LANL [48].\7\
---------------------------------------------------------------------------

    \7\ For example, the LANL protective action guide only addresses 
sheltering as a ``strategy to reduce exposure to airborne 
materials.''
---------------------------------------------------------------------------

    Severe Events: During Board public hearings and meetings at the 
Savannah

[[Page 56786]]

River Site [1], LANL [2], Pantex Plant [3], and Y-12 [4], the Board 
discussed weaknesses in the ability of DOE sites to respond to severe 
events. In addition, as part of its reviews of the overall state of 
emergency preparedness and response at DOE sites, members of the 
Board's staff reviewed the preparedness for, and the ability to respond 
to, severe events. During these reviews, the staff team identified 
weaknesses in existing programs, as well as elicited input from the 
sites on gaps in the existing requirements and guidance. Many sites 
have not completed a hazard assessment for severe events; particularly 
events that can affect multiple facilities and events that can affect a 
regional area [15, 20]. As a result, they have not developed EALs and 
protective actions commensurate with the unique hazards and complexity 
of these events. Technical planning requirements are focused on 
individual facilities without consideration of the impact of collective 
facilities with additional and varied hazards.
    Specific gaps in requirements and guidance that were identified by 
the sites during the reviews by members of the Board's staff or through 
the staff's review of their existing programs include:
     The need for clarification of the definition of a severe 
event, and the actions that sites are expected to take to prepare for 
such events, particularly addressing the question of ``how much 
preparation is enough for severe events.''
     The focus of existing requirements on individual 
facilities with no current direction on evaluating multi-facility 
events.
     The need to develop a methodology for prioritizing 
response to multi-facility events, including the development of 
prioritization strategies for response, mitigation, and reentry.
     The need to incorporate self-help and basic preparedness 
training into workforce refresher training.
     The need to develop a logistical process for providing 
food, water, and other essentials to responders if they are required to 
stay on site for an extended period of time.

Although DOE's OE-1 highlights the need to incorporate some of these 
considerations in site emergency management programs, it does not 
provide explicit guidance on how to do so.

    Members of the Board's staff also had the opportunity to observe 
pilot studies at WESF at the Hanford Site, and at the tank farms and 
Tritium Facility at the Savannah River Site. The studies were conducted 
by HSS in tandem with the Office of Emergency Operations to develop 
guidance on how to address beyond design basis events in documented 
safety analyses and how to address severe events in emergency 
management programs [18, 19]. One major gap identified by the staff 
team during its reviews, as well as by the pilot study group at both 
the Hanford and Savannah River sites, is related to the actions to be 
taken by facility personnel in the immediate aftermath of a severe 
event (i.e., actions taken by facility personnel that will put the 
facility into a safe and stable condition). Although the pilot study 
report, BDBE Pilot Evaluations, Results and Recommendations for 
Improvements to Enhance Nuclear Safety at DOE Nuclear Facilities [18], 
highlights this gap, it does not identify who will develop guidance to 
address the gap. DOE's OE-1 does not mention this issue.
    In general, members of the Board's staff observed problems 
associated with requirements (or lack of requirements) addressing 
severe events, specifically those addressing the scope of hazards 
assessments, EALs, and protective actions that address the complexity 
of events that could cascade or affect multiple facilities. The staff 
team also observed problems with identification and development of 
actions to be taken by workers in the immediate aftermath of an event 
and in situations where outside response is delayed.
    Training and Drills--With respect to preparation for emergencies, 
DOE Order 151.1C, Chapter IV, 4.a requires that:
    A coordinated program of training and drills for developing and/or 
maintaining specific emergency response capabilities must be an 
integral part of the emergency management program. The program must 
apply to emergency response personnel and organizations that the site/
facility expects to respond to onsite emergencies.
    The associated emergency management guide [7] contains detail on 
meeting this requirement. Members of the Board's staff submitted 
comments pertaining to training requirements in the order and guides 
during the last order revision cycle in 2005. At the conclusion of the 
RevCom process, DOE personnel responded to these comments with a 
commitment to address them during the next revision cycle [49]. These 
comments focused on the need to include requirements for the 
effectiveness of training and drills, and for responsibilities to 
ensure the adequacy and consistency of training and drills. These 
comments were based on the staff team's observation that implementation 
of training and drill programs was inconsistent among the DOE sites, 
and that more specificity was needed in the requirements.
    During its recent reviews, members of the Board's staff continued 
to observe that the implementation of training and drill programs at 
DOE sites is variable; these programs were also addressed during Board 
public meetings and hearings [1, 3]. At some sites such as Y-12, 
Savannah River Site, and Hanford Site, the training of emergency 
response personnel is well developed and executed. At some sites, a 
task analysis of individual positions was completed, and training was 
developed and executed to address these tasks. Drills were scheduled to 
practice these tasks, and the basis for qualification was determined 
and confirmed. As part of the training program, some sites identified 
continuing training and the need for retraining based on feedback from 
performance on drills and exercises.
    However, at other sites, the quality of training varied 
significantly, sometimes to the point of being perfunctory and limited 
to only participation of the emergency response organization. Some 
sites schedule drills, but rarely perform them, while other sites do 
not have a drill program that meets the expectations of the guidance. 
In general, the training and drills conducted at some sites frequently 
do not reflect lessons learned and feedback from performance of 
exercises. For example, the Pantex Plant has a drill program, but 
conducts few of the scheduled drills. SNL conducts drills; however, the 
drills involving facility personnel are only evacuation drills and are 
essentially the equivalent of fire drills.
    The staff also observed issues with the training and qualification 
of emergency management program staff at various sites. Some sites, 
such as the contractors at Y-12, Savannah River Site, and Hanford Site, 
have established qualification programs for these personnel and hire 
experienced personnel or train personnel to fill these positions. Other 
sites, such as the Pantex Plant, have not established training 
qualification requirements for their emergency management program 
staff.
    Exercises--As part of a site's preparedness for responding to 
emergencies, DOE Order 151.1C requires that ``[a] formal exercise 
program must be established to validate all elements of the emergency 
management program over a five-year period.'' The Order also stipulates 
that ``[e]ach exercise must have specific objectives and must be fully

[[Page 56787]]

documented (e.g., by scenario packages that include objectives, scope, 
timelines, injects, controller instructions, and evaluation 
criteria).'' In addition, Chapter 4, 4.b(1) of the Order requires that:
    (a) Each DOE/NNSA facility subject to this chapter must exercise 
its emergency response capability annually and include at least 
facility-level evaluation and critique.
    (b) Site-level emergency response organization elements and 
resources must participate in a minimum of one exercise annually. This 
site exercise must be designed to test and demonstrate the site's 
integrated emergency response capability. For multiple facility sites, 
the basis for the exercise must be rotated among facilities.
    This requirement to conduct exercises is further clarified in 
section 3.1 of the DOE Emergency Management Guide 151.1-3, Programmatic 
Elements, which provides guidance for DOE sites to:

    * * * establish a formal exercise program that validates all 
elements of a facility/site or activity emergency management program 
over a 5-year period. The exercise program should validate both 
facility- and site-level emergency management program elements by 
initiating a response to simulated, realistic emergency events or 
conditions in a manner that, as nearly as possible, replicates an 
integrated emergency response to an actual event.

    Members of the Board's staff reviewed exercise programs at various 
DOE sites as part of its programmatic reviews of emergency management 
programs, as well as through observations of exercises conducted at DOE 
sites. The staff team observed a wide variability in the quality of the 
scenarios. Some sites had challenging scenarios and a few recent site 
exercises involved severe events, including multiple facilities and 
cascading events. However, other sites had scenarios that were not 
challenging and did not fully test the capabilities of the site. Some 
sites do not have a 5-year plan for exercises that involves all of the 
hazards and accidents at their facilities with EPHAs. In addition, some 
sites do not exercise all of their facilities with EPHAs and all of 
their response elements on an annual basis.
    Exercises are intended to be a demonstration of performance and, 
therefore, addressing all the elements of emergency response on an 
annual basis is important. The staff team observed specific problems 
with planning and scheduling of exercises at various sites. Some sites, 
such as the Pantex Plant, did not conduct an annual site-wide exercise 
in 2013 [50]; while other sites, such as SNL, are not conducting annual 
exercises (or appropriately tailored drills to test emergency 
preparedness and response) for each facility that has an EPHA [51-53]. 
In addition, some of these sites, such as the Pantex Plant [23, 54, 
55], do not conduct exercises to ``validate all elements of an 
emergency management program over a 5-year period.'' At SNL, the staff 
team was particularly concerned that emergency management personnel are 
not scheduling drills and exercises that address the different types of 
hazards and accident scenarios possible at its nuclear facilities. The 
drills and exercises should train and test the various elements of 
their capability for responding to radiological hazards and scenarios. 
In addition, the staff team observed that few if any of the sites have 
scheduled exercises to be conducted during swing and night shifts.
    As part of its observations of exercises and review of exercise 
packages, members of the Board's staff observed several examples of 
exercise scenarios that were not challenging enough to demonstrate 
proficiency. For example, the 2013 annual exercise at the Savannah 
River Site [56] involved the drop of a 55-gallon drum of radioactive 
waste during a repackaging operation at the Solid Waste Management 
Facility. The exercise assumed that the dropped drum injured an 
employee and resulted in contamination in the immediate area of the 
drum. Similarly, the 2013 exercise at the Pantex Plant [50], which was 
conducted in January 2014, also involved a simplistic scenario 
involving a liquid nitrogen truck in a vehicular accident. The 
hazardous release was limited and required little protective action to 
be taken by the plant population. In contrast to these simplistic 
scenarios, the 2013 site-wide exercise at the Hanford Site [57] 
involved an earthquake that led to problems at multiple facilities, 
including a tunnel collapse at PUREX and a release of contamination and 
a fire at WESF, that were compounded initially by problems with 
communications.
    In addition to the use of simplistic scenarios, another problem 
observed by the staff team was the failure of most sites to adequately 
incorporate recovery actions into the exercise. Due to the hazardous 
nature of operations at DOE sites, planning and implementing recovery 
and reentry actions will be extremely complex, as evidenced by the 
current recovery activities at WIPP. Recovery at other DOE sites could 
be more difficult due to the more hazardous and complex nature of 
operations at those sites. Planning and implementing recovery actions 
are typically not demonstrated in detail during the normal scope of 
annual emergency exercises at DOE sites, or in follow-on exercises [3, 
4, 58]. For example, the 2013 Savannah River Site annual site-wide 
exercise demonstrated the importance of more fully exercising recovery 
planning. The exercise team did not appear to understand the level of 
detail required for developing a recovery plan outline and had a 
difficult time completing the outline for recovery planning that is 
included in the Savannah River Site emergency procedures [59].
    Members of the Board's staff also observed problems with the 
preparation and conduct of exercises. Problems associated with 
preparation for exercises have involved both the content and timing. 
Specifically, the staff team observed that some sites use identical 
scenarios in the drills preparing for exercises, and some sites often 
schedule the majority of their drills immediately prior (i.e., within 
days) to the exercise [60, 61]. Although it is appropriate to use 
drills to train and practice, these strategies can lead to a false 
impression of a site's preparedness and response capability (i.e., 
``cramming for the exam''). The graded exercise becomes a snapshot of 
proficiency rather than being a true representation of long-term 
proficiency. For example, at the Savannah River Site, the staff team 
observed that the scenarios used in preparation for the 2013 evaluated 
exercise for Building 235-F addressing concerns raised in Board 
Recommendation 2012-1 were identical to the scenario planned for the 
actual exercise. Based on feedback from the Board's Savannah River site 
representatives, the scenario was changed [61]. The Board's site 
representatives raised similar concerns with scenarios used to prepare 
for other exercises at the Savannah River Site, and this practice 
appears to have been changed. The staff team observed that at some 
sites, such as the Hanford Site, these preparatory drills are conducted 
immediately prior to the actual performance of the exercise, ensuring 
that the participants can perform adequately during the actual 
exercise, but not addressing the need for making sustained improvements 
in emergency preparedness and response capabilities by conducting 
preparation activities throughout the course of the year.
    As part of its observation of exercises at various sites, members 
of the Board's staff had the opportunity to observe after-exercise 
critiques, as well as to review the after action reports for the 
exercises. During many exercises, the staff team observed that 
evaluators

[[Page 56788]]

failed to document needed improvements identified during the course of 
the exercise. The staff team also observed that the critiques were 
often not adequate to identify the underlying causes of problems during 
the exercise and that subsequent assessments and evaluations did not 
ensure the effectiveness of corrective actions to address these 
problems. One example of a flawed critique system was observed at the 
Pantex Plant, where the 2011 exercise was originally graded as 
``satisfactory'' and the 2012 exercise was originally graded as 
``successful.'' After Board Member questions during the public meeting 
and hearing on the Pantex Plant and subsequent staff questions, Babcock 
& Wilcox Technical Services Pantex, LLC (B&W Pantex) regraded the 2011 
exercise as ``unsatisfactory'' and the 2012 exercise as ``marginal'' 
[3, 62].
    Members of the Board's staff also observed that some sites 
incorporated severe event scenarios into their drill and exercise 
programs. Some sites have conducted exercises that include severe event 
scenarios that encompass multiple facilities; however, some sites such 
as the Pantex Plant and Y-12 have yet to do so [3, 4]. It is important 
to practice and demonstrate proficiency in responding to severe event 
scenarios due to the complexity of response, the need to prioritize 
limited resources, the need to make decisions about protective actions 
when multiple facilities are involved, the potential need to respond 
without the assistance of mutual aid, and the potential loss of 
infrastructure (e.g., power, communications, mobility). The current DOE 
directives do not contain requirements or expectations to conduct these 
types of challenging exercises. While DOE's OE-1 contains guidance on 
the scope of severe event scenarios that should be conducted by the 
sites, it does not explicitly require that the sites conduct these 
types of exercises.
    Facilities and Equipment--DOE Order 151.1C requires a site's 
emergency program to address the ``provision of facilities and 
equipment adequate to support emergency response, including the 
capability to notify employees of an emergency to facilitate the safe 
evacuation of employees from the work place, immediate work area, or 
both.'' Facilities include an emergency operations center (EOC) and an 
alternate, and the Order stipulates that these facilities must be 
``available, operable, and maintained.'' Maintenance and appropriate 
upgrading of emergency response facilities and equipment are an 
important part of ensuring that the emergency preparedness and response 
capabilities of a site are sustainable. Communications and notification 
systems are necessary to initiate protective actions and enable safe 
evacuation of employees. Chapter 4 of the Order requires ``[p]rompt 
initial notification of workers, emergency response personnel, and 
response organizations, including DOE/NNSA elements and State, Tribal, 
and local organizations, and continuing effective communication among 
response organizations throughout an emergency.''
    The staff team observed some problems with the survivability, 
habitability, and maintenance of emergency response facilities and 
equipment, as well as communications and notification systems [63, 64] 
that the staff believes are due to the lack of explicit requirements or 
expectations in the DOE Order and Guides. Specifically, members of the 
Board's staff observed that many of the emergency response facilities 
may not be habitable in the aftermath of a hazardous or radiological 
material release event, or survivable in the aftermath of a severe 
natural phenomena event. These facilities were not designed to survive 
an earthquake, and many do not have ventilation systems that will 
filter radiological and toxicological materials. Examples of such 
facilities include the Emergency Control Center (ECC), the Technical 
Support Center (TSC), and the fire house at Y-12 [4, 66]; the EOC at 
the Hanford Site [67]; the EOC and alternate EOC, the Department 
Operations Centers, and the Emergency Communications Center at LLNL 
[68]; and the EOC and Central Monitoring Room at WIPP [69].
    Some facilities were designed with filtered air systems that would 
enable them to remain habitable in the event of a hazardous release in 
proximity to the facility. However, members of the Board's staff 
observed that some of these systems were not being properly maintained 
[63, 64, 68-71]. Habitability of these facilities could also be 
compromised by failures of their emergency backup systems. Many of the 
facilities have backup systems that are general service and do not have 
a pedigree for an expectation of reliability. In general, the staff 
team observed problems with the lack of established maintenance 
programs for these facilities and support equipment, such as backup 
generators and fuel tanks [63, 64, 67-69, 71]. It should be noted that 
some of these facilities are scheduled to be replaced. For example, 
Babcock and Wilcox Technical Services Y-12, LLC (B&W Y-12) has a new 
project planned to replace the ECC and the TSC, with funding beginning 
in fiscal year 2015 and project completion scheduled in fiscal year 
2017, and B&W Y-12 is preparing for Critical Decision-0 for a new fire 
house [4]. Similarly, there are plans to replace the LLNL EOC.
    Members of the Board's staff also observed problems with systems 
used to support emergency communications and notifications. For 
example, the staff observed problems with the systems used to notify 
workers and visitors about an emergency and protective actions that are 
to be taken, such as was observed recently at WIPP during the 
underground truck fire [72]. Some systems have experienced failures to 
broadcast due to failures of sirens, overriding signals, and incomplete 
coverage, or have provided workers with garbled messages [73-78]. The 
staff team also observed potential problems with the method by which 
remote workers, such as those at the Hanford Site, are notified of 
emergencies via portable alerting systems, and the process by which 
they are refreshed on hazards and responses (e.g., pre-job briefings).
    In addition to the vulnerabilities of some of these facilities 
during an emergency, the Board's staff team also observed, based on its 
review of site exercise schedules across DOE sites, that alternate 
emergency response facilities were not being exercised on a periodic 
basis. In general, many of the alternate response facilities have 
limited, older, less-effective communications systems and support 
equipment, which could dramatically hamper on-site emergency response. 
Their locations are sometimes so close to the primary facilities that 
they will suffer the same habitability problems. Conversely, sometimes 
they are so distant that it will be difficult for personnel to travel 
to the alternate facilities. Therefore, it is important for emergency 
response personnel to practice using the less-effective equipment and 
understand the challenges of using alternate facilities.
    Oversight and Assessment--As part of its readiness assurance 
requirements, DOE Order 151.1C stipulates the need for assessments of 
emergency management programs and capabilities by the contractor and 
oversight of these programs and capabilities by DOE program and field 
(site) offices. Additionally, in the general requirements sections of 
the Order, the HSS Office of Security and Safety Performance is tasked 
with responsibility for independent oversight of emergency management 
programs at

[[Page 56789]]

DOE sites.\8\ Members of the Board's staff have observed problems with 
oversight of emergency management programs overseen by DOE Headquarters 
and site office personnel, and with assessments and self-assessments 
conducted by the contractors. These failures are contributing to the 
problems with the emergency management programs at the various sites 
that have been observed by the staff team, particularly problems that 
are long-standing or recurrent.
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    \8\ The Office of Independent Enterprise Assessments now has 
this responsibility. See Footnote 2.
---------------------------------------------------------------------------

    Federal Independent Oversight: The Office of Safety and Emergency 
Management Evaluations in HSS was responsible for oversight of 
emergency management programs at DOE sites.\9\ The Office of Emergency 
Operations is responsible for the development and maintenance of 
emergency management requirements for programs at all DOE sites, and is 
also responsible for providing interpretations of these requirements. 
The Office of Emergency Operations also has responsibility for NNSA 
emergency management programmatic support to NNSA sites. The Office of 
Emergency Operations does not conduct assessments of emergency 
management programs at DOE (or NNSA) sites. However, when requested, it 
provides assistance to sites and subject matter experts to support 
reviews, such as readiness reviews and biennial reviews by the NNSA 
Chief of Defense Nuclear Safety (CDNS).
---------------------------------------------------------------------------

    \9\ The Office of Emergency Management Assessments now has this 
responsibility. See Footnote 2.
---------------------------------------------------------------------------

    After operating in an assistance mode since 2010, HSS returned in 
2012 to conducting independent assessments. These assessments are 
targeted reviews, currently focused on the ability of the sites to 
prepare and respond to severe events, and do not encompass all elements 
of emergency management programs. In 2012, HSS focused on five elements 
(Emergency Response Organization, Equipment and Facilities, Technical 
Planning Basis, EPHAs, and Off-site Interfaces) for severe event 
preparedness in its reviews at five sites and one facility (Y-12 [70], 
LANL [71], Idaho National Laboratory [79], WIPP [69], Paducah Gaseous 
Diffusion Plant [80], and the Tritium Facilities at the Savannah River 
Site [81]). In 2013, HSS focused on three new elements, while retaining 
three elements from its 2012 reviews (Off-site Interfaces, Equipment 
and Facilities, EPHAs, Medical Response, Training and Drills, and 
Termination and Recovery) at four sites (LLNL [68], Portsmouth Gaseous 
Diffusion Plant [82], Hanford Site [67], and the Nevada National 
Security Site (NNSS) [83]). After each of its reviews, HSS produced a 
document summarizing the results of the review and identifying findings 
and OFIs. HSS also issues a year-end report that highlights common 
issues, lessons learned, and recommended actions [63, 64]. Unlike the 
independent assessments conducted previously in the 2000-2009 
timeframe, adjudication of findings is left to site offices. HSS does 
not review corrective actions or their effectiveness, although it may 
review the resolution of findings from previous assessments as part of 
its follow-up review.
    As part of its review of the efficacy of federal oversight, members 
of the Board's staff reviewed the reports issued by HSS in 2012 and 
2013, and observed its targeted assessments at LLNL, Hanford Site, and 
NNSS conducted in 2013. The staff team observed that these assessments 
were effective in identifying issues associated with a site's 
preparedness to respond to severe events. The HSS assessment team does 
not assess the site's capability to respond to less severe events that 
are more likely to occur. Although the assessment team does identify 
fundamental program weaknesses as part of its assessment, it does not 
document these weaknesses. As a result, the assessments do not evaluate 
the overall effectiveness of a site's emergency preparedness and 
response capability. As observed recently with the emergency responses 
to the truck fire and radioactive release events at WIPP, there can be 
fundamental problems with a site's emergency preparedness and response 
capability that will only be identified by more comprehensive 
assessments designed to evaluate the overall effectiveness of a site's 
emergency management program. Independent assessments conducted prior 
to 2010 focused on overall effectiveness. These assessments 
consistently identified problems with site emergency preparedness and 
response, and HSS sought to ensure continuous improvement of these 
programs by conducting follow up assessments.
    The HSS targeted assessments did not include an observation of 
drills or exercises. Drills and exercises are representative of a 
site's broader response capability. While the HSS team observed a drill 
during its assessment at LLNL, this exercise was outside the scope of 
the assessment and was not incorporated into the potential findings and 
OFIs of their report. During 2014, HSS is observing severe event 
exercises as part of its assessments.
    Members of the Board's staff found that many of the HSS findings 
from its independent assessments conducted prior to 2010, as well as 
findings from the HSS targeted assessments, were not effectively 
addressed. Specifically, based on its review of numerous federal and 
contractor assessments and associated corrective action plans, the 
staff team found that many of the corrective actions did not adequately 
address the specifics of the findings or did not result in long-term 
resolution of the issue. In many cases, there was not adequate causal 
analysis and there was no review of the effectiveness of the corrective 
actions. As a result, findings have gone uncorrected, sometimes for 
many years, and are found again in subsequent assessments.
    For example, members of the Board's staff reviewed the 2009 HSS 
report [30] as part of the staff's 2013 assessment at SNL. Several of 
the findings in the report addressed the inability of emergency 
response personnel to effectively use emergency plans and procedures to 
implement protective actions. In addition, as part of their discussions 
of program weaknesses and items requiring attention, the HSS assessors 
identified problems with using EALs due to their complexity and the 
overly conservative nature of the protective actions. The staff team 
reviewed the EALs [23-25] and protective actions [84-97], as well as 
other technical planning documents such as EPHAs [23-25]. The staff 
team found them to be of poor quality and difficult to implement. When 
the staff team discussed the HSS findings with Sandia Field Office and 
SNL emergency management personnel, the SNL personnel indicated that 
they developed corrective actions to address the findings in the HSS 
report and all corrective actions had been completed. However, based on 
its 2013 assessment, the staff team found that the original problems 
identified by HSS still existed. SNL did not address the implications 
of the systemic program weaknesses identified by HSS regarding the 
entire suite of SNL technical planning documents, not just EALs. Thus, 
the original findings identified by HSS were not effectively addressed 
by SNL.
    Similarly, during the HSS targeted assessment conducted at the 
Hanford Site in 2013 that was observed by members of the Board's staff, 
HSS team members noted that the same issues had been identified during 
the team's assist visit to the Hanford Site in 2010 [67]. HSS team 
members also noted that recommendations from the 2010 visit had been 
entered and closed in the site's corrective active tracking system but

[[Page 56790]]

were observed again during the 2013 assessment.
    Federal Line Oversight: In addition to oversight conducted by DOE 
Headquarters personnel, members of the Board's staff also reviewed 
oversight by site office personnel of contractor emergency management 
programs. The scope of this review included numerous federal assessment 
reports and associated contractor corrective action plans. The level 
and type of oversight conducted by site office personnel varied widely 
across DOE sites. At some sites, the federal employee responsible for 
emergency management did not have any other responsibilities; at other 
sites, such as Y-12, emergency management was a collateral duty. At 
some sites, this position rotated frequently and there was a long 
period of time before the individual responsible for oversight of the 
contractor's emergency management program was qualified as an emergency 
management specialist per the DOE qualification standard [98, 99].
    The type of oversight conducted by site office personnel varied 
widely, ranging from independent assessments to shadow assessments of 
contractor reviews to reviews of data provided by contractor assurance 
systems. Sole reliance on data provided by the contractor assurance 
system without confirmatory independent reviews can be problematic. For 
example, the Y-12 emergency management program manager relied heavily 
on the results of B&W Y-12 management self-assessments of its emergency 
management program against the 15 assessment criteria suggested by the 
DOE Emergency Management guides, with the exception of direct 
observation of Y-12 exercises by the program manager, assisted by other 
personnel. Although the general health of the Y-12 emergency management 
program appeared to be consistent with DOE requirements and guidance, 
the oversight strategy employed by the NNSA Production Office may not 
be able to identify a reduction in effectiveness of the program. While 
this has not been a problem at Y-12, the programs at SNL and WIPP 
demonstrate that this is a problem at sites that do not have a strong 
contractor emergency management program.
    Contractor Assessments: Most of the sites reviewed by members of 
the Board's staff were conducting annual assessments of their emergency 
management programs using the 15 criteria suggested by the DOE 
Emergency Management Guides. However, based on its review of numerous 
contractor assessment reports, the staff team observed that many of the 
assessments were not effective at identifying problems and weaknesses 
with their programs. For example, many of the observations identified 
by HSS were not identified by the contractor assessments. As already 
discussed, SNL did not identify problems with its technical planning 
documents or its failure to conduct required exercises, and B&W Pantex 
did not identify problems with its training and drill and exercise 
programs. Similarly, LANL did not identify problems with the membership 
of its emergency response organization [100].
    Members of the Board's staff also observed that while most sites 
developed corrective actions to address issues identified in their 
assessments, as well as independent assessments, and tracked actions to 
closure, few sites were evaluating the effectiveness of these 
corrective actions. As already discussed, many of the sites, such as 
the Hanford Site and SNL, were not effectively addressing the findings 
and OFIs identified by external reviewers such as HSS and CDNS. 
Specifically, they were performing poor root cause analyses and were 
not performing reviews of the effectiveness of these corrective actions 
to address the issues and prevent their recurrence.
    Another area of weakness noted by members of the Board's staff 
during its review of assessments and corrective actions, and 
observation of exercises was exercise assessment and critique. The 
staff team reviewed numerous exercise packages, after action reports, 
and corrective action plans, and observed many annual site exercises. 
The staff team observed that the critiques were often superficial, were 
not self-critical, and downplayed the significance of findings while 
conveying an aura of success. Most critiques failed to identify the 
root causes of problems, thus these problems recurred. For example, 
several significant findings of critical response capabilities, such as 
delayed notifications and lack of communication within the response 
organization, were identified during exercises at the Pantex Plant, yet 
the results of the exercises were graded as satisfactory [3]. The need 
for critical review of exercises has now been recognized by the NNSA 
Production Office and B&W Pantex, and corrective actions are now being 
implemented.
    Summary of Observations. The following table summarizes the Board's 
staff team's observations of the three questions that formed the 
foundation of its review of the state of emergency preparedness and 
response at DOE sites with defense nuclear facilities:

------------------------------------------------------------------------
       Review Question 1:         Review Question 2:  Review Question 3:
------------------------------------------------------------------------
Does DOE provide facility         Does DOE provide    Do the contractor
 workers, response personnel,      adequate            assurance systems
 and emergency management          equipment and       and DOE oversight
 decision makers with adequate     hardened            provide an
 direction and guidance to make    facilities that     effective
 timely, conservative emergency    enable emergency    performance
 response decisions and take       response            assurance
 actions that focus on             personnel and       evaluation of
 protection of the public and      emergency           emergency
 workers?                          management          preparedness and
                                   decision makers     response?
                                   to effectively
                                   respond to
                                   emergencies and
                                   protect the
                                   public and
                                   workers?
Many EPHAs did not adequately     Many emergency      Many contractor
 cover plausible emergency         facilities will     assurance systems
 scenarios, including severe       not be survivable   were not
 events.                           or habitable        effective at
                                   during an           sustainably
                                   emergency.          correcting
                                                       identified
                                                       emergency
                                                       preparedness and
                                                       response issues.
Many EALs did not provide a       Many emergency      DOE Headquarters
 clear method to identify the      facilities and      and local site
 severity of events in order to    their alternates    personnel were
 categorize and classify an        did not have        not providing
 emergency and select protective   reliable support    effective
 actions.                          systems,            oversight to
                                   including an        ensure emergency
                                   adequate            preparedness and
                                   maintenance         response issues
                                   program.            are identified
                                  Many                 and corrected.
                                   communications
                                   and notification
                                   systems were not
                                   adequate to
                                   ensure
                                   notification of
                                   workers and the
                                   public.
Many emergency protective
 actions did not have the
 clarity to ensure the
 protection of workers and the
 public during an emergency.

[[Page 56791]]

 
Many facility worker, initial
 responder, and EOC personnel
 training and drills were not
 adequate to prepare and qualify
 personnel to ensure timely,
 effective response during an
 emergency.
Many site emergency exercise
 programs did not demonstrate
 proficiency and did not
 identify weaknesses that will
 allow management to effectively
 drive improvements in emergency
 preparedness and response.
------------------------------------------------------------------------

    In general, the staff team observed that implementation of DOE's 
requirements for emergency preparedness and response programs varies 
widely at various DOE sites with defense nuclear facilities. DOE has 
noted these types of problems in the HSS reports documenting 
independent assessments of its sites and in its annual reports on the 
status of its emergency management system. The annual reports also 
noted a lack of progress in addressing these problems [101-103].
    Based on an evaluation of these observations, the staff team 
determined that the most important underlying root causes of these 
problems were inadequate implementation and revision of requirements, 
and ineffective contractor and federal verification and validation of 
readiness for responding to emergencies.
    Conclusions. In the aftermath of DOE's implementation of corrective 
actions addressing Board Recommendation 98-1, members of the Board's 
staff observed considerable improvement in emergency preparedness and 
response at many DOE sites across the complex. However, during this 
review of emergency preparedness and response, the staff team found 
that many sites had not continued to improve their programs, and in 
some cases, there had been degradation in these programs. One of the 
contributing factors in this lack of sustained continuous improvement 
was the failure of DOE as a regulator of emergency management programs 
at its sites. Although the problems observed by the Board's staff team 
were largely associated with a failure to implement existing 
requirements and guidance, the Office of Emergency Operations has 
failed to maintain and improve the requirements and guidance in its 
directives, particularly in response to addressing lessons learned, 
needed improvements to site programs, and inconsistent interpretation 
and implementation of the requirements. The Office of Emergency 
Operations has also failed to revise its requirements to address 
lessons learned from Fukushima and use feedback from its sites on the 
type of guidance needed to effectively prepare and respond to severe 
events.
    Many problems result from inconsistent implementation of existing 
requirements by the various DOE sites; therefore, the staff team 
concluded that some requirements do not have the level of specificity 
to ensure effective implementation. Requirements for hazards 
assessments lack detail on addressing severe events. Requirements do 
not address reliability of emergency response facilities and equipment. 
Requirements for training and drills do not address expectations for 
the objectives, scope, frequency, and reviews of effectiveness. 
Requirements for exercises do not include expectations for the 
complexity of scenarios, scope of participation, grading of 
proficiency, and corrective actions. Some of the additional detail that 
addresses the deficiencies in these requirements is already included in 
the Emergency Guides that accompany DOE Order 151.1C. However, many 
sites have not implemented the practices described in the guides.
    Contractor assessment and federal oversight often did not identify 
needed improvements to site emergency preparedness and response, which 
compounded the observed problems with the implementation of 
requirements. When problems were identified, they often lacked adequate 
causal analysis and appropriate corrective actions. When corrective 
actions were developed and implemented, sites (contractors and federal 
entities) frequently did not measure the effectiveness of these 
actions.
    During its period of focus on conducting assist visits rather than 
independent assessments, HSS failed to conduct effective oversight of 
emergency management programs and enforcement of existing requirements 
at DOE sites, and did not ensure that the sites adequately responded to 
its findings and OFIs. HSS has made progress on reengaging in its role 
of independent oversight of emergency management programs at DOE sites 
with its recent transition back to independent oversight. The 
effectiveness of this oversight has been constrained by both the 
limited scope of the assessments currently being conducted by HSS and 
by the lack enforcement to ensure that its findings and OFIs are 
effectively addressed by the sites. The HSS focus on targeted 
assessments of a site's ability to respond to severe events can lead to 
a failure to identify fundamental weaknesses in a site's emergency 
management program. The HSS failure to engage in the resolution of its 
findings and OFIs is similar to the problem that was the genesis of 
Board Recommendation 98-1.
    These deficiencies in implementation and oversight have led to 
failures to identify and prepare for the suite of potential emergency 
scenarios and to demonstrate proficiency, and ultimately to the failure 
to recognize and respond appropriately to indications of an emergency, 
as was seen in the recent radioactive material release event at WIPP. 
Therefore, the Board's staff review team believes that DOE has not 
comprehensively and consistently demonstrated its ability to protect 
the worker and the public in the event of an emergency.
    DOE Headquarters can address many of these problems by conducting 
more rigorous and comprehensive independent oversight and by revising 
its directives to address lessons learned, needed improvements to site 
programs, and inconsistent interpretation and implementation of the 
requirements.
    Technical and Economic Feasibility of Recommendation. The results 
of this review by members of the Board's staff were used to support the 
development of Recommendation 2014-1, Emergency Preparedness and 
Response. The deficiencies identified in this review relate to problems 
with DOE's safety management framework. The recommendation is 
technically feasible because it can be addressed using known scientific 
and engineering principles. The recommendation is

[[Page 56792]]

economically feasible because it has been structured to allow DOE to 
identify short-term and long-term enhancements to its emergency 
management programs.
    Several of these enhancements may involve improvements in 
infrastructure, while other improvements require the revision and 
strengthening of directives and guidance, as well as strengthening DOE 
oversight. Revising its directives is part of its normal process for 
maintaining the currency of its directives as codified in DOE Order 
251.1C, Departmental Directives Program [104]. Much of the detail 
needed to resolve problems of variability of implementation of 
requirements is already addressed in existing Emergency Management 
Guides. In addition, improvements to oversight would simply return the 
type of Headquarters oversight to the levels in which it was previously 
engaged and is an expectation in its directives on oversight (DOE Order 
226.1B, Implementation of Department of Energy Policy [105] and DOE 
Order 227.1, Independent Oversight Program [106]). Members of the 
Board's staff are confident that DOE can identify solutions to address 
these deficiencies that are technically and economically feasible.
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Office of Safety and Emergency Management Evaluations, Independent 
Oversight Review of Preparedness for Severe Natural Phenomena Events 
at the Paducah Site, April 2013.
[81] Department of Energy, Office of Health, Safety and Security's 
Office of Safety and Emergency Management Evaluations, Independent 
Oversight Review of Site Preparedness for Severe Natural Phenomena 
Events at the Savannah River Site Tritium Facilities, December 2012.
[82] Department of Energy, Office of Health, Safety and Security's 
Office of Safety and Emergency Management Evaluations, Independent 
Oversight Review of Preparedness for Severe Natural Phenomena Events 
at the Portsmouth Gaseous Diffusion Plant, November 2013.
[83] Department of Energy, Office of Health, Safety and Security's 
Office of Safety and Emergency Management Evaluations, Independent 
Oversight Review of Preparedness for Severe Natural Phenomena Events 
at the Nevada National Security Site, February 2014.
[84] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6588 PA Plan 400, March 22, 2011.
[85] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6588 PA Plan 1590, March 22, 2011.
[86] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6588 PA Plan 3650, March 22, 2011.
[87] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6588 PA Plan 7710, March 22, 2011.
[88] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6588 PA Plan 17480, March 22, 2011.
[89] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6597 PA Plan 330 Alert, December 16, 2009.
[90] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6597 PA Plan 500, December 16, 2009.
[91] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6597 PA Plan 4429 SAE, December 16, 2009.

[[Page 56794]]

[92] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6597 PA Plan 15000 GE, December 17, 2009.
[93] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6590 PA Plan 330 Alert, November 5, 2009.
[94] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6590 PA Plan 500, November 5, 2009.
[95] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6590 PA Plan 4429 SAE, November 5, 2009.
[96] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6590 PA Plan 15840 GE, November 6, 2009.
[97] Sandia National Laboratories, Emergency Response Protective 
Action Plan--6590 PA Plan 65050 GE, November 6, 2009.
[98] Department of Energy, Emergency Management Functional Area 
Qualification Standard, DOE-STD-1177-2004, January 2004.
[99] Department of Energy, FTCP Site Specific Information, http://energy.gov/hss/services/assistance/federal-technical-capability-program-ftcp/ftcp-site-specific-information, accessed on May 27, 
2014.
[100] Department of Energy, Office of Safety and Emergency 
Management Evaluations, Independent Oversight Review of the 
Emergency Response Organization at the Los Alamos National 
Laboratory, April 2012.
[101] Krol, J, Annual Report for Fiscal 2009 on the Status of the 
Department's Emergency Management System, Memorandum with attached 
report, June 23, 2010.
[102] Krol, J, Annual Report for Fiscal 2010 on the Status of the 
Department's Emergency Management System, Memorandum with attached 
report, October 25, 2011.
[103] Krol, J, Annual Report for Fiscal 2011 on the Status of the 
Department's Emergency Management System, Memorandum with attached 
report, April 2, 2013.
[104] Department of Energy, Departmental Directives Program, DOE O 
251.1C, January 15, 2009.
[105] Department of Energy, Implementation of Department of Energy 
Policy, DOE O 226.1B, April 25, 2011.
[106] Department of Energy, Independent Oversight Program, DOE O 
227.1, August 30, 2011.

Risk Assessment for Recommendation 2014-01

Emergency Preparedness & Response

    The recommendation addresses vulnerabilities in the Department of 
Energy's (DOE) safety framework for defense nuclear facilities 
resulting from deficiencies in the content and implementation of DOE's 
requirements for emergency preparedness and response. In accordance 
with the Defense Nuclear Facilities Safety Board's (Board) Policy 
Statement 5 (PS-5), Policy Statement on Assessing Risk, this risk 
assessment was conducted to support the Board's recommendation on 
Emergency Preparedness and Response. As stated in PS-5,
    The Board's assessment of risk may involve quantitative information 
showing that the order of magnitude of the risk is inconsistent with 
adequate protection of the health and safety of the workers and the 
public . . . the Board will explicitly document its assessment of risk 
when drafting recommendations to the Secretary of Energy in those cases 
where sufficient data exists to perform a quantitative risk assessment.

DOE's hazards assessments address initiating events, preventive and 
mitigative controls, and consequences. Initiating events in these 
assessments include operational and natural phenomena events. 
Preventive and mitigative controls are design basis controls identified 
in safety analysis documents. Consequences cover a wide spectrum, 
ranging from insignificant to catastrophic effects.
    Emergency preparedness and response programs exist at DOE sites 
with defense nuclear facilities because the risk associated with those 
facilities is acknowledged by DOE and is required by law. Therefore, 
emergency preparedness and response programs need to function 
effectively to protect the workers and the public.
    This recommendation is focused on improving the effectiveness of 
DOE's emergency preparedness and response programs. A quantitative risk 
assessment on the effectiveness of these programs requires data on 
probability and consequences. However, data do not exist on the 
probability of failure of elements of the emergency preparedness and 
response programs. Therefore, it is not possible to do a quantitative 
assessment of the risk of these elements to provide adequate protection 
of the workers and the public.

CORRESPONDENCE FROM THE SECRETARY

August 5, 2014.

The Honorable Peter S. Winokur, Chairman
Defense Nuclear Facilities Safety Board
625 Indiana Avenue NW., Suite 700
Washington, DC 20004

    Dear Mr. Chairman: Thank you for the opportunity to review the 
Defense Nuclear Facilities Safety Board (DNFSB) Draft Recommendation 
2014-01, Emergency Preparedness and Response. DOE agrees that 
actions are needed to improve emergency preparedness and response 
capabilities at its defense nuclear facilities. The Department's 
emergency preparedness and response infrastructure, capabilities, 
and resources are of great importance to me and DOE's senior 
leadership. Recommendation 2014-01 will complement actions that the 
Department has already initiated to improve emergency management.
    Following my review of the Draft Recommendation with my 
leadership team, it appears the document establishes a timeline for 
accomplishing the recommended actions. I recommend the DNFSB remove 
the specific time for completing responsive actions. It is the 
Department's responsibility to determine the necessary resources, 
including the requisite timeline to accomplish the actions in our 
implementation plan to address DNSFB recommendations. I share your 
intent to improve emergency management in the Department and I 
assure you that the Department takes this situation seriously. We 
will prioritize efforts and plan to consult with you. I have already 
directed my staff to expeditiously proceed with improvements which 
we identified separately, accomplishing the highest priorities 
within a one year period.
    In addition to the wording change identified above, I offer 
suggested language that may help clarify the DNFSB's intent in the 
Draft Recommendation. These changes are included as an enclosure for 
your consideration.
    We appreciate the DNFSB's perspective and look forward to 
continued positive interactions. If you have any questions, please 
contact me or Mr. Joseph J. Krol, Associate Administrator for 
Emergency Operations, at 202-586-9892.

Sincerely,

Ernest J. Moniz

Enclosure

Specific DOE Comments on

Draft DNFSB Recommendation 2014-01,

Emergency Preparedness and Response

    1. The formal process for developing an implementation plan for an 
accepted recommendation will establish a schedule commensurate with 
careful consideration of scope, capabilities, and resources, subject to 
the expectations for timeliness found in the DNFSB enabling 
legislation. The Department recommends changing the phrase at the 
beginning of the Draft Recommendation, striking the words, ``. . . 
during each site's 2015 annual emergency response exercise'', which 
would change the statement to read, ``To address the deficiencies 
summarized above, the Board recommends that DOE take the following 
actions:''
    2. Regarding Action 1, the Departmental management model currently 
uses criteria and review approaches. The current wording, ``develop and 
initiate'', could lead the public to believe that the Department does 
not have a criteria and review approach, whereas your staff recognizes 
that such approaches exist and are in use. The use of this terminology 
``criteria and review approach'' also seems to focus narrowly on a 
particular solution when other parts of the

[[Page 56795]]

DNFSB's Draft Recommendation appear to imply that systemic changes are 
needed in the overall DOE oversight and continuous improvement 
processes. DOE recommends changing Action 1 to read, ``In its role as a 
regulator, standardize and improve implementation of its criteria and 
review approach to confirm . . . .''
    3. Regarding Action 2c, as written, it is not clear that you may 
have intended for ``facility specific drill programs'' to mean drill 
programs for facility operators, who, as part of conduct of operations, 
take actions under abnormal and emergency operating procedures to 
mitigate conditions or that bring facilities into safe shut-down, 
separate from actions taken by the emergency response organization. DOE 
recommends changing this action to read, ``. . . including requirements 
that address facility conduct of operations drill programs and the 
interface with emergency response organization team drills.''
    4. Regarding Action 2e, the intent of this element is unclear since 
the Department already has continuous improvement processes in place 
and processes for including lessons learned during implementation of 
DOE directives into future directive revisions. In addition, Action 2e 
appears to imply that improvements should be made to the emergency 
management directive on a one-time basis and that the directive should 
not be changed until after program reviews called for in Action 1 are 
completed. The Department recommends a clarification of the intent of 
this action.

       Disposition of DOE Comments on Draft Recommendation 2014-1
------------------------------------------------------------------------
           DOE comment              Board response      Revised wording
------------------------------------------------------------------------
The formal process for            The Board           To address the
 developing an implementation      understands the     deficiencies
 plan for an accepted              DOE rationale for   summarized above,
 recommendation will establish a   removing the time   the Board
 schedule commensurate with        constraint from     recommends that
 careful consideration of scope,   the                 DOE take the
 capabilities, and resources,      Recommendation.     following
 subject to the expectations for   However, the        actions:
 timeliness found in the DNFSB     Board's enabling   1. In its role as
 enabling legislation. The         legislation         a regulator, by
 Department recommends changing    states that ``not   the end of 2016,
 the phrase at the beginning of    later than one      standardize and
 the Draft Recommendation,         year after the      improve
 striking the words, ``during      date on which the   implementation of
 each site's 2015 annual           Secretary of        its criteria and
 emergency response exercise'',    Energy transmits    review approach
 which would change the            an implementation   to confirm that
 statement to read, ``To address   plan with respect   all sites with
 the deficiencies summarized       to a                defense nuclear
 above, the Board recommends       Recommendation      facilities:
 that DOE take the following       (or part thereof)
 actions:''                        under subsection
                                   (f), the
                                   Secretary shall
                                   carry out and
                                   complete the
                                   implementation
                                   plan.'' The Board
                                   believes that the
                                   actions in the
                                   first sub-
                                   Recommendation
                                   can be
                                   accomplished by
                                   the end of 2016
                                   and has revised
                                   the wording of
                                   the
                                   Recommendation
                                   accordingly.
Regarding Action 1, the           The Board           1. In its role as
 Departmental management model     acknowledges that   a regulator, by
 currently uses criteria and       DOE uses criteria   the end of 2016,
 review approaches. The current    and review          standardize and
 wording, ``develop and            approaches in its   improve
 initiate'', could lead the        current oversight   implementation of
 public to believe that the        of the emergency    its criteria and
 Department does not have a        preparedness and    review approach
 criteria and review approach,     response            to confirm that
 whereas your staff recognizes     capabilities of     all sites with
 that such approaches exist and    its sites.          defense nuclear
 are in use. The use of this       However, as         facilities:
 terminology ``criteria and        discussed in the
 review approach'' also seems to   Recommendation,
 focus narrowly on a particular    '' the current
 solution when other parts of      scope of DOE
 the DNFSB's Draft                 independent
 Recommendation appear to imply    oversight is not
 that systemic changes are         adequate to
 needed in the overall DOE         identify needed
 oversight and continuous          improvements and
 improvement processes. DOE        to ensure
 recommends changing Action 1 to   effectiveness of
 read, ``In its role as a          federal and
 regulator, standardize and        contractor
 improve implementation of its     corrective
 criteria and review approach to   actions.'' In
 confirm ''                        addition, the
                                   Recommendation
                                   notes ``that DOE
                                   has not
                                   effectively
                                   conducted
                                   oversight and
                                   enforcement of
                                   its existing
                                   requirements.''
                                   Therefore, the
                                   scope and
                                   implementation of
                                   the existing
                                   criteria and
                                   review approaches
                                   should be
                                   standardized and
                                   improved. The
                                   Board believes
                                   that DOE's
                                   suggested
                                   rewording
                                   addresses this
                                   issue and is
                                   appropriate.
Regarding Action 2c, as written,  The Board           2.c Criteria for
 it is not clear that you may      acknowledges that   training and
 have intended for ``facility-     the meaning of      drills, including
 specific drill programs'' to      ``facility-         requirements that
 mean drill programs for           specific drill      address facility
 facility operators, who, as       programs'' needs    conduct of
 part of conduct of operations,    to be clarified.    operations drill
 take actions under abnormal and   The use of this     programs and the
 emergency operating procedures    term was intended   interface with
 to mitigate conditions or that    to address the      emergency
 bring facilities into safe shut-  response of         response
 down, separate from actions       facility            organization team
 taken by the emergency response   operators during    drills.
 organization. DOE recommends      emergency events
 changing this action to read,     and their
 ``including requirements that     interactions with
 address facility conduct of       emergency
 operations drill programs and     response
 the interface with emergency      personnel. The
 response organization team        Board believes
 drills.''                         that DOE's
                                   suggested
                                   rewording
                                   addresses this
                                   need for
                                   clarification and
                                   is appropriate.

[[Page 56796]]

 
Regarding Action 2e, the intent   Based on DOE's      2.e
 of this element is unclear        comment, the        Vulnerabilities
 since the Department already      Board               identified during
 has continuous improvement        acknowledges that   independent
 processes in place and            clarification of    assessments.
 processes for including lessons   the intent of
 learned during implementation     this element is
 of DOE directives into future     necessary. The
 directive revisions. In           clarification
 addition, Action 2e appears to    that DOE
 imply that improvement should     requested can be
 be made to the emergency          accomplished by
 management directive on a one-    phrasing the
 time basis and that the           required element
 directive should not be changed   more simply as
 until after program reviews       ``Vulnerabilities
 called for in Action 1 are        identified during
 completed. The Department         independent
 recommends a clarification of     assessments''.
 the intent of this action.
------------------------------------------------------------------------

[FR Doc. 2014-22510 Filed 9-22-14; 8:45 am]
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