Yucca Mountain: DOE's Planned Nuclear Waste Repository Faces
Quality Assurance and Management Challenges (25-APR-06,
GAO-06-550T).
The Department of Energy (DOE) is working to obtain a license
from the Nuclear Regulatory Commission (NRC) to construct a
nuclear waste repository at Yucca Mountain in Nevada. The
project, which began in the 1980s, has been beset by delays. In
2004, GAO raised concerns that persistent quality assurance
problems could further delay the project. Then, in 2005, DOE
announced discovery of employee e-mails suggesting quality
assurance problems. Quality assurance, which establishes
requirements for work to be performed under controlled conditions
that ensure quality, is critical to making sure the project meets
standards for protecting public health and the environment. This
testimony, which summarizes GAO's March 2006 report (GAO-06-313),
provides information on (1) the history of the project's quality
assurance problems, (2) DOE's tracking of these problems and
efforts to address them since GAO's 2004 report, and (3)
challenges facing DOE as it continues to address quality
assurance issues within the project.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-06-550T
ACCNO: A52421
TITLE: Yucca Mountain: DOE's Planned Nuclear Waste Repository
Faces Quality Assurance and Management Challenges
DATE: 04/25/2006
SUBJECT: Accountability
Licenses
Nuclear waste disposal
Nuclear waste management
Nuclear waste storage
Performance measures
Program evaluation
Program management
Quality assurance
Schedule slippages
DOE Yucca Mountain Project (NV)
Yucca Mountain (NV)
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GAO-06-550T
* Background
* DOE Has a Long History of Quality Assurance Problems at Yucc
* DOE Cannot Be Certain Its Efforts to Improve Quality Assuran
* DOE's New Path Forward to Submitting a License Application F
* Conclusions
* GAO Contact and Staff Acknowledgments
* GAO's Mission
* Obtaining Copies of GAO Reports and Testimony
* Order by Mail or Phone
* To Report Fraud, Waste, and Abuse in Federal Programs
* Congressional Relations
* Public Affairs
Testimony
Before the Subcommittee on the Federal Workforce and Agency Organization,
Committee on Government Reform, House of Representatives
United States Government Accountability Office
GAO
For Release on Delivery Expected at 2:00 p.m. EDT
Tuesday, April 25, 2006
YUCCA MOUNTAIN
DOE's Planned Nuclear Waste Repository Faces Quality Assurance and
Management Challenges
Statement of Jim Wells, Director Natural Resources and Environment
GAO-06-550T
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss our work concerning quality
assurance and other management challenges facing the Department of Energy
(DOE) as it prepares to construct a deep geological repository at Yucca
Mountain in Nevada for the nation's nuclear wastes. My testimony is based
on our March 2006 report entitled Yucca Mountain: Quality Assurance at
DOE's Planned Nuclear Waste Repository Needs Increased Management
Attention.1
DOE is preparing an application for a license from the Nuclear Regulatory
Commission (NRC) to construct an underground geological repository at
Yucca Mountain for the permanent storage of highly radioactive nuclear
waste. Nuclear waste is a by-product of the production of nuclear power,
which provides about 20 percent of U.S. electricity. About 50,000 metric
tons of nuclear waste are stored at 72 sites around the country,
principally at commercial nuclear power plants. These wastes have been
accumulating for several decades in surface storage designed to be
temporary. The Nuclear Waste Policy Act of 1982 required DOE to construct
a repository for permanent storage and to begin accepting these wastes by
January 31, 1998. In 2002, after more than 15 years of scientific study,
the President recommended and the Congress approved Yucca Mountain as a
suitable location for the repository. However, DOE continues to encounter
delays, and it is not certain when it will apply for the license to
construct the repository.
The licensing process requires DOE to demonstrate to NRC that its plans
for the repository will meet Environmental Protection Agency standards for
protecting public health and the environment from harmful exposure to the
radioactive waste. To show that it can meet these standards, DOE has been
conducting scientific and technical studies at the Yucca Mountain site
that will provide supporting documentation for its planned license
application. DOE has also established a quality assurance program to meet
NRC requirements and ensure that its work and the technical information it
produces are accurate and defensible. To accomplish this goal, the program
established procedures that require scientific, design, engineering,
procurement, records keeping, and other work to be performed under
controlled conditions that ensure quality and enable the work to be
verified by others. However, persistent problems implementing these
procedures and resulting questions about the quality of the work are
significantly contributing to delays in DOE's submission of the license
application. Resolving these quality assurance issues is essential to
proceeding with construction.
1 GAO-06-313 (Washington, D.C.: Mar. 17, 2006).
In April 2004, we reported that recurring quality assurance problems at
the Yucca Mountain project could delay the licensing and operation of the
repository. At that time, we also reported that DOE had completed
efforts-known as Management Improvement Initiatives (Initiatives)-to
better manage quality assurance problems, but could not assess their
effectiveness because its performance goals lacked objective measures and
time frames for determining success.2 Then, in early 2005, DOE reported
that it had discovered a series of e-mail messages written in the late
1990s by U.S. Geological Survey (USGS) employees working on the Yucca
Mountain project under a contract with DOE that appeared to imply that
workers had falsified records for scientific work. Several of these
messages appeared to show disdain for the project's quality assurance
program and its requirements. In October 2005, DOE began planning an
aggressive series of changes-known as the "new path forward"-to the
facility design, organization, and management of the Yucca Mountain
project. These efforts are intended to address quality assurance and other
challenges, including those associated with the USGS e-mails, and advance
the license application process. However, in December 2005 and again in
February 2006, some project work was stopped due to continuing quality
assurance problems.
Our March 2006 report examined (1) the history of the project's quality
assurance problems since its start in the 1980s, (2) DOE's tracking of
quality problems and progress implementing quality assurance requirements
since our April 2004 report, and (3) challenges that DOE faces as it
continues to address quality assurance issues with the project. To
determine the history of quality assurance problems, we reviewed previous
GAO, DOE, and NRC documents, visited the Yucca Mountain site, and
interviewed officials from DOE, NRC, and Bechtel/SAIC Company, LLC (BSC),
which is DOE's management contractor for the Yucca Mountain project. To
assess DOE's tracking of quality-related problems and progress in
addressing them, we examined management tools and associated
documentation, and interviewed BSC and DOE officials regarding those
tools. To identify current quality assurance and other challenges, we
attended quarterly NRC management meetings, interviewed the Acting
Director and other senior managers of the DOE project, and gathered
information on management turnover. The work on our report was conducted
from July 2005 through January 2006 in accordance with generally accepted
government auditing standards.
2GAO, Yucca Mountain: Persistent Quality Assurance Problems Could Delay
Repository Licensing and Operation, GAO-04-460 (Washington, D.C.: Apr. 30,
2004).
In summary, we found the following:
o DOE has had a long history of quality assurance problems at the
Yucca Mountain project. In the late 1980s and early 1990s, DOE had
problems assuring NRC that it had developed adequate plans and
procedures related to quality assurance. As we reported in 1988,
NRC had found that DOE's quality assurance procedures were
inadequate and its efforts to independently identify and resolve
weaknesses in the procedures were ineffective. By the late 1990s,
DOE had largely addressed NRC's concerns about its plans and
procedures, but its own audits identified quality assurance
problems with the data, software, and models used in the
scientific work supporting its potential license application. For
example, in 1998, a team of project personnel determined that 87
percent of the models used to simulate the site's natural and
environmental conditions, and to demonstrate the future
repository's performance over time, did not comply with
requirements for demonstrating their accuracy in predicting
geologic events. More recently, DOE has relied on costly and
time-consuming rework to resolve lingering quality assurance
concerns. Specifically, in the spring of 2004, DOE implemented a
roughly $20 million, 8-month project called the Regulatory
Integration Team to ensure that scientific work was sufficiently
documented and explained to support the license application. This
effort involved about 150 full-time employees from DOE, USGS, and
multiple national laboratories, such as Sandia and Los Alamos,
working to inspect technical documents to identify and resolve
quality problems.
o DOE cannot be certain that its efforts to improve quality
assurance have been effective because the management tools it
adopted did not target existing management concerns and did not
track progress in addressing significant and recurring problems.
DOE announced in 2004 that it was making a commitment to
continuous quality assurance improvement and that its efforts
would be tracked by performance indicators that would enable it to
assess progress and direct management attention as needed;
however, its management tools have not been effective for this
purpose. Specifically, its one-page summary, or "panel," of
selected performance indicators that project managers used in
monthly management meetings was not an effective tool for
assessing progress because the indicators poorly represented the
major management concerns and were changed frequently. For
example, the panel did not include an indicator to represent the
management concern about unclear roles and responsibilities-a
problem that could undermine accountability within the project.
Use of the indicator panel was discontinued in late 2005, and DOE
is deciding on a tool to replace it. Moreover, a second management
tool-trend evaluation reports-also did not track relevant
concerns. The reports generally had technical weaknesses for
identifying recurrent and significant problems and inconsistently
tracked progress toward resolving the problems. For example,
lacking reliable data and an appropriate performance benchmark for
determining the significance of human errors as a cause of quality
problems, DOE's trend reports offered no clear basis for tracking
progress on such problems. In addition, under the trend reports'
rating categories, the rating assigned to convey the significance
of a problem was overly influenced by a judgment in the report
that there were already ongoing management actions to address the
problem, rather than solely assessing the problem's significance.
For example, the trend report's rating of one particular problem
at the lowest level of significance did not accurately describe
the problem or sufficiently draw management's attention to it.
o DOE's aggressive "new path forward" effort faces substantial
quality assurance and other challenges, as it prepares to submit
the license application to construct the repository at Yucca
Mountain. First, the March 2005 announcement of the discovery of
USGS e-mails suggesting the possible falsification of quality
assurance records has resulted in extensive efforts to restore
confidence in scientific documents, and DOE is conducting a
wide-ranging review of approximately 14 million e-mails to
determine whether they raise additional quality assurance issues.
Such a review creates a challenge not just because of the sheer
volume of e-mails to be reviewed, but also because DOE will have
to decipher their meaning and determine their significance,
sometimes without clarification from authors who have left the
project. Furthermore, if any of the e-mails raise quality
assurance concerns, further review, inspection, or additional work
may need to be performed. Second, DOE faces quality assurance
challenges associated with an inadequate requirements management
process-the process responsible for ensuring that broad plans and
regulatory requirements affecting the project are tracked and
incorporated into specific engineering details. In December 2005,
DOE issued a stop-work order on some design and engineering work
until it can determine whether the requirements management process
has been improved. Third, DOE continues to be challenged by
managing a changing and complex program and organization. The
significant project changes initiated under the new path forward
create the potential for confusion over accountability as roles
and responsibilities change-a situation DOE found to contribute to
quality assurance problems during an earlier transition period.
For example, one proposed reorganization-establishing a lead
laboratory to assist the project-would not only have to be
effectively managed, but also would introduce a new player whose
accountability DOE would have to ensure. DOE has also experienced
turnover in 9 of 17 key management positions since 2001-including
positions related to quality assurance-that has created management
continuity challenges. For example, three individuals have
directed the project since 1999, and the position is currently
occupied by an acting director. Since DOE is still formulating its
plans, it is too early to determine whether its new path forward
effort will resolve these challenges.
In our report, we recommend that DOE strengthen its management
tools by (1) improving the tools' coverage of the Initiatives'
areas of concern, (2) basing the tools on projectwide analysis of
problems, (3) establishing quality guidelines, (4) making
indicators and analyses more consistent over time, and (5)
focusing rating categories on problem significance rather than a
judgment on the need for management action. In commenting on the
report, DOE agreed with our recommendations.
The Congress enacted the Nuclear Waste Policy Act of 1982 to
establish a comprehensive policy and program for the safe,
permanent disposal of commercial spent nuclear fuel and other
highly radioactive wastes in one or more mined geologic
repositories. The act charged DOE with (1) establishing criteria
for recommending sites for repositories; (2) "characterizing"
(investigating) three sites to determine each site's suitability
for a repository (1987 amendments to the act directed DOE to
investigate only the Yucca Mountain site); (3) recommending one
suitable site to the President, who would submit a recommendation
of such site to the Congress if he considered the site qualified
for a license application; and (4) upon approval of a recommended
site, seeking a license from NRC to construct and operate a
repository at the site. The Yucca Mountain project is currently
focused on preparing an application for a license from NRC to
construct a repository. DOE is compiling information and writing
sections of the license application, conducting technical
exchanges with NRC staff, and addressing key technical issues
identified by NRC to ensure that sufficient supporting information
is provided.
In February 2005, DOE announced that it does not expect the
repository to open until 2012 at the earliest, which is more than
14 years later than the 1998 goal specified by the Nuclear Waste
Policy Act of 1982. More recently, the conference report for DOE's
fiscal year 2006 appropriations observed that additional
significant delays to submitting a license application are likely.
In October 2005, the project's Acting Director issued a memorandum
calling for the development of wide-ranging plans for the "new
path forward" to submitting the license application. The plans
address the need to review and replace USGS work products,
establish a lead national laboratory to assist the project, and
develop a new simplified design for the waste canisters and
repository facilities, among other things. In addition, DOE
announced, in April 2006, that it was proposing legislation
intended to accelerate licensing and operations. For example, the
legislation provides that if NRC authorizes the repository,
subsequent licensing actions would be conducted using expedited,
simplified procedures.
Given the delays, the Congress has considered other options for
managing existing and future nuclear wastes, such as centralized
interim storage at one or more DOE sites. In addition, the
conference report for DOE's fiscal year 2006 appropriations
directed DOE to develop a spent nuclear fuel recycling plan to
reuse the spent fuel. However, according to the Nuclear Energy
Institute, which represents the nuclear energy industry, none of
technological options being considered will eliminate the need to
ultimately dispose of nuclear waste in a geologic repository.
DOE has had a long history of quality assurance problems at the
Yucca Mountain project. In the project's early stages, DOE had
problems assuring NRC that it had developed adequate quality
assurance plans and procedures. By the late 1990s, DOE had largely
addressed NRC's concerns about its plans and procedures, but its
own audits identified quality assurance problems with the data,
software, and models used in the scientific work supporting its
potential license application. While recently resolving these
quality problems, DOE is now relying on costly and time-consuming
rework to ensure the traceability and transparency of several
technical work products that are key components of the license
application.
As we reported in 1988, NRC reviewed DOE's quality assurance
program for the Yucca Mountain project and concluded that it did
not meet NRC requirements3 and that DOE's quality assurance audits
were ineffective. In 1989, NRC concluded that DOE and its key
contractors had yet to develop and implement an acceptable quality
assurance program. However, by March 1992, NRC determined that DOE
had made significant progress in improving its quality assurance
program, noting among other things, that all of the contractor
organizations had developed and were in the process of
implementing quality assurance programs that met NRC requirements,
and that DOE had demonstrated its ability to evaluate and correct
deficiencies in the overall quality assurance program.
By the late 1990s, however, the DOE quality assurance program
began detecting new quality problems in three areas critical to
demonstrating the repository's successful performance over time:
data management, software management, and scientific models.
o Data management. In 1998, DOE identified quality assurance
problems with the quality and traceability of data, specifically
that some data had not been properly collected or tested to ensure
its accuracy and that data used to support scientific analysis
could not be properly traced back to its source. DOE found similar
problems in April and September 2003.
o Software management. DOE quality assurance procedures require
that software used to support analysis and conclusions about the
performance and safety of the repository be tested or created in
such a way to ensure that it is reliable. From 1998 to 2003,
multiple DOE audits found recurring quality assurance problems
that could affect confidence in the adequacy of software.
o Model validation. In 1998, a team of project personnel
evaluated the mathematical models used to simulate natural and
environmental conditions and determined that 87 percent of them
did not comply with validation requirements to ensure they
accurately predict geologic events. In 2001, and again in 2003,
DOE audits found that project personnel were not properly
following procedures, specifically in the areas of model
documentation, model validation, and checking and review. Further,
the 2003 audit concluded that previous corrective actions designed
to improve validation and reduce errors in model reports were not
fully implemented.
After many years of working to address these quality assurance
problems with data, software, and models, DOE had mostly resolved
these problems by February 2005.
As DOE prepares to submit the Yucca Mountain project license
application to NRC, it is relying on costly and time-consuming
rework to ensure that the documents supporting its license
application are accurate and complete. Although the department had
known for years about quality assurance problems with the
traceability and transparency of technical work products called
Analysis and Model Reports (AMR)-a key component of the license
application--DOE did not initiate a major effort to address these
problems until 2004. AMRs contain the scientific analysis and
modeling data that demonstrate the safety and performance of the
planned repository and, among other quality requirements, must be
traceable to their original source material and data and be
transparent in justifying and explaining their underlying
assumptions, calculations, and conclusions. In 2003, based in part
on these problems, as well as DOE's long-standing problems with
data, software, and modeling, NRC conducted an independent
evaluation of three AMRs to determine if they met NRC requirements
for being traceable, transparent, and technically appropriate for
their use in the license application. In all three AMRs, NRC found
significant problems with both traceability and transparency.4 NRC
concluded that these findings suggested that other AMRs may have
similar problems and that such problems could delay NRC's review
of the license application, as it would need to conduct special
inspections to resolve any problems it found with the quality of
technical information.
To address problems of traceability and transparency, DOE
initiated an effort in the spring of 2004 called the Regulatory
Integration Team (RIT) to perform a comprehensive inspection and
rework of the AMRs and ensure they met NRC requirements and
expectations.5 According to DOE officials, the RIT involved
roughly 150 full-time personnel from DOE, USGS, and multiple
national laboratories such as Sandia, Los Alamos, and Lawrence
Livermore. The RIT decided that 89 of the approximately 110 AMRs
needed rework. According to DOE officials, the RIT addressed or
corrected over 3,700 problems, and was completed approximately 8
months later at a cost of about $20 million. In a February 2005
letter to DOE, the site contractor stated that the RIT effort had
successfully improved the AMRs' traceability and transparency.
Subsequently, however, DOE identified additional problems with
traceability and transparency that required further inspections
and rework. DOE initiated a review of additional AMRs that were
not included in the scope of the 2004 RIT review after a March
2005 discovery of e-mails from USGS employees written between May
1998 and March 2000 implying that employees had falsified
documentation of their work to avoid quality assurance standards.
These additional AMRs contained scientific work performed by the
USGS employees and had been assumed by the RIT to meet NRC
requirements for traceability and transparency. However, according
to DOE officials, DOE's review determined that these AMRs did not
meet NRC's standards, and rework was required. DOE identified
similar problems as the focus of the project shifted to the design
and engineering work required for the license application. In
February 2005, the site contractor determined that, in addition to
problems with AMRs, similar traceability and transparency problems
existed in the design and engineering documents that constitute
the Safety Analysis Report-the report necessary to demonstrate to
NRC that the repository site will meet the project's health,
safety, and environmental goals and objectives. In an analysis of
this problem, the site contractor noted that additional resources
were needed to inspect and rework the documents to correct the
problems.
DOE's management tools for the Yucca Mountain project have not
enabled it to effectively identify and track progress in
addressing significant and recurring quality assurance problems.
Specifically, its panel or one-page summary of selected
performance indicators did not highlight the areas of management
concern covered by its Management Improvement Initiatives
(Initiatives) and had weaknesses in assessing progress because the
indicators kept changing. Its trend reports also did not focus on
tracking these management concerns, had technical weaknesses for
identifying significant and recurrent problems, and has
inconsistently tracked progress with problems. Furthermore, the
trend reports have sometimes been misleading as to the
significance of the problems being presented because their
significance ratings tend to be lower if corrective actions were
already being taken, without considering the effectiveness of the
actions or the problem's importance to the project.
In April 2004, DOE told us it expected that the progress achieved
with its Initiatives for improving quality assurance would
continue and that its performance indicators would enable it to
assess further progress and direct management attention as needed.
By that time, the actions called for by the Initiatives had been
completed and project management had already developed a "panel"
of indicators to use at monthly management meetings to monitor
project performance. The panel was a single page composed of
colored blocks representing selected performance indicators and
their rating or level of performance. For example, a red block
indicated degraded or adverse performance warranting significant
management attention, a yellow block indicated performance
warranting increased management attention or acceptable
performance that could change for the worse, and a green block
indicated good performance. The panel represented a hierarchy of
indicators where the highest-level indicators were visible, but
many lower-level indicators that determined the ratings of the
visible indicators were not shown. Our review analyzed a subset of
these indicators that DOE designated as the best predictors in
areas affecting quality.
We found that the panel was not effective for assessing continued
progress because its indicators poorly represented the management
concerns identified by the Initiatives. The Initiatives had raised
concerns about five key areas of management weakness as adversely
affecting the implementation of quality assurance requirements,
and had designated effectiveness indicators for these areas.
(These areas of concern are described in app. I.) However, two of
the Initiatives' five key areas of concern-roles and
responsibilities as well as work procedures-were not represented
in the panel's visible or underlying indicators. In other cases,
the Initiatives' effectiveness indicators were represented in
underlying lower-level indicators that had very little impact on
the rating of the visible indicator. For example, the Initiatives'
indicator for timely completion of employee concerns was
represented by two lower-level indicators that together
contributed 3 percent of the rating for an indicator visible in
the panel.
Another shortcoming of the panel was that frequent changes to the
indicators hindered the ability to identify problems for
management attention and track progress in resolving them. The
indicators could change in many ways, such as how they were
defined or calculated. Such changes made it difficult to measure
progress because changes in indicator ratings could reflect only
the changes in the indicators rather than actual performance
changes. Some of the indicators tracking quality issues changed
from one to five times during the 8-month period from April 2004
through November 2004. Even after a major revision of the panel in
early 2005, most of the performance indicators tracking quality
issues continued to change over the next 6 months-that is, from
March 2005 through August 2005. Only one of these five indicators
did not change during this period. One indicator was changed four
times during the 6-month period, resulting in it being different
in more months than it remained the same. Moreover, the panel was
not always available to track problems. It was not created for
December 2004 through February 2005, and it has not been created
since August 2005. In both cases, the panel was undergoing major
revisions. In December 2005, a senior DOE official told us that
the project would begin to measure key activities, but without use
of the panel.
According to DOE, a second management tool, the project's
quarterly trend evaluation reports, captured some aspects of the
Initiatives' areas of concern and their associated effectiveness
indicators that were not represented in the performance
indicators. However, the trend reports are designed more to
identify emerging and unanticipated problems than to monitor
progress with already identified problems, such as those addressed
by the Initiatives. In developing these reports, trend analysts
seek to identify patterns and trends in condition reports, which
document problematic conditions through the project's Corrective
Action Program. For example, analysis might reveal that most
occurrences of a particular type of problem are associated with a
certain organization.
In practice, DOE missed opportunities to use trend reports to
assess progress in the Initiatives' areas of concern. For example,
DOE missed an opportunity to use trend reports to discuss the
Initiatives' goal that the project's work organizations become
more accountable for self-identifying significant problems. The
August 2005 trend report briefly cited an evaluation of a
condition report highlighting the low rate of self-identification
of significant problems during the previous quarter and reported
the evaluation's conclusion that it was not a problem warranting
management attention. However, the trend report did not mention
that about 35 percent of significant problems were self-identified
during the previous quarter, while the Initiatives' goal was that
80 percent of significant problems would be self-identified.
Beyond whether they effectively track the Initiatives' areas of
concern, trend reports generally face serious obstacles to
adequately identifying recurrent and significant problems. For
example, trend analysis tends to focus on the number of condition
reports issued, but the number of reports does not necessarily
reflect the significance of a problem. For example, the number of
condition reports involving requirements management decreased by
over half from the first quarter to the second quarter of fiscal
year 2005. However, this decrease was not a clear sign of
progress. Not only did the number rise again in the third quarter,
but the May 2005 trend report also noted that the number of all
condition reports had dropped during the second quarter. According
to the report, the volume of condition reports had been high in
the first quarter because of reviews of various areas, including
requirements management.
Due, in part, to these obstacles, trend reports have not
consistently determined the significance of problems or performed
well in tracking progress in resolving them. For example, trend
reports have questionably identified human performance as a
significant problem for resolution and ineffectively tracked
progress in resolving it because there was (1) no clearly
appropriate or precise benchmark for performance, (2) a changing
focus on the problem, and (3) unreliable data on cause codes. The
February 2004 trend report identified a human performance problem
based on Yucca Mountain project data showing the project's
proportion of skill-based errors to all human performance errors
was two times higher than benchmark data from the Institute of
Nuclear Power Operations (INPO).6 Interestingly, the report
cautioned that other comparisons with these INPO data may not be
appropriate because of differences in the nature, complexity, and
scope of work performed, but did not explain why this caution did
not apply to the report's own comparison. While this comparison
has not appeared in trend reports since May 2004, a November 2004
trend report changed the focus of the problem to the predominance
of human performance errors in general, rather than the
skill-based component of these errors. (Later reports
reinterpreted this predominance as not a problem.) The report
cited an adverse trend based on the fact that the human
performance cause category accounted for over half of the total
number of causes for condition reports prepared during the
quarter. Nevertheless, by February 2005, trend reports began
interpreting this predominance as generally appropriate, given the
type of work done by the project. That is, the project's work
involves mainly human efforts and little equipment, while work at
nuclear power plants involves more opportunities for errors caused
by equipment. In our view, this interpretation that a predominance
of human performance errors would be expected implies an imprecise
benchmark for appropriate performance.
Further, although trend reports continued to draw conclusions
about human performance problems, the February 2005 report
indicated that any conclusions were hard to justify because of
data reliability problems with cause coding. For example, the
majority of problems attributed to human performance causes are
minor problems, such as not completing a form, that receive
less-rigorous cause analysis. This less-rigorous analysis tends to
reveal only individual human errors-that is, human performance
problems-whereas more-rigorous analysis tends to reveal
less-obvious problems with management and procedures.
Another shortcoming of the trend reports was that their rating
categories made it difficult to adequately determine the
significance of some problems. Specifically, trend reports
sometimes assigned a problem a lower significance than justified
because corrective actions were already being taken. The rating
categories for a problem's significance also involve an assessment
of the need for management action. In their current formulation,
DOE's rating categories cannot accurately represent both these
assessments, and the designated rating category can distort one or
the other assessment. For instance, a November 2005 trend report
rated certain requirements management issues as a "monitoring
trend"-defined as a small perturbation in numbers that does not
warrant action but needs to be monitored closely. However, this
rating did not accurately capture the report's simultaneous
recognition that significant process problems spanned both BSC and
DOE and the fact that the numbers and types of problems were
consistently identified over the previous three quarters. A more
understandable explanation for why the problem received a low
rating is that designating the problem at any higher level of
significance would have triggered guidelines involving the
issuance of a condition report, which, according to the judgment
expressed in the report, was not needed. Specifically, the report
indicated that existing condition reports have already identified
and were evaluating and resolving the problem, thereby eliminating
the need to issue a new condition report.
However, by rating the problem at the lowest level of
significance, the trend report did not sufficiently draw
management's attention to the problem. At about the same time the
trend report judged no new condition reports were necessary, a
separate DOE investigation of requirements management resulted in
14 new condition reports-3 at the highest level of significance
and 8 at the second-highest level of significance. These condition
reports requested, for instance, an analysis of the collective
significance of the numerous existing condition reports and an
assessment of whether the quality assurance requirement for
complete and prompt remedial action had been met. As a result of
the investigation and a concurrent DOE root cause analysis,7 DOE
stated during the December 2005 quarterly management meeting with
NRC that strong actions were required to address the problems with
its requirements management system and any resulting uncertainty
about the adequacy of its design products.
I would now like to update you on the project's February 2006
stop-work order, which occurred too late to be included in our
report. We believe this incident is an example of how the
project's management tools have not been effective in bringing
quality assurance problems to top management's attention. After
observing a DOE quality assurance audit at the Lawrence Livermore
National Laboratory in August 2005, NRC expressed concern that
humidity gauges used in scientific experiments at the project were
not properly calibrated-an apparent violation of quality assurance
requirements. According to an NRC official, NRC communicated these
findings to BSC and DOE project officials on six occasions between
August and December 2005, and issued a formal report and letter to
DOE on January 9, 2006. However, despite these communications and
the potentially serious quality assurance problems involved, the
project's acting director did not become aware of the issue until
January 2006, after reading about it in a news article. Due to
concerns that quality assurance requirements had not been followed
and the length of time it took top management to become aware of
the issue, BSC issued a February 7, 2006, stop-work order
affecting this scientific work. Project officials have begun a
review of the issue.
In pursuing its new path forward, DOE faces significant quality
assurance and other challenges, including (1) determining the
extent of problems and restoring confidence in the documents
supporting the license application after the discovery of e-mails
raising the potential of falsified records, (2) settling the
design issues and the associated problems with requirements
management, and (3) replacing key personnel and managing the
transition of new managers and other organizational challenges.
The early 2005 discovery of USGS e-mails suggesting possible
noncompliance with the project's quality assurance requirements
has left lingering concerns about the adequacy of USGS's
scientific work related to the infiltration or flow of water into
the repository and whether other work on the project has similar
quality assurance problems. As part of its new path forward, DOE
has taken steps to address these concerns. It is reworking
technical documents created by USGS personnel to ensure that the
science underlying the conclusions on water infiltration is
correct and supportable. In addition, DOE is conducting an
extensive review of approximately 14 million e-mails to determine
whether they raise additional quality assurance concerns.
According to NRC on-site representatives, screening these millions
of e-mails to ensure that records were not falsified will be
challenging. Further, many of the e-mails were written by
employees who no longer work at the project or may be deceased,
making it difficult to learn their true meaning and context.
Moreover, if additional e-mails raise quality assurance concerns,
DOE may have to initiate further review, inspections, or rework.
DOE officials have stated that it will need to resolve
long-standing quality assurance problems involving requirements
management before it can perform the design and engineering work
needed to support the revised project plans called for by its new
path forward. According to a 2005 DOE root cause analysis report,
low-level documents were appropriately updated and revised to
reflect high-level design changes through fiscal year 1995.
However, from 1995 through 2002, many of these design documents
were not adequately maintained and updated to reflect current
designs and requirements. Further, a document that is a major
component of the project's requirements management process was
revised in July 2002, but has never been finalized or approved.
Instead, the project envisioned a transition to a new requirements
management system after the submission of the license application,
which at that time was planned for December 2004. However, for
various reasons, the license application was not submitted, and
the transition to a new requirements management system was never
implemented. The DOE report described this situation as
"completely dysfunctional" and identified the root cause of these
conditions as DOE's failure to fund, maintain, and rigidly apply a
requirements management system. According to an NRC on-site
representative, repetitive and uncorrected issues associated with
the requirements management process could have direct implications
for the quality of DOE's license application.
In December 2005, DOE issued a stop-work order on design and
engineering for the project's surface facility and certain other
technical work. DOE stated that a root cause analysis and an
investigation into employee concerns had revealed that the project
had not maintained or properly implemented its requirements
management system, resulting in inadequacies in the design control
process. The stop-work order will be in effect until, among other
things, the lead contractor improves the requirements management
system, validates that processes exist and are being followed, and
requirements are appropriately traced to implementing mechanisms
and products. Further, DOE will establish a team to take other
actions necessary to prevent inadequacies in requirements
management and other management systems from recurring.
Finally, DOE continues to be challenged to effectively manage a
changing and complex program and organization. The significant
project changes initiated under the new path forward create the
potential for confusion over accountability as roles and
responsibilities change-a situation DOE found to contribute to
quality assurance problems during an earlier transition period. An
important part of this challenge is ensuring that accountability
for quality and results are effectively managed during the
transition to the new path forward. For example, DOE's plan to
establish a lead laboratory to assist the project would not only
have to be effectively managed, but also would introduce a new
player whose accountability DOE would have to ensure. According to
one DOE manager, transitioning project work to a lead laboratory
under a direct contract with DOE could pose a significant
challenge for quality assurance because the various laboratories
assisting with the project are currently working under BSC quality
assurance procedures and will now have to develop their own
procedures.
In addition, the project faces management challenges related to
ensuring management continuity at the project. DOE has experienced
turnover in 9 of 17 key management positions since 2001. For
example, in the past year, the project has lost key managers
through the departures of the Director of Project Management and
Engineering, the Director of the License Application and Strategy,
the Director of Quality Assurance, and the contractor's General
Manager. To ensure the right managers move the project forward to
licensing, the project has a recruitment effort for replacing key
departing managers. Further, the director position for the project
has been occupied by three individuals since 1999 and is currently
filled by an acting director. The current Acting Director took his
position in summer 2005, and initiated the new path forward in
October 2005. DOE is currently awaiting congressional confirmation
of a nominee to take the director position. However, the current
Acting Director told us he expects that the new path forward will
be sustained after the new director assumes the position because
it has been endorsed by the Secretary of Energy.
DOE has a long history of trying to resolve quality assurance
problems at its Yucca Mountain project. Now, after more than 20
years of work, DOE once again faces serious quality assurance and
other challenges while seeking a new path forward to a fully
defensible license application. Even as DOE faces new quality
assurance challenges, it cannot be certain that it has resolved
past problems. It is clear that DOE has not been well served by
management tools that have not effectively identified and tracked
progress on significant and recurring problems. As a result, DOE
has not had a strong basis to assess progress in addressing
management weaknesses or to direct management attention to
significant and recurrent problems as needed. Unless these quality
assurance problems are addressed, further delays on the project
are likely.
Mr. Chairman, this concludes my prepared statement, I would be
happy to respond to any questions that you or other Members of the
Subcommittee may have at this time.
For further information about this testimony, please contact Jim
Wells at (202) 512-3841 or [email protected]. Casey Brown, John
Delicath, Terry Hanford, and Raymond Smith also made key
contributions to this statement.
The Department of Energy's Management Improvement Initiatives
(Initiatives) perceived five key areas of management weakness as
adversely affecting the implementation of quality assurance
requirements at the Yucca Mountain project:
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1. Roles and responsibilities were becoming confused
as the project transitioned from scientific studies
to activities supporting licensing. The confusion
over roles and responsibilities was undermining
managers' accountability for results. The
Initiatives' objective was to realign DOE's project
organization to give a single point of responsibility
for project functions, such as quality assurance and
the Corrective Action Program, and hold the project
contractor more accountable for performing the
necessary work in accordance with quality, schedule,
and cost requirements.
2. Product quality was sometimes being achieved
through inspections by the project's Office of
Quality Assurance rather than being routinely
implemented by the project's work organizations. As a
result, the Initiatives sought to increase work
organizations' responsibility for being the principle
means for achieving quality.
3. Work procedures were typically too burdensome and
inefficient, which impeded work. The Initiatives
sought to provide new user-friendly and effective
procedures, when necessary, to allow routine
compliance with safety and quality requirements.
4. Multiple corrective action programs existed,
processes were burdensome and did not yield useful
management reports, and corrective actions were not
completed in a timely manner. The Initiatives sought
to implement a single program to ensure that problems
were identified, prioritized, and documented and that
timely and effective corrective actions were taken to
preclude recurrence of problems.
5. The importance of a safety-conscious work
environment that fosters open communication about
concerns was not understood by all managers and
staff, and they had not been held accountable when
inappropriately overemphasizing the work schedule,
inadequately attending to work quality, and acting
inconsistently in practicing the desired openness
about concerns. Through issuing a work environment
policy, providing training on the policy, and
improving the Employee Concerns Program, the
Initiatives sought to create an environment in which
employees felt free to raise concerns without fear of
reprisal and with confidence that issues would be
addressed promptly and appropriately.
Background
DOE Has a Long History of Quality Assurance Problems at Yucca Mountain
3GAO, Nuclear Waste: Repository Work Should Not Proceed Until Quality
Assurance Is Adequate, GAO/RCED-88-159 (Washington, D.C.: Sept. 29, 1988).
4U.S. Nuclear Regulatory Commission, U.S. Nuclear Regulatory Commission
Staff Evaluation of U.S. Department of Energy Analysis Model Reports,
Process Controls, and Corrective Actions (Washington, D.C., Apr. 7, 2004).
5In addition, the RIT edited the AMRs to assure consistency and ease of
technical and regulatory reviews.
DOE Cannot Be Certain Its Efforts to Improve Quality Assurance Have Been
Effective Because of Weaknesses in Tracking Progress and Identifying Problems
6Skill-based errors are defined in trend reports as unintentional errors
resulting from people not paying attention to the task at hand.
7A root cause analysis seeks to determine the root cause of a problem,
which is the underlying cause that must change in order to prevent the
problem from reoccurring.
DOE's New Path Forward to Submitting a License Application Faces Substantial
Quality Assurance and Other Challenges
Conclusions
GAO Contact and Staff Acknowledgments
Appendix I: The Management Improvement Initiatives' Key Areas of Concern
(360683)
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Highlights of GAO-06-550T, a testimony before the Subcommittee on the
Federal Workforce and Agency Organization, Committee on Government Reform,
House of Representatives
April25,2006
YUCCA MOUNTAIN
DOE's Planned Nuclear Waste Repository Faces Quality Assurance and
Management Challenges
The Department of Energy (DOE) is working to obtain a license from the
Nuclear Regulatory Commission (NRC) to construct a nuclear waste
repository at Yucca Mountain in Nevada. The project, which began in the
1980s, has been beset by delays. In 2004, GAO raised concerns that
persistent quality assurance problems could further delay the project.
Then, in 2005, DOE announced discovery of employee e-mails suggesting
quality assurance problems. Quality assurance, which establishes
requirements for work to be performed under controlled conditions that
ensure quality, is critical to making sure the project meets standards for
protecting public health and the environment.
This testimony, which summarizes GAO's March 2006 report (GAO-06-313),
provides information on (1) the history of the project's quality assurance
problems, (2) DOE's tracking of these problems and efforts to address them
since GAO's 2004 report, and (3) challenges facing DOE as it continues to
address quality assurance issues within the project.
What GAO Recommends
In its March 2006 report, GAO recommended actions DOE can take to improve
the project's management tools and their use in identifying and addressing
quality assurance and other problems. In commenting on a draft of the
report, DOE agreed with GAO's recommendations.
DOE has had a long history of quality assurance problems at the Yucca
Mountain project. In the 1980s and 1990s, DOE had problems assuring NRC
that it had developed adequate plans and procedures related to quality
assurance. More recently, as it prepares to submit a license application
for the repository to NRC, DOE has been relying on costly and
time-consuming rework to resolve lingering quality assurance problems
uncovered during audits and after-the-fact evaluations.
DOE announced, in 2004, that it was making a commitment to continuous
quality assurance improvement and that its efforts would be tracked by
performance indicators that would enable it to assess progress and direct
management attention as needed. However, GAO found that the project's
performance indicators and other key management tools were not effective
for this purpose. For example, the management tools did not target
existing areas of concern and did not track progress in addressing them.
The tools also had weaknesses in detecting and highlighting significant
problems for management attention.
DOE continues to face quality assurance and other challenges. First, DOE
is engaged in extensive efforts to restore confidence in scientific
documents because of the quality assurance problems suggested in the
discovered e-mails between project employees, and it has about 14 million
more project e-mails to review. Second, DOE faces quality assurance
challenges in resolving design control problems associated with its
requirements management process-the process for ensuring that high-level
plans and regulatory requirements are incorporated into specific
engineering details. Problems with the process led to the December 2005
suspension of certain project work. Third, DOE continues to be challenged
to manage a complex program and organization. Significant personnel and
project changes initiated in October 2005 create the potential for earlier
problem areas, such as confusion over roles and responsibilities, to
reoccur.
View of Yucca Mountain and the Exploratory Tunnel for the Repository
*** End of document. ***