Nuclear and Worker Safety: Actions Needed to Determine the	 
Effectiveness of Safety Improvement Efforts at NNSA's Weapons	 
Laboratories (31-OCT-07, GAO-08-73).				 
                                                                 
Federal officials, Congress, and the public have long voiced	 
concerns about safety at the nation's nuclear weapons		 
laboratories: Lawrence Livermore, Los Alamos, and Sandia. The	 
laboratories are overseen by the National Nuclear Security	 
Administration (NNSA), while contractors carry out the majority  
of the work. A recent change to oversight policy would result in 
NNSA's relying more on contractors' own management controls,	 
including those for assuring safety. This report discusses (1)	 
the recent history of safety problems at the laboratories and	 
contributing factors, (2) steps taken to improve safety, and (3) 
challenges that remain to effective management and oversight of  
safety. To address these objectives, GAO reviewed almost 100	 
reports and investigations and interviewed key federal and	 
laboratory officials.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-73						        
    ACCNO:   A77803						        
  TITLE:     Nuclear and Worker Safety: Actions Needed to Determine   
the Effectiveness of Safety Improvement Efforts at NNSA's Weapons
Laboratories							 
     DATE:   10/31/2007 
  SUBJECT:   Accident prevention				 
	     Accidents						 
	     Employees						 
	     Laboratories					 
	     Nuclear facilities 				 
	     Nuclear facility safety				 
	     Nuclear weapons					 
	     Nuclear weapons plant safety			 
	     Occupational safety				 
	     Performance measures				 
	     Program management 				 
	     Safety standards					 
	     Strategic planning 				 
	     Corrective action					 
	     Government agency oversight			 

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GAO-08-73

   

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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

October 2007: 

Nuclear And Worker Safety: 

Actions Needed to Determine with Effectiveness of Safety Improvement 
Efforts at NNSA's Weapons Laboratories: 

GAO-08-73: 

GAO Highlights: 

Highlights of GAO-08-73, a report to congressional committees. 

Why GAO Did This Study: 

Federal officials, Congress, and the public have long voiced concerns 
about safety at the nationï¿½s nuclear weapons laboratories: Lawrence 
Livermore, Los Alamos, and Sandia. The laboratories are overseen by the 
National Nuclear Security Administration (NNSA), while contractors 
carry out the majority of the work. A recent change to oversight policy 
would result in NNSAï¿½s relying more on contractorsï¿½ own management 
controls, including those for assuring safety. 

This report discusses (1) the recent history of safety problems at the 
laboratories and contributing factors, (2) steps taken to improve 
safety, and (3) challenges that remain to effective management and 
oversight of safety. To address these objectives, GAO reviewed almost 
100 reports and investigations and interviewed key federal and 
laboratory officials. 

What GAO Found: 

The nuclear weapons laboratories have experienced persistent safety 
problems, stemming largely from long-standing management weaknesses. 
Since 2000, nearly 60 serious accidents or near misses have occurred, 
including worker exposure to radiation, inhalation of toxic vapors, and 
electrical shocks. Although no one was killed, many of the accidents 
caused serious harm to workers or damage to facilities. Accidents and 
nuclear safety violations also contributed to the temporary shutdown of 
facilities at both Los Alamos and Lawrence Livermore in 2004 and 2005. 
Yet safety problems persist. GAOï¿½s review of nearly 100 reports issued 
since 2000 found that the contributing factors to these safety problems 
generally fall into three key areas: relatively lax laboratory 
attitudes toward safety procedures, laboratory inadequacies in 
identifying and addressing safety problems with appropriate corrective 
actions, and inadequate oversight by NNSA site offices. 

NNSA and its contractors have been taking some steps to address safety 
weaknesses at the laboratories. Partly in response to continuing safety 
concerns, NNSA has begun taking steps to reinvigorate a key safety 
effortï¿½integrated safety managementï¿½originally started in 1996. This 
initiative was intended to raise safety awareness and provide a formal 
process for employees to integrate safety into every work activity by 
identifying potential safety hazards and taking appropriate steps to 
mitigate these hazards. NNSA and its contractors have also begun taking 
steps to develop or improve systems for identifying and tracking safety 
problems and the corrective actions taken in response. Finally, NNSA 
has initiated efforts to strengthen federal oversight at the 
laboratories by improving hiring and training of federal site office 
personnel. NNSA has also taken steps to strengthen contractor 
accountability through new contract mechanisms. Many of these efforts 
are still under way, however, and their effect on safety performance is 
not clear. 

NNSA faces two principal challenges in its continuing efforts to 
improve safety at the weapons laboratories. First, the agency has no 
way to determine the effectiveness of its safety improvement efforts, 
in part because those efforts rarely incorporate outcome-based 
performance measures. The department issued a directive in 2003 
requiring use of a disciplined approach for managing improvement 
initiatives, often used by high-performing organizations, including 
results-oriented outcome measures and a system to evaluate the 
effectiveness of the initiative. Yet GAO found little indication that 
NNSA or its contractors have been managing safety improvement efforts 
using this approach. Second, in light of the long-standing safety 
problems at the laboratories, GAO and others have expressed concerns 
about the recent shift in NNSAï¿½s oversight approach to rely more 
heavily on contractorsï¿½ own safety management controls. Continuing 
safety problems, coupled with the inability to clearly demonstrate 
progress in remedying weaknesses, make it unclear how this revised 
system will enable NNSA to maintain an appropriate level of oversight 
of safety performance at the weapons laboratories. 

What GAO Recommends: 

GAO recommends that NNSA strengthen management and oversight of 
laboratory safety by ensuring that safety improvement initiatives be 
carried out in a systematic manner, with effective performance measures 
based on outcomes, not process; retaining sufficient independent 
federal oversight; and reporting annually to Congress on progress 
toward making the weapons laboratories safer. In commenting on a draft 
of this report, NNSA generally agreed with the report and 
recommendations. 

To view the full product, including the scope and methodology, click on 
GAO-08-73. For more information, contact Gene Aloise, 202-512-3841, 
[email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Long-standing Management Weaknesses Contribute to the Laboratories' 
Persistent Safety Problems: 

NNSA and Contractors Have Been Taking Some Steps to Address Management 
Weaknesses: 

NNSA Faces Fundamental Challenges to Effective Management and Oversight 
of Safety at Weapons Laboratories: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: List of Key Safety Evaluations: 

Appendix III: Enforcement Actions at NNSA Weapons: 

Appendix IV: Comments from the Department of Energy: 

Appendix V: GAO Contact and Staff Acknowledgments: 

[End of section] 

October 31, 2007: 

The Honorable Joe Barton: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable Ed Whitfield: 
Ranking Member: 
Subcommittee on Oversight and Investigations: 
Committee on Energy and Commerce: 
House of Representatives: 

The National Nuclear Security Administration[Footnote 1] (NNSA) 
oversees three weapons laboratories--Lawrence Livermore, Los Alamos, 
and Sandia national laboratories[Footnote 2]--to help carry out its 
missions of nuclear weapons stewardship, environmental cleanup, and 
scientific and technical research. The sensitive research conducted at 
these laboratories involves the handling of radioactive and hazardous 
materials, such as plutonium, and radioactive wastes that, if not 
handled safely, could cause nuclear accidents or expose the public and 
the environment to heavy doses of radiation. The weapons laboratories 
also conduct a wide range of other activities, including construction 
and routine maintenance and operation of equipment and facilities, that 
also run the risk of accidents. Although the consequences of such 
accidents could be less severe than one involving nuclear materials, 
they could also lead to long-term illness, injury, or even deaths among 
workers or the public. 

NNSA relies on contractors and subcontractors to perform day-to-day 
operations at each site. To promote laboratory and worker safety, 
NNSA's primary approach has been to require its contractors to follow 
federal safety laws and Department of Energy (DOE) requirements, 
including policies, orders, and standards, by incorporating these 
requirements into the contracts. DOE requirements address safety both 
in nuclear operations (nuclear safety) and in maintaining health and 
safety of laboratory workers (worker safety). NNSA site offices located 
at the laboratories are responsible for direct oversight of the 
contractors, including monitoring contractor-generated data on safety- 
related incidents and observing daily work activities in the facility. 
A recent change in DOE policy places more responsibility on the 
contractor for having a reliable system of management controls, 
including those addressing safety, and focuses NNSA oversight efforts 
on high-hazard activities. 

Over the years, federal officials, Congress, and members of the public 
have expressed concerns about safety problems and weaknesses at the 
weapons laboratories. The Defense Nuclear Facilities Safety Board 
(Safety Board), which was created by Congress to provide an independent 
assessment of safety conditions and operations at defense nuclear 
facilities, held a series of eight public hearings starting in 2002 to 
address concerns with DOE's approach to ensuring safety--including at 
NNSA's weapons laboratories--and in 2004 recommended that the 
department take a number of steps, such as strengthening the federal 
oversight role, in an effort to improve safety at these facilities. In 
addition, more than a dozen congressional hearings have addressed 
management problems at Los Alamos National Laboratory, including a May 
2005 hearing that raised questions about the laboratory's ability to 
manage safety issues.[Footnote 3] 

In this context, you asked us to examine NNSA's safety performance at 
the three weapons laboratories. This report discusses (1) the recent 
history of safety problems that have occurred at the weapons 
laboratories and contributing factors, (2) steps NNSA and its 
contractors have taken to improve safety management, and (3) challenges 
that remain to effective management and oversight of safety performance 
at the weapons laboratories. 

To address these issues, we reviewed federal laws and regulations 
describing safety requirements for nuclear safety and for worker safety 
and health. We also reviewed DOE policies and procedures regarding 
safety management. We reviewed relevant reports issued since 2000 
evaluating safety issues at the three weapons laboratories, including 
accident investigations, inspections by DOE's Office of Independent 
Oversight and Performance Assurance,[Footnote 4] reviews by NNSA's 
Chief of Defense Nuclear Safety, and reviews by the Safety Board. We 
also discussed the safety problems and contributing factors with 
representatives from these organizations, as well as with DOE and NNSA 
headquarters officials. In addition, we visited the three weapons 
laboratories and met with NNSA officials and contractors to discuss 
safety management and safety problems at the laboratories and to 
determine what steps NNSA and contractors were taking to address these 
issues. Appendix I describes our scope and methodology in more detail. 
We performed our work in accordance with generally accepted government 
auditing standards, which included an assessment of data reliability, 
from September 2006 through September 2007. 

Results in Brief: 

The three NNSA weapons laboratories have experienced persistent safety 
problems--including accidents and violations of nuclear safety rules 
designed to protect workers and the public--stemming largely from long- 
standing management weaknesses. Since 2000, nearly 60 serious accidents 
or near misses have occurred at the laboratories, including worker 
exposure to radiation, inhalation of toxic vapors, and electrical 
shocks. Although no one was killed, many of the accidents caused 
serious harm to workers or damage to facilities. For example, in an 
accident at Los Alamos in 2000, seven workers received significant 
doses of radiation--four requiring immediate medical attention-- 
because, the accident investigation concluded, the laboratory had 
failed to take appropriate corrective action after similar previous 
accidents. In addition, since 2000, two of the laboratories (Los Alamos 
and Lawrence Livermore) have been found in violation of nuclear safety 
rules on a total of eight separate occasions--violations that signal 
safety vulnerabilities. Accidents and nuclear safety violations also 
contributed to the temporary shutdown of facilities at both Los Alamos 
and Lawrence Livermore in 2004 and 2005, respectively, costing 
taxpayers hundreds of millions of dollars in lost productivity. 
Nevertheless, safety problems persist. We reviewed nearly 100 reports 
issued since 2000 that address safety at the three weapons 
laboratories--including accident investigations and independent 
assessments of safety--and found that factors contributing to these 
safety problems generally fall into three key areas: 

* A relatively lax attitude toward safety procedures. Lax safety 
attitudes at the three laboratories have created an environment where 
workers can become complacent about following safety requirements, and 
managers about enforcing them, raising the potential for accidents. 

* Weaknesses in identifying safety problems and taking appropriate 
corrective actions. Fundamental weaknesses in the laboratories' ability 
to accurately identify and fully understand safety problems and 
implement appropriate corrective actions have hampered the 
laboratories' ability to improve safety performance. 

* Inadequate oversight by NNSA site offices. Shortcomings in federal 
oversight of safety at the laboratories have included insufficient 
technical and safety expertise at the site offices to perform adequate 
and timely on-site reviews. 

NNSA and its contractors have been taking some steps to address 
weaknesses in these three key areas. NNSA's key safety effort-- 
integrated safety management--was originally launched in 1996 in 
response to concerns raised by the Safety Board about safety culture 
and safety management issues DOE-wide. This effort was intended to 
raise safety awareness and provide a formal process for employees to 
integrate safety into every work activity by identifying potential 
safety hazards and taking appropriate steps to mitigate these hazards. 
In response to continuing Safety Board concerns about safety at NNSA 
nuclear facilities, NNSA began taking steps to reinvigorate this 
program. To address weaknesses in how safety problems are identified 
and corrected, NNSA and its contractors have also begun taking steps to 
develop or improve systems for identifying and tracking safety problems 
and the corrective actions taken in response. Further, NNSA has 
initiated efforts to strengthen federal oversight at the laboratories 
by improving hiring and training of federal site office personnel. In 
addition, NNSA has been taking steps to hold contractors more 
accountable for safety, including using new contract mechanisms that 
provide for additional fee or contract extensions for meeting annual 
safety and other goals. It also implemented a new regulation in 
February 2007, which allows the agency to either impose fines on 
contractors or reduce contractors' fees or profit for failing to follow 
existing worker safety requirements. Many of these efforts are still 
under way, however, and their effect on safety performance is not 
clear. 

NNSA faces two principal challenges in its continuing efforts to 
improve safety at the laboratories. First, the agency lacks a way to 
determine the effectiveness of its safety improvement efforts, in part 
because those efforts rarely incorporate outcome-based performance 
measures. We have found that high-performing organizations often use a 
systematic approach to managing improvement efforts that includes, 
among other things, clear goals and results-oriented outcome measures. 
Despite a DOE directive calling for a disciplined, systematic approach 
to implementing improvement initiatives--one including results- 
oriented outcome measures and a system to evaluate effectiveness--NNSA 
has not adopted such an approach with regard to safety at the weapons 
laboratories. Rather, safety performance measures are often process- 
oriented, with no indication of how they might be used to gauge the 
effectiveness of safety improvement efforts. Second, because of the 
long-standing safety problems at the laboratories, we and others have 
raised concerns over the agency's shift in its oversight approach to 
rely more heavily on contractors' own safety management controls. Given 
the persistent safety problems at the laboratories, coupled with NNSA's 
and contractors' continued inability to clearly demonstrate progress in 
remedying weaknesses, it is unclear how this revised system will enable 
NNSA to maintain an appropriate level of oversight of safety 
performance at the weapons laboratories. 

To strengthen safety management and oversight at the nation's weapons 
laboratories, we recommend that the Secretary of Energy direct the 
Administrator of NNSA to ensure that safety improvement initiatives 
comply with DOE requirements, in particular, that they be carried out 
in a systematic manner, with effective performance measures based on 
outcomes, not process; retain sufficient independent federal oversight 
of safety to fulfill its responsibilities associated with protecting 
workers, the public, and the environment; and report annually to 
Congress on progress toward making the weapons laboratories safer. 

In commenting on a draft of this report, NNSA generally agreed with the 
report and recommendations. 

Background: 

NNSA carries out the department's nuclear weapons research missions at 
three weapons laboratories--Lawrence Livermore, Los Alamos, and Sandia 
national laboratories. These three laboratories have primarily a 
science and technology mission, which focuses on maintaining the 
nation's nuclear weapons stockpile; preventing nuclear proliferation; 
and furthering basic scientific knowledge in chemistry, structural 
biology, and mathematics. In addition to their primary mission, the 
three laboratories perform work for other federal agencies, such as 
supporting homeland security efforts, and they coordinate research 
efforts with DOE's Office of Science national laboratories in areas 
such as climate change and nanotechnology. In support of these various 
missions, contractors at the laboratories may carry out major 
construction projects, as well as projects to clean up radioactive and 
hazardous wastes from decades of producing materials or components for 
nuclear weapons. 

NNSA relies heavily on contractors to carry out its work, making 
effective federal oversight crucial to accomplishing its missions. At 
each of the laboratories, about 100 NNSA staff at the site office have 
responsibility for overseeing the work performed under contract by 
thousands of contractor employees. The contractors, in turn, may 
subcontract out major portions of their work, especially in mission- 
support areas such as constructing and maintaining facilities. Although 
NNSA has no direct relationship with these subcontractors, it is 
ultimately responsible for ensuring that all work, whether done by the 
prime contractor or its subcontractors, is performed in a manner 
consistent with the contract, including with all requirements for 
nuclear and worker safety. 

NNSA's contracts for the three laboratories generally provide for 
reimbursing contractors for allowable costs plus an additional fee. The 
total fee available to the contractors may include a base, or fixed, 
amount that is guaranteed and an "at-risk" amount that is tied to 
performance measures in the contract. To help strengthen 
accountability, the department established a new contract provision in 
1999 that allows it to reduce the fee otherwise earned if a contractor 
does not meet certain environmental, safety, and health performance 
standards.[Footnote 5] 

DOE regulations and directives set forth requirements for ensuring that 
nuclear facilities are operated safely to protect workers and the 
public.[Footnote 6] NNSA's primary approach to ensuring nuclear and 
worker safety is to incorporate these regulations and directives into 
contracts. These rules require contractors to develop and maintain 
documentation that (1) describes the work to be performed; (2) 
evaluates all potential hazards and accident conditions; (3) contains 
appropriate controls, including technical requirements, that will 
eliminate or minimize the risk of hazards; and (4) delineates 
procedures and practices for operating the facilities safely. This 
documentation is commonly referred to as the facility's documented 
safety basis. In addition, DOE regulations require that radiation doses 
to workers at DOE facilities be maintained within prescribed limits. 

NNSA's laboratories and facilities, with few exceptions, are not 
regulated by the Nuclear Regulatory Commission or by the Occupational 
Safety and Health Administration. Instead, DOE and NNSA provide 
internal oversight of the three weapons laboratories at several 
different levels. NNSA provides direct oversight of the laboratories 
and the contracts through its site offices. In addition, NNSA 
headquarters staff offices, such as the offices of Defense Programs and 
Nuclear Nonproliferation, provide funding and program direction to the 
site offices. DOE's Office of Enforcement[Footnote 7] and Office of 
Independent Oversight and Performance Assurance (now called the Office 
of Environment, Safety and Health Evaluations) and NNSA's Chief of 
Defense Nuclear Safety and Senior Advisor for Environmental Safety and 
Health also provide oversight of laboratory activities to ensure 
nuclear and worker safety. Finally, the Safety Board, an independent 
oversight organization created by Congress in 1988, provides advice and 
recommendations to the Secretary of Energy to help ensure adequate 
protection of public health and safety at all of the department's 
defense nuclear facilities, including those at the three weapons 
laboratories. As part of its independent oversight, the Safety Board 
has full-time representatives at the Los Alamos and Lawrence Livermore 
laboratories to work with the NNSA site offices and to observe 
contractor work activities at the site's nuclear facilities. 

Long-standing Management Weaknesses Contribute to the Laboratories' 
Persistent Safety Problems: 

From 2000 through 2007, the three NNSA weapons laboratories have been 
troubled by persistent safety problems, including accidents and 
violations of nuclear safety rules designed to protect laboratory 
employees and the public. Our review of nearly 100 internal and 
external safety reviews since 2000 found that factors contributing to 
safety problems stemmed largely from weaknesses in NNSA's management of 
safety issues at the weapons laboratories--weaknesses that leave the 
laboratories vulnerable to continued, and potentially serious, safety 
problems. 

Accidents and Violations of Nuclear Safety Rules Persist at All Three 
Weapons Laboratories: 

From 2000 through 2007, nearly 60 accidents or near misses--each 
serious enough to be investigated--have occurred at the three NNSA 
weapons laboratories.[Footnote 8] The accidents have included radiation 
exposures, inhalation of toxic vapors, electrical shocks, and injuries 
during construction projects or maintenance activities. Fortunately, no 
one has been killed, but many of these accidents have resulted in 
serious worker injuries or facility damage. (Appendix II lists the 
major accident investigations at the three weapons laboratories since 
2000.) For example: 

* In 2000, seven workers at a Los Alamos plutonium-processing and - 
handling facility received significant doses of radiation from 
plutonium released into the air from a faulty unit, known as a 
glovebox, that shields people working with radioactive materials. When 
plutonium is inhaled, it can damage cells or raise a person's risk of 
getting cancer. In this incident, a technician was trying to determine 
why the glovebox system was not operating properly; seven other workers 
were in the room at the time. As the technician was working, a fitting 
in the system leaked plutonium into the air, setting off alarms. 
Although the eight workers left the room at once, at least four of them 
were exposed to radiological releases much higher than the allowable 
annual exposure limits set in regulation, raising their cancer risk. 
(The workers were provided immediate treatment). 

An internal DOE accident investigation found a number of factors behind 
this accident--which, because of the number of workers involved and the 
potential radiological doses, ranked among the top 10 worst 
radiological intake accidents in 41 years of data gathering by DOE and 
its predecessor agencies. These contributing factors included 
inadequate design and configuration of the glovebox and its auxiliary 
systems, lack of communication between workgroups tasked with 
maintaining different parts of interconnected systems, weaknesses in 
the technician's training, and informal operations in the plutonium- 
handling facility. Moreover, according to the investigation report, the 
Los Alamos Laboratory had apparently failed to apply lessons learned 
from previous contamination releases in the same facility--including a 
similar event 2 years before, involving the same glovebox and some of 
the same people. 

* In 2002, at another Los Alamos unit, liquid chlorine dioxide formed 
unexpectedly during an experiment and then exploded, sending debris 
into the air with enough force to destroy the fume hood where the 
experiment was taking place and to knock out pieces of wall, ceiling, 
and concrete. One of the two researchers present during the experiment 
noticed a rapid rise in temperature in the experimental apparatus, and 
both researchers fled the room seconds before the explosion, thus 
averting serious injury or death. According to an independent 
investigation of this accident, the experiment was changed to use 100 
percent chlorine gas instead of 4 percent chlorine gas, a change that 
warranted a formally changed hazard control plan; yet only informal 
evaluations, without adequate analyses, review, or authorization, were 
done. As a result, the researchers failed to recognize the potential 
for formation of liquid chlorine dioxide and carried out the altered 
experiment inside a vessel that could not withstand the high pressure 
of the unanticipated liquid chlorine dioxide. According to the 
investigation report, this accident represents a case in which division 
management, line management, and workers had not adequately evaluated 
or ensured implementation of existing safety requirements. 

* In 2003, an accident at a construction site on the New Mexico campus 
of Sandia National Laboratories seriously injured two ironworkers who 
were part of a crew of three installing a steel stairway in one 
building's open stairwell. As the crew was hoisting and positioning a 
stair section near the top of the stairwell, a temporary hoisting beam 
slipped and fell; it struck the first worker's hardhat on its way down 
and crushed his foot before hitting the ground. Other parts of the 
hoisting apparatus also collapsed, cutting another worker's shin and 
knocking over a third worker. The first worker was hospitalized for a 
week; the second worker required six stitches to close the wound on his 
leg; the third worker escaped injury. The accident investigation report 
stated that neither the installation of the temporary hoisting beam nor 
the lifting of the stair section conformed to safety requirements. The 
report further noted that lack of clarity in safety requirements and 
poor communication between NNSA's Sandia site office, project 
management, and subcontractors contributed to this preventable 
accident. 

Since 2000, Los Alamos and Lawrence Livermore have also been cited a 
total of eight times for violating nuclear safety rules.[Footnote 9] 
These rules are intended to protect workers and the public from nuclear 
hazards, including unintended nuclear explosions and radiation 
exposure, and under federal law,[Footnote 10] DOE has the authority to 
impose fines, or civil penalties, on contractors that violate them. In 
general, the rules (1) require analyses of work to be performed in a 
nuclear facility so as to identify potential hazards and operate the 
facility at an acceptably low level of risk and (2) spell out controls 
needed to ensure the safety of workers and the public. The eight 
citations levied since 2000 against Los Alamos and Lawrence Livermore 
laboratories have carried total penalties of nearly $4 million[Footnote 
11] for violations of a number of nuclear safety requirements by, for 
example: 

* failing to test safety equipment, such as fire-alarm systems, before 
beginning work to ensure proper operation; 

* failing to follow protective procedures for handling radioactive 
materials; 

* failing to label areas that contained high levels of radiation; 

* illegally storing radioactive waste in a facility that lacked proper 
operating documentation; and: 

* failing to maintain proper documentation for the safe operation of 
nuclear facilities. 

In addition to accidents serious enough to warrant formal investigation 
and violations of nuclear safety rules, the three laboratories have 
experienced a number of less serious accidents and near misses. For 
example, from 2004 to mid-2007,[Footnote 12] the three laboratories 
have reported 97 worker injuries serious enough to require off-site 
medical attention[Footnote 13] and more than 150 electrical and 
mechanical near-miss incidents where serious injury could have 
occurred. Other reviews have also raised concerns about safety at the 
laboratories. In 2004, for instance, DOE's Office of Independent 
Oversight and Performance Assurance and the Safety Board both raised 
concerns about safety management at Lawrence Livermore Laboratory's 
plutonium-handling facility, including concerns over the adequacy of 
fire-suppression and ventilation systems in case of an accident. 

At both Los Alamos and Lawrence Livermore laboratories, such persistent 
safety problems (combined with concerns about security at Los Alamos) 
ultimately resulted in the temporary closure, or stand- down, of 
certain of the laboratories' facilities. On July 16, 2004, the director 
of Los Alamos Laboratory suspended all laboratory operations, except 
those specifically designated as critical, to address safety and 
security concerns. The ensuing 10-month shutdown cost taxpayers an 
estimated $121 million to $370 million in lost productivity. Similarly, 
on January 15, 2005, the director of Lawrence Livermore Laboratory 
suspended all programmatic work at the site's plutonium-handling 
facility, largely because of numerous unresolved safety issues and 
failure to address these issues adequately. The facility did not return 
to full operation for 16 months. During the stand-downs, both 
laboratories conducted comprehensive investigations into the causes of 
the numerous safety and security problems and found hundreds of 
deficiencies in both areas, which ranged from muddled lines of 
authority to overly complex and unclear safety policies and procedures 
to inadequate documentation and training. 

Despite the stand-downs, however, all three laboratories have continued 
to experience accidents warranting formal investigation, as well as 
violations of nuclear safety rules. For example, of the nearly 60 
accidents investigated at the three weapons laboratories since 2000, 15 
of them have occurred since the stand-downs. In addition, Los Alamos 
and Lawrence Livermore have both been cited for nuclear safety 
violations since the stand-downs were declared. Accidents included the 
following: 

* In 2005, a worker at Los Alamos received and opened a package 
containing radioactive material delivered from another Los Alamos site 
and unknowingly contaminated himself, his clothing, and things he later 
touched; the contamination was not detected for 11 days. The shippers 
assumed the receiver would know that radiological contamination was 
possible and would act accordingly, and they did not test the package 
for contamination before shipping. The receiver, in contrast, assumed 
the package was uncontaminated because he had not been alerted 
otherwise. When the worker left that day, he was not screened for 
potential contamination because the room he was working in was not 
designated as a radiological control area. Over the next days and 
weeks, the worker unwittingly spread contamination to his home, to 
relatives' homes in Kansas and Colorado, and to other locales at Los 
Alamos. In addition, he handled some otherwise nonradioactive parts, 
which also became contaminated and were shipped to Pennsylvania. The 
officials investigating this accident found a number of failures to 
follow safety procedures, unverified assumptions, and undocumented 
requirements; according to their report, "all of the accident's causal 
factors were well established" before the accident. 

* In 2006, an electrician working alone on a project to replace rooftop 
air conditioners at Lawrence Livermore missed a step while climbing a 
ladder mounted on the building. The worker fell and sustained multiple 
fractures of his wrist, shoulder, and pelvis, along with other 
injuries; he was hospitalized for nearly a month. The officials 
investigating this accident explicitly stressed the "significance of 
this seemingly simple accident--a worker slipped and fell from a 
ladder" because workers frequently climb similar ladders, the potential 
consequences of a fall are serious, and remedies--from ladder design to 
worker training--are straightforward and easy to put in place. 

Other safety problems have also occurred since the stand-downs. For 
example, the three laboratories have reported 33 electrical shock 
incidents since 2005. In one case at Los Alamos, two employees 
operating a generator-powered winch received electrical shocks on 
multiple occasions over a 4-day period without stopping work to report 
the shocks; the winch then malfunctioned, and the employees reported 
the shocks. At Sandia, a subcontractor employee received an electrical 
shock requiring the attention of paramedics after touching a "hot" 
screw on a 120-volt receptacle he was testing. 

Long-standing Management Weaknesses Leave Sites Vulnerable to Continued 
Safety Problems: 

In our review of nearly 100 safety studies--including accident 
investigations and independent assessments by the Safety Board and 
others since 2000--we found that factors contributing to safety 
problems stemmed largely from weaknesses in how NNSA manages safety at 
the weapons laboratories. These contributing factors generally fall 
into three key areas: 

* A relatively lax attitude toward safety procedures. Accident 
investigations and other reviews of the weapons laboratories have 
repeatedly found an informal or lax attitude toward safety. 
Specifically, reviews have cited weaknesses such as (1) laboratory 
management that does not consistently and effectively emphasize the 
importance of working safely and following prescribed safety 
procedures, (2) employees who rely on their own expertise and knowledge 
of work hazards rather than following safety procedures, and (3) 
subcontractors who understand and implement safety procedures 
inadequately. The Safety Board and others have cautioned that such lax 
safety attitudes--including employees' reluctance to question potential 
safety problems or inadequate leadership insistence on safety--create 
an environment where workers become complacent, and accidents occur. At 
the Los Alamos plutonium-handling facility, multiple accidental 
releases of airborne plutonium since 1996-- including the 2000 incident 
involving seven workers and another one in 2003 involving the same 
group of employees in the same facility--led the investigators of the 
2003 accident to conclude that "the organizational safety culture has 
evolved to one of complacency towards safety such that workers and 
managers fail to respect the hazards present in the workplace, and 
risks to workers are accepted without understanding the magnitude of 
those risks." Study after study has highlighted the informality of 
laboratory operations and the lack of emphasis on safety throughout, 
from division management levels to individual worker levels. As a 
result of lax attitudes over the years, the laboratories have 
repeatedly failed to prevent what many reports and reviews regard as 
preventable accidents and near misses. 

* Weaknesses in identifying safety problems and taking appropriate 
corrective actions. Fundamental weaknesses in the laboratories' ability 
to accurately identify and fully understand safety problems and take 
appropriate corrective actions have hindered safety performance. Many 
reviews have cited (1) an inability to learn from past incidents, (2) a 
lack of rigorous self-assessments by the laboratories to identify 
problems, and (3) a failure to develop appropriate or timely corrective 
actions to mitigate these problems as factors contributing to recurring 
accidents. Several investigations stressed that accidents could have 
been prevented had lessons from previous accidents been learned and 
properly applied. 

* Inadequate oversight by NNSA site offices. Many reviews have pointed 
out continuing deficiencies in federal oversight of the laboratories, 
including that oversight was insufficiently formal or documented (for 
example, that roles and responsibilities for safety were not clearly 
and consistently delineated). Such weaknesses have been exacerbated by 
staff shortages at the site offices, specifically, (1) unfilled 
positions resulting in too few staff available to serve as NNSA's eyes 
and ears at the laboratories and (2) shortages in staff with adequate 
technical expertise. For example, positions for critical senior nuclear 
safety officials at both the Lawrence Livermore and Los Alamos site 
offices went unfilled for more than a year. 

These safety evaluations have repeatedly indicated that key management 
weaknesses have contributed to the laboratories' continuing safety 
problems and that accidents could have been prevented had weaknesses 
been properly addressed. Together, these safety evaluations indicate 
that unless corrected, the weaknesses create conditions that leave the 
laboratories vulnerable to continued--and potentially more serious--
safety problems. 

NNSA and Contractors Have Been Taking Some Steps to Address Management 
Weaknesses: 

Steps taken by NNSA and its contractors include on-site efforts to 
address weaknesses in three key areas, as well as mechanisms to hold 
contractors more accountable for safety. 

Steps Taken at the Laboratories Include Efforts in Three Key Areas: 

NNSA and its contractors have been taking steps intended to address 
weaknesses in three key areas: safety culture, systems for identifying 
and correcting safety problems, and federal oversight: 

* Safety culture. Since at least 2006, NNSA and its contractors have 
been taking steps to reinvigorate NNSA's key safety improvement effort, 
called integrated safety management. Launched in 1996, integrated 
safety management was designed to respond to concerns raised by the 
Safety Board about the lack of formal, standardized procedures 
throughout DOE for ensuring that hazardous activities were carried out 
safely. The effort was intended to raise safety awareness and provide a 
formal process for employees to integrate safety into work activities 
by requiring employees to (1) define the scope of work, (2) analyze the 
hazards associated with that scope of work, (3) develop and implement 
hazard controls to address possible safety issues, (4) perform work 
within those controls, and (5) provide a feedback system for continuing 
to improve safety. This program aims to instill in every individual at 
the laboratories a sense of responsibility for working safely. 

Despite the program's longevity and the soundness of the concepts 
behind integrated safety management, many safety reviews have stated 
that the program has not been fully or successfully implemented. In the 
decade since it began, NNSA and laboratory contractors have developed 
policies and procedures under program guidelines, but the laboratories 
have been unable to ensure that managers and employees consistently 
follow these policies and procedures in their work. Many of the 
accident and other reports we examined specifically cited ineffective 
implementation of integrated safety management at NNSA's laboratories 
as a key factor contributing to the accidents. 

To remedy these recognized shortcomings, NNSA is revising its guidance 
to clarify integrated safety management requirements, and the 
laboratories have been taking various steps to reemphasize the 
principles of integrated safety management. First, according to 
laboratory officials, the laboratory directors have publicly stressed 
safety by, for example, at Sandia making unannounced monthly visits to 
different laboratory units to observe operations firsthand. At Lawrence 
Livermore, the laboratory director holds monthly performance reviews 
requiring his associate directors to report on specific safety metrics 
for their division. Second, several hundred managers and employees at 
all three laboratories have undergone training on why accidents happen 
and how to prevent them, in part through better communication and 
teamwork. In addition, Los Alamos and Sandia site office officials told 
us, the laboratories have been hiring staff from contractors at other 
DOE sites or from other programs where adherence to safety procedures 
has been more consistent, a move they believe will help shift the 
safety culture at the laboratories. 

* Identifying safety problems and taking corrective actions. NNSA and 
its contractors at the laboratories have been taking steps to better 
identify safety problems and appropriate corrective actions. For 
example, Lawrence Livermore has created a new process in which teams of 
workers and managers annually review and assess implementation of work 
practices to identify deficiencies in safety procedures or other 
opportunities to improve safety. Sandia has also begun to standardize 
its annual self-assessment process for identifying safety and other 
problems, although officials told us that the new approach cannot yet 
provide consistent and useful information across laboratory divisions. 

Two laboratories (Los Alamos and Sandia) have also created new 
processes and computer systems for managing safety issues. Previously, 
reviews found deficiencies in processes for assigning and tracing 
accountability for safety problems. Both laboratories now have 
management boards that review identified safety issues and assign 
responsibility for those issues to individual managers, who must 
analyze and address the identified problems. To complete the process, 
individual managers must sign off on the fixes they have directed and 
either have the issue re-reviewed by the assigning board or have 
independent verification that the corrective action was completed. 

Further, the laboratories and site offices have begun using new 
software systems to help them track safety issues. Specifically, Los 
Alamos and Sandia have been improving their electronic management 
systems for tracking safety deficiencies and associated corrective 
actions, and two of the site offices, at Sandia and Lawrence Livermore, 
are using new integrated software systems intended to help the site 
offices track safety issues at the labs and document oversight efforts. 
Previously, this information was stored in multiple systems across the 
labs and site offices, which made it more difficult to track overall 
safety efforts. 

* NNSA site office oversight. The site offices have initiated efforts 
to address concerns about inadequate federal oversight by instituting 
more-formal oversight procedures, seeking to fill vacant positions, and 
providing additional training. The site offices at Lawrence Livermore 
and Sandia have revised their operating procedures and documentation on 
staff responsibilities, qualifications of technical staff, and 
schedules for evaluating laboratory operations. Los Alamos and Lawrence 
Livermore site officials told us they have begun to fill vacant 
positions, including hiring a senior nuclear safety expert at Lawrence 
Livermore who directly advises the site office manager.[Footnote 14] 
The site offices told us that they have also been formalizing their 
process to provide training related to general scientific and technical 
expertise, applicable regulations, contract administration, and safety 
management. 

Many of these efforts are still under way, however, and their effect on 
safety performance is not clear. 

Additional Steps Target Contractor Accountability for Safety 
Performance: 

To hold its contractors more accountable for safety performance, NNSA 
has incorporated into its contracts at Los Alamos and Sandia new 
contract mechanisms that provide for additional fee or contract 
extensions for meeting annual safety and other goals.[Footnote 15] 
Under the new contract incentives, contractors can earn substantially 
larger fees--or, in the case of Sandia, a one-year contract extension 
as well--if they improve safety performance. At Los Alamos, incentive 
fees are offered for improving safety documentation and decreasing 
rates of illness and injury, for example.[Footnote 16] In 2005, Sandia 
had the opportunity to earn the 1-year extension but could not do so, 
primarily because of safety problems. NNSA officials we spoke with were 
hopeful that these contract incentives would foster greater 
accountability but said that improvements could take years to achieve. 
Moreover, officials expressed concern that incentives to reduce 
accidents could actually lead to underreporting, rather than actual 
reductions in the number of accidents. 

NNSA also is expecting to hold contractors more accountable through a 
newly implemented regulation--referred to as the "851 rule"--that 
requires contractors to follow worker safety requirements and imposes 
penalties for violations.[Footnote 17] Promulgated in response to a 
2002 congressional requirement, and similar to nuclear safety 
regulations, the worker safety regulation (effective as of February 
2007) encourages contractors to report violations of worker safety 
requirements and provides for DOE's Office of Enforcement to levy civil 
penalties carrying monetary fines up to $70,000 per day. As of 
September 2007, DOE had not yet levied any fines against its 
contractors. 

NNSA Faces Fundamental Challenges to Effective Management and Oversight 
of Safety at Weapons Laboratories: 

NNSA faces two principal challenges in its continuing efforts to 
improve safety at the nation's weapons laboratories. First, the agency 
has no way to determine the effectiveness of its safety improvement 
efforts, in part because those efforts rarely incorporate outcome-based 
performance measures. Second, concerns have arisen over the agency's 
shift in its oversight approach to rely more heavily on contractors' 
own safety management controls. 

NNSA Has No Way of Determining the Effectiveness of Its Safety 
Improvement Efforts: 

NNSA does not have effective outcome-based performance measures that 
would enable it to evaluate the impact of individual improvement 
initiatives on safety performance. When asked what impact integrated 
safety management has had on safety performance, for example, NNSA and 
contractor officials at the laboratories described positive trends in 
measures such as illness and injury rates. However, in a December 2005 
report reviewing NNSA's implementation of integrated safety management 
at seven of its sites, including the weapons laboratories, the Safety 
Board noted that, although the illness and injury rates had been 
declining, the number of serious accidents, nuclear safety enforcement 
actions, and other safety occurrences had not declined. According to 
the Safety Board, this evidence indicated that the integrated safety 
management program had not reduced the number of serious safety 
problems, and the Safety Board suggested that NNSA develop a way to 
evaluate the effectiveness of integrated safety management. Yet 
effective performance measures were not included in the action plan to 
revitalize integrated safety management; rather, the planned actions 
were primarily process-oriented, such as developing new policies or 
manuals or providing additional training. The few measures that were 
included in the plan focused on, for example, defining annual 
performance measures in contracts or increasing the use of measures 
related to repeated incidents, with no indication of how these measures 
might help gauge effectiveness. 

We have found that NNSA and its contractors have not consistently 
managed safety improvement efforts using a disciplined approach 
incorporating substantive outcome measures and a system to evaluate its 
efforts' effectiveness.[Footnote 18] Such an approach, often taken by 
high-performing organizations, generally includes four key elements: 
(1) defining clear goals, (2) developing an implementation strategy 
that sets milestones and establishes responsibility, (3) establishing 
results-oriented outcome measures to gauge progress toward the goals, 
and (4) using results-oriented data to evaluate the effectiveness of 
the effort and making additional changes where warranted. We have 
previously recommended that DOE develop and use this systematic 
approach in future improvement efforts. In response to this 
recommendation, the department issued a directive (DOE Notice 125.1) in 
October 2003 that adopted these principles.[Footnote 19] In February 
2004, we reported on challenges at Los Alamos and Lawrence Livermore 
national laboratories, including problems with ensuring the safe 
operations of nuclear facilities[Footnote 20] and recommended that NNSA 
include in its contracts for the two laboratories a requirement that 
the contractors manage future improvement efforts in accordance with 
the October 2003 directive, to better ensure that its efforts are 
effective.[Footnote 21] Nevertheless, we found little indication that 
either NNSA or the contractors have been using the systematic approach 
specified by the October 2003 directive, and the approach in the 
directive has not been incorporated into the laboratory contracts. 

Rather than following the recommended systematic approach, the safety 
improvement efforts described by NNSA and its contractors echo previous 
attempts while continuing to lack useful measures of effectiveness. 
Specifically, the laboratory contractors have been providing managers 
and workers with additional safety training, but the contractors have 
not instituted any systems to evaluate whether the trainees have put 
into practice what they have been taught. In another example, the 
laboratories have changed their systems for tracking identified safety 
problems and the corrective actions taken to address those problems. 
But these systems still measure whether corrective actions were 
completed and completed on time, rather than how effective the actions 
were in addressing underlying weaknesses. What outcome-based measures 
do exist to evaluate safety performance--specifically, accident, 
illness, and injury rates--consider just part of the safety situation 
and do not address underlying management weaknesses that allow these 
incidents to recur. In short, NNSA has no objective way of determining 
whether improvement efforts are effective, whether these efforts will 
correct long-standing safety problems, or whether reduced accident 
rates are merely coincidental. Without stronger performance measures, 
NNSA and its contractors have no way of knowing whether the time and 
money invested in their improvement initiatives have actually resulted 
in safer laboratories. 

Given the persistent nature of safety problems at the laboratories, it 
appears that either the identification of the underlying causes or the 
corrective actions taken have been inadequate. A crucial step in the 
October 2003 directive is to fully understand problems and their 
underlying causes so that corrective actions will be effective. Yet 
over the past decade, NNSA and laboratory contractors have developed 
corrective action plans that were essentially reactive--responding to 
findings and recommendations from one or another internal or external 
report--without consistently taking the next step of identifying 
deeper, systemic weaknesses and taking steps to mitigate these 
weaknesses. Moreover, for at least two of the weapons laboratories, 
neither the safety problems nor the efforts to correct them are new. As 
we reported in February 2004, NNSA had put into place contract 
mechanisms and requirements to address known problems in areas 
including nuclear safety.[Footnote 22] Although this effort was 
intended to strengthen management and federal oversight of nuclear 
safety at Los Alamos and Lawrence Livermore, most of the measures 
included in the contracts were aimed at establishing processes or 
developing plans. In reports issued as recently as 2007, the Safety 
Board and others have again raised similar concerns about safety 
management weaknesses and suggested that NNSA and its contractors have 
not fully understood the safety problems or their underlying causes and 
have not identified and implemented the appropriate corrective actions. 
It thus appears likely that agency efforts will continue to be 
disjointed, and incidents and vulnerabilities could continue. 

Weaknesses in Federal Oversight Raise Concerns about NNSA's Decision to 
Rely More Heavily on Contractors' Management Controls: 

NNSA has revised its laboratory contractor oversight policy to rely 
more on the contractors' own systems of management controls to identify 
and correct safety problems. Nevertheless, we and others have expressed 
concerns in the past, however, about these changes to its oversight 
policy and the increased emphasis and reliance on the contractors' 
systems of management controls. In its draft policy of August 2003, 
NNSA proposed relying more on contractor assurance systems and self- 
assessments to identify and correct problems in all areas of 
operations, including safety. NNSA would then use a risk-based approach 
to its oversight, tailoring the extent of federal oversight to the 
quality and completeness of the contractor's assurance system and the 
extent to which NNSA could rely on the contractor's system to identify 
and correct problems effectively. In our February 2004 report, we 
acknowledged the potential benefits of a risk-based approach to federal 
oversight, but we also raised concerns about NNSA's ability to 
effectively carry out this approach while successfully meeting its 
responsibility for safety. Furthermore, we recommended that NNSA retain 
sufficient independent federal oversight of contractors' activities to 
fulfill its responsibilities for protecting workers, the public, and 
the environment.[Footnote 23] In addition, the Safety Board, in a 
series of public meetings in late 2003 and early 2004, expressed 
concerns about NNSA's proposed oversight policy and stressed that NNSA 
should not delegate responsibility for the inherently high-risk area of 
operations at its nuclear facilities. The Safety Board was concerned 
about both the adequacy and the quality of federal oversight; it was 
also concerned that the contractors' systems of management controls had 
yet to be proven effective. 

In response to these concerns, NNSA revised its oversight policy to 
outline how contractors' systems of management controls, federal line 
management oversight, and independent reviews would work together to 
ensure effective operations, including safety.[Footnote 24] To 
specifically address the Safety Board's concerns about high-hazard 
operations, the revised policy requires additional, and more rigorous, 
federal oversight of nuclear facilities and other high-hazard 
operations. The departmentwide oversight policy's stated objective is 
to ensure that contractor assurance systems and federal oversight 
programs are comprehensive and integrated for all aspects of operations 
essential to mission success. According to the policy, contractor 
assurance systems should identify and address program and performance 
deficiencies and opportunities for improvement, provide the means and 
requirements to report deficiencies, establish and effectively 
implement corrective and preventive actions, and share lessons learned 
across all aspects of operations. 

Regardless, NNSA lacks a cohesive implementation strategy for how it 
will maintain appropriate levels of oversight of its laboratory 
contractors' safety performance under this revised policy. At the site 
offices, oversight consists of a collection of activities, such as 
observations of work activities and reviews of contractor data, but it 
is not clear how these activities will fit into NNSA's overall 
oversight structure. Furthermore, the NNSA site offices lack their own 
clear goals for improving oversight but instead equate improved 
oversight to ensuring that the contractors meet contract goals and 
annual performance measures. For example, at the Lawrence Livermore 
site office, the goals and outcomes for fiscal year 2007 included (1) 
ensuring that the contractor completes all required nuclear facility 
safety documentation, (2) ensuring that lessons learned from the 2005 
plutonium facility stand-down are implemented at the laboratory's other 
nuclear facilities, and (3) ensuring that the contractor implements the 
new worker safety rule. Yet these three goals and outcomes are still 
geared more toward process rather than safety improvements and are 
generally activities that the contractor should already have completed. 
Specifically, one of these goals--ensuring that the contractor 
completes all required nuclear facility safety documentation to 
identify the potential nuclear hazards and mitigation plans to protect 
workers, the public, and the environment--has been part of Lawrence 
Livermore's contract requirements since 2001. Yet the laboratory had 
nuclear facilities that lacked completed safety documentation until 
September 2007. 

Furthermore, no clear criteria or results-oriented outcome measures 
exist for determining when a contractor assurance system is mature and 
reliable enough for NNSA to depend on the contractor for identifying 
and correcting safety problems. Without such measures, NNSA has no 
assurance that contractors can and will effectively identify and 
correct safety problems. In line with what we reported 3 years 
ago,[Footnote 25] we continue to believe it is premature for NNSA to 
rely so heavily on the contractors to maintain laboratory safety. Given 
the perennial safety problems at the laboratories, coupled with NNSA's 
and contractors' continued inability to clearly demonstrate progress in 
remedying weaknesses, it is unclear how this revised system will enable 
NNSA to maintain an appropriate level of oversight of safety 
performance at the weapons laboratories. 

Conclusions: 

The NNSA weapons laboratories, which conduct important but potentially 
dangerous research, have experienced persistent safety problems despite 
years of effort to make the laboratories safer. Although dozens of 
reviews since 2000 have repeatedly highlighted significant safety 
management problems at the laboratories, and NNSA and contractors have 
been taking steps aimed at improving safety, many of the steps appear 
to be revision or repackaging of earlier efforts, with few new 
approaches to correcting underlying problems. A key shortcoming may be 
that--despite a DOE-wide directive requiring that improvement 
initiatives include results-oriented outcome measures--neither NNSA nor 
its contractors have developed performance measures suitable for 
assessing the effect, if any, of safety improvement efforts on 
identified safety weaknesses. As a result, NNSA has no assurance that 
the resources expended on safety improvement efforts will successfully 
remedy fundamental weaknesses or strengthen laboratory safety. 
Furthermore, we remain concerned about NNSA's recent shift to relying 
more on contractors to police themselves at a time when the 
laboratories remain vulnerable to safety problems, including accidents. 
We and others have raised concerns that although effective oversight of 
laboratory safety requires a strong, qualified federal presence, 
federal oversight remains problematic. Until contractors at the weapons 
laboratories can demonstrate improved safety performance, and until 
their efforts to address underlying management weaknesses are 
effective, our misgivings remain about NNSA's ability to maintain 
effective independent oversight. As the responsible owner of these 
weapons laboratories, NNSA must be able to demonstrate that it is 
carrying out sufficient independent federal oversight of contractors' 
activities to fulfill its responsibilities for protecting the health 
and safety of workers, the public, and the environment. Unless NNSA 
addresses these fundamental challenges and adopts a more structured and 
disciplined approach to improvement efforts and federal oversight, the 
weapons laboratories will continue to be vulnerable to safety problems 
and potentially serious consequences. 

Recommendations: 

To strengthen safety management and oversight at the nation's weapons 
laboratories, we recommend that the Secretary of Energy direct the 
Administrator of NNSA to take the following four actions: 

* Ensure that safety improvement initiatives comply with DOE Notice 
125.1, which requires, in particular, that improvement initiatives be 
carried out in a systematic manner, with effective performance measures 
based on outcomes, not process. 

* Negotiate with the weapons laboratories to include in their contracts 
a requirement that safety improvement initiatives be managed in a 
manner consistent with the best practices of high-performing 
organizations, as defined in accordance with the framework established 
in DOE Notice 125.1. 

* Ensure that as NNSA implements its proposed oversight and contractor 
assurance policy, it develops a clear plan and specific measures that 
enable it to (1) determine when a contractor's assurance system is 
sufficiently mature and reliable to identify and address safety 
problems at the weapons laboratories effectively and (2) retain 
sufficient independent federal oversight of safety to fulfill its 
responsibilities associated with protecting workers, the public, and 
the environment. 

* Report annually to Congress on progress toward making the weapons 
laboratories safer, including the status and effectiveness of safety 
improvement initiatives, using outcome-based performance measures. 

Agency Comments: 

We provided a draft of this report to NNSA for its review and comment. 
In written comments, NNSA's Associate Administrator for Management and 
Administration stated that NNSA generally agreed with the report and 
its recommendations. NNSA's written comments on our draft report are 
included in appendix IV. 

While generally agreeing with the facts in our report and its 
corresponding recommendations, NNSA sought to provide additional 
context in which our findings could be viewed. Specifically, NNSA 
stated that it believes that, given the numbers of employees, the 
period of years covered, and the high-hazard work that is performed at 
these laboratories, safety at the laboratories has been impressive. 
NNSA suggests that the ladder incident we describe does not exemplify 
lax safety. Yet this view overlooks the fact that even an accident as 
simple as a ladder fall can result in serious personal injuries. NNSAï¿½s 
own accident investigation report stressed the ï¿½significance of this 
seemingly simple accidentï¿½ because the consequences can be serious, and 
the remedies are relatively easy to put into place. Furthermore, we 
cited a number of examples illustrating the range and severity of 
accidents at the laboratories, including major radiation exposures. We 
remain concerned that such safety incidents are symptoms of more 
pervasive problems. 

NNSA also stated that, contrary to our criticism of its oversight of 
the weapons laboratories, it believes that oversight of safety at the 
laboratories is excellent. NNSA offers as evidence the existence of 
safety evaluations performed by its offices and other DOE offices. 
While we agree that reports by NNSAï¿½s offices and other DOE offices are 
useful, our report focused on oversight at the NNSA site office level. 
In fact, NNSAï¿½s safety evaluations themselves point out the same long-
standing concerns about the adequacy of NNSA site office oversight. In 
addition, NNSA pointed to a decrease in its illness and injury rates at 
the weapons laboratories as evidence of the effectiveness of federal 
oversight of safety at the weapons laboratories. We acknowledge in the 
report that NNSA and its contractors described recent positive trends 
in safety measures such as illness and injury rates. We remain 
concerned about relying solely on this measure as evidence of improved 
safety performance because a number of factors could affect these 
rates, including instances of underreporting. In addition, illness and 
injury rates are not useful in indicating performance in nuclear 
safety, where a single accident can carry serious consequences not only 
for workers but for the public at large. Finally, as we stated in our 
report, a December 2005 Safety Board report noted that, although 
illness and injury rates had declined, the number of serious accidents 
and nuclear safety enforcement actions had not declined. We continue to 
believe that until NNSA adopts a more disciplined approach to 
improvement efforts and federal oversight--an approach that 
incorporates meaningful performance indicators--the laboratories cannot 
assure that safety improvement efforts have been effective or will be 
sustained. 

As agreed with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the date of this letter. At that time, we will send copies of this 
report to the Secretary of Energy; the Administrator, NNSA; and 
appropriate congressional committees. We will also make copies 
available to others on request. In addition, the report will be 
available at no charge on the GAO Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions on this report, please contact 
me at (202) 512-3841 or [email protected]. Contact points for our Office 
of Congressional Relations and Public Affairs may be found on the last 
page of this report. GAO staff who made major contributions to this 
report are listed in appendix V. 

Signed by: 

Gene Aloise: 

Director, Natural Resources and Environment: 

Appendix I: Scope and Methodology: 

To determine the safety problems that have occurred at the weapons 
laboratories and contributing factors, we reviewed documents, including 
federal laws and regulations describing safety requirements for nuclear 
safety and for worker safety and health, Department of Energy (DOE) 
policies and procedures regarding safety management, and about 100 
relevant reports issued since 2000 evaluating safety issues at the 
three weapons laboratories: Lawrence Livermore, Los Alamos, and Sandia 
national laboratories. Reports included inspections or reviews of the 
weapons laboratories by DOE's Office of Independent Oversight and 
Performance Assurance, the National Nuclear Safety Administration's 
(NNSA) Chief of Defense Nuclear Safety, the Defense Nuclear Facilities 
Safety Board (Safety Board), and our past reports. Reports also 
included all type A and type B accident investigation reports for the 
three weapons laboratories and, when possible, any contractor-led 
accident investigations. We also reviewed all enforcement actions for 
violations of nuclear safety rules taken against the laboratories by 
DOE's Office of Enforcement. We reviewed the factors these reports 
identified as contributing to safety problems and categorized them into 
three key areas, using an analytical tool developed in consultation 
with our methodologist. We also analyzed safety performance data 
provided by DOE, specifically, safety incident data contained in DOE's 
Occurrence Reporting and Processing System and Computerized Accident/ 
Incident Reporting System. We determined that these data were 
sufficiently reliable for the purposes of this report. We discussed the 
safety problems and contributing factors, as well as our categorization 
of them, with representatives from DOE's Office of Independent 
Oversight and Performance Assurance, NNSA's Chief of Defense Nuclear 
Safety and Senior Advisor for Environmental Safety and Health, and the 
Safety Board, as well as with DOE and NNSA headquarters officials. In 
addition, we visited the three weapons laboratories and met with NNSA 
officials and contractors to discuss the factors we identified as 
contributing to safety problems at the laboratories. 

To identify the steps NNSA and its contractors have taken to improve 
safety management and address underlying management weaknesses, we 
reviewed agency documents, including implementation plans; laboratory 
contracts; and, to the extent it was available, documentation on safety 
improvement initiatives. We also interviewed officials at the three 
laboratories and NNSA site offices to discuss efforts taken by NNSA and 
the laboratories to improve safety and to more specifically address the 
areas of concern we identified. We also discussed efforts to improve 
safety performance with independent experts, including officials from 
DOE's Office of Enforcement and representatives from the Safety Board. 

To determine the challenges that remain to effective management and 
oversight of safety performance at the weapons laboratories, we 
reviewed and analyzed relevant GAO reports on safety issues at the 
laboratories; recommendations made, if any; steps taken in response, if 
any; and issues remaining. We reviewed relevant DOE, NNSA, and 
contractor documents, including DOE policies and orders, site office 
strategies and plans, laboratory contracts, and annual evaluations of 
contractor performance. We also discussed challenges with DOE and NNSA 
officials; contractor officials; and independent experts, including 
officials from the Safety Board. 

We performed our work in accordance with generally accepted government 
auditing standards, which included an assessment of data reliability, 
from September 2006 through September 2007. 

[End of section] 

Appendix II: List of Key Safety Evaluations: 

Los Alamos National Laboratory: 

Department of Energy, National Nuclear Safety Administration. Type B 
Accident Investigation of the Americium Contamination Accident at the 
Sigma Facility, Los Alamos National Laboratory, New Mexico, July 14, 
2005. Washington, D.C.: January 2006. 

Department of Energy, Office of Security and Safety Performance 
Assurance. Inspection of Environment, Safety, and Health Programs at 
the Los Alamos National Laboratory. Washington, D.C.: November 2005. 

Department of Energy, National Nuclear Safety Administration. Type B 
Accident Investigation of the Acid Vapor Inhalation on June 7, 2005, in 
Technical Area 48, Building RC-1, Room 402, Los Alamos National 
Laboratory. Washington, D.C.: June 2005. 

Tarantino, Frederick A., et al. LANL Investigation of a Laser Eye 
Injury. LA-UR-04-6229. Los Alamos, New Mexico: Los Alamos National 
Laboratory, 2004. 

Department of Energy, National Nuclear Safety Administration. Type B 
Accident Investigation of the August 5, 2003, Plutonium-238 Multiple 
Uptake Event at the Plutonium Facility, Los Alamos National Laboratory, 
New Mexico. Washington, D.C.: December 2003. 

Hargis, Barbara, et al. Unanticipated Formation and Explosion of Liquid 
Chlorine Dioxide in a Parr Reaction. LA-CP-02-206. Los Alamos, New 
Mexico: Los Alamos National Laboratory, 2002. 

Department of Energy, Office of Security and Safety Performance 
Assurance. Inspection of Environment, Safety, and Health Programs at 
the Los Alamos National Laboratory. Washington, D.C.: 2002. 

Department of Energy, National Nuclear Safety Administration. Type B 
Accident Investigation of the Mineral Oil Leak Resulting in Property 
Damage at the Atlas Facility, Los Alamos National Laboratory, New 
Mexico. Washington, D.C.: March 2001. 

Department of Energy, National Nuclear Safety Administration. Type A 
Accident Investigation of the March 16, 2000, Plutonium-238 Multiple 
Intake Event at the Plutonium Facility, Los Alamos National Laboratory, 
New Mexico. Washington, D.C.: July 2000. 

Lawrence Livermore National Laboratory: 

Department of Energy, Office of Health, Safety and Security. Inspection 
of Environment, Safety, and Health Programs at the Lawrence Livermore 
National Laboratory. Washington, D.C.: May 2007. 

Department of Energy, National Nuclear Safety Administration. Type B 
Accident Investigation of the July 31, 2006, Fall from Ladder Accident 
at the Lawrence Livermore National Laboratory, Livermore, California. 
Washington, D.C.: October 2006. 

Department of Energy, Office of Security and Safety Performance 
Assurance. Inspection of Environment, Safety, and Health Programs at 
the Lawrence Livermore National Laboratory. Washington, D.C.: December 
2004. 

Department of Energy, National Nuclear Safety Administration. Type B 
Accident Investigation Board Report of the June 2002 High Radiation 
Dose to Extremities in Building 151, Lawrence Livermore National 
Laboratory, Livermore, California. Washington, D.C.: Department of 
Energy, October 2002. 

Department of Energy, Office of Security and Safety Performance 
Assurance. Inspection of Environment, Safety, and Health Programs at 
the Lawrence Livermore National Laboratory. Washington, D.C.: July 
2002. 

Sandia National Laboratories: 

Department of Energy, Office of Security and Safety Performance 
Assurance. Inspection of Environment, Safety, and Health Programs at 
the Sandia National Laboratories. Washington, D.C.: 2005. 

Department of Energy, National Nuclear Safety Administration, Type B 
Accident Investigation of the March 20, 2003, Building 752 Stair 
Installation Accident at the Sandia National Laboratories, New Mexico. 
Washington, D.C.: Department of Energy, April 2003. 

Department of Energy, Office of Security and Safety Performance 
Assurance, Inspection of Environment, Safety, and Health Programs at 
the Sandia National Laboratories, New Mexico. Washington, D.C.: 2003. 

Other Key Safety Reports: 

Defense Nuclear Facilities Safety Board, Safety Management of Complex, 
High-Hazard Organizations. DNFSB/TECH-35. Washington, D.C.: December 
2004. 

Defense Nuclear Facilities Safety Board, Integrated Safety Management: 
The Foundation for a Successful Safety Culture. DNFSB/TECH-36. 
Washington, D.C.: December 2005. 

[End of section] 

Appendix III: Enforcement Actions at NNSA Weapons Laboratories, 2000 
through September 2007: 

Office of Enforcement citation number: Los Alamos National Laboratory: 
EA 2000-13; 
Date of enforcement action: Los Alamos National Laboratory: Jan. 19, 
2001; 
Penalty assessed: Los Alamos National Laboratory: $605,000; 
Severity level[A]: Los Alamos National Laboratory: I, II; 
Description of violation: Los Alamos National Laboratory: Significant 
multiple deficiencies in work control, quality improvement, and 
radiation protection resulting in exposure of eight employees to 
airborne radioactive material (estimated to be 1 of 10 worst 
radiological exposures over past 41 years). Failure to address long-
standing deficiencies at an additional nuclear facility, which should 
have been identified and corrected during routine assessments and 
reviews. 

Office of Enforcement citation number: Los Alamos National Laboratory: 
EA 2002-05; 
Date of enforcement action: Los Alamos National Laboratory: Dec. 17, 
2002; 
Penalty assessed: Los Alamos National Laboratory: $220,000; 
Security level [A]: Los Alamos National Laboratory: II; 
Description of violation: Los Alamos National Laboratory: Management 
failures leading to establishing and operating an unauthorized nuclear 
facility for 5 years by storing radioactive waste in a facility without 
a safety evaluation and necessary controls. Failure of management 
processes, including oversight and assessments to identify inventory of 
nuclear materials that required analysis and controls. 

Office of Enforcement citation number: Los Alamos National Laboratory: 
EA 2003-02; 
Date of enforcement action: Los Alamos National Laboratory: Apr. 10, 
2003; 
Penalty assessed: Los Alamos National Laboratory: $385,000; 
Security level [A]: Los Alamos National Laboratory: II, III; 
Description of violation: Los Alamos National Laboratory: Numerous work 
process and radiological control violations resulting in exposure of 
workers to radioactive material and contamination of facility. Numerous 
failures to follow nuclear safety requirements and repeated work and 
radiological control deficiencies. Long-standing weaknesses in 
recognizing and addressing nuclear safety deficiencies. 

Office of Enforcement citation number: Los Alamos National Laboratory: 
EA 2004-05; 
Date of enforcement action: Los Alamos National Laboratory: June 21, 
2004; 
Penalty assessed: Los Alamos National Laboratory: $770,000; 
Security level [A]: Los Alamos National Laboratory: I; 
Description of violation: Los Alamos National Laboratory: Significant 
work control deficiencies resulting in two workers receiving greater 
than annual allowed doses of radioactive material and exposure of five 
workers to toxic vapors. Severity levels increased because of long-
standing nature of underlying problems and failure of management 
assessments and controls to identify or correct such problems. 

Office of Enforcement citation number: Los Alamos National Laboratory: 
EA 2006-05; 
Date of enforcement action: Los Alamos National Laboratory: Feb. 16, 
2007; 
Penalty assessed: Los Alamos National Laboratory: $1,100,000; 
Security level [A]: Los Alamos National Laboratory: I, II; 
Description of violation: Los Alamos National Laboratory: Fifteen 
separate violations of nuclear safety rules, which reflect continuing 
safety performance deficiencies over past several years. Deficiencies 
in work controls and quality improvement. Lack of fundamental 
improvements noted since stand-down of facilities. 

Total for Los Alamos; 
Office of Enforcement citation number: [Empty]; 
Date of enforcement action: Los Alamos National Laboratory: [Empty]; 
Penalty assessed: Los Alamos National Laboratory: $3,080,000; 
Security level [A]: Los Alamos National Laboratory: [Empty]; 
Description of violation: Los Alamos National Laboratory: [Empty]. 

Office of Enforcement citation number: Lawrence Livermore National 
Laboratory: EA 2000-12; 
Date of enforcement action: Lawrence Livermore National Laboratory: 
Sept. 27, 2000; 
Penalty Assessed: Lawrence Livermore National Laboratory: $82,500; 
Security level [A]: Lawrence Livermore National Laboratory: II; 
Description: Lawrence Livermore National Laboratory: Failure to 
adequately address or take steps to correct programmatic weaknesses 
previously identified in maintaining and adhering to documents that 
form the safety basis for nuclear facilities. Failure to perform work 
using established controls over work processes. 

Office of Enforcement citation number: Lawrence Livermore National 
Laboratory: EA 2003-04; 
Date of enforcement action: Lawrence Livermore National Laboratory: 
Sept. 3, 2003; 
Penalty Assessed: Lawrence Livermore National Laboratory: $137,500; 
Security level [A]: Lawrence Livermore National Laboratory: II; 
Description: Lawrence Livermore National Laboratory: Radiation 
protection deficiencies resulting in significant radiological 
overexposure to one worker. Inadequate radiological controls and 
failure to implement a required hazard assessment. 

Office of Enforcement citation number: Lawrence Livermore National Date 
of enforcement action: EA 2006-01; 
Date of enforcement action: Lawrence Livermore National Laboratory: 
Feb. 23, 2006; 
Penalty Assessed: Lawrence Livermore National Laboratory: $588,500; 
Security level [A]: Lawrence Livermore National Laboratory: I, II, III; 
Description: Lawrence Livermore National Laboratory: Long-standing and 
repeated failures to effectively track and correct radiological program 
deficiencies. Significant failure of management to properly oversee the 
correction of repeated problems. Weaknesses in determining underlying 
causes and corrective action plans. 

Total for Lawrence Livermore; 
Office of Enforcement citation number: Lawrence Livermore National Date 
of enforcement action: [Empty]; 
Date of enforcement action: Lawrence Livermore National Laboratory: 
[Empty]; 
Penalty Assessed: Lawrence Livermore National Laboratory: $808,500; 
Security level [A]: Lawrence Livermore National Laboratory: [Empty]; 
Description: Lawrence Livermore National Laboratory: [Empty]. 

Total for both laboratories; 
Office of Enforcement citation number: Lawrence Livermore National Date 
of enforcement action: [Empty] 
Date of enforcement action: Lawrence Livermore National Laboratory: 
[Empty]; 
Penalty Assessed: Lawrence Livermore National Laboratory: $3,888,500; 
Security level [A]: Lawrence Livermore National Laboratory: [Empty]; 
Description: Lawrence Livermore National Laboratory: [Empty]. 

Source: DOE Office of Enforcement. 

Notes: The contractors were exempt from paying these penalties under 
the provisions of the Price-Anderson Amendments Act of 1988. The Energy 
Policy Act of 2005 removed this exemption after a new contract went 
into effect. From 2000 through September 2007, no enforcement actions 
were taken at Sandia National Laboratories. 

[A] Severity level I violations, the most significant, are those that 
involve actual or high potential for an adverse impact on the safety of 
the public or workers at DOE or NNSA facilities. Level II violations 
are those that show a significant lack of attention or carelessness 
toward the contractors' responsibilities for protecting the public or 
worker safety and that could, if uncorrected, potentially lead to an 
adverse impact on public or worker safety. Level III violations are 
less serious but of more than minor concern and, if left uncorrected, 
could lead to a more serious condition. 

[End of table] 

Appendix IV: Comments from the Department of Energy: 

Department of Energy: 
National Nuclear Security Administration: 
Washington, DC 20585: 

October 3, 2007: 

Mr. Gene Aloise: 
Director: 
Natural Resources and Environment Government Accountability Office: 
Washington, D.C. 20548:  

Dear Mr. Aloise: 

The National Nuclear Security Administration (NNSA) appreciates the 
opportunity to review the Government Accountability Office's (GAO) 
report, GAO-08-73, "Nuclear And Worker Safety: Actions Needed to 
Determine the Effectiveness of Safety Improvement Efforts at NNSA's 
Weapons Laboratories." We understand that this work was requested by 
the House's Subcommittee on Oversight and Investigations, Committee on 
Energy and Commerce to review safety records at NNSA's major 
laboratories. 

NNSA generally agrees with the facts in the draft report and its 
corresponding recommendations. The facts reported in the report, if put 
in the context of the numbers of employees, the period of years covered 
and the cutting-edge, high hazard work that is being performed at the 
laboratories, are favorably impressive. However, the reader would not 
have that impression because of the manner used to describe the status 
of safety at our Laboratories. The fact that GAO mentions a fall from a 
ladder as an example that safety is lax does not support the facts that 
are, in fact, presented in their own report. 

Contrary to the criticism of the report, the oversight/review by NNSA 
is excellent, as is demonstrated by the very reports the GAO 
references. The existence of the reported deficiencies and penalties 
demonstrates that NNSA and the rest of the Department's safety 
infrastructure are doing their job. The absence of reports would 
actually be cause for concern. Safety is a discipline that must always 
be managed and reinforced to affect the human element of our work, and 
the very data that GAO dismisses (lowered illness and injury rates) is 
proof that our oversight/management model is working to improve safety 
in a general sense. 

Should you have any questions about this response, please contact 
Richard Speidel, Director, Policy and Internal Controls Management at 
202-586-5009. 

Sincerely: 

Signed by: 

Michael C. Kane: 

Associate Administrator for Management and Administration: 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Gene Aloise, (202) 512-3841 or [email protected]: 

Staff Acknowledgments: 

In addition to the individual named above, Janet E. Frisch, Assistant 
Director; Carole Blackwell; Timothy Bober; Candace Carpenter; Ellen W. 
Chu; Doreen Eng; Daniel Feehan; Nancy Kintner-Meyer; Thomas Laetz; 
Mehrzad Nadji; Omari Norman; Keith Rhodes; Rebecca Shea; and William R. 
Swick made contributions to this report. 

[End of section] 

Related GAO Products: 

Department of Energy: Consistent Application of Requirements Needed to 
Improve Project Management. GAO-07-518. Washington, D.C.: May 11, 2007. 

National Nuclear Security Administration: Security and Management 
Improvements Can Enhance Implementation of the NNSA Act. GAO-07-428T. 
Washington, D.C.: January 31, 2007. 

National Nuclear Security Administration: Additional Actions Needed to 
Improve Management of the Nation's Nuclear Programs. GAO-07-36. 
Washington, D.C.: January 19, 2007. 

DOE Contracting: Better Performance Measures and Management Needed to 
Address Delays in Awarding Contracts. GAO-06-722. Washington, D.C.: 
June 30, 2006. 

Stand-down of Los Alamos National Laboratory: Total Costs Uncertain; 
Almost All Mission-Critical Programs Were Affected but Have Recovered. 
GAO-06-83. Washington, D.C.: November 18, 2005. 

Department of Energy: Further Actions Are Needed to Strengthen Contract 
Management for Major Projects. GAO-05-123. Washington, D.C.: March 18, 
2005. 

National Nuclear Security Administration: Key Management Structure and 
Workforce Planning Issues Remain As NNSA Conducts Downsizing. GAO-04- 
545. Washington, D.C.: June 25, 2004. 

Department of Energy: Mission Support Challenges Remain at Los Alamos 
and Lawrence Livermore National Laboratories. GAO-04-370. Washington, 
D.C.: February 27, 2004. 

Contract Reform: DOE's Policies and Practices in Competing Research 
Laboratory Contracts. GAO-03-932T. Washington, D.C.: July 10, 2003. 

Nuclear Security: NNSA Needs to Better Manage Its Safeguards and 
Security Program. GAO-03-471. Washington, D.C.: May 30, 2003. 

Department of Energy: Status of Contract and Project Management 
Reforms.GAO-03-570T. Washington, D.C.: March 20, 2003. 

Contract Reform: DOE Has Made Progress, but Actions Needed to Ensure 
Initiatives Have Improved Results. GAO-02-798. Washington, D.C.: 
September 13, 2002. 

Nonproliferation R&D: NNSA's Program Develops Successful Technologies, 
but Project Management Can Be Strengthened. GAO-02-904. Washington, 
D.C.: August 23, 2002. 

Nuclear Security: Lessons to Be Learned from Implementing NNSA's 
Security Enhancements. GAO-02-358. Washington, D.C.: March 29, 2002. 

Department of Energy: NNSA Restructuring and Progress in Implementing 
Title 32. GAO-02-451T. Washington, D.C.: February 26, 2002. 

Department of Energy: Fundamental Reassessment Needed to Address Major 
Mission, Structure, and Accountability Problems. GAO-02-51. Washington, 
D.C.: December 21, 2001. 

National Laboratories: Better Performance Reporting Could Aid Oversight 
of Laboratory-Directed R&D Program. GAO-01-927. Washington, D.C.: 
September 28, 2001. 

Nuclear Security: DOE Needs to Improve Control Over Classified 
Information. GAO-01-806. Washington, D.C.: August 24, 2001. 

Department of Energy: Follow-Up Review of the National Ignition 
Facility. GAO-01-677R. Washington, D.C.: June 1, 2001. 

Department of Energy: Views on Proposed Legislation on Civil Penalties 
for Nuclear Safety Violations by Nonprofit Contractors. GAO-01-548T. 
Washington, D.C.: March 22, 2001. 

Nuclear Weapons: Improved Management Needed to Implement Stockpile 
Stewardship Program Effectively. GAO-01-48. Washington, D.C.: December 
14, 2000. 

National Ignition Facility: Management and Oversight Failures Caused 
Major Cost Overruns and Schedule Delays. GAO/RCED-00-141. Washington, 
D.C.: August 8, 2000. 

Department of Energy: Views on Proposed Civil Penalties, Security 
Oversight, and External Safety Regulation Legislation. GAO/T-RCED-00- 
135. Washington, D.C.: March 22, 2000. 

Nuclear Security: Security Issues at DOE and Its Newly Created National 
Nuclear Security Administration. GAO/T-RCED-00-123. Washington, D.C.: 
March 14, 2000. 

Department of Energy: Views on DOE's Plan to Establish the National 
Nuclear Security Administration. GAO/T-RCED-00-113. Washington, D.C.: 
March 2, 2000. 

Nuclear Security: Improvements Needed in DOE's Safeguards and Security 
Oversight. GAO/RCED-00-62. Washington, D.C.: February 24, 2000. 

Department of Energy: Need to Address Longstanding Management 
Weaknesses. GAO/T-RCED-99-255. Washington, D.C.: July 13, 1999. 

Nuclear Weapons: DOE Needs to Improve Oversight of the $5 Billion 
Strategic Computing Initiative. GAO/RCED-99-195. Washington, D.C.: June 
28, 1999. 

Department of Energy: DOE's Nuclear Safety Enforcement Program Should 
Be Strengthened. GAO/RCED-99-146. Washington, D.C.: June 10, 1999. 

National Laboratories: DOE Needs to Assess the Impact of Using 
Performance-Based Contracts. GAO/RCED-99-141. Washington, D.C.: May 7, 
1999. 

Department of Energy: Key Factors Underlying Security Problems at DOE 
Facilities. GAO/T-RCED-99-159. Washington, D.C.: April 20, 1999. 

[End of section] 

Footnotes:  

[1] NNSA, a semiautonomous agency within the Department of Energy, was 
established under Title 32 of the National Defense Authorization Act 
for Fiscal Year 2000 as a separately organized agency within the 
Department of Energy; it is responsible for the management and security 
of the nation's nuclear weapons, nuclear nonproliferation, and naval 
reactor programs. 

[2] Lawrence Livermore National Laboratory is located in California; 
Los Alamos National Laboratory is located in New Mexico; and Sandia 
National Laboratories has two campuses--the main campus in Albuquerque, 
New Mexico, and a smaller California campus near Lawrence Livermore 
National Laboratory. 

[3] A Review of Ongoing Management Concerns at Los Alamos National 
Laboratory, Hearing before the Subcommittee on Oversight and 
Investigations of the Committee on Energy and Commerce, House of 
Representatives, serial no. 109-45 (May 5, 2005). 

[4] As of October 1, 2006, the Office of Independent Oversight and 
Performance Assurance was renamed the Office of Environment, Safety and 
Health Evaluations. 

[5] This provision is often referred to as the conditional-payment-of- 
fee clause. 

[6] Nuclear Safety Management, 10 C.F.R., part 830; Occupational 
Radiation Protection, 10 C.F.R., part 835; Worker Safety and Health 
Program, 10 C.F.R., part 851; and Procedural Rules for DOE Nuclear 
Activities, 10 C.F.R., part 820. 

[7] DOE's Office of Enforcement is responsible for identifying 
violations of the nuclear safety rules and assessing civil penalties 
against contractors. This enforcement program, originally established 
in 1996, now also includes enforcement of rules that have been issued 
for security and safeguarding of classified information and for worker 
or industrial health and safety. 

[8] The severity of an accident determines which category of safety 
investigation is carried out. Type A investigations are for the most 
serious accidents; the investigation team is appointed by DOE's Chief 
Health, Safety and Security Officer. Threshold criteria for type A 
investigations include a fatality, high-dose radiation exposure, or 
property damage of $2.5 million or more. Type B investigations are 
managed by the NNSA site office. Threshold criteria for type B 
investigations include one or more people injured and requiring 
hospitalization for 5 days or more, radiation exposure exceeding 
certain thresholds, or property damage of $1.0 million to less than 
$2.5 million. Serious accidents not meeting the type A or type B 
criteria are investigated by the contractor. 

The 60 accidents at the laboratories from 2000 to 2007 include all type 
A and type B accident investigations conducted by DOE, as well as the 
most serious incidents investigated by the contractors. We included all 
investigations of events resulting in injury or property damage as well 
as those considered near misses. If one investigation included more 
than one incident, we counted each incident separately. 

[9] Sandia National Laboratories has not been cited for a nuclear 
safety violation since 2000, although it was cited on four occasions 
from 1996 through 1999, with total assessed penalties of $61,250. 

[10] Under section 234A of the Atomic Energy Act of 1954, as amended, 
42 U.S.C. 2282a, DOE has the authority to impose civil penalties on 
contractors for violations of nuclear safety requirements. However, 
under section 234A(d), certain nonprofit contractors (including the 
University of California, which operated the Los Alamos laboratory 
until June 2006 and the Lawrence Livermore laboratory until October 
2007) were specifically exempted from paying such penalties. In 2005, 
Congress passed the Energy Policy Act of 2005, which removed this 
exemption for contracts becoming effective after passage of the act. 
Because a new Los Alamos contract became effective on June 1, 2006, and 
a new Lawrence Livermore contract took effect on October 1, 2007, the 
new contractors are required to pay any penalties levied. 

[11] Because of the exemption under section 234A(d) of the Atomic 
Energy Act of 1954, as amended, 42 U.S.C. 2282a, under the contractors 
at the time, neither of the laboratories paid the penalties associated 
with the enforcement actions levied against them. 

[12] According to DOE, because of a change in the system for reporting 
incidents, consistent data were available only from 2004 and later. 

[13] Many of these injuries resulted from slips, trips, and falls. 

[14] Initially proposed by the Safety Board in 2005, this position was 
filled in August 2007. 

[15] Specific performance criteria, including criteria for safety, were 
incorporated into the contract for Sandia National Laboratories in 
fiscal year 2004, into the contract for Los Alamos National Laboratory 
in fiscal year 2006, and for Lawrence Livermore National Laboratory in 

fiscal year 2008. 

[16] The Los Alamos contractor can earn about $3 million in fiscal year 
2007 for improving the safety documentation at its nuclear facilities 
and another $2 million for completing and implementing required safety 
manuals and other requirements for nuclear facilities. The contractor 
can also earn about $600,000 for decreasing illness and injury rates by 
20 percent during fiscal year 2007. 

[17] Worker Safety and Health Program, 10 C.F.R., part 851. 

[18] GAO, Contract Reform: DOE Has Made Progress, but Actions Needed to 
Ensure Initiatives Have Improved Results, GAO-02-798 (Washington, D.C.: 
Sept. 13, 2002). 

[19] DOE Notice 125.1, "Managing Critical Management Improvement 
Initiatives," Oct. 1, 2003. The objectives of this directive were to 
establish a systematic, results-oriented approach for managing critical 
improvement initiatives. Among other things, the directive requires 
that improvement initiatives must identify the nature and source of 
current problems; analyze theories about the causes; consider 
alternative solutions; and provide measures for assessing outputs and 
outcomes, which will permit an assessment of the effectiveness and 
identification of any needed changes. 

[20] GAO, Department of Energy: Mission Support Challenges Remain at 
Los Alamos and Lawrence Livermore National Laboratories, GAO-04-370 
(Washington, D.C.: Feb. 27, 2004). 

[21] In commenting on a draft of the report, NNSA was silent on the 
usefulness of this recommendation, instead stating that the contractors 
were committed to ensuring that their improvement efforts continued to 
achieve the desired results. However, we pointed out that although the 
contractors had made progress in implementing corrective actions and 
new requirements, the extent to which those actions had resulted in 
improved performance in mission support activities was unclear. 

[22] GAO-04-370. 

[23] GAO-04-370. 

[24] DOE Order 226.1, ï¿½Implementation of Department of Energy Oversight 
Policyï¿½, Sept. 15, 2005. The contractor assurance systems cover areas 
beyond safety, including security and business operations, which have 
also been problematic at the laboratories. 

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