Work Planning, Authorization, and Control

ES&H Questionnaire Process

The Laboratory uses a question-naire that is sent to new project initiators to identify projects that may pose environment, safety, and health risks.

LANL Administrative Requirement 1-10, "Environment, Safety and Health Questionnaire," (August 30, 1991), requires that all new projects be assessed for ES&H concerns. The procedure identifies those projects requiring an ES&H review, the review process, and line management's resolution of ES&H concerns arising from the review. The ESH Division's Risk Assessment Group is responsible for gathering information from new project initiators, via a questionnaire, and distributing the information to the ES&H Questionnaire Committee for review. The ES&H Questionnaire Committee is composed of subject matter experts representing various ES&H disciplines.

LANL personnel initiating new projects are required to complete the questionnaire contained in Administrative Requirement 1-10 for projects that may include new construction and building modifications, groundbreaking, or soil disturbance, or for projects that may involve high energy sources. The Risk Assessment Group in ESH-3 then distributes the completed questionnaire to the Questionnaire Committee for review, evaluation, and comment on matters such as project siting, occupational safety, fire protection, industrial hygiene, and health physics. The Committee is also required to determine whether Federal, state, or local statutes and regulations apply to the proposed project.

If subject matter experts identify potential ES&H concerns during their review of the questionnaire, Administrative Requirement 1-10 requires the Risk Assessment Group to send the project initiator an ES&H checklist, which lists the possible ES&H concerns related to the project and the appropriate contact for each concern. The project initiator is responsible for contacting the personnel listed and for maintaining a permanent file to document the resolution of the concerns raised during the review. The permanent file is required to meet the DOE audit requirements specified in Administrative Requirement 1-5, "Environment, Safety, and Health Audits and Appraisals."

Development of an Informal ES&H Review Process

A project summary process was developed to supplement the questionnaire process.

In 1992, the LANL Associate Director for Operations designated the ESH Division as the office of primary responsibility for the ES&H Questionnaire process. In November 1993, a Quality Improvement Team was formed to identify needed improvements in the ES&H Questionnaire process. In December 1993, the Quality Improvement Team issued a report on the ES&H Questionnaire process, recommending process improvements for project-related data gathering and turnaround times for subject matter expert reviews.

In December 1993, the Facilities Review Section in ESH-3 developed the ESH Identification Process to (1) implement the Quality Improvement Team's recommendations, and (2) alleviate problems with poor response from project initiators who were responsible for completing the forms contained in Administrative Requirement 1-10.

The ESH Identification Process involves the Facilities Review Section conducting face-to-face interviews with project initiators to gather information for inclusion in a nested logic database. Following data collection, ESH-3 documents the data in an ESH Identification Project Summary, and distributes the Summary to subject matter experts for review.

The Facilities Review Section forwards the results of subject matter expert reviews to the project initiator to address any ES&H impacts.

Administrative Requirement 1-10 has not been revised to reflect the changes in the process, procedures, and practices that the Facilities Review Section implemented in the new ESH Identification Process and, as of the date of the accident, the new process was in direct conflict with Administrative Requirement 1-10.

2.2.1.2 Work Authorization

For this project, initial reviews identified some potential hazards.

On August 24, 1995, ESH-18 initiated ESH Identification Process #95-0188 for the Waste Stream Corrections Project. The ESH Identification Project Summary was completed by ESH-3 technicians, and ESH-18 provided factual accuracy review/comments to ESH-3 on September 15, 1995. Information provided by ESH-18 characterized the Waste Stream Corrections Project as a construction-related activity and identified explosives, industrial hygiene, operational safety, and radiological safety as potential hazard areas that could be encountered during the project. Subject matter expert review comments were provided to ESH-18 via ESH-3 memorandum, "Project Summary Closure Letter," dated November 13, 1995.

On or about September 6, 1995, FSS-9 representatives completed Service Request #02447 for Waste Stream Corrections. This service request was later assigned Standing Work Order #06006, to "Provide labor and materials to perform modifications to drain systems within Laboratory buildings as directed by ESH-18 to correct environmental code deficiencies as recommended by the waste stream surveys schedules." The Standing Work Order noted that "manpower will be requested by the account controller as needed." The Waste Stream Corrections service request received final management approval on September 21, 1995. On September 28, 1995, ESH-3 Facility Safety personnel completed their ES&H review of the Waste Stream Corrections service request.

On October 5, 1995, JCI forwarded a "Request for Davis-Bacon Determination" for the Waste Stream Corrections Project to the LAAO Determining Official for review. The JCI transmittal specified, in part,

"Perform modifications to original waste systems within the Laboratory to correct environmental deficiencies... This determination will be used on all Facility Management Unit standing work orders for this work." On October

10, 1995, the LAAO Determining Official responded that the Waste Stream Corrections Project was "uncovered" (maintenance) work.

Both the Waste Stream Corrections service request (September 21, 1995) and ESH-3's technical safety review of the service request (September 28, 1995) were completed before the subject matter expert reviews were completed for the Project Summary (November 13, 1995). The subject matter experts' safety input could have been useful in the other reviews.

There was concern about the lack of detailed information about some conditions.

In a November 1, 1995, memorandum to Distribution, "Update of ESH ID

#95-0188, Waste Stream Corrections," ESH-3 stated that attempts had been made to address the entire Waste Stream Corrections Project on a Laboratory-wide scale, but because of this wide-scale approach, several subject matter experts were concerned about the lack of detail contained in the Project Summary. The memorandum outlined ESH-18's plans for organizing the project to address those concerns, including:

• Small job tickets would be used for corrections costing less than $2,000, with JCI performing the work.

• Standing Work Orders, work tickets, and service requests would be used for corrections inside buildings, excluding excavations of any kind, with the work conducted by JCI and managed by FSS-9.

• Corrections involving major cost projects would be managed by FSS-6, and would address all excavations, either inside or outside, including dirt or concrete. This work would be accomplished by Basic Ordering Agreement contractors, and would involve a total of approximately 15 projects. ESH-18 later updated this information to state that the Waste Stream Corrections Project would utilize JCI rather than Basic Order Agreement contractors for the work managed by FSS-6.

• ESH-18 would be responsible for addressing any administrative corrections to permits.

The project was performed as a series of small jobs that normally require radiological and risk management reviews.

The memorandum also noted that "Small job tickets, service requests, and work tickets, authorizing work by JCI are currently reviewed by ESH-3 or a facility management team. If identified risks or hazards cannot be adequately addressed on the ESH Review page of the small job ticket or service request, the ESH Identification Process can be initiated by ESH-3, the facility manager, or the project contact."

The small job ticket and work ticket forms normally used by LANL and JCI personnel allow for ESH-1 (Radiological Protection) and ESH-3 reviews.

For the Waste Stream Corrections Project, ESH-18 developed its own tailored small job ticket form, whose purpose was to track project costs and NPDES permit compliance status. However, the tailored form did not include space for either ESH-1 or ESH-3 reviews. In addition to the ESH-3 reviews noted above, the JCI ES&H Manual, Procedure 12-21-112, "Hazard Assessment Requirements," dated November 7, 1995, requires JCI craft

supervisors to conduct a preliminary hazard analysis prior to any work conducted by JCI personnel.

A lack of detailed design draw-ings allowed the excavation site to be placed directly over the electrical line.

Board interviews with ESH-18 project leaders and reviews of archived records indicate that ESH-18 began work on Waste Stream Corrections subtasks prior to completion of subject matter expert reviews of the Project Summary. Using the ESH-3 November 13, 1995, memorandum, "Project Summary Closure Letter, ESH ID #95-0188," as a baseline to determine completion of the ESH Identification Process, records indicate that between September 11, 1995, and November 8, 1995, ESH-18 issued 16 Waste Stream Corrections Project subtasks for work without detailed work packages. Some of the work packages involved hazards associated with plumbing and electrical modifications and installations.

2.2.1.3 Work Control

No detailed reviews were performed.

ESH-18 provided the Board with information to indicate that, on December 6, 1995, project engineers from ESH-18 and SFE were in Building TA-21-209 to scope portions of the Waste Stream Corrections Project. Their written statements indicated they were approached by the building manager and informed by him of their activities in scoping out portions of the Waste Stream Corrections project.

On December 20, 1995, ESH-18 issued Waste Stream Corrections Project FMU70-009 to FSS-9. It was one of 15 subtasks under FMU70, and involved the work in the basement of Building TA-21-209. It had a target completion date of January 13, 1996. No detailed work package was prepared, and no further ES&H reviews were required. Concurrent with the release of the project for work, JCI pipefitters and masons scoped the job and laid out sites where excavation would be required to install sumps. The planned location of one sump appeared, on preliminary design drawings, to interfere with a door in the basement of Building TA-21-209. A JCI pipefitter contacted an ESH-18 representative to request approval for a deviation to relocate the sump. The ESH-18 representative contacted an SFE representative responsible for that subtask, who approved the change by telephone. The approval by ESH-18 to deviate from the preliminary design drawings was documented by JCI personnel on the FSS-9 Work Order Form. The approved sump relocation placed the sump location directly over an energized 13.2 kV electrical line.