A report sent Oct. 11 to Secretary of Energy Rick Perry by the Defense Nuclear Facilities Safety Board alleges weaknesses in federal oversight of the Los Alamos National Laboratory’s emergency preparedness and response program, the Lab’s demonstrated emergency response during drills and exercises, the site emergency exercise program and facility-level emergency planning and drills.
The Board told Secretary Perry that its staff team performed a review of the Lab’s emergency preparedness and response program in April 2016 and subsequently observed several on-site drills and exercises.
A letter signed by Board Chairman Sean Sullivan says members considered and decided against issuing a final recommendation and understand that NNSA and LANL have begun to address many of the weaknesses.
The staff report says federal oversight has not been effective and that the National Nuclear Security Administration (NNSA) Los Alamos Field Office has not completed all the requirements of the emergency preparedness and response program and facility exercise assessments. It says that NA-LA has not performed independent assessments of the LANL emergency management program, which they say could identify issues that a contractor might not self-identify, although they did participate in the Security and Emergency Operations Division self-assessment and reviewed those reports.
Evidence was not found that NNSA conducted independent evaluations of facility emergency management exercises every three years, according to the report, which adds that LANL has 18 hazardous materials facilities so NNSA should have conducted 18 individual evaluations rather than one evaluation for the entire site.
The report alleges that LANL has not demonstrated adequate response capability during drills and exercises and cites a failure to establish an effective incident command at an event scene and make decisions that prioritize the health and safety of the emergency responders and the Lab workforce.
“The staff team observed that incident command team members did not demonstrate an understanding of their defined roles and responsibilities, did not effectively coordinate responses to the event scene, did not share common understanding of the event and response, did not establish objectives and prioritize elements of response and did not communicate effectively with the emergency operations center. The staff team also found several examples of the failure of facility-level and site-level commander to implement a unified command structure,” the report states.
The report refers to an August 2016 site-wide exercise noting that control of the incident involved six commanders; the LANL emergency manager, LANL protective force, Los Alamos Fire Department, Los Alamos Police Department, the Hazardous Materials Response Team and the FBI but that no one individual assumed command and control of the response. It says the commanders did not demonstrate a common understanding of the event scene and response actions.
“They didn’t hold formal briefs, establish objectives or create an action plan, so emergency responders didn’t enter the facility until 1.5 hours after the security threat had been eliminated,” the report states.
Other issues raised in the report pertained to a September 2016 annual exercise at the Weapons Engineering Tritium Facility involving a potential active shooter. The exercise allegedly did not include LAPD “who would have had responsibility in part in a unified incident command in an active shooter event”. The report says that LAPD officers do not receive familiarity and hazard awareness training that LAFD gets. It states, “exercise participants expressed concerns that the police procedures and response actions may not appropriately account for unique hazards at certain LANL facilities”.
“The exercise failed to demonstrate the integration of a key responder in a unified incident command structure,” the report added.
It also states that the incident command team failed to make and prioritize decisions that affect response time such as staging command in the isolation zone or proceeding downwind from the event.
The report alleges that in an August 2016 site-wide annual exercise at TA 55 involving simulated mass casualties, there was “lack of focus on worker safety and lack of coordination between responders in the unified incident command”. It states that 1.5 hours after the event commenced, the simulated casualties still hadn’t received medical attention despite emergency responders waiting outside the security area.
“As a result, protective force personnel (who are not trained to provide medical support) began transporting contaminated patients in security vehicles. Further, protective force personnel were standing unprotected in the release plume for the duration of the exercise,” the report notes.
In addressing shelter in place situations, the report states that for certain emergency situations, the LANL emergency response program depends on workers to take protective actions. It says that during some drills and exercises, the team observed the inability of workers to demonstrate appropriate shelter-in-place protective actions.
“Gaps in adequate implementation include the failure to secure ventilation, the failure to achieve personnel accountability, and the failure to develop contingency plans when emergency responders are affected by shelter-in-place protective actions,” the report states. It goes on to list four examples of drills that raised concerns in this area.
The report alleges that LANL has not consistently demonstrated an ability to notify affected workers of an event in progress. It says that LANL’s notification system assigns workers to a specific facility’s notification list, but that many personnel have work areas at a location separate from their assignment on the list, so the notification system is not set up for notifying workers who are at a location other than the one designated by the notification list.
The report also alleges that LANL also relies on the individual facility public address systems to notify facility workers who do not receive a page, text, or email but that not all facilities have PA systems.
Another area of concern listed by the team was that as of February, LANL had performed no exercises during off-hours at a defense nuclear facility in more than four years.
Based on its observations, the staff team also concluded that LANL facility-level emergency programs are “immature and inconsistently exercised” and that the technical planning documents have “unrecognized weaknesses”. The report says LANL does not have effective facility-level drill programs to ensure that facility personnel are able to identify abnormal conditions, take immediate actions, recognize emergency conditions, and make appropriate notifications. It states additionally that LANL “has not established a site-wide standard for determining the scope and frequency for training and drills based on each facility’s hazards”.
A spokesman for NNSA said Monday that NNSA and LANL have a comprehensive emergency management in place that is routinely tested and validated through drills and exercises “with a focus on continuous improvement.”
“As noted in the DNFSB’s letter, NNSA and LANL are taking proactive measures to strengthen emergency preparedness and response based on lessons learned from these drills and exercises,” the spokesman said. “NNSA is committed to having world-class emergency management capabilities to protect our employees, the public and the environment.”