The foaming chemicals and orange smoke rising from containers of nuclear waste at Los Alamos National Laboratory were warning signs that something wasn’t right.

But when subcontract employees repackaging the waste for the lab told supervisors about the reaction, they were told to “simply wait out the reaction and return to work once the foaming ceased and the smoke subsided,” says a report released Thursday by federal investigators.

The report by the Accident Investigation Board appointed by the Department of Energy is the most definitive look yet at the events that led to the Feb. 14, 2014, radiation leak at the nuclear waste repository near Carlsbad from a LANL waste container that ruptured.

The report concluded that incompatible chemicals and a culture of lax oversight and inadequate safety protocols and training at Los Alamos National Laboratory led to the leak.

“If LANL had adequately developed and implemented repackaging and treatment procedures that incorporated suitable hazard controls and included a rigorous review and approval process, the release would have been preventable,” the Accident Investigation Board said in its final report.

In interviews with lab employees and contractors, the board identified an environment of distrust between workers and supervisors within pockets of the lab. The board found that workers did not feel comfortable raising safety issues and felt pressured to “get it done at all costs.” At least one worker told the board in an interview that when concerns were raised over the use of organic kitty litter as an absorbent packing material, the employee was told to “focus on their area of expertise and not to worry about the other areas of the procedure,” the authors of the report wrote.

Employees also raised concerns that workers were brought in with little or no experience and rushed through a training program that was not adequate.

“As a result … there was a failure to adequately resolve employee concerns which could have identified the generation of non compliant waste prior to shipment” to the Waste Isolation Pilot Plant in Southern New Mexico, investigators said.

Much of the board’s findings match conclusions reached in a six-month investigation by The New Mexican that published in November.

A lab spokesman said in a statement that officials there were reviewing the report and “will incorporate recommendations into the Lab’s ongoing extensive corrective action program.”

“We will continue to work closely with DOE, [the National Nuclear Security Administration] and the New Mexico Environment Department throughout the recovery process,” the statement added.

In a memo to lab employees following the release of the report, lab Director Charles McMillan was more blunt:

“A central theme that runs through the [Accident Investigation Board] report is the lack of appropriate internal regulatory and technical reviews in transuranic waste handling and processing operations,” McMillan wrote. “Quite simply, we — as a laboratory — failed to execute sufficient regulatory and technical reviews in our management of the legacy (transuranic waste) nitrate-salt waste stream.”

Transuranic waste refers to the mix of contaminated lab clothing, equipment and other waste left over from decades of nuclear research at various Department of Energy sites, including Los Alamos. The container that eventually burst in the underground storage facility held waste first processed nearly four decades ago at the lab to recover plutonium.

The Accident Investigation Board found that the ruptured container had been repacked by contractors in 2013 with an incompatible mix of nitrate salts, neutralizer and organic kitty litter, in addition to a tungsten-lined glove used to handle the waste.

Contractors preparing the container for shipment to the Waste Isolation Pilot Plant erroneously added organic kitty litter as an absorbent, based on instructions from the lab management company, Los Alamos National Security LLC. Wording in those treatment instructions, when they were rewritten in 2012, changed from “clay” kitty litter to “organic” kitty litter. The change was inconsistent with an expert’s earlier paper about what types of materials could safely be mixed with nitrate salts.

The inherent problems of combining nitrates with flammable materials like organic kitty litter had held up waste processing once before. In 2012, those managing the waste containers raised concerns about the use of the organic absorbent WasteLock 770 mixed with nitrate salts. Two years later, despite the earlier concerns, employees mixed the nitrate salts with a different organic absorbent, the kitty litter Swheat Scoop. “Lessons were not learned,” investigators said in Thursday’s report.

Federal investigators concluded a slow chemical reaction inside the container built up heat and gases inside the container until it popped open and leaked radiation. Tests performed on the drum before it was shipped to WIPP would not have caught the gas buildup unless they were done at exactly the right moment, according to a technical team of scientists. The hot waste that burst out of the container caused nearby fiberboard, cardboard and other combustible materials to burn, but investigators believe no other waste containers stored in the underground room leaked. No employees were underground at the time the container ruptured.

Don Hancock of the WIPP watchdog group Southwest Research and Information Center said the report had “an inadequate discussion of where contamination occurred in the underground — more than 8,000 feet of tunnels — and does not include any sampling data of the nature of that contamination, how it occurred and whether it is consistent with the contaminants that were analyzed.”

Hancock said the report also had good recommendations for resolving problems at the lab and WIPP, but “it is not at all comprehensive.”

Federal investigators found that a dozen problems at the lab and Department of Energy offices overseeing waste processing contributed to the accident, including failure of Los Alamos National Security to effectively review and control waste packaging, train contractors and identify weaknesses in waste handling. The board also found that Los Alamos National Security, contractor EnergySolutions and the National Nuclear Security Administration office at the lab failed “to ensure that a strong safety culture existed within … the organization at the lab.”

The lab and the Department of Energy are already facing more than $54 million in fines from the state Environment Department related to violations of a hazardous waste permit and the container leak. The state has scheduled hearings on July 27 for the WIPP fines and Sept. 21 for the fines against the lab.

The state Environment Department is reviewing the federal report.

Before the accident, the lab was facing a deadline to move thousands of barrels of Cold War-era nuclear waste from Los Alamos to WIPP by June 30, 2014. Meeting the deadline was an important measure in helping Los Alamos National Security LLC, the private consortium that runs the lab, extend its $2.2 billion annual contract with the Department of Energy. In interviews with the board, workers “described what they perceived as production and schedule pressure to get the job done” during that campaign, the report said.

The investigation also found that “several of the managers and workers involved in the processing of the waste did not fully understand the complexities or hazards associated with the waste they were handling,” the report said.

Since the accident, the lab has instituted a number of changes — including in leadership and training of the waste management team — to help address the shortfalls that caused the leak. In his memo to employees Thursday, McMillan detailed many of those changes and appeared to address worker concerns listed in the report.

“As I have reiterated in the past several months, every employee plays a valuable role in our recovery process,” he wrote. “Please feel free to discuss with your leadership where you might be able to offer unique talents, capabilities, or insights — even if it is outside your normal duties. With your help, I am confident that we can continue to deliver on our national security mission safely and securely, and in an environmentally responsible manner.”

Several times in the report, federal investigators noted the lab’s need to improve its “safety culture.”

That culture can’t improve without some fundamental changes in how the lab is paid, said Greg Mello of the watchdog Los Alamos Study Group. The lab’s manager, Los Alamos National Security, receives bonuses from the Department of Energy for meeting goals such as removing nuclear waste by a certain deadline.

“You can’t just say everyone has to try harder,” Mello said. “Mixing profit, deadlines and dangerous radioactive waste is incompatible.”

At a community meeting Thursday night in Carlsbad, federal investigators said several containers with a chemical mix similar to the one that ruptured in WIPP are stored in a secure facility at Los Alamos and are being monitored. The chemicals in the drums are “active” but not at the same pace as one that ruptured, officials said.

 

Contact Staci Matlock at 986-3055 or smatlock@sfnewmexican.com. Follow her on Twitter @StaciMatlock.

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(3) comments

Chris Mechels

This problem goes back to 1990, when the DOE began dealing with waste.

Underlying the problem since that time is that LANL has always dealt with waste as a "funding opportunity". Waste Management, with Nuclear Weapons, and Beam lines, were the Big 3 budget areas, when I retired in 1994.

The only "solution" to LANL mismanagement was the removal of the University of California from the contract, as they fed mismanagement for decades.

Instead, in 2005, due to Senator Domenici's interference, the contract went to LANS, which is simply more UC mismanagement, in a more virulent form.

Needed was a "real" change in management, to Sandia/UT, and that got blocked by Pete.

The current problem traces directly to that 2005 decision to keep UC.

LANL problems WILL CONTINUE, so long as LANS/UC has the contract. The whole culture "stinks" of mismanagement, as it always has.

Unlike LANL, Sandia, in spite of its flaws, is well run, and this has been true historically. To cure the LANL problems, which are many in addition to WIPP, will require a change in management, and Sandia is the only obvious choice.

Keeping LANS will not work, as it supports the corrupt management culture.

Thomas Harris

Not really clear why a LockMart/UT consortium would have been any better than the current LANS. Further, most employees at LANL since contract transition in 2006 will point the finger at Bechtel as the big dog, not UC, in the ongoing challenges with LANL operations. Similarly, most employees at LANL would likely state that the Laboratory (and the nation) would have been better served by not privatizing the national Laboratories and plants with carpetbagger for-profit contractors.

Finally, Mr. Mechels' incessant negative comments regarding LANL--21 years after retiring under duress--seem to be a bad case of sour grapes. That is a very long time to carry a chip on one's shoulder and only undermines one's credibility.

Vernon Brechin

The DOE’s internal investigation often alludes to a chemical reaction caused a slow buildup of pressure that cracked the lid. The visual evidence, of the accident scene, indicates a runaway reaction that was violent. If it wasn’t violent the contamination wouldn’t have been found upstream of it’s origin. The bulk of the contamination data is still being withheld from the public.

Many members of the public, who are familiar with the historical planning process that went into the waste packing procedures and the creation of WIPP, were repeatedly reassured, by officials, that the entire process had undergone a rigorous review and approval process. That process involved about a decade of planning and an expenditure of at least $1-billion.

There will always be people who look at this investigation as an opportunity to make improvements in the system. I wonder why it doesn’t raise more doubts regarding certain people’s confidence in dealing with many types of nuclear waste and the technologies behind them.

The root cause still has not been determined because a decision was made, in the summer of 2014, to not retrieve the breached drum so a thorough forensic review of its contents could be performed. The TAT investigation team admitted they couldn’t be certain of the root cause due to a lack of data regarding how it was packed.

See on YouTube: WIPP Leak Reaction Simulation Experiment

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