In a long-awaited – and damning – final report, Investigators blamed Los Alamos National Laboratory and failures in Department of Energy oversight for the radiation leak that shut down WIPP more than a year ago, concluding that the release was “preventable.”
The Department of Energy-appointed Accident Investigation Board found that waste processing managers didn’t listen to worker concerns – including when fears were raised about foam and neon smoke emanating from drums – and “did not fully understand the hazards related to waste processing.”
The report traced what led one of the nation’s top nuclear facilities to commit – and never catch – what amounted to an error in instructions for processing nitrate salts, a volatile byproduct of nuclear weapons production.
LANL’s own “difficult waste team” had warned that nitrate salts should not be mixed with organic matter, and yet hundreds of drums containing the salts were packaged with an organic wheat-based cat litter and sent to the Waste Isolation Pilot Plant for permanent disposal. The cat litter was used to absorb liquids in the drums.
One drum blew. The report confirmed that those incompatible ingredients led to a hot reaction that cracked the drum’s lid, releasing radiation into the WIPP underground and into the environment on Valentine’s Day of 2014.
The leak contaminated nearly two dozen workers with low levels of radiation.
In a statement to all LANL staff Thursday and obtained by the Journal, LANL director Charles McMillan said the report “points out serious deficiencies in our processes and procedures.”
He wrote, “We now know from the investigations that if LANL had followed certain basic steps, this event would not have happened. Also, if we had complied with our hazardous waste permit, we would have avoided the serious legal and credibility issues we now face.”
McMillan outlined LANL’s long list of changes and improvements that have been made. “I believe we are turning a corner on this difficult time for the Lab,” he wrote.
Investigators criticized LANL contractor Los Alamos National Security LLC, a consortium including the Bechtel Corp. and the University of California, for not implementing required controls.
But the report also points the finger at DOE headquarters and its Los Alamos and Carlsbad field offices for not ensuring LANL followed adequate waste packaging procedures.
Nitrate waste problem
Three years ago, Los Alamos recognized the difficulties of processing waste containing nitrate salts, which are known to be reactive when combined with organic matter. LANL discovered a plastic organic material was being used to absorb liquids in the drums – a potential hazard.
LANL’s “Difficult Waste Team” issued a white paper in May 2012 with new recommendations to use “Kitty litter/Zeolite clay” to absorb liquids. Clay is inorganic.
But when contractor LANS prepared a revision to its packing procedure to reflect the new recommendations in July of that year, its instructions for processing nitrate salts mandated “an organic” absorbent instead of “an inorganic” absorbent. The Lab began using a wheat-based litter called Swheat Scoop.
The report traced that error to a manager in charge of the packing, or “glovebox,” operation at LANL. The manager told investigators he heard “organic” kitty litter specified in a meeting. Still, the mistake should have been caught if there had been appropriate management and technical review, the investigators say.
“Lessons were not learned” that would have prevented mixing yet another organic material with the oxidizing nitrates and creating the potential for combustion, the report states.
Pressure to clean up
In addition to interviews with government and contractor managers and workers, investigators set up a hotline to collect information from whistle-blowers.
While managers at both LANS and waste packaging subcontractor Energy Solutions told investigators that “safety culture” was being properly implemented, the board found that “several of the workers and a few hotline calls indicated that some of the managers at LANL were not receptive to bad news and would retaliate in response to reported issues.”
Furthermore – as an example of deficiencies in LANL’s “safety culture” – management didn’t listen when workers at the waste processing facility reported witnessing “foaming and an orange or yellow colored smoke” coming from drums during the process of neutralizing drum contents.
“After conditions cleared, the workers were instructed by the first line supervisor to continue operations,” the report states.
One employee also said that when workers questioned “the logic” of using organic cat litter, “they were told to focus on their area of expertise and not to worry about other areas of the procedure.”
LANL was under pressure to clean up waste from nuclear weapons testing. The investigating board noted the state mandate to remove the waste from LANL’s Area G by June of last year. Gov. Susana Martinez’s administration had pushed for the cleanup after the 2012 Las Conchas wildfire was the second to burn close to Area G.
“There were several examples of high workload and time stress to accomplish the Area G (cleanup campaign) by June 2014,” the report states.
Investigators said the pressure could have been a “precursor” to the errors made in packaging the waste to dispose of at WIPP.
New Mexico’s congressional delegation said in a joint statement Thursday, “A series of critical failures of leadership at every level led to the very serious accident and release that put numerous New Mexicans at risk, shuttered WIPP for over a year and (has) already cost taxpayers tens of millions of dollars. This report makes clear that the DOE and its contractors failed to keep faith with the people of New Mexico.”
New Mexico Environment Secretary Ryan Flynn called the report “very thorough and appropriately critical.”
“It identifies a lot of weaknesses from both an operational and management perspective that need to be addressed,” he said.
DOE is currently in negotiations over $54 million in fines the state Environment Department has levied against WIPP and LANL in connection with the WIPP leak. Flynn said the report “doesn’t change the nature of the negotiations,” which have been ongoing since December.
The deep underground facility outside Carlsbad serves as the final resting place for certain types of radioactive waste from the nation’s nuclear weapons production.
More than 2,000 feet below the surface, waste drums and containers are stacked in rooms mined from ancient salt beds.
U.S. Energy Sec. Ernest Moniz told a congressional subcommittee in March that “bringing this facility back online is a very high priority and we believe we are on schedule to resume operations in about a year.”
He added it will likely take at least two years to resume full-scale operations.
“We need to have major changes in the WIPP permit before WIPP can reopen,” said Don Hancock, a longtime WIPP watchdog with Albuquerque’s Southwest Research and Information Center. “Permit modifications have to be a public process.”
In the meantime, waste destined for WIPP is staying put at DOE’s national labs.