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Copyright © 2015 Albuquerque Journal
CARLSBAD – On July 15 at 1:30 p.m., deep underground in the
WIPP nuclear waste repository, a candle-sized flame ignited on rubber flashing as three workers torched through a metal bulkhead. One of the workers tamped out the flame with his leather glove and sprayed it with a fire extinguisher.
No one was hurt. The workers mentioned the fire to a supervisor but didn’t alert the Central Monitoring Room, or CMR, as safety policy required. The supervisor also forgot to report the flame to the CMR until the next morning.
A candle-sized flame – which caused no harm and was extinguished within seconds – wouldn’t get much notice in most work environments.
But in a high-hazard nuclear facility, struggling to recover from a radiological release and underground fire last year, the flame and the workers’ failure to report it – along with other safety issues – prompted a two-day work stoppage this summer and a fresh round of soul-searching by local Department of Energy managers and the site contractor.
Investigations into the two February 2014 accidents uncovered a broken safety culture at the Waste Isolation Pilot Plant, the nation’s only repository for Cold War-era defense nuclear waste. WIPP workers feared raising safety concerns to managers, had grown accustomed to poorly maintained equipment and were unable to identify risks. The contractor allowed the safety culture to deteriorate, and DOE failed in its oversight, the investigations found.
WIPP has been undergoing a monumental – and by many accounts, transformative – effort to change how things are done, to make safety the priority at all costs, to win over the “hearts and minds” of the workers on the front line of the effort to dispose of the country’s legacy nuclear waste.
WIPP’s ability to reopen is at stake.
“One of our expectations is that workers will stop work when they are not sure” about something, said Philip Breidenbach, president of site contractor Nuclear Waste Partnership. “You want to know that if that worker is unsure, they will never hesitate to stop. Because they could be the only thing between you and the next event.”
Valentine’s Day 2014
Dana Bryson, then-deputy director of DOE’s Carlsbad Field Office, showed up to WIPP the morning after the
Valentine’s Day 2014 radiation release to assess the response. No one knew yet that a drum of waste packaged at Los Alamos National Laboratory had ruptured 2,150 feet underground in one of WIPP’s disposal rooms carved from ancient salt beds.
It would later come to light that LANL had improperly packaged hundreds of waste drums with a combustible mix of nitrate salts – a byproduct of nuclear weapons production – and organic cat litter, causing a hot reaction in one drum that cracked the lid. The rupture released americium and plutonium into the deep salt mine and, in small amounts, into the environment.
Unknowingly, Bryson became one of 21 WIPP workers contaminated by the radiation at low levels.
Bryson had been hired months before to set WIPP’s safety culture on a new course. Even before the Feb. 14 radiation release and an unrelated salt haul truck fire that occurred underground nine days prior, WIPP managers knew there were issues.
“When I first got here two years ago, one thing I really noticed was that it was really hierarchical,” said Bryson, who retired this month as acting manager of CBFO, as the field office is known. “People did not ask questions. They went and did what they were told.”
Some of the safety culture issues were flagged as early as 2012 and 2013 in surveys reviewed by investigators, and Nuclear Waste Partnership and CBFO made little progress correcting the issues before the truck fire and radiation release brought a new sense of urgency, according to an April 2014 accident investigation report.
Some 40 percent of NWP employees and nearly 60 percent of CBFO employees surveyed in 2012 and 2013 said they were reluctant to raise issues to management. Investigators slammed the contractor and CBFO for “weak safety leadership” and “allowing an environment to exist that does not value open communication without fear of retribution.”
Most accidents don’t happen during the highest hazard operations but rather during the daily grind, investigators said, noting, “The challenge for leadership is to establish and reinforce the safety culture expectations continuously so that workers are mindful and careful during all operations.”
Today, WIPP workers are being encouraged to question everything, to trust their gut and call a “timeout” if something concerns them – and they are being rewarded for doing so.
In interviews with CBFO and NWP managers and a half-dozen workers, Carlsbad leaders and longtime WIPP observers, all described a shift in WIPP’s ability to safely run the nation’s only deep underground nuclear waste repository.
“Our ability to respond to a radiological event, it is night and day compared to where we are now and where we were,” said Breidenbach, who took over leadership of NWP in June.
NWP says it is hammering home a new set of expectations designed to elevate safety to top of mind.
More than 200 new hires, especially in emergency management and safety, are also helping shift the paradigm, NWP managers and workers say.
A new monthlong leadership academy in conjunction with New Mexico State University-Carlsbad is winning accolades as a DOE best practice, Bryson said.
NWP workers say the changes haven’t come easy.
“There were a lot of people that were upset about the changes,” said maintenance engineer Larry Diaz, who started at WIPP in February 2014, three days before the truck fire. “There was a lot of resistance. The site has come a long way.”
The candle-sized flame underground wasn’t the only incident this summer outlined in DOE “Occurrence
Reports.” There were others. Also in July, an engineer trying to get a look at the waist hoist controller brushed past two “danger” and “do not enter” signs to access a platform. He didn’t stop until a manager questioned him.
CBFO and NWP called a two-day work stoppage. Breidenbach led 11 sessions and put 1,000 people through a values training. The training asked workers to evaluate the events: Where did we fail? How does this event matter to me? Where do I need to change?
Then the workers established a set of commitments that they all signed, Breidenbach said.
“Even bad companies have a poster on the wall,” he said. “They all say they have values. They all say they have expectations. They all say they have standards. The key is figuring out how do you get those words off the wall and into people’s hearts and minds?”
“The amount of rigor we have to go through now just to do the normal, everyday tasks has multiplied exponentially,” said Diaz, the maintenance engineer for key instruments, including underground air monitors. “Everybody’s job has been changed drastically on the site just because now we have a constituent we never thought we would have at WIPP, a radiation element. We’re having to prepare and plan and take that into consideration before we do anything on the site.”
In August, NWP established a program called “timeout of the day,” and at NWP’s morning meeting, managers review the previous day’s calls. The person who called the timeout, and the manager responsible for listening, go out to lunch on the company dime.
“That’s a reward system,” Breidenbach said. “One of our expectations is that workers will stop work when they are not sure. It’s words on a wall until you put in a reinforcement system that helps those workers think, ‘Hey these guys really mean it.’ ”
“One of the things that is counterintuitive about changes like this is typically you go in and you don’t have any incidents,” Bryson said. “That’s what I first encountered when I came here. When people said, ‘We’re great. We don’t have any problems,’ I said, ‘So do we not have any problems, or is your reporting system broke?’ So now you see a curve where, when you start getting better, you start getting a lot of incidents identified. It looks bad, but that’s the path to good health.”
Steven Elias, an NMSU business school professor and expert in organizational behavior, backed that idea.
“What they have been doing for more than a decade is so ingrained, to stop on a dime and change the way they do things is hard,” he said. “Like the old saying, ‘Things get worse before they get better.’ It makes it seem like there are a lot of problems; it’s just that they are being brought up.”
Don Hancock, a longtime WIPP observer with Albuquerque’s Southwest Research and Information Center, this month became the first member of the New Mexico public, not including elected officials, to go underground at WIPP since it closed. A relentless critic over the years, Hancock questioned DOE’s commitment to safety and the contractor’s ability to deliver on its promises when the pressure to reopen WIPP is high.
“In terms of how far things have come, that is quite hard to judge,” he said. “We don’t really have the kind of data that one would need to do that.”
Still, he said he saw some signs of progress: a “combustible-free zone” to protect against underground fires; colored reflectors on the salt walls indicating exit routes.
“They are trying to do things to improve safety, there is no question,” he said. “There is still a long ways to go. They themselves admit they are not ready to reopen.”
A DOE Office of Enterprise Assessments internal memo, sent to employees last week and obtained by the Journal, noted that in a review of WIPP operations through May that ” strong and unrealistic schedule pressures on the workforce contributed to poor safety performance.”
This summer, DOE backed off a March 2016 target reopening due to delays in the recovery as well as safety concerns. Then earlier this month, DOE Secretary Ernest Moniz said WIPP was still on track to reopen sometime next year. It may take more than the original estimate of $500 million to fully recover the facility, and new cost estimates are expected this fall.
“We’d like it to be open tomorrow, but safety is the No. 1 issue,” said Jay Jenkins, a member of the Carlsbad mayor’s Nuclear Task Force. “We can’t afford to make any other mistakes.”
WIPP workers know what is on the line – the nation’s ability to clean up legacy defense nuclear waste, much of which is sitting on the surface in places like Los Alamos, Idaho and South Carolina.
“Every one of us cares about what we’re doing,” said Laura Garcia, an engineer for a multitude of systems at the site including fire suppression. “We’re trying to help get rid of all this waste. Every day we go in with that thought in mind. I’m doing it for my child. I’m doing it for someone else’s child. I’m doing it for my neighbor. I’m doing it for the community.”