State Seal
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Carson City, Nevada 89701
Telephone: (702) 687-3744
Fax: (702) 687-5277
Executive Director

March 13, 1998

David R. Kozlowski, Associate Director
Office of Safety and Assessment
Department of Energy,
Ohio Field Office, Fernald Area Office
P.O. Box 538705
Cincinnati, Ohio 45253-8705

Re:State Review — Type B Accident Investigation Board Report of the December 15, 1997, Leakage of Waste Containers near Kingman, Arizona.

Dear Mr. Kozlowski:

The State of Nevada has concluded its review of the above referenced accident investigation report prepared by the Department of Energy (DOE). According to DOE, the investigation was convened to address the impact of leaking containers of low-level radioactive waste shipped from DOE's Fernald site near Cincinnati, Ohio, to the Nevada Test Site (NTS).1

Nevada officials are hopeful that this review will lead to programmatic changes that will reduce future risks to public health and safety, as well as safeguard Nevada's tourist-based economy. Our review focuses on the organizational failures between DOE and its contractors, as well as on the Department's lack of regard for the perception of risks associated with the management and transportation of radioactive waste. In addition, this review addresses the depth and extent of the recommendations presented in the report.

State officials recognize the actions taken by DOE following the leaking container incidents that occurred at Kingman, Arizona and at the NTS. Those actions included halting the use of the suspected metal shipping containers, suspending radioactive waste shipments from Fernald to the NTS, and organizing a Type B Accident Investigation of the incident. We also credit DOE for including State regulatory officials in the investigation process.

As expected, the accident investigation report found numerous technical, organizational, and management failures that involved multiple DOE organizations, contractors, and subcontractors. In brief, the report found that:

  • DOE's contract procurement process for acquiring waste containers was fraught with problems and failed to produce strong, tight waste containers. The containers delivered to and accepted by DOE/Fernald did not meet the design specifications in the procurement contract and did not match the prototype container used for design confirmation testing. Also, these waste containers continued to be used even though leaks (designs flaws) were identified almost 7 months earlier;

  • DOE failed to assess or understand the formation of free liquid in the waste material during shipment. DOE does not fully understand the waste stream characteristics that cause the formation of free liquid during transport. To compound the problem, the sorbent material used to control the formation of free liquid was inadequate;

  • DOE's formal plans for deploying response teams to accidents involving radioactive waste were nonexistent; and

  • DOE had no formal corrective action program and procedures for resolving reported incidents involving mismanagement of radioactive waste between NTS and Fernald Environmental Management Project (FEMP). In this case, the failure involved multiple DOE organizations and contractors.

To resolve these problems, DOE is proposing several corrective actions before resuming radioactive waste shipments to the NTS. However, State officials contend that any resumption of shipments must meet the State's expectations to safeguard public health and protect the environment.

DOE's Contract Procurement Process

To address contract procurement problems for acquiring reliable waste containers, DOE is suggesting that Fluor Daniel ensure all white metal box designs meet performance criteria and receive DOE approval prior to shipping. Apparently, DOE believes that this recommendation will solve the host of past problems, such as the delivery of containers that differed from the original prototype design tested and the use of modified boxes that still failed to ensure physical integrity of the waste containers.

State officials believe that the proposed recommendation will be insufficient to correct the identified problem. The recommendation falls short since it fails to:

  • require contractors to provide detailed design drawings of test boxes including retention of a prototype for use in post-production inspections;

  • require random tests to assess the effects of vibration on full waste material payloads with different quantities of liquid and absorbent materials, and;

  • stipulate an adequate quality assurance program to certify conformance to the originally tested design.

Moreover, it appears to State officials that, in the procurement process, DOE made the award to the contractor to manufacture the containers, in accordance with the technical specifications contained in the procurement documents, based on the contractor's low bid. Shortly after DOE awarded the contract, it appears that the selected contractor requested that DOE relax some of the technical specifications. For example, it was proposed that the center rail support be eliminated, that the gauge of metal be reduced, and that the vibration and drop tests be eliminated. It appears that DOE granted these requested changes.

Not only is this unfair to the other bidders whose bids were based on the original specifications, but the relaxation of these specifications by DOE directly, in our opinion, contributed to the failure of the containers.

Sorbent Materials

As mentioned above, DOE failed to assess or understand the formation of free liquid in the waste material during shipping. This failure can be traced to DOE's lack of understanding of the high moisture content waste stream characteristics. To address this problem, DOE is recommending that Fluor Daniel understand the physical properties of the high moisture content waste streams and the effects of sorbents in packaging and transportation.

Obviously, this action will help understand the formation of free liquid during transport. However, one of the shortcomings of the investigation report was a failure to disclose that Dicalite (the sorbent material used in the containers) was never actually marketed or sold to DOE for use as a sorbent material. According to the manufacturer of Dicalite, it is a dewatering filter agent, not an absorbent.

DOE Response Teams

The report does acknowledge that formal plans for deploying DOE response teams to accidents involving radioactive waste were nonexistent. This finding is appalling given the sheer number of annual waste shipments made between Fernald and NTS, (nearly 400 shipments in 1997 alone).

If a major accident involving a significant release of radioactive waste had occurred, it is clear that DOE could not have provided an adequate response. To address this situation, DOE is proposing to develop more comprehensive, formal plans for deploying support teams at significant distances from Fernald.

Once again, it is apparent that DOE believes that by simply developing formal plans the problems associated with deploying response teams will somehow be resolved. In order to ensure that this recommendation is adequately implemented, the State will require oversight of the development and implementation of these formal plans

Organizational Failures Among DOE and Contractors

As pointed out in the accident investigation report, the leaking container incidents at Kingman and the NTS were actually preceded by two previous leaking container events. The first reported event occurred on May 21, 1997, six months prior to the Kingman incident. The second reported event occurred just 5 months later on October 5, 1997. While both of these occurrences were discovered by DOE contractors at the NTS, they did not prevent the Kingman incident.

According to the investigation report, the reason the Kingman and NTS incidents were not prevented was because the process for resolving issues involving both the NTS and DOE/Fernald was informal and thus ineffective. In other words, the system DOE had in place to address reported problems, such as leaking waste containers, failed.

To address this systemic management breakdown, the report recommends that "DOE-FEMP, DOE Ohio, and DOE Nevada need to clarify the roles and responsibilities for notification, validation, and closeout of corrective actions, including root cause analysis."

From the State's perspective, this recommendation is indicative of a much more serious and deep rooted problem. As the report points out, DOE failed to manage a multiple-organization program charged with packaging, transporting, and disposing of large quantities of radioactive waste. This failure constitutes a significant impact on the public trust of a federally controlled waste management program. Yet, DOE's answer to solving the problem is to simply "clarify roles and responsibilities." In fact, it is more than possible that the fact that neither DOE nor its contractors wanted to chance stopping shipments, played a major role in the failure of DOE's corrective action program, even though DOE blamed the problem on "confusion about roles and responsibilities among DOE and it's contractors."

Clearly, the waste management program at Fernald has systemic and deeply rooted problems. The white metal boxes used for transport and disposal had known design problems that led to failures, and yet DOE continued to use the boxes even after the precursor events discovered in May and October, 1997. The sorbent material used for high moisture content waste streams was found inadequate, especially given the fact that it was not provided to DOE as a sorbent material. The procurement contracting process for the white metal boxes was fraught with failure, and the deployment of response "support teams" for radioactive spill events was judged wholly inadequate.

State Recommendations

Overall, State officials find the recommendations contained in the report for resolving these problems inadequate. In fact, DOE must go far beyond the mere clarification of the roles and responsibilities of the respective DOE and DOE-contractor organizations involved in the day-to-day radioactive waste management program. As mentioned previously, DOE has suggested that radioactive waste shipments from Fernald to the NTS will resume, pending completion of the accident investigation and implementation of necessary corrective actions. In response, the State has said that any resumption of shipments must meet our expectations to safeguard public health while protecting the environment.

Central to meeting these expectations is the development and implementation of a joint federal/state oversight program for the disposal of low-level defense waste involving the NTS. After the December events at Kingman and NTS, Governor Bob Miller asked Energy Secretary Federico Peña to consider several measures to protect public health and safety concerning any future shipments of low-level radioactive waste to Nevada. The Governor suggested the development of a shared federal/state regulatory oversight program for DOE's low-level waste disposal program at the NTS. Among other activities, Governor Miller also suggested that such a program should include the ability to inspect, at the State's discretion, packaging and loading activities at generator facilities, as well as inspection of the waste packages as they arrive at NTS.

Taking this action might begin to establish renewed confidence in DOE's low-level waste disposal operations at the NTS. State oversight activities would focus on the protection of public health and safety, and this focus would be the State's first and foremost priority. Unlike DOE and its contractors, at the onset of an identified problem, State officials would not be faced with any reasons not to stop waste shipments, if necessary.

After the December incidents, Governor Miller asked that procedures for waste acceptance at NTS that require generator facilities that ship low-level waste to NTS to avoid the heavily populated and congested Las Vegas Valley. The Governor further requested that a system of monitoring stations be established along those routes to monitor exposures and identify any contamination resulting from such shipments.

Currently, hundreds of shipments containing thousands of cubic feet of low-level waste are transported to NTS each year by out-of-state generators.2 Nearly all of these shipments are trucked across Hoover Dam through the Las Vegas Valley by way of the notorious "spaghetti bowl" freeway interchange. Disposal volumes reaching NTS could also increase substantially3 if the site is selected as a central or regional disposal facility by DOE.

While DOE generally discounts the public's negative perceptions about risks associated with the transport of low-level radioactive waste, this belief is not shared by officials in Nevada. The Las Vegas area is unique, not only because it is the fastest growing metropolitan area in the country, but because it hosts an unprecedented volume of tourists. In 1997 alone, nearly 30 million tourists visited Las Vegas. This raises the question of what would happen if a transportation accident involving radioactive waste were to occur in the valley. Nevada officials believe such an accident could have a devastating socioeconomic impact on the State's economy.

State officials do recognize the limits of the conclusions and recommendations contained in the Kingman Type B Accident Investigation Report. Nevertheless, DOE must consider the potential socioeconomic impacts that could be caused by a radioactive waste transportation accident in the Las Vegas Valley.

It is instructive that the investigation report found that leaking low-level radioactive waste shipments were not properly factored into DOE's transportation risk analysis. To address this issue, the report recommends that DOE, in conjunction with other affected parties, "establish criteria for transportation of low-level waste so that programmatic and operational needs can be property assessed."

The State takes the position that the assessment of programmatic and operational needs must be conducted within the context of Governor Miller's ongoing discussions with DOE. These discussions, in part, are focused on the development of the shared regulatory oversight program for disposal operations at NTS, as mentioned above, and on efforts to eliminate the transportation of radioactive waste through the Las Vegas Valley

Concluding Remarks

From Nevada's perspective, the recommendations presented in the investigation report should be amended to include DOE's commitment to an External State oversight program. Also, to best assure effective implementation of the detailed recommendations in the investigation report, the additional safeguard of state oversight should be required during the implementation process before these radioactive waste shipments to NTS are resumed.

We are aware that DOE will soon provide State regulatory officials a briefing on further activities concerning the Type B Accident Investigation Report. Accordingly, we are submitting these comments to further clarify the State's policy and program-specific issues concerning the accident investigation.

If you have questions, or wish to discuss any of these issues further, please don not hesitated to contact me.


Robert R. Loux
Executive Director

Attached (Endnotes) RRL/jbw cc: Governor Bob Miller
Leo Penne, Washington Office
Nevada Congressional Delegation
Lew Dodgin & Paul Liebendorfer, NDEP
Alan Tinnie & Stan Marshall, State Health Division
State Clearinghouse
The Honorable Federico Peña, Secretary of Energy
G. Johnson, DOE/NV
-- Endnotes --
  1. The incident occurred on December 15, 1997. The leakage incident involved five metal low- level waste containers being shipped from Fernald to the Nevada Test Site for disposal . The leaking containers were white-painted carbon steel boxes, 4' wide x 4' deep x 7' long. They were manufactured by CGR Compacting Incorporated and contained deleted and slightly enriched uranium residues.

  2. In 1997 alone, DOE reported that 782 shipments containing an estimated 850,000 cubic feet of LLW were received at the NTS. (DOE/NV Draft Annual Report "Transportation Mitigation" FEIS NTS and Off-Site Locations in the State of Nevada, February 1998 [DOE/EIS 0243]).

  3. In terms of LLW shipments to the NTS, DOE's Waste Management Programmatic Environmental Impact Statement (PEIS) found that a combined total of more than 295,000 truck shipments or more than 106,000 rail shipments of waste could be transported through the Las Vegas Valley. According to DOE, this translates to about 118 truck shipments or 42 rail shipments per day for a period spanning 10 years. These estimates also fail to account for DOE's inventory of "cleanup waste" that could add thousands of additional shipments for decades to come.

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