Presentation to the Operating Experience Committee – September 9, 2014
Lessons Learned from the NFO/NSTec
Joint Accident Investigation Addressing
June 13, 2014, Drum Explosion
at the Nonproliferation Test and Evaluation
Complex (NPTEC)
Mike Kinney, CSP, SGE
National Security Technologies, LLC
September 9, 2014
Nevada National Security Site
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Presentation to the Operating Experience Committee – September 9, 2014
Facility History
•
In 1982, Congress authorized construction of the Liquefied Gaseous
Fuels Spill Test Facility (later renamed NPTEC).
– Performed tests using hazardous chemicals and liquefied gaseous fuels
– Certified operational in 1986
•
•
NPTEC is located along the eastern edge of the NNSS within the general
western side of Frenchman Lake.
NPTEC is used as a basic research tool for studying the dynamics of
releases of various hazardous materials.
– Physics of atmospheric dispersion of chemical releases
– Validation of equipment and techniques for chemical release detection
– Effectiveness of mitigation technologies
•
NPTEC is the only facility in the world authorized by the EPA to conduct
these types of chemical releases.
– Essential support for Homeland Security
– Three letter agencies (e.g., DOD, FBI)
– Troops in theater
Nevada National Security Site
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Presentation to the Operating Experience Committee – September 9, 2014
Facility History (continued)
Facility is equipped with:
- Cameras
- Public address system
- Evacuation alarms
- Radio network
Staffing:
- 6 to 14 personnel during
customer testing
- 3 to 5 personnel during
other periods
Management:
- Global Security
Directorate (GS): program
management, customers
- Nuclear Operations
Directorate (NOD): facility
management,
maintenance
Location of drum
explosion
Nevada National Security Site
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Presentation to the Operating Experience Committee – September 9, 2014
Accident Description
• June 13, 2014
– NPTEC, West Motel, Bay 30, approximately 0850 hrs
– Two workers enter Bay 30 to obtain test chemicals
• One worker lifts open top (empty) drum by hand
– Instantaneous explosion
• Other worker had just moved further inside Bay 30, thereby avoiding
more extensive injuries
– Both workers injured
• Worker approximately 6–8 feet from explosion had ringing in ears;
examined by medical personnel and released
• Worker lifting drum was projected 8 feet out of the bay;
received contusions and lacerations from shrapnel
–
–
–
–
–
Transported to hospital for medical treatment
10 stitches to right calf
Approximately 12 stitches to big toe of right foot
Also experienced singed hair on forearms, face, and head
Individual has recovered from the injuries
– EOC Monitoring Team activated, approximately 1130 hrs
– NFO/NSTec Joint Accident Investigation Board (AIB) requested
Nevada National Security Site
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Presentation to the Operating Experience Committee – September 9, 2014
AIB Results
•
Direct Cause: the immediate events or conditions that caused the accident
– The preponderance of evidence indicates that the direct cause of the event was
the detonation of shock-sensitive peroxides caused by movement of the event
drum
•
Root Causes: causal factors that, if corrected, would prevent recurrence of the
same or similar accidents
– The safety culture at NPTEC did not facilitate the effective identification and
resolution of problems
• Personnel hesitant to raise concerns; concerns with chemical storage assigned
lowest possible priority
– NSTec failed to fully implement formality and operational rigor necessary for
managing and operating NPTEC
• NPTEC not adequately staffed; CONOPS implementation not effective; limited
NOD management presence
– NSTec did not effectively manage chemicals in a safe and compliant manner,
including the disposition of legacy chemicals
• Lack of comprehensive chemical management plan; West Motel not authorized for
storage of flammable/combustible substances; chemicals of unknown origin, and/or
unknown content, were stored at this location for several years
Nevada National Security Site
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Presentation to the Operating Experience Committee – September 9, 2014
AIB Results (continued)
•
Contributing Cause: events or conditions that collectively with other causes
increased the likelihood of an accident, but that individually did not cause the
accident
– The transition of NPTEC facility management from GS to NOD created a
false sense of security with respect to the formality of facility operations.
• NSTec Senior Management was not aware of adversarial
relationship/unhealthy tension between GS and NOD; promoted a culture of
indifference regarding storage of legacy chemicals
– NPTEC Facility and Program organizations did not effectively manage
issues.
• On occasion, non-conservative decisions were made when addressing
issues due to time and/or resource constraints; need for consideration of
potential systemic and/or programmatic impacts not always recognized
– NSTec and NNSA/NFO processes did not enable risk-informed decision
making regarding operation and maintenance of NPTEC.
• NPTEC oversight (facility, project, federal) did not fully recognize hazards
associated with storage of legacy chemicals; operational/maintenance criteria
for Moderate Hazard Facilities have not been established
Nevada National Security Site
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Presentation to the Operating Experience Committee – September 9, 2014
Key Stressors
• Safety Culture Challenges
– NvE Safety/Security Culture Assessment (S/SCA), FY 2013
• Requested by NNSA/HQ to not release report
• Limited ability of NNSA/NFO and NSTec to clearly link improvement efforts
with S/SCA Report results
– NvE S/SCA Report identified a series of challenges, including:
• Leadership involvement, lack of accountability, fear of reprisal
– Similar safety challenges identified at NPTEC
• Limited visibility of senior management at NPTEC
• Lack of accountability
• Hesitant to raise issues
• Lack of risk-informed decision making
– NFO/NSTec Senior Management not aware of decisions involving
legacy chemicals
• Original disposition request, submitted 2005 timeframe, denied
• Second disposition request, submitted by NOD in 2012, was also denied
– Adverse impacts of staffing reductions/minimal staffing not fully realized
nor understood
Nevada National Security Site
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Presentation to the Operating Experience Committee – September 9, 2014
Key Stressors (continued)
•
Lack of guidance for facilities designated Moderate or High Hazard
– Commonly established to ensure these types of facilities have the requisite
operational requirements in place
– Only evidence provided to AIB consisted of CONOPS Matrix
•
Use of “On Hold” designation for issues/findings
– Appeared to be primarily used when funding was not available
– Responsible Manager (RM) makes this determination
– Concurrence by NFO/NSTec Senior Management not required prior to issues
being placed “on hold”
– Once so designated, limited visibility of these “on hold” issues
•
Work control not consistently implemented
– Work package did not address chemical dispensing/transfers
• One of the most hazardous, and most frequent, activities conducted at NPTEC
– Field walk-down or table-top review of work package not performed
– Lid left off drum for two days prior to the explosion, evaporation of liquid
– Required PPE (safety shoes) not worn by worker treated at hospital after the
drum explosion
Nevada National Security Site
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Presentation to the Operating Experience Committee – September 9, 2014
Final Thoughts
• Cost estimates to dispose of legacy chemicals
– 2005: $11,000
– 2012: $35,000
– 2014: $300,000+
AIB Conclusion: The accident was completely preventable.
Nevada National Security Site
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