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Executive Summary The Department of Energy (DOE) operates 17 major facilities to develop and produce nuclear weapons. The facilities, which together are termed the "weapons complex," include laboratories that design and test the weapons and components; materials production facilities that produce plutonium, tritium, and other special materials for use in weapons; and weapons production facilities that either produce various components or assemble them into completed weapons, or both. This report, which was requested of the National Research Council by DOE at the direction of Congress, sets out an assessment of various management, environmental, health, and safety issues relating to the operation of the complex. An examination of the weapons complex is an immense undertaking. The facilities are located throughout the United States, and each of the major facilities is a huge and sophisticated operation. The total budget of the complex for FY 1990 amounts to some $10 billion and involves a staff of some 80,000 people working for the Department and its contractors. The Department confronts a variety of problems in connection with its stewardship of the complex. Many of the facilities are old, and maintenance over the years has been inadequate. Tl~ere is a legacy of environmental contamination that must be addressed. Moreover, DOE must be prepared to operate under close public scrutiny and in compliance wig environmental and safety standards that have become increasingly stringent over time. The challenges are many, and the funds available to respond to them are, in this age of budget stringency, likely to be limited. It is thus essential for DOE, with the support of others in the Executive Branch and in the Congress, to assure that the demand for weapons production is consistent with available resources, to set

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2 THE NUCIAR WEAPONS COMPLEX clear priorities, to harness technical strengths, to develop and maintain the competence of staff, and perhaps most important, to develop a culture in which health, safety, and environmental concerns become an integral part of every facet of facility operations. In an important respect, the need for change clearly extends far beyond DOE. The demand for production arises from requirements for weapons that are established through a decisionmaking process in which the Department of Defense (DOD) plays a dominant role. DOE is obligated to meet DOD demands regardless of whether sufficient funds are available. In He past, when cuts in expenditures were necessary, it was health, safety, and environmental programs as well as maintenance that suffered rather than production. The United States faces the challenge indeed, the obligationof assuring that the full spectrum of considerations relating to production including health, safety, and environmental considerations is incorporated into the governmentwide decisionmaking process. MANAGEMENT The venous facilities in the weapons complex are owned by the federal government and operated by contractors subject to oversight by DOE. The Secretary of Energy has recognized that DOE has not fulfilled all of its responsibilities in the past, and he has stated his intention to make sweeping reforms. We applaud these developments. We conclude, however, that improvement of the management system should be guided by several simple principles, some of which have been addressed by the Secretary, while others, as yet, have not. Lines of authority in Be complex should be clear, simple, and unambiguous. Perhaps largely as a result of history, DOE has maintained a management structure with varying and complicated reporting lines. For example, most of the offices that provide day-t~day direction to the contractors report to the Undersecretary, even though the Assistant Secretary of Defense Programs is designated as the principal DOE official with days day responsibility for the complex. Moreover, some field offices, such as the Albuquerque Operations Office, have broad responsibilities affecting activities throughout the complex that might otherwise be considered headquarters functions. Continuing efforts to simplify and streamline the management structure are warranted. Although upper management must be fully Formed about controversial issues and must have the authority to review decisions by subordinates, decisions should be made initially at the lowest level of management with the competence to make them. Under any other approach, upper management levels would be swamped with unresolved matters, increasing the likelihood of faulty or misinformed decisions. It appears, however, that too many decisions are pushed upward today, particularly in the budget process. DOE should strengthen its management structure by delegating authority and responsibility for the inituai resol~i~E~-n of

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EXECUTIVE SUMMARY 3 issues to the lowest possible management levels, subject to clear guidance and support from upper management. An internal health, safety, and environment oversight staff should tee maintained at all levels of management with the power to raise issues to the next level when unresolved conflicts arise. The responsibility for safe operations must reside with line management the role of an internal oversight staff must not be to supplant or undermine Hat authority but, rather, to assure that controversial or questionable decisions affecting safety, health, or the environment at a given level of line management are brought to the next level of line management for reexamination. Such a system of dynamic oversight can provide independent expertise and an important element of redundancy in assuring safe operations. Many past studies of the complex have urged the strengthening of the oversight function, but some of the recent organizational changes may serve to limit its effectiveness. Headquarters must provide clear guidance to the field offices and the contractors if DOE's objectives are to be achieved. The formal vehicle for providing such guidance is the system of DOE orders. Orders relating to health, safety, or environmental performance are conically binding directives. Although efforts have been made to rationalize the orders, DOE, in developing them, has not adequately harnessed the knowledge and expertise available in the complex. Ideally, orders would be so carefully drawn as to provide specific guidance and, at the same time, be flexible enough to address appropriately the wide range of different facilities to which they are applicable. It might be easier to tailor the orders to specific facilities or types of facilities, for example, research laboratories or production plants, instead of requiring all facilities to meet the same requirements. In addition, greater efforts at facilitating communication among DOE staff and contractors are needed. The [)eparunent and its contractors have tended to look inward in responding to problems. But technical advice from outside the complex can be a source of insight from people with broader experience and a fresh perspective, and by demonstrating openness, can help to restore public confidence in DOE decisions. The Advisory Committee on Nuclear Facility Safety, an advisory committee composed of knowledgeable individuals largely from outside the complex, should be maintained and encouraged to provide advice across the spectrum of activities in the complex. Perhaps most significant, DOE's performance ultimately depends on the quality and morale of its staff and those of its contractors at all levels. Constant attention must be paid to the maintenance and improvement of technical capabilities. Conceded efforts are needed to recruit competent technical personnel at all levels; and DOE must maintain an environment for the retention of employees by providing challenging assignments, meaningful paruc~pat~on In oec~s~onmax~ng, and professional advancement Strong training programs are necessary to build a culture in which health, safety' and environmental considerations are seen as an integral component of operations.

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4 TIIENUC1AR WEAPONS COMPLEX Both DOE and its contractors must smuggle to obtain required security clearances for new employees Spending additional funds to get proficient staff on the job sooner is likely to be worth the cost. ENVIRONMENT Virtually every facility in the complex has contamination on site, some of it extensive, and many of them have contamination off site as well. Although contamination by radioactive materials has received the greatest public attention, a considerable fraction of the contamination of concern arises Torn toxic chemicals. Indeed, at some sites the significant problems are presented by conventional hazardous chemicals. Where the contaminants are isolated from population centers by distance and natural barbers, there is reason to believe that immediate threats to public health are slight. Moreover, the ecological impacts of contamination~he effects on systems of plants and animal~are less significant than those of many other human activities at the sites. Nonetheless, the cleanup will be extensive. The commitment of DOE and its comprehensive plan for action are welcome and deserving of praise. In our view, the evaluation of cleanup actions should be guided by the consideration of risk that is, the likelihood that contamination will present a threat to human health or the environment. Although we do not urge any particular decisionmaking calculus, some consistent form or forms of risk analysis should be used, along win assessments of other relevant factors (e.g., costs, benefits? feasibility), in the decisionmalcing process. In particular, risk should be considered in defining appropriate remedial actions at individual sites. When uniform cleanup levels are promulgated, they typically are based on a conservative or worst-case hypothetical human exposure. Although such an approach provides assurance that a certain risk level will never be exceeded, it sets up standards that are likely to be overly protective ir most circumstances and, hence, not cost effective. We therefore advocate that the determination of specific goals for cleanup activities at a given site should be guided by the assessment of risk at that site, using consistent risk assessment methodologies throughout the complex. If this approach is to be applied, intensified sampling and careful and uniform data management will be required, and higher priority must be given ~ research that focuses on the Ape of contaminated ecosystems that are found in the weapons complex. Moreover, to assure public acceptance of its cleanup decisions, the Department and its contractors must significantly increase the involvement of public and state officials in activities related to environmental issues at the sites. The cleanup challenge now confronting DOE is the legacy of past operations. To assure that current operations do not leave a similar burden for future generations, DOE should improve its current waste management techniques and

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EXECUTIVE SUMMARY 5 develop innovative technologies for waste handling. In particular, DOE's consideration of waste management should include all production wastes and residuals, not only those involving radioactivity. Waste minimization principles should be applied across the complex. Process modifications to minimize waste generation often require significant front-end capital investment, but they can be cost effective in the long term by reducing overall waste management expenses. An economic framework for evaluating such issues is needed. SAFETY Viewed from the perspective of conventional U.S. industry, the weapons complex has an excellent occupational safety record. Workdays lost because of injury per worker-hour are considerably fewer On those observed in the Private sector as a whole. Nonetheless, Were is room for improvement. Indeed, DOE and its contractors must be especially vigilant because of the unique hazards that arise from the materials that are handled in He complex and the special risks that could arise if a catastrophic event, such as a fire or earthquake, were to release hazardous materials. We identified a variety of safety matters that deserve examination by DOE and its contractors. We cannot claim, however, that our scrutiny was so extensive or thorough that other similar hazards might not be found on more probing scrutiny. Clearly, some circumstances are more serious than others; we believe three particular areas deserve priority attention. First, the organization, staffing, training, and equipment of the site fire departments are, with few exceptions, superior; but there are-troublesome elements in the fire protection program. For example, although DOE fire protection criteria require that fire suppression equipment be installed in locations where a fee could cause damage to critical equipment and interrupt production for extended periods, we found instances in which such protections were not provided. The protection criteria should also cover safety systems. Second, efforts to control the inhalation of radioactive materials, particularly at Rocky Flats, have led to an unwarranted reliance on respirators. Respirators are uncomfortable; increase fatigue; and impair employee alertness, efficiency, oral communication, and morale. Moreover, they are not effective over the long term in preventing radioactive inhalation problems. In our view, a pattern of routine use of respirators is an indication of the failure of production, maintenance, and housekeeping procedures. Plutonium exists in the exhaust ducts downstream of the high-efficiency particulate air (HEPA) filters at the plutonium finishing facility at Hanford. Kilogram quantities of plutonium have also accumulated downstream of the HEPA prefilters in an exhaust duct of Building 771 at Rocky Flats. It is noted that similar problems may exist elsewhere in the complex.

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6 TlIENUC~AR WEAPONS COMPLY Third, while strong nuclear safety programs exist throughout the complex, Here are weaknesses in He program for controlling the more conventional industrial hazards. HEALTH The production of nuclear weapons involves activities and materials that can affect human health adversely. Indeed, some of the hazards present in the work environment, such as those arising from certain weapons materials, are unique. An occupational health program is aimed ~ preventing illness, diagnosing and Hating illness, and monitoring the exposure of workers to dons chemicals and radioactive substances. In our view, programs in the complex for the Occupational health of employees of DOE and its contractors need significant improvement Although medical attention is provided to employees with injuries or potentially harmful exposures to radiation or chemicals, medical departments are rarely involved in decisions related to monitoring and controls in the workplace. Medical personnel must often rely on their patients to identify the chemicals to which Hey have been exposed. In short, the medical departments are for the most part relegated to a reactive role. Although the central focus of programs in health physics, safer, industrial hygiene, and emergency planning is the protection of human heals, medical input has been slight. DOE should assure that there is collaboration in all these matters involving medical expertise, and that the medical department in DOE headquarters is given sufficient resources to administer, monitor, and effect changes in these programs. In addition to improving the protection programs, it is essential to monitor workers to assess the effectiveness of the programs, to identify opportunities for improvement, and to allow for timely medical intervention. Medical monitoring and surveillance progr~ns in the complex should be improved substantially through the use of standardized protocols for data collection, storage, and analysis. There is considerable concern in the general public about the risks arising from exposure to radiation. Although the best available estimates suggest that the radiation risks arising from past and current releases of radiation from the complex are low enough not to have resulted in any significant increase in risk to the public, more detailed assessment of the effects of these exposures is of both scientific and public interest. DOE should therefore continue to support epidemiologic studies to examine the facilities' effects, if any, on the public. To be credible, the studies should be designed and directed outside DOE and subject to external peer review. Moreover, DOE should compile data on its workers in a comprehensive data base and, with these data, continue to support peer-reviewed epidemiologic research.

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EXECUTIVE SUMMARY 7 MODERNIZATION Much of the physical plant of the weapons complex is old, and many of the processes used in production are outdated. Opportunities and challenges exist not only in refurbishing the complex, but also in in~ducing alternative processes that could improve overall efficiency and facilitate the attainment of health, safety, and environmental, as well as p~ucdon, goals. At the request of Congress, DOE prepamd a report on the modernization of the complex that placed a high priority on the refurbishment of the plutonium recovery capacity in Building 371 at the Rocky Flats Plant and in the construction of a special isotope separation (SIS) facility for separating weapons-grade plutonium from spent reactor fuel at the Idaho National Engineering I~bomory. Although we were not in a position to assess current or future requirements for weapons material, it is apparent Hat the current supply of plutonium and the current capacity to process both virgin and recycled plutonium from red weapons and scrap are adequate to meet the demand for plutonium for weapons of the number and general character currently in the national stockpile. Because plutonium is costly, long-lived, toxic, and must be carefully safeguarded, it is not sensible to produce more weapons-grade plutonium than is reasonably needed. The renovation of Building 371 is questionable in light of the plutonium recovery capacity that exists elsewhere in the complex. Not only may SIS be unneeded, it also presents important new considerations relating to safety and nuclear safeguards. The committee thus urges the Deparunent to reconsider its plans relating to these facilities. It is inevitable, however, that DOE will eventually be obliged to replace or renovate some of its aging facilities. In undertaking this modernization, clear opportunities exist to make more effective use of technology. They include the opportunity to eliminate or minimize fluonde-based plutonium processing and to make more effective use of advanced metal-forming, computer, communications' and robotics technologies. DOE and its contractors must tee alert to opportunities to introduce new technology, to reduce the generation of wastes, or to employ less hazardous materials, thereby improving the effectiveness of the complex in meeting production goals in a way that is consistent with health, safety, and environmental goals.