Kenneth Fletcher
WC Monitor
3/13/2015
After more than a year of probes into the 2014 radiological release at the Waste Isolation Pilot Plant, the Department of Energy is poised to release in the coming weeks its final Accident Investigation Board report into the root cause of the incident. The report is expected to implicate failures by not only Los Alamos National Laboratory, which processed the drum linked to the WIPP release, but also Department of Energy oversight and WIPP and Carlsbad’s Central Characterization Project, which characterizes waste before it is emplaced in WIPP, WC Monitor has learned. It will likely contain around 40 “judgements of need” split between Los Alamos and WIPP that point to corrective actions, according to officials familiar with the investigation.
The long-awaited third and final DOE AIB report is expected to wrap up DOE’s investigation into the 2014 incidents at WIPP, which also included an earlier truck fire, as the focus shifts to corrective actions and reopening WIPP. The final AIB report will be released around the same time as a DOE Technical Assistance Team report, conducted by experts from across DOE’s national laboratories. DOE and LANL so far have largely remained tight-lipped as to the contents of the reports. “Taken together, these reports will provide a comprehensive overview of the cause of the event and associated programmatic issues,” a DOE spokesperson said this week.
DOE had first hoped to complete the final AIB report by the end of 2014, but pushed it back due to delays in an effort to take images of the waste drums in the WIPP underground, which wrapped up last month. The final report comes after the previous release of an initial AIB report into the Feb. 5, 2014, fire in the WIPP underground and a second AIB report focusing on the response to the Feb. 14, 2014, release that contaminated workers and shut down the nation’s transuranic waste program for years.
Was It Really Just a Typo…
The drum breach that led to the WIPP release is believed to have originated from a reaction inside a single drum processed at Los Alamos that contained a volatile mixture of materials including nitrate salts and organic kitty litter, which was used as an absorbent for liquids in the waste. LANL was faulted for the procedure change from inorganic absorbent to the more reactive organic kitty litter. Previous reports have focused on a notetaking error by one employee who wrote down in a 2012 meeting that “an organic” absorbent should be used rather than an “inorganic” absorbent, pointing to that mistake as a key factor that ultimately led to the release.
… Or ‘A Target-Rich Environment for Things to Go Wrong’
However, the fact that the error was incorporated into Los Alamos waste processing procedures and was not caught until after the WIPP release two years later indicates a much larger breakdown in nuclear safety culture and the system of checks and balances that should have been in place, one official familiar with the investigation told WC Monitor. “Procedures that should have been followed simply weren’t. They were modified and changed. There was everything from technical competency, which really was highly lacking, to procedural compliance, which was highly lacking, to management oversight, which was highly lacking,” the official said. “I hate to say it, but it was a target-rich environment for things to go wrong. It was remarkable to me how many of the checks and balances that could have caught this didn’t because there were so many changes made to the mode of operation.”
‘So Many … Mechanisms All Failed Simultaneously’
The AIB report follows a string of independent reviews commissioned by Los Alamos into the root cause of the event, including a report completed in December by the consulting firm Longenecker & Associates obtained by WC Monitor. It found issues including cultural weaknesses, deviation from the intended management model, lack of competencies commensurate with responsibilities and a failure to provide adequate independent oversight. “While the team was able to identify numerous strengths and best practices at LANL, e.g., a fundamentally strong management model, structure and highly competent staff, the fact that so many critical management, safety, and oversight mechanisms all failed simultaneously over an extended period of time and contributed to the mixing of incompatible materials and shipment of waste to WIPP are of a significant concern,” the report states.
Questions Remain as to the Reaction’s Trigger
In recent weeks, Los Alamos investigators Dave Clark and Dave Funk briefed DOE officials on the results of an extensive investigation by the Lab into the reaction that is believed to have taken place inside the breached drum. The months-long LANL effort involved more than 20 scientists working full-time on the investigation with dozens more brought in and a total of at least 1,000 experiments, according to officials. It included mixing the volatile materials known to be in the drum—nitrates, organics, acids and elements found in discarded glovebox gloves—in various proportions to try and recreate the reaction.
But a persistent question is what triggered the reaction, which would require a substantial amount of heat to occur. The various experiments started out assuming a reaction trigger temperature that would need to be hundreds of degrees Celsius, though subsequent combinations were able to bring it down to below 100 degrees Celsius. However, with the mine’s underground temperature likely not topping 30 degrees Celsius at the time of the reaction, the trigger remains a mystery. Theories have included a link to the Feb. 5 fire, a connection with an electrical event at WIPP around the time of the reaction or heat produced by microbes consuming the organics. It’s unclear if the AIB report will put forth a definitive theory as to the exact cause of the reaction.
Will We Ever Know?
However, one official says that it may be difficult to ever pinpoint the trigger with complete certainty. “It’s been a tortured analysis in my opinion to try to make that happen,” the official said, noting that there were not careful records of what went into the waste drums. “When you have that casual or inadequate characterization of the contents you can easily say that they missed something,” the official said. “My hunch is that since we can’t get the current composition to ignite in any serious way means that there may be other things in there that caused the problem.”
