Report of the Ad Hoc Committee
on Environmental, Safety,
and Health Decision Making
at Brookhaven National Laboratory

April 29, 1997

Committee Members
Chair: R.A. Bari, BNL
D. Gordon, BNL
D. Moran, Suffolk County Dept. of Health Services
N. Volkow, BNL

Advisor to Committee
C. Meinhold, BNL


TABLE OF CONTENTS



EXECUTIVE SUMMARY

PREFACE

LIST OF ACRONYMS

INTRODUCTION

MAJOR THEMES

I. Discretionary Funding for ESH Projects

II. Application and Suitability of Prioritization
Scheme


III. Safety & Environmental Protection Division

IV. Reactive vs Proactive ESH Activities

V. Compliance and Commitments

VI. Fragmentation of Responsibility

VII. Management Approach and Communication

VIII. Mindsets

IX. ESH Culture

SUMMARY

I. Correlation of Themes with Items of the Charge

II. List of Recommendations

REFERENCES


EXECUTIVE SUMMARY


An ad hoc committee was formed to review the decision making process for Environmental, Safety, and Health (ESH) activities at Brookhaven National Laboratory (BNL). This review includes: decisions on allocation of Laboratory resources to ESH activities; determination of priorities within ESH activities; the appropriateness of the management level for the various decisions; and the effectiveness of communication of information among different decision making levels.

The review used the events and decisions related to the tritium plume as the mode of inquiry to evaluate the decision making processes. It should be emphasized that the committee was not charged to do an investigation of the tritium plume situation per se. Other groups are conducting such investigations.

The method of review was to interview several management and staff with responsibility in the ESH area. Some of these interviews led to subsequent interviews of others. In addition, a general
announcement was issued to all Laboratory employees to contact the committee if they had information that would be relevant to the review. The committee also reviewed many documents, reports, letters, and memoranda that pertain to the ESH function and to the tritium plume situation. Several executive sessions of the committee were held in which our observations and tentative
conclusions were freely discussed.

As a result of these discussions, several major themes emerged with regard to ESH decision making. These relate to: discretionary funding for ESH projects; application and suitability of the
prioritization scheme; Safety & Environmental Protection Division; reactive vs proactive ESH activities; compliance and commitments; fragmentation of responsibility; management approach and communication; mindsets; and ESH culture. Comments, observations, and recommendations are provided under each theme. The themes are then correlated with the charge to the committee.

The charge was formulated on the basis of an initial impression that the root causes of the tritium plume problem were in the decision making process. While the findings of this review do support the items of the charge as major aspects of the problems that were uncovered, the items are interrelated (as are the themes discussed above). Thus, issues are not compartmentalized and any
corrective actions will have a bearing on more than one area.

The following is a summary of the findings.

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PREFACE


This report is based on the information gathered and the impressions formed by the committee. The Laboratory members of the committee have much prior familiarity with the organizations that
were reviewed and this is part of the knowledge base for the evaluation. It is recognized by the committee that it is always easy to criticize, especially when the basis for a review is the existence of a problem. It should also be stated that even though we are focusing on a problem area, much is done by BNL to comply with regulations. We hope that this report will be regarded as constructive with suggestions for a positive path forward for the Laboratory. The reviewers are thankful to the several staff members of the Laboratory who openly provided fact and opinion. Finally, because of the broader potential readership, the report contains information that would be regarded as superfluous in an internal document.

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LIST OF ACRONYMS



ADS - Activity Data Sheets

AUI - Associated Universities, Inc.

BNL - Brookhaven National Laboratory

DOE - Department of Energy

ESH - Environmental, Safety, and Health

GPP - General Plant Projects

HFBR - High Flux Beam Reactor

OER - Office of Environmental Restoration

RPM - Risk-based Priority Model

SM - Special Maintenance

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INTRODUCTION


An ad hoc committee was formed by the Laboratory Director on March
3, 1997 to review the decision making process for Environmental,
Safety, and Health (ESH) activities at Brookhaven National
Laboratory (BNL). The specific charge to the committee is given in
the memorandum (Attachment A) from N. P. Samios to All Employees.
The initial membership of the committee was R. Bari, C. Meinhold,
and N. Volkow. On March 13, 1997, two additional members (D. Gordon
and D. Moran) were added and C. Meinhold became an advisor to the
committee.

This review includes:



The committee was also given the following guidance via discussion
with Drs. Samios and Sakitt.

1. Focus on decision making related to the Laboratory's own
discretionary funds.

2. Focus on the Laboratory's own decision making process. Do
not review internal decision making processes of organizations that
interface with the Laboratory on ESH matters.

3. Use the events and decisions related to the tritium plume
as the mode of inquiry about ESH decision making at the
Laboratory.

With regard to item 3, it should be emphasized that the committee
was not charged to do an investigation of the tritium plume
situation per se. Other groups are conducting such investigations.
Rather, the committee has sought to understand the Laboratory's
decision making process for ESH in general. Clearly, because of
the timeliness of the tritium plume situation, our focus was drawn
to specific engineering, organizational, historic, social, and
political aspects of that situation. This report should be
regarded as a review of ESH decision making at Brookhaven with
specific examples from the tritium plume situation and NOT as an
investigation of the latter with implications (or lessons learned)
for the former.

The method of review was to interview several management and staff
with responsibility in the ESH area. Some of these interviews led
to subsequent interviews of others. In addition, a general
announcement was issued to all Laboratory employees to contact the
committee if they had information that would be relevant to the
charge of the committee. A list of those who were formally
interviewed as a result of these initiatives is given as Attachment
B. Finally, tours of the High Flux Beam Reactor were arranged
through the Reactor Division for members of the committee.

As a result of these discussions, several major themes emerged with
regard to ESH decision making at the Laboratory. These are
presented in the main body of this report which is comprised of
several subsections that relate to the themes. In each subsection,
comments, observations, and recommendations are provided. In a
summary section, the major themes are correlated with the specific
items in the charge to the committee. The recommendations of this
report are also listed in the summary section, for the convenience
of the reader.

The narrative includes specific examples from the tritium plume
situation. These are provided in support of the more general
recommendations. As a byproduct of this review, the committee
developed a particular understanding of the events that led to the
plume. In Appendix I, a chronology is provided of the events, as
understood by the committee, that appear to be relevant to the
development of the plume. The reasons for doing this are: 1) to
provide the context for the review by the committee; 2) to provide
information that may be useful to the direct reviews of the causes
of the plume. Again, it was not the purpose of this committee to
do a root cause analysis of the plume. Thus, there may be
incompleteness in our understanding of the sequence of events.
Nevertheless, the recommendations provided herein are believed to
be robust and would lead to improved decision making by the
Laboratory in the ESH area. The Laboratory Director also asked the
committee to review decision processes related to the tritium
measurements from Potable Well #1. Appendix II is a review of the
history of tritium measurements in Potable Well #1. Other supporting materials are included as attachments.

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MAJOR THEMES



I. Discretionary Funding for ESH Projects


Funds for ESH represent a considerable fraction of the Laboratory
budget. In FY 1995, expenditures for ESH, including environmental
restoration, totaled more than $55 million out of the total
Laboratory operating cost of approximately $450 million. ESH funds
come from several sources and can be provided for particular
projects or functions. For example, funds are provided through
line item programs from DOE for specific facilities (e.g.,
Alternating Gradient Synchrotron, High Flux Beam Reactor, National
Synchrotron Light Source) and the managers who control these funds
expend a part on program activities and a part on ESH. Other funds
are provided through Laboratory overhead for the operation of ESH
activities (e.g., approximately half of the $22 million annual
budget of the Safety and Environmental Protection Division is
derived from overhead). This report focusses on another, distinct
source of funding for ESH; namely, the funding that is apportioned
at the discretion of the Laboratory Director.

During the 1990s, the discretionary funding has been, on average,
approximately $2.7 million per year. The discretionary funding
for ESH is derived from two primary sources: a line item in the
budget from the Department of Energy (DOE), termed General Plant
Projects (GPP) and a portion of the Laboratory overhead, which is
annually allocated to correspond typically to 10% of the Special
Maintenance (SM) funding. This portion of the overhead fund which
is referred to as the "ESH Operating Funds" was instituted in 1993.
The "ESH Operating Funds" are allocated to projects by the Associate
Director for Reactor, Safety, and Security. The Safety and
Environmental Protection Division under this Associate Director
facilitates this management activity.

GPP and SM funds are used to maintain and improve the Laboratory
infrastructure in ESH and programmatic areas. DOE typically
allocates $5-6 million per year to BNL for GPP and then BNL assigns
$1 million from this allocation to ESH. The SM funding has varied
over the last several years in the range $2 million to $7
million. The SM funding is managed by the Assistant Director for
Management and Physical Plant. Approximately 28% of this balance
has been used for ESH-related projects during the 1990s. The Plant
Engineering Division under this Assistant Director is responsible
for implementing this program and for the execution of the GPP
program.

Many of those interviewed stressed the challenge of securing
adequate funding for ESH projects. The facilities at the Laboratory
are aging and there is a continuing need to address problems
resulting from past practices. The requests for funding for ESH to
address known problems exceed the amount available. One manager
estimated that the project funding is low by a factor of two to
three.

The discretionary funding for ESH projects is determined by the
Director in consultation with the Directorate (see Attachment E).
The Director apportions his discretionary funding pool in a manner
that he believes will properly balance ESH and other program needs.
This balance is subject to audit by DOE for how federal funds are
being used. Although it is believed that there would always be
funding available for a significant ESH problem, the concern is
that the overall budget is limited.

Recommendation 1: The Laboratory should critically review
its allocation of discretionary funding to ESH and either
validate or rebaseline to a level that is sufficient to
carry out its ESH mission.

A further complication for the SM-derived ESH resources is that,
because it comes from Laboratory overhead, it is dependent on
anticipated total revenues. The revenues are not certain at the
beginning of each fiscal year and thus the SM-derived ESH funding
is uncertain. As the revenues become more certain during the year,
the ESH funds are adjusted. In most years, the budget has been
adjusted in an upward direction. Nevertheless, it is difficult to
plan and implement ESH projects on this basis.

Recommendation 2: The Laboratory should develop a mecha-
nism for stabilizing the ESH funding that is derived from
the Special Maintenance component of Laboratory overhead
so that important projects will not be subject to the
uncertainties in total revenue.

The earmarking of a specified amount of the discretionary funds
from GPP and the ESH Operating Funds would appear to be a very
positive statement in support of ESH activities. Unfortunately, one
of the consequences of this widely known allocation has been that
the operating organizations (departments and divisions) have tried
to use these funds to solve ESH concerns, which might more properly
have been funded by the scientific programs. This has been
exacerbated by a lack of a clear definition of funding responsibilities for ESH activities.

Recommendation 3: The budgetary responsibilities of the
operating organizations vis a vis the Safety and Environmental Protection
Division for funding ESH activities should be clearly defined.

A recurring subtheme that was evident in many of the interviews was
the competition between ESH and programmatic needs for discretionary funding.
This is, no doubt, a perennial issue and is not
peculiar to just BNL within the DOE system. Much of the DOE complex
is fifty years old and the effects of age are apparent in many
locations, resulting in the need for significant infrastructure
improvements. BNL must compete with other DOE facilities for
limited funds in a time of federal deficit reduction and this
competition, of course, is difficult. Nevertheless, it is a real
issue that Laboratory management must confront.

Recommendation 4: The Laboratory management should
continue to communicate with the DOE program offices on
the need to increase the budget for ESH projects so that
the conflict between ESH and programmatic needs is
minimized.

The decision process for allocating the discretionary funds does
not always involve formal communication and participation of the
suborganizations involved in ESH activities. Thus priorities tend
not to be coordinated.

Various suborganizations within the Laboratory that must seek and
compete for these funds noted that the process for obtaining funds
is either vague or incomprehensible.

Recommendation 5: The process for establishing discretionary funding
should be formalized and specifically
include coordinated input from the Plant Engineering
Division and the Safety and Environmental Protection
Division. The mechanism for securing discretionary
funding for ESH activities should be clearly defined and
communicated.

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II. Application and Suitability of Prioritization Scheme


The determination of which ESH projects obtain funding is made, in
part, on the basis of a Risk-based Priority Model (RPM) that was
provided to BNL by DOE (Reference 1) beginning in 1992. (The
Laboratory participated in an incomplete pilot exercise with DOE in
1991). While this is not the exclusive basis for selection of
projects at BNL, it has been a major determinant in the fate of
proposed projects over the past several years. For example, the
project to place wells near the High Flux Beam Reactor was scored
very low using the RPM in 1994 (Reference 2) and this same score
was carried forward to 1996 (Reference 3).

The BNL ESH Management Plan for FY 1997-2002 discusses a
"management adjustment" to scoring using the RPM. This allows the staff
(who are doing the ranking) and the upper management (who do the
review) in the Safety and Environmental Protection Division and
their cognizant Associate Director to adjust the scoring based on
other information known to them. Attachment C is p. 8 of this Plan
and it notes that this information includes "consistency with BNL
objectives, efficiency of operations..., and activities necessary
to promote good standing in the local and regional community."
Thus, there was an opportunity, with the management adjustment, to
score the HFBR groundwater monitoring well project significantly
higher by recognizing the commitment to Suffolk County under
Article 12 of the Suffolk County Sanitary Code.

The RPM, with management adjustment, can be a useful technique for
developing a relative ranking of projects. However, as the hard
lesson of the wells has demonstrated, one cannot base decisions on
this process alone. There are several concerns with this process.

1. For a set of projects to be prioritized, have they been
clearly characterized and articulated in terms of their ESH
significance? The basis for this concern is that, if an
otherwise significant project is not formulated and
presented well by its champion, it could be ranked relatively
lower than less significant projects.

2. Are the members of the Prioritization Committee (Attachment
D) sufficiently cognizant, as a group, of the topics of all
projects to be prioritized? Given the wide range of
technical disciplines involved and the breadth of ESH
issues, it is important to assure that potential blindspots
in the collective knowledge base are minimized.

3. Are the members of the Prioritization Committee the
appropriate group to consider certain "Impact Categories"
of the RPM? For example, are they sufficiently cognizant
of the "Compliance" and "Mission Impact" categories? This
is related to item 2, above. If the group, collectively,
does not have a good understanding of these particular
categories, then something important may be overlooked at
this stage.

4. Are the members of the Prioritization Committee adequately
trained in the use of the RPM? The basis for this concern
is that the prioritization process involves the assignment
of probabilities to a set of ESH impacts. It is well known
that unintentional biases can be introduced into the
assignment of probabilities. It is also well known that
many people do not feel intellectually comfortable with the
concept of assigning probabilities.

5. Are they given sufficient time and resources to perform the
scoring? This concern came from a direct observation of
the charge to the newly appointed Prioritization Committee
(see Attachment D) at a meeting held on March 12, 1997.
The Committee has been given one month to prioritize over
200 proposed projects. Many of these people are, no doubt,
already working on high priority ESH issues. It does not
appear that adequate planning went into this current task.
Apparently, this task is being accelerated to meet a
commitment to DOE. Clearly, it is an important task to
prioritize these projects, especially in light of the
significance of the prioritization process to decision
making for ESH. Therefore, the prioritization must be done
with due care.

6. Is the Prioritization Committee representative of the
Laboratory's interests and expertise? It was expressed by
several BNL staff that the Committee was overrepresented
by the Safety and Environmental Protection Division with
a resultant control of the prioritization process and the
associated funds.

Recommendation 6: The Safety and Environmental Protection
Division, together with Laboratory management, should
address the six questions and the associated concerns
raised with regard to the application and suitability of
the DOE Risk-based Priority Model and take appropriate
action.

It is hard to understand why "Compliance" appears as it does within
the RPM. For example, it appears that Article 12 was narrowly
regarded as a compliance issue. Clearly, not enough weight has
been given to the sensitivities of the community surrounding the
Laboratory. BNL should recognize that the people of Long Island
have special environmental concerns, in particular, for issues
related to radioactivity. This special concern should be given
adequate attention at all stages of, and by all participants in,
the prioritization process for ESH Activity Data Sheets for
projects dealing with radioactive-materials-related issues with
potential impacts on the environment (e.g., compliance with
Federal, State, and Local laws; detection and monitoring capabilities, etc.).

Recommendation 7: Compliance should be treated explicitly
in the process for prioritization (including "management
adjustment") of proposed ESH projects, and with full view
of Laboratory, Associated Universities, Inc. (AUI), and
DOE agreements and understandings. A category should be
added to the Risk-Based Priority Model to address
community concerns.

The current approach within the prioritization scheme emphasizes
small projects rather than integrated programs. This forces a
fragmentation of the risk management activities and does not favor
a coordination of related ESH projects at the Laboratory.

There is another limitation to the current application of the
prioritization scheme. Because the proposed projects relate to
known problems that require attention, the risks posed by unexplored
problems (see section IV) are not included in the scheme.


It is also noteworthy that the Plant Engineering Division has its
own Prioritization Methodology for Special Maintenance Projects
(dated December 1995). While the methodology does rely on the
results of the above-mentioned RPM for ranking of projects that are
explicitly designated in the ESH category, their other categories
of the plant engineering methodology (e.g., major maintenance,
renovation) also have ESH implications.

Recommendation 8: The Laboratory should make a strategic
reassessment of its overall ESH program and formulate a
cohesive risk management plan that gives appropriate
weight to the liabilities of significance.

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III. Safety & Environmental Protection Division

The budget of the Safety and Environmental Protection Division
( $22 million) is a significant portion of the overall ESH budget
at the Laboratory. Their role in the ESH decision making process
has been a central component of this review. We recognize the
Division is subject to oversight from external organizations
including DOE, AUI, United States Environmental Protection Agency
and New York State Department of Environmental Conservation and
that an internal review of the Safety and Environmental Protection
Division was performed by the Laboratory in 1992 by the Cost
Control Committee.

Although these audits and reviews provide some assistance in
fostering standards of performance by the Laboratory, a more direct
and detailed assessment by an external organization should be given
consideration. Scientific Departments at the Laboratory are
reviewed for scientific performance regularly by visiting committees
comprised of knowledgeable peers from outside of BNL. The
Safety and Environmental Protection Division as well as the entire
Laboratory ESH program could also benefit from external peer
review.

Recommendation 9: An external peer review of the Safety
and Environmental Protection Division should be performed
to determine its effectiveness. This review should focus
on strategies and prioritization issues for the ESH
program. Because ESH activities in the Laboratory are
line responsibilities for departments and divisions, this
review should also include the ESH programs throughout
the Laboratory.

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IV. Reactive vs Proactive ESH Activities


The Laboratory has mechanisms in place for dealing with reactive
ESH issues (i.e., existing problems), but rather less for proactive
issues (i.e., the anticipation and aversion of problems). For
example, in the area of environmental remediation, Brookhaven is
known to be more aggressive than other laboratories in implementing
its program. This is due, in part, to the level of scrutiny
applied to the Laboratory by the State and County. Furthermore, the
Office of Environmental Restoration (OER) at BNL has direct funding
(currently $14 million) from DOE to carry out its mission.

With regard to program funds, ESH proactive projects compete with
the scientific component of a project. With regard to discretionary funds
(particularly for ESH), the allocated funding is already
oversubscribed by identified problems and identification of
exploratory funds is considered to be very difficult. As a result
of this situation, proactive ESH studies are very limited for
existing facilities. Systematic hazard assessments of an exploratory,
hypothetical nature are not routinely done.

The Reactor Division identified a U. S. Nuclear Regulatory
Information Notice (92-11, February 5, 1992) and, although it was
specifically addressed to uranium fuel fabrication and conversion
facilities, they considered its potential relevance to the HFBR (a
quite different facility). They realized the potential implications of this
Notice for the HFBR and began an evaluation, within
two months of the Notice date, of the possibility of pool leakage
and the possibility of installation of one or more monitoring
wells. Unfortunately, tests that were conducted did not detect
leakage since they did not have adequate sensitivity. Also, though
they requested the ground water monitoring wells, they relied on
the project prioritization process for funding and not on their own
budgets.

Both the Reactor Division and the Safety and Environmental
Protection Division should have been more proactive with regard to
the HFBR leakage issue. The SEP Division should have questioned
the Reactor Division on the conclusion that there was no leakage
from the spent fuel pool. In their ESH oversight role, they should
have had a mechanism for reviewing this issue. They should place
more emphasis on the assessment of potential risk and its management.
There appears to be more of a focus on facilitation of
solutions to specific problems and support activities and rather
less on taking a strategic view. It was the impression of the
committee that the Division needs a proactive component of its
operation which would encourage the active identification of
relevant issues.

As another example, elevated levels of tritium were detected in
Potable Well #1, particularly during the period 1983-1986. A
detailed discussion of tritium measurements in Potable Well #1 is
provided in Appendix II. While it is now evident why Potable Well
#1 itself was not sampled further, the Safety and Environmental
Protection Division did not follow-up, periodically, with an
investigation of the causes of the elevated tritium. The detection
of tritium levels in the groundwater at approximately 1000 pCi per
liter was not regarded as a high priority problem, according to the
Division Head.

Two examples of a reactive versus proactive activities were evident
from the interview process. First, the Reactor Division found that
it was much easier to fund safety-related issues after the fire in
the Tristan experimental facility at the HFBR. Second, the
hydrologist in the Safety and Environmental Protection Division now
expects that it will be much easier to obtain his long sought
groundwater characterization wells as a result of the tritium plume
situation.

These examples illustrate the importance of exploratory programs
that would proactively identify potential ESH issues.

Recommendation 10: The Laboratory should formalize a
proactive component of its ESH program including funding
and organizational identification. Systematic hazard
assessments of existing facilities should be performed.

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V. Compliance and Commitments


As a result of the agreement between BNL and Suffolk County in
1987, the Laboratory has expended $15,277,000.00 of its own funds
on complying with the Suffolk County Sanitary Code. However, as
noted in Section II, there is a need to recognize that compliance
issues and commitments (such as Article 12) have not been
adequately prioritized in the budget process. It is not only the risk
prioritization methodology which require "management adjustment",
it is also necessary for the Laboratory to view attainment of
external compliance requirements on a broader basis. The release
of toxic or hazardous materials from Laboratory operations not only
has the potential for affecting the drinking water aquifer outside
the Laboratory boundaries but also creates a negative public image.
Experience with storage tank failures, which resulted in several
groundwater contamination episodes, illustrates the need for a
rigorous oversight mechanism to scrutinize activities which may
affect neighboring communities. Compliance with regulatory codes
designed to prevent environmental damage should be a prime
component of the oversight review. A case can be made that
compliance with Article 12 would have led to an earlier detection
of contamination.

While it is the stated policy of the Laboratory to comply, there is
at least one instance where the Laboratory did not fully follow
through with its commitments to an outside agency. In a letter
from BNL to Suffolk County dated January 20, 1989, it was stated
"we are also installing a monitoring well down gradient of the
reactor facility." However, the wells that were installed were not
located immediately down gradient of the HFBR, even though 51
groundwater monitoring wells were installed at other locations
during 1989. Specific details are provided in Appendices I and II.

The Division Head for Safety and Environmental Protection has
commented to the committee that two of the 51 wells were installed
south of Potable Well #1 in the summer of 1989 and tritium
measurements for these wells, made in that year, showed negative
results. Based on the then-current knowledge of ground water flow,
it was believed that these wells would adequately monitor the HFBR.
He now regards this to have been a poor selection of well location
rather than poor follow-through in meeting the 1989 BNL statement
to Suffolk County. Wells installed immediately down gradient of
the HFBR were not placed until 1996.

Recommendation 11: Senior management should assure that
there is full awareness of its commitments and take
appropriate actions to comply with regulatory mandates
with special emphasis upon any activities which may have
an impact outside the Laboratory boundaries.

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VI. Fragmentation of Responsibility


The responsibility for ESH management at the Laboratory is
fragmented. This hinders good communication and impedes positive
action. The Director has delegated (see Attachment E) to the
Associate Director for Reactor, Safety, and Security "the responsi-
bility and commensurate authority to act for him in all matters
pertaining to safety and environmental protection." The Assistant
Director for Management and Physical Plant is responsible for
implementation of non-programmatic maintenance and improvement of
systems and structures that comprise the Laboratory. In addition,
the line organizations have a responsibility for ESH requirements
that pertain to their activities. As was noted in Section I, a
significant portion of the Assistant Director's Special Maintenance
and GPP funds are focussed on ESH projects. It is interesting to
note that the monitoring wells that were installed immediately
down gradient of the HFBR (to detect potential leakage from the
spent fuel pool) to fulfill the Laboratory's commitment to Suffolk
County were funded by the Assistant Director and not through the
Associate Director. The Associate Director and Assistant Director
report to the Director through separate management lines.

The Division Head for Safety and Environmental Protection and the
Division Head for Reactor each were considering (at low priority)
the installation of these wells. Each had a reason to consider
installation of these wells. The Safety and Environmental
Protection Division is the interface with Suffolk County on the
agreement that pertains to well installation (Article 12 issue).
The Reactor Division, in response to an Information Notice on soil
and water contamination that was issued by the U. S. Nuclear
Regulatory Commission, considered (in early 1992) the possibility
of installing one or more monitoring wells. Neither Division Head
was aware of the reason for the other's interest in monitoring
wells. One had no knowledge of the Article 12 issue and the other
had no knowledge of the Information Notice. Both report to the
same Associate Director.

From the committee's discussions with the various managers and
personnel that have ESH-related responsibilities, we have found
that there is not a consensus and, moreover, a clear, articulated,
and documented understanding of the roles of the various
suborganizations (including organizations that operate facilities)
in the placement of wells for monitoring of groundwater. Senior
managers related to Plant Engineering and to the Reactor Division
explicitly stated to the committee that they are not in the
"monitoring well business".

More generally, the responsibilities for ESH activities are not
always clear between the Safety and Environmental Protection
Division and the other Laboratory organizations. This is confounded
by the fact that some buildings and facilities are used by
more than one organization and have waste management issues that
originated from previous programs.

Another important example of fragmentation is the fact that the
neither the Assistant Director for Management and Physical Plant
nor anyone in his organizational line participate in the "management
adjustment" to the prioritization of ESH projects. Given
their responsibility for and understanding of the status of the
Laboratory's physical infrastructure, their input to this important
decision making process is essential.

More generally, since 1992, the lead management from the Plant
Engineering Division and the Safety and Environmental Protection
Division have met formally three to four times annually. However,
frequent meetings are held throughout the year at lower levels
between the organizations. The committee feels that good communication between these organizations, which have essential ESH
responsibilities, also requires more frequent interactions at the
higher managerial levels. A more integrated approach to the
prioritization and planning of ESH projects is needed.

Fragmentation is also evident at the budgetary level where the
boundaries for funding of projects and prioritization between
subgroups is not always clear to those directly involved in the
process.

Throughout our interviews there was the repeated concern that there
is a lack of overall leadership for ESH activities.

Recommendation 12: The Laboratory should improve the
organizational linkages within its ESH function. This
includes setting forth clear definitions of roles and
responsibilities and stronger leadership by the individual
ultimately responsible for all ESH activities. In
addition, mechanisms for improved communication and
coordination should be established.

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VII. Management Approach and Communication


The management style of the Laboratory is known to be informal.
This works well to promote a sense of collegiality and openness.
However, when communication is predominantly oral, as it is in our
ESH area, important information may not get conveyed. Informed
decision making is best done when all relevant information is
known. Throughout the various interviews it became evident that
information had not been transmitted across groups and/or sometimes
even to the Directorate.

The communication channel with AUI on ESH matters was also found to
be very limited. For example, the AUI Vice-President for ESH was
unaware of Article 12 until the tritium plume situation occurred
and was not advised of elevated levels of tritium in the groundwater
near the High Flux Beam Reactor until January, 1997.

It is the committee's understanding that no feedback is provided by
the Safety and Environmental Protection Division to the proposers
of ESH projects that failed to get a priority that would lead to
funding. Furthermore, how the "management adjustment" procedure is
done is not evident to those outside of this process. It is felt by
them that the management input is quite informal and unclear. There
is no documentation of the results of this process. This has been
a point of discouragement among ESH professionals at the Laboratory.
It is also related to a perception by them that the Safety
and Environmental Protection Division uses the prioritization
process to control the selection of projects that get funding.

Recommendation 13: The Laboratory should enhance the
communication and feedback channels and establish more
formal procedures within its broader ESH community to
assure good decision making and also to allay distrust.

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VIII. Mindsets

A major mindset leading to the tritium plume problem was that the
HFBR spent fuel pool was not leaking. This overconfidence was
reinforced by:

a. the safety focus of the Reactor Division has traditionally
been on preventing damage to the reactor core.

b. the failure of tests and measurements to detect leakage;

c. a DOE Study (dated November 1993) of the HFBR spent fuel
pool that did not identify leakage as a vulnerability;

d. three other DOE studies of BNL during 1989-1993 that failed
to identify leakage of the pool as a potential vulnerability.

The Division Head for Safety and Environmental Protection commented
to the committee that a less questioning oversight was applied to
the Reactor Division because of the rigor that has been inherent in
the latter's program.

Another example of a mindset relates to previous measurements of
elevated levels of tritium. When increased tritium was detected in
groundwater, or at the sewage treatment plant, safety and environmental
protection representatives for each of the potential source
buildings were asked to investigate. The emphasis at the High Flux
Beam Reactor was on releases to the building air which is condensed
by the air conditioning systems and then runs off to drains. Such
sources were found and an aggressive tritium reduction program was
accomplished both at the HFBR and the Waste Concentration Facility.
Leaking sewer lines which handled contaminated condensates and
distillates were assumed to be the cause of elevated tritium in the
groundwater.

Recommendation 14: Both line and oversight staff responsible for
ESH should critically question assumptions and
conclusions and eschew complacency.

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IX. ESH Culture


In the 1994 and 1995 editions of the Laboratory's ESH Management
Plan, a section appears on the "Integration of ESH and Scientific
Cultures". The ESH organization is commended for developing this
section. These plans identify "the need to improve the integration
of an ESH culture with the BNL research and scientific culture" and
then state that "Our challenge is to ensure that the essential
national mission of quality research is maintained without
compromise to employee and public safety or environmental quality".
Specific goals are set and an implementation process is put forth.
This sounds very promising and forwardlooking in the 1994 edition.
However, there was no apparent follow-through in subsequent years.

ESH culture varies among industries and organizations and there is
no unique prescription for how organizational and management
practices influence ESH. One BNL staffer with much knowledge of
ESH awareness within the U.S. commercial nuclear power industry
observed that BNL tends to have a lesser ESH culture than most
commercial nuclear power plants. However, BNL has higher ESH
awareness and culture than non-nuclear commercial organizations.
Several staffers also commented on an insular attitude at BNL for
ESH matters, without much consultation with other experts or on
activities and experiences elsewhere. BNL could benefit from the
experiences of these other cultures.

The ESH Management Advisory Committee was created by the Laboratory
as a standing committee of senior Laboratory managers with the
charge of providing oversight to ensure integration of ESH and
program needs and to focus on long-range ESH planning. This
committee met 16 times during 1993-1994, but met only once during
1995-1996. This further exacerbates the culture of insularity. We
note that the committee has been recently reactivated and had its
first meeting in 1997.

The committee believes that informed and good decisions can best be
made within the context of a positive ESH culture.

Furthermore, an improvement in the ESH culture involves its
acceptance at all levels of the organization. In this respect, the
ESH management advisory committee could assist in enhancing ESH
culture.

Recommendation 15: The program to integrate the ESH and
scientific cultures at the Laboratory should be revitalized. A positive,
top-down management approach should be
used, perhaps with assistance from a revitalized ESH
Management Advisory Committee.

Recommendation 16: The Laboratory should encourage a
more open approach to input from the ESH community
outside BNL.

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SUMMARY


I. Correlation of Themes with Items of the Charge

The charge to the committee was formulated on the basis of an
initial impression that the root causes of the tritium plume
problem were in the decision making process. While the findings of
this review do support the items of the charge as major aspects of
the problems that were uncovered, the items are interrelated (as
are the themes discussed above). Thus, issues are not compartmentalized
and any corrective actions will have a bearing on more than
one area.

1. Decisions on Allocation of Laboratory Resources to ESH
Activities


At the senior management level, decision making on ESH resources
requires and is done with careful consideration of the constraints
on the overall budget. However, the overall budget is limited and
it is not apparent that the risks of not funding ESH at a higher
level have been adequately assessed. Stability of funding for ESH
projects is important for their proper and timely planning and
execution. Communication of information with regard to ESH
resources should be expanded and formalized. Also, the process for
securing funding for ESH projects should be made more understandable.
Input and feedback from all relevant operating and support
organizations should be incorporated in this process. The Laboratory
management should continue to communicate with the DOE program
offices on the need to increase the budget for ESH projects so that
the conflict between ESH and programmatic needs is minimized.

2. Determination of Priorities within ESH Activities

Priorities for ESH projects are determined with the assistance of
a risk-based model provided by DOE. This model can be helpful as
a guide to thought and to communication of priorities. However,
the numerical results of the model should not replace a critical
contextual analysis of the issue(s). Rather, the results should be
regarded as input to informed decision making. Furthermore, it is
important for the Laboratory decision makers to ascertain the
robustness of the results of the model applications.

It is also important that the committee which prioritizes proposals
has good representation from departments and divisions, including
Plant Engineering, and that there are individuals with expertise
not only on technical issues but also with knowledge about
compliance issues and commitments of the Laboratory.

3. Appropriateness of Management Levels for Various Decisions

An important lesson to be learned from the tritium plume situation
is that senior management should be mindful of the significance of
its commitments and set firm and specific directives to staff with
regard to compliance with regulatory mandates. In addition, the
Laboratory should fully meet commitments to outside agencies.

4. Effectiveness of Communication Among Decision Making Levels

Communication needs to be improved with regard to ESH matters.
Improvement in organizational linkages would be beneficial to this
end. Fragmentation of responsibility is evident and thus roles and
responsibilities need to be more clearly defined and communicated.

5. Other Topics

It is important that the Laboratory become much more proactive with
regard to potential ESH problems. Systematic hazard assessments of
existing facilities should be performed. ESH staff in line
organizations and in oversight roles should critically question
assumptions and conclusions. The Laboratory should adopt a more
open posture to information from and review by outsiders (much as
it does in the scientific areas). A more positive ESH culture
should be developed with commitment from senior management.

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II. List of Recommendations


Recommendation 1: The Laboratory should critically review its
allocation of discretionary funding to ESH and either validate or
rebaseline to a level that is sufficient to carry out its ESH
mission.

Recommendation 2: The Laboratory should develop a mechanism for
stabilizing the ESH funding that is derived from the Special
Maintenance component of Laboratory overhead so that important
projects will not be subject to the uncertainties in total revenue.

Recommendation 3: The budgetary responsibilities of the operating
organizations vis a vis the Safety and Environmental Protection
Division for funding ESH activities should be clearly defined.

Recommendation 4: The Laboratory management should continue to
communicate with the DOE program offices on the need to increase
the budget for ESH projects so that the conflict between ESH and
programmatic needs is minimized.

Recommendation 5: The process for establishing discretionary
funding should be formalized and specifically include coordinated
input from the Plant Engineering Division and the Safety and
Environmental Protection Division. The mechanism for securing
discretionary funding for ESH activities should be clearly defined
and communicated.

Recommendation 6: The Safety and Environmental Protection
Division, together with Laboratory management, should address the
six questions and the associated concerns raised with regard to the
application and suitability of the DOE Risk-based Priority Model
and take appropriate action.

Recommendation 7: Compliance should be treated explicitly in the
process for prioritization (including "management adjustment") of
proposed ESH projects, and with full view of Laboratory, Associated
Universities, Inc. (AUI), and DOE agreements and understandings.
A category should be added to the Risk-Based Priority Model to
address community concerns.

Recommendation 8: The Laboratory should make a strategic
reassessment of its overall ESH program and formulate a cohesive
risk management plan that gives appropriate weight to the liabilities of significance.

Recommendation 9: An external peer review of the Safety and
Environmental Protection Division should be performed to determine
its effectiveness. This review should focus on strategies and
prioritization issues for the ESH program. Because ESH activities
in the Laboratory are line responsibilities for departments and
divisions, this review should also include the ESH programs
throughout the Laboratory.

Recommendation 10: The Laboratory should formalize a proactive
component of its ESH program including funding and organizational
identification. Systematic hazard assessments of existing facilities should be performed.

Recommendation 11: Senior management should assure that there is
full awareness of its commitments and take appropriate actions to
comply with regulatory mandates with special emphasis upon any
activities which may have an impact outside the Laboratory
boundaries.

Recommendation 12: The Laboratory should improve the
organizational linkages within its ESH function. This includes setting
forth clear definitions of roles and responsibilities and stronger
leadership by the individual ultimately responsible for all ESH
activities. In addition, mechanisms for improved communication and
coordination should be established.

Recommendation 13: The Laboratory should enhance the communication
and feedback channels and establish more formal procedures within
its broader ESH community to assure good decision making and also
to allay distrust.

Recommendation 14: Both line and oversight staff responsible for
ESH should critically question assumptions and conclusions and
eschew complacency.

Recommendation 15: The program to integrate the ESH and scientific
cultures at the Laboratory should be revitalized. A positive, top-down
management approach should be used, perhaps with assistance
from a revitalized ESH Management Advisory Committee.

Recommendation 16: The Laboratory should encourage a more open
approach to input from the ESH community outside BNL.

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REFERENCES


1. The DOE Risk-based Priority Model is described on the
Worldwide Web site
http://homer.hsr.ornl.gov/bps/eshplan/

2. Activity Data Sheet, BNL-H94D0002, 3/8/94.

3. Activity Data Sheet, BNL-H94D0002, revised 3/8/96.

 

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For a bound copy of this report, including Appendices and Attachments,
contact Nancy Nelson, BNL, nelson@dnenet.nov.dne.bnl.gov

Posted by Kara Villamil, BNL Public Affairs
May 5, 1997

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