{"id":371006,"date":"2017-06-18T21:30:03","date_gmt":"2017-06-19T03:30:03","guid":{"rendered":"http:\/\/nmpolitics.net\/index\/?p=371006"},"modified":"2017-06-27T18:23:33","modified_gmt":"2017-06-28T00:23:33","slug":"a-near-disaster-at-los-alamos-lab-takes-a-hidden-toll-on-americas-arsenal","status":"publish","type":"post","link":"https:\/\/nmpolitics.net\/index\/2017\/06\/a-near-disaster-at-los-alamos-lab-takes-a-hidden-toll-on-americas-arsenal\/","title":{"rendered":"A near-disaster at Los Alamos lab takes a hidden toll on America\u2019s arsenal"},"content":{"rendered":"<div id=\"attachment_68140\" class=\"wp-caption module image alignnone\" style=\"max-width: 771px;\"><a href=\"https:\/\/www.flickr.com\/photos\/larry1732\/7753373502\/in\/photolist-geZGR2-cP94Pu-9YrggZ-77mo8-BxHcn-BxGUr-BxGZe-BxHgX-BxH6F-5kjXta-6Z68Po-5kim1e-54gHFM-eRshz5-3Pyg5A-aXbjoa-9Xec8-ai7UQt-ai7UQc-9Xe6f-9Xedu-b4UhuX-vcCASK-vcveWj-fhx61Z\" target=\"_blank\" rel=\"noopener noreferrer\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-68140 size-large\" src=\"http:\/\/nmpolitics.net\/index\/wp-content\/uploads\/2015\/07\/LANL-771x443.jpg\" alt=\"\" width=\"771\" height=\"443\" srcset=\"https:\/\/nmpolitics.net\/index\/wp-content\/uploads\/2015\/07\/LANL-771x443.jpg 771w, https:\/\/nmpolitics.net\/index\/wp-content\/uploads\/2015\/07\/LANL-336x193.jpg 336w, https:\/\/nmpolitics.net\/index\/wp-content\/uploads\/2015\/07\/LANL-768x441.jpg 768w, https:\/\/nmpolitics.net\/index\/wp-content\/uploads\/2015\/07\/LANL-1170x672.jpg 1170w, https:\/\/nmpolitics.net\/index\/wp-content\/uploads\/2015\/07\/LANL.jpg 1500w\" sizes=\"auto, (max-width: 771px) 100vw, 771px\" \/><\/a><p class=\"wp-media-credit\">Larry Lamsa \/ Creative Commons<\/p><p class=\"wp-caption-text\">Los Alamos National Laboratory. (<a href=\"https:\/\/creativecommons.org\/licenses\/by\/2.0\/\" target=\"_blank\" rel=\"noopener noreferrer\">Photo use\u00a0info<\/a>)<\/p><\/div>\n<p>Technicians\u00a0at the U.S. government\u2019s Los Alamos National Laboratory settled on what seemed like a surefire way to win praise from their bosses in August 2011: In a hi-tech testing and manufacturing building pivotal to sustaining America\u2019s nuclear arsenal, they gathered eight rods painstakingly crafted out of plutonium, and positioned them side-by-side on a table to photograph how nice they looked.<\/p>\n<p>At many jobs, this would be innocent bragging. But plutonium is the unstable, radioactive, man-made fuel of a nuclear explosion, and it isn\u2019t amenable to showboating. When too much is put in one place, it becomes \u201ccritical\u201d and begins to fission uncontrollably, spontaneously sparking a nuclear chain reaction, which releases energy and generates a deadly burst of radiation.<\/p>\n<p>The resulting blue glow \u2014 known as Cherenkov radiation \u2014 has accidentally and abruptly flashed at least 60 times since the dawn of the nuclear age, signaling an instantaneous nuclear charge and causing a total of 21 agonizing deaths. So keeping bits of plutonium far apart is one of the bedrock rules that those working on the nuclear arsenal are supposed to follow to prevent workplace accidents. It\u2019s Physics 101 for nuclear scientists, but has sometimes been ignored at Los Alamos.<\/p>\n<aside class=\"module align-left half type-aside\">\n<h3>About this article<\/h3>\n<p>This story was originally published\u00a0by\u00a0<a href=\"https:\/\/apps.publicintegrity.org\/nuclear-negligence\/near-disaster\/?utm_content=buffere7058\" target=\"_blank\" rel=\"noopener noreferrer\">The Center for Public Integrity<\/a>, a nonprofit, nonpartisan investigative news organization in Washington, D.C.<\/p>\n<p>Read the full series, “Nuclear Negligence,” from the Center for Public Integrity <a href=\"http:\/\/nmpolitics.net\/index\/series\/nuclear-negligence\/\" target=\"_blank\" rel=\"noopener noreferrer\">here<\/a>.<\/p>\n<\/aside>\n<p>As luck had it that August day, a supervisor returned from her lunch break, noticed the dangerous configuration, and ordered a technician to move the rods apart. But in so doing, she violated safety rules calling for a swift evacuation of all personnel in \u201ccriticality\u201d events, because bodies \u2014 and even hands \u2014 can reflect and slow the neutrons emitted by plutonium, increasing the likelihood of a nuclear chain reaction. A more senior lab official instead improperly decided that others in the room should keep working, according to a witness and an Energy Department report describing the incident.<\/p>\n<p>Catastrophe was avoided and no announcement was made at the time about the near-miss \u2014 but officials internally described what happened as the most dangerous nuclear-related incident at that facility in years. It then set in motion a calamity of a different sort: Virtually all of the Los Alamos engineers tasked with keeping workers safe from criticality incidents decided to quit, having become frustrated by the sloppy work demonstrated by the 2011 event and what they considered the lab management\u2019s callousness about nuclear risks and its desire to put its own profits above safety.<\/p>\n<p>When this exodus was in turn noticed in Washington, officials there concluded the privately-run lab was not adequately protecting its workers from a radiation disaster. In 2013, they worked with the lab director to shut down its plutonium handling operations so the workforce could be retrained to meet modern safety standards.<\/p>\n<p>Those efforts never fully succeeded, however, and so what was anticipated as a brief work stoppage has turned into a nearly four-year shutdown of portions of the huge laboratory building where the plutonium work is located, known as PF-4.<\/p>\n<p>Officials privately say that the closure in turn undermined the nation\u2019s ability to fabricate the cores of new nuclear weapons and obstructed key scientific examinations of existing weapons to ensure they still work. The exact cost to taxpayers of idling the facility is unclear, but an internal Los Alamos report estimated in 2013 that shutting down the lab where such work is conducted costs the government as much as<a href=\"http:\/\/permalink.lanl.gov\/object\/tr?what=info:lanl-repo\/lareport\/LA-UR-13-29624\">\u00a0<\/a><a href=\"http:\/\/permalink.lanl.gov\/object\/tr?what=info:lanl-repo\/lareport\/LA-UR-13-29624\" target=\"_blank\" rel=\"noopener noreferrer\">$1.36 million a day<\/a>\u00a0in lost productivity.<\/p>\n<p>And most remarkably, Los Alamos\u2019s managers still have not figured out a way to fully meet the most elemental nuclear safety standards.\u00a0When the Energy Department on Feb. 1 released its annual<a href=\"https:\/\/www.dnfsb.gov\/sites\/default\/files\/document\/10666\/DOE%20Letter_2016%20Metrics%20Report_Feb-1-2017.pdf\">\u00a0<\/a><a href=\"https:\/\/www.dnfsb.gov\/sites\/default\/files\/document\/10666\/DOE%20Letter_2016%20Metrics%20Report_Feb-1-2017.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">report card<\/a>\u00a0reviewing criticality risks at each of its 24 nuclear sites, ranging from research reactors to weapon labs, Los Alamos singularly did \u201cnot meet expectations.\u201d<\/p>\n<p>In fact, Los Alamos violated nuclear industry rules for guarding against a criticality accident three times more often last year than the Energy Department\u2019s 23 other nuclear installations combined, that report said. Because of its shortcomings, federal permission has not been granted for renewed work with plutonium liquids, needed to purify plutonium taken from older warheads for reuse, normally a routine practice.<\/p>\n<p>Moreover, a year-long investigation by the Center makes clear that pushing the rods too closely together in 2011 wasn\u2019t the first time that Los Alamos workers had mishandled plutonium and risked deaths from an inadvertent burst of radiation. Between 2005 and 2016, the lab\u2019s persistent and serious shortcomings in \u201ccriticality\u201d safety have been criticized in more than 40 reports by government oversight agencies, teams of nuclear safety experts, and the lab\u2019s own staff.<\/p>\n<p>The technicians\u2019 improvised photo-op, an internal Energy Department report concluded later, revealed the staff had become \u201cde-sensitized\u201d to the risk of a serious accident. Other reports have described flimsy workplace safety policies that repeatedly left workers uninformed of proper procedures and left plutonium packed hundreds of times into dangerously close quarters or without appropriate shielding to prevent a serious accident.<\/p>\n<p>Workplace safety, many of the reports say, has frequently taken a back seat to profit-seeking at the Los Alamos, New Mexico, lab \u2014 which is run by a group of three private firms and the University of California \u2014 as managers there chase lucrative government bonuses tied to accomplishing specific goals for producing and recycling the plutonium parts of nuclear weapons.<\/p>\n<p>And these safety challenges aren\u2019t confined to Los Alamos. The Center\u2019s probe revealed a frightening series of glaring worker safety risks, previously unpublicized accidents, and dangerously lax management practices. The investigation further revealed that the penalties imposed by the government on the private firms that make America\u2019s nuclear weapons were typically just pinpricks, and that instead the firms annually were awarded large profits in the same years that major safety lapses occurred. Some were awarded new contracts despite repeated, avoidable accidents, including some that exposed workers to radiation.<\/p>\n<p>Asked about this record, spokesman Gregory Wolf of the National Nuclear Security Administration (NNSA), which oversees and pays for the country\u2019s nuclear weapons work, responded that \u201cwe expect our contractors to perform work in a safe and secure manner that protects our employees, our facilities, and the public. When accidents do occur, our focus is to determine causes, identify corrective actions, and prevent recurrences.\u201d<\/p>\n<p>His colleague James McConnell, the top NNSA safety official, said in an interview that \u201csafety is an inherent part of everything we do.\u201d But at a public hearing in Santa Fe on June 7, McConnell was also candid about Los Alamos\u2019s failure to meet federal standards. \u201cThey\u2019re not where we need them yet,\u201d he said of the lab and its managers.<\/p>\n<p>Los Alamos spokesman Kevin Roark said in an email the lab chose to defer to NNSA for its response. But the lab\u2019s director over the past seven years, nuclear physicist Charles McMillan, said in a 2015 promotional video that while \u201cwe\u2019ve got to do our mission\u201d \u2014 which he said was vital to the nation\u2019s security as well as the world\u2019s stability \u2014 \u201cthe only way we can do that is by doing it safely.\u201d<\/p>\n<h3>No usable warhead production for four years<\/h3>\n<p>The huge, 39-year-old, two-story, rectangular building at Los Alamos where the 2011 incident occurred is the sole U.S. site that makes plutonium cores \u2014 commonly known as pits because they are spherical and placed near the center of nuclear bombs \u2014 for the warheads meant to be installed over the next three decades in new U.S. missiles, bombers and submarines.<!--more--><\/p>\n<p>Production of these cores is a key part of the country\u2019s effort to modernize its nuclear arsenal at a cost of hundreds of billions of dollars, which President Obama supported and President Trump has said he wants to \u201cgreatly strengthen and expand.\u201d Trump\u2019s proposed fiscal year 2017 and 2018 budgets would boost U.S. spending on such work by $1.4 billion, representing a slightly higher percentage increase (11 percent) than requested overall for the Defense Department.<\/p>\n<p>But mostly because of the Los Alamos lab\u2019s safety deficiencies, it hasn\u2019t produced a usable new warhead core in at least six years. Congress mandated in the 2015 National Defense Authorization Act that Los Alamos must be capable of manufacturing up to 20 war-ready cores a year by 2025, 30 the next year and 80 by 2027. Wolf said the agency remains committed to meeting this goal, but other government officials say the dramatic slowdown at PF-4 has put fulfillment of that timetable in doubt.<\/p>\n<p>PF-4 is also the only place where existing cores removed randomly from the arsenal can be painstakingly tested to see if they remain safe and reliable for use in the nuclear stockpile. That work has also been blocked, due to PF-4\u2019s extended shutdown, according to internal DOE reports.<\/p>\n<p>The lab tried to conduct those tests in late 2016, but without success. The initial experiment destroyed a plutonium pit without collecting useful results about its safety or reliability, the latest<a href=\"https:\/\/nnsa.energy.gov\/sites\/default\/files\/nnsa\/multiplefiles\/fy_2016_lans_fdo_memo_publicly_releasable_per.pdf\">\u00a0<\/a><a href=\"https:\/\/nnsa.energy.gov\/sites\/default\/files\/nnsa\/multiplefiles\/fy_2016_lans_fdo_memo_publicly_releasable_per.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">annual review<\/a>\u00a0of Los Alamos\u2019 performance by the National Nuclear Security Administration (NNSA) stated. The lab canceled a second planned pit analysis in 2016, according to the NNSA\u2019s annual evaluation of the lab\u2019s performance.<\/p>\n<p>\u201cI don’t think they’ve made mission goals the last four years,\u201d said Michaele Brady Raap, a past president of the American Nuclear Society and member of the Energy Department\u2019s elite Criticality Safety Support Group, a team of 12 government experts that analyzes and recommends ways to improve struggling federal nuclear safety programs.<\/p>\n<p>The lab\u2019s criticality safety shortcomings have been so persistent that NNSA in August 2015<a href=\"https:\/\/energy.gov\/sites\/prod\/files\/2015\/09\/f26\/LANS%20PNOV%20%28NEA-2015-02%29%20-%20web.pdf\">\u00a0<\/a><a href=\"https:\/\/energy.gov\/sites\/prod\/files\/2015\/09\/f26\/LANS%20PNOV%20%28NEA-2015-02%29%20-%20web.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">threatened<\/a>\u00a0to fine Los Alamos\u2019 managing contractors more than a half-million dollars for failing to correct them. In the end, the NNSA administrator decided to not to impose the fine, exemplifying what critics allege is a climate of impunity for mistakes within DOE.<\/p>\n<p>\u201cThere is no doubt, they have had some management and operational problems,\u201d said MIT Professor Ernest Moniz, who served as the Obama administration\u2019s Energy Secretary from 2013 until the end of January, speaking about Los Alamos\u2019s handling of nuclear safety. \u201cWe were obviously quite concerned about it.\u201d<\/p>\n<p>Moniz said in an interview with the Center that the laboratory\u2019s lapses had played a role in the department\u2019s decision last year not to extend its existing management contract. Instead, the contract was opened to a new competition, with the winner expected to be named in early 2018 and take over the lab in Sept. 2018. Moniz added, however, that in 2016 the lab \u201cstarted to turn things around.\u201d<\/p>\n<p>But others see Los Alamos\u2019s conduct differently. \u201cThere\u2019s a systemic issue here,\u201d said Brady Raap. \u201cThere are a lot of things there [at Los Alamos] that are examples of what not to do.\u201d<\/p>\n<p>George Anastas, a past president of the Health Physics Society who analyzed dozens of internal government reports about criticality problems at Los Alamos for the Center, said he wonders if \u201cthe work at Los Alamos [can] be done somewhere else? Because it appears the safety culture, the safety leadership, has gone to hell in a handbasket.\u201d<\/p>\n<p>Anastas said the reports, spanning more than a decade, describe \u201ca series of accidents waiting to happen.\u201d The lab, he said, is \u201cdodging so many bullets that it\u2019s scary as hell.\u201d<\/p>\n<h3>Ghastly deaths after the blue glow<\/h3>\n<p>The consequences of a \u201ccriticality\u201d accident are ghastly. When Japanese technicians sloppily packed too much enriched uranium \u2014 another nuclear weapons fuel \u2014 into some wide-mouthed buckets at a factory 75 miles northeast of Tokyo in September 1999, it started to fission spontaneously in a classic \u201ccriticality\u201d incident.<\/p>\n<p>Two Japanese workers died, neighboring towns were contaminated with radiation, and industries essential to the region\u2019s economy were disrupted. Schools closed, police barricaded roads, and trains stopped running. More than 160 people within a quarter-mile were evacuated, and another 310,000 people living and working nearby were ordered to seek shelter.<\/p>\n<p>There was no explosion, just the usual blue Cherenkov flash, marking the spread of radiation around the Tokaimura plant in a chain reaction that pulsed intermittently for 20 hours. It exposed 119 people to doses exceeding the 1 millisievert level recognized by the International Commission on Radiological Protection as the maximum that members of the public can safely be exposed to in a year, according to the World Nuclear Association, a nonprofit organization that advocates expanded reliance on nuclear energy. Those contaminated were a mix of plant workers and others who by chance happened to live or work nearby.<\/p>\n<p>Hisashi Ouchi and Masato Shinohara, who were in the room where the criticality occurred and absorbed extremely high doses \u2014 1,700 and 1,200 rems of radiation, respectively \u2014 appeared normal when they entered the University of Tokyo Hospital Emergency Department on the same day. But within weeks, Ouchi became unrecognizable, inside and out.<\/p>\n<p>Slowly, his skin sloughed off and his muscle tissue died. Externally, his body withered into a skeletal silhouette, covered in open sores. Inside his body, his chromosomes shattered like glass. Sequentially, his organs failed. By the 63rd\u00a0day of his ordeal, doctors were pumping 10 liters of liquid into Ouchi to replace the fluid he was losing from surface wounds and massive intestinal bleeding. He died in December, 1999, 83 days after the accident.<\/p>\n<p>Shinohara\u2019s physical decline wasn\u2019t as meticulously chronicled as Ouchi\u2019s. But the outer layer of his skin molted from 70 percent of his body, and his body shut down in the same sequence that Ouchi\u2019s had. He lived for 210 days after the accident, until he succumbed to MRS pneumonia on April 27, 2000.<\/p>\n<p>Official studies by the Japanese government and the U.S.<a href=\"https:\/\/www.nrc.gov\/reading-rm\/doc-collections\/commission\/secys\/2000\/secy2000-0085\/attachment1.pdf\">\u00a0<\/a><a href=\"https:\/\/www.nrc.gov\/reading-rm\/doc-collections\/commission\/secys\/2000\/secy2000-0085\/attachment1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Nuclear Regulatory Commission<\/a>\u00a0chronicled a poor safety culture that had discounted the likelihood of a criticality accident. In 1999, Sixto T. Almodovar, a senior nuclear criticality analyst consultant at the Hanford Nuclear Site in Washington state, summarized the mindset about criticality safety at JCO Co. Ltd., the company that operated the Japanese nuclear fuel plant, as \u201cTitanic thinking.\u201d<\/p>\n<p>\u201cThis ship is unsinkable, therefore why obstruct the view of the first-class passengers with unneeded life boats,\u201d Almodovar said. Citing Japanese media reports, he noted that company officials had admitted they not only condoned, but encouraged, workers to take shortcuts, often at the expense of safety, to increase their productivity.<\/p>\n<p>Taking safety shortcuts to boost productivity to the level managers wanted to see isn\u2019t just a foreign problem, Almodovar warned. At the Y-12 National Security Complex, an Energy Department-funded nuclear weapons plant in Tennessee, workers even coined a euphemism for the practice. \u201cThe Oak Ridge Y-12 workers call this, a \u2018Bubba said,\u2019\u201d Almodovar said, after interviewing some of them. A spokeswoman at Y-12, Ellen Boatner, didn\u2019t reply to a request for comment.<\/p>\n<h3>Repeatedly playing with danger<\/h3>\n<p>Los Alamos\u2019s first death from criticality-produced radiation occurred in September 1945, 25 days after physicist Harry Daghlian deliberately lowered a large piece of plutonium into a cavity made of tungsten bricks that reflected the plutonium\u2019s escaping neutrons back toward it, in a risky experiment that scientists dubbed \u201ctickling the dragon\u2019s tail.\u201d<\/p>\n<p>As Daghlian moved the final brick closer to the stack, a nearby radiation meter clicked frantically as neutrons collided angrily with other particles, warning him that a criticality accident loomed. But as he tried to withdraw the brick, it dropped, and the flash caught him. He died 28 days after he was irradiated.<\/p>\n<p>The following May, Los Alamos scientist Louis Slotin was also testing the boundaries of plutonium criticality while seven other scientists looked on. Slotin was positioning a spherical beryllium shell around a plutonium pit. But as he slowly lowered the upper hemisphere onto the lower one, it slipped downward, off the tip of his screwdriver.<\/p>\n<p>The telltale blue flash that followed gave Slotin enough radiation to kill him five times over, and the seven observers in the room received doses ranging from nearly lethal to benign. Slotin prevented a worse calamity by quickly separating the two halves of the pit, before the reaction could become self-sustaining. Nine days later, he died at the age of 35.<\/p>\n<p>It happened again at Los Alamos, twelve years later, when chemist Cecil Kelley stood on a small ladder to stir a vat that included plutonium residue. When it became too concentrated, workers outside saw a bright blue flash and heard a dull thud. Soon, they saw Kelley standing outside, bewildered. \u201cI\u2019m burning up!\u201d he screamed. \u201cI\u2019m burning up.\u201d<\/p>\n<p>The first medics to treat Kelley weren\u2019t sure what had happened because he was working alone and too stunned to describe his experience. A nurse, among the first to treat him, didn\u2019t suspect he\u2019d been exposed to radiation and remarked on his \u201cnice pink skin,\u201d a sunburn-like symptom of his radiation exposure, according to an account of the accident \u00a0published in the journal<a href=\"https:\/\/fas.org\/sgp\/othergov\/doe\/lanl\/pubs\/00326644.pdf\">\u00a0<\/a><a href=\"https:\/\/fas.org\/sgp\/othergov\/doe\/lanl\/pubs\/00326644.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Los Alamos Science<\/a>\u00a0in 1995.<\/p>\n<p>Kelley died at the hospital in Los Alamos about 35 hours after the accident.<\/p>\n<p>These deaths were all avoidable. \u201cThe human element was not only present but the dominant cause in all of the accidents,\u201d a team of criticality safety experts from Los Alamos and their Russian counterparts wrote in a<a href=\"https:\/\/www.orau.org\/ptp\/Library\/accidents\/la-13638.pdf\">\u00a0<\/a><a href=\"https:\/\/www.orau.org\/ptp\/Library\/accidents\/la-13638.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">definitive study<\/a>\u00a0of 60 criticality accidents published by the lab in 2000.<\/p>\n<p>Reports over the past decade suggest, however, that these mistakes didn\u2019t have a huge impact on criticality practices at Los Alamos. That lab has always been the most prominent and best funded \u2014 and according to Secretary of Energy Samuel Bodman\u2019s notorious remark at a 2007 congressional hearing, the most infected by \u201carrogance\u201d and resistant to independent scrutiny \u2014 of the U.S. nuclear weapons laboratories.<\/p>\n<p>In 2005, shortly before the profit-making firms wrested majority control of the laboratory from the University of California, the lab\u2019s \u201cnuclear criticality safety program did not meet many of the\u201d nuclear industry\u2019s standards, according to a DOE report in 2008.<\/p>\n<p>\u201cWe couldn\u2019t prove we were safe,\u201d said Doug Bowen, a nuclear engineer who was on the laboratory\u2019s criticality safety staff at the time, \u201cnot even close.\u201d<\/p>\n<p>Two months after the takeover, the Defense Nuclear Facilities Safety Board \u2014 an independent federal oversight agency in Washington \u2014 concluded that the lab\u2019s staff of 10 criticality safety engineers would need to more than triple. Its chairman also said the deficiencies hadn\u2019t gotten adequate attention from the NNSA.<\/p>\n<p>Los Alamos\u2019s director of nuclear and high-hazard operations at the time, Robert McQuinn, dismissed that complaint in a written reply the following month. \u201cLANL does not believe an inadvertent criticality is credible,\u201d McQuinn said, without referencing the lab\u2019s history. But he also promised the lab \u201chas and is continuing to make significant progress in resolving the issues.\u201d<\/p>\n<p>But safety was not the foremost concern in Washington. To encourage higher efficiency and productivity, the Energy Department waved millions of dollars at its\u00a0new corporate partners as potential rewards for meeting deadlines for designing weapons and building bomb components at PF-4. Doing so created a mindset among managers and their work crews that posed challenges for safety experts like Bowen.<\/p>\n<p>\u201cOperations is always going to try to push the boundaries so they can produce as much as they can within the safety envelope when they\u2019re pushing to get something done,\u201d Bowen said. \u201cOccasionally, they make decisions that they assume are going to be okay\u201d but instead wind up exceeding limits, he explained.<\/p>\n<p>A bonus was also offered if the laboratory started meeting basic criticality safety standards. But Bowen said that, in his view, meeting minimum requirements shouldn\u2019t need and didn\u2019t deserve bonus pay.<\/p>\n<p>The new corporate group promised to bring the lab up to the required safety standards in 2007. But that September, when members of the Defense Nuclear Facilities Safety Board inspected plutonium vaults at PF-4, they discovered much more material present than inventories showed, posing new risks of spontaneous fissioning if some of it became too tightly packed together. So in September 2007, the lab shut down PF-4 for a month and told DOE it had created a Nuclear Criticality Safety Board to analyze and fix the lab\u2019s persistent problems.<\/p>\n<p>In 2010, when the Energy Department did a checkup, however, it found \u201cno official notes or records\u201d the group had ever met, according to an internal Energy Department report. The lab\u2019s promised date to improve criticality safety had slid to 2008, then 2010, and then to 2011.<\/p>\n<h3>Too much plutonium in a glove box<\/h3>\n<p>When a nuclear technician put those eight plutonium rods dangerously close together on the afternoon of Aug. 11, 2011, he used a \u201cglove box\u201d \u2014 a device with gloved portholes that is designed to contain any radioactive particles \u2014 that he lacked permission to use. A sign on the box specifically warned against packing too much material inside, but he ignored it and went roughly 25 percent over the limit.<\/p>\n<p>In one photo, obtained by the Center, two of the rods are touching each other as they rest on a roll of duct tape. In another, eight rods are clustered tightly enough to fit within a pencil\u2019s length, propped up against a pyramid-shaped stick with black and yellow candy stripes to indicate \u201ccaution.\u201d Workers had forged the plutonium rods as aliquots \u2014 samples that could be useful to researchers in the weapons program and to teams trying to perfect the conversion of weaponized plutonium into fuel for civilian power plants.<\/p>\n<p>Bowen, who was then Los Alamos\u2019s top criticality safety expert and now supervises safety work throughout the weapons program, recalls getting a phone call about the technicians\u2019 error from an assistant lab director around 90 minutes after it had been discovered. By then, the rods had already been picked up and moved by hand while other work in the room continued \u2014 contrary to procedures calling for an evacuation, his immediate notification, and for the dispatch of workers in hazmat suits to reconfigure the rods.<\/p>\n<p>It was also a violation of the approach McMillan touts in the LANL promotional video. \u201cI think it\u2019s critical that if something doesn\u2019t feel quite right, then you pause the work,\u201d MacMillan said there. \u201cIt\u2019s a lot better to stop than it is to just muscle through.\u201d<\/p>\n<p>Reaching into the box was dangerous, said Don Nichols, the NNSA associate administrator for safety and health at the time, because the water present in human bodies reflects neutrons and slows their speed, increasing the likelihood that those emitted by plutonium will collide with the nuclei of other plutonium atoms and emit more neutrons, triggering a nuclear chain reaction, with its accompanying release of energy and radiation.<\/p>\n<p>As a result, Nichols said, the first thing to do upon noticing a near-criticality is \u201cthe opposite of what you want to do,\u201d such as reach in and separate the offending materials. Instead, he said, those in charge should get \u201ceveryone to back off\u201d and then call for engineers to start calculating safe approaches.<\/p>\n<p>When Bowen reached the site, it was bathed in red lights as a belated warning for workers to stay away. He found the photographer looking despondent, with his head in his hands. Nearby, other workers consoled the equally upset technician. Both men were worried they\u2019d be fired. During a lab-wide safety training a few days later, one of Los Alamos\u2019 top safety officials called it \u201cthe most severe event\u201d in years involving nuclear safety there, according to a copy of his presentation.<\/p>\n<p>\u201cThe really horrible part that stuck in my mind is that they got lucky,\u201d Bowen said. \u201cThey violated all these controls. They could have brought in more material to take pictures,\u201d and had they done so, it could have cost the technicians their lives, never mind their jobs. Senior managers, he said, delayed calling in safety experts because they didn\u2019t want to see the episode revealed in bold headlines.<\/p>\n<p>\u201cThe management saw it as more of a political thing,\u201d Bowen said. \u201cThey didn\u2019t want this to get out in the papers or the news.\u201d The fact that the call summoning him to PF-4 came from an assistant lab director \u2014 not a rank-and-file employee, but someone higher up \u2014 meant \u201cthey realized they were in trouble,\u201d Bowen said.<\/p>\n<p>The lab\u2019s decision to downplay the risks of the 2011 incident was not an isolated one, Bowen added. An official with URS \u2014 one of the private contractors running PF-4 under a government contract \u2014 told Bowen \u201call the time that we don\u2019t even need a criticality safety program,\u201d Bowen recalled.<\/p>\n<p>The URS official, Charles Anderson, who was appointed in July 2011 to oversee nuclear high-hazard safety, \u201cbasically said he didn\u2019t need us and he could make more money\u201d by replacing all the members of the criticality safety team with URS employees. (In 2014, a firm called AECOM acquired URS, including its stake in the consortium of contractors that operates Los Alamos.)<\/p>\n<p>\u201cThat kind of culture really spawned the exodus\u201d of the lab\u2019s safety staff, Bowen said in an interview, which he gave to CPI before being promoted to his current leadership role in the NNSA criticality safety program. \u201cWithin a year, maybe a year and a half, there was one, maybe two left \u2014 12 of 14 of the staff left. [And] because there was no criticality expertise there, it led to the closing of PF-4.\u201d<\/p>\n<div class=\"text\">\n<p>It was, Bowen said, \u201ca perfect storm of total boneheaded decisions by certain management [officials] at Los Alamos\u201d that created such havoc. A former senior NNSA official in Washington recounted hearing a similar depiction of the URS contractor\u2019s disdainful attitudes about criticality.<\/p>\n<p>Numerous messages left on Anderson\u2019s work and personal phones and emails as well as his social media accounts seeking comment went unanswered. A spokesman for the consortium of contractors that operates Los Alamos referred questions about Anderson\u2019s reported actions to the NNSA, whose spokesman didn\u2019t address those specific questions. AECOM, which bought URS, also did not reply to request for comment.<\/p>\n<p>A special expert group created to monitor safety throughout the Energy Department\u2019s facilities, known as the Criticality Safety Support Group, documented the exodus of trained personnel from Los Alamos in an April 2012 report, which said that experts \u201chad lost trust in their line management.\u201d<\/p>\n<p>Nichols recalled in an interview that due to \u201csome mismanagement, people voted with their feet. They left.\u201d The attrition rate was around \u201c100%,\u201d according to a private \u201clessons learned\u201d report last month by the lab\u2019s top criticality expert and the lone NNSA criticality expert assigned to work there, which they prepared for counterparts at the nearby Sandia nuclear weapons lab.<\/p>\n<p>The 2011 incident \u201cwas an egregious event,\u201d agreed Brady Raap, who is presently a chief engineer in the nuclear engineering and analysis department of the national security division at the Energy Department\u2019s Pacific Northwest National Laboratory. \u201cThat was what said, really, \u2018Look, there\u2019s not the respect for safety that there needs to be.\u2019 The problem was more than a few disgruntled people or anything that people [in management] portrayed it as.\u201d<\/p>\n<p>\u201cOperations wasn\u2019t fully integrated with safety, as it should be,\u201d she said. \u201cThere\u2019s an inherent conflict between safety objectives, which can slow down work, and productivity pressure\u2026. Management, in particular, is focused on a mission goal \u2014 processing a certain amount of material or manufacturing enough widgets, or what have you. If they don\u2019t have enough respect for the safety activities that support that, things become a little detached. You proceed when it would have been better to wait.\u201d<\/p>\n<p><em>National security managing editor R. Jeffrey Smith contributed to this article.<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Repeated safety lapses hobble Los Alamos National Laboratory\u2019s work on the cores of U.S. nuclear warheads.<\/p>\n","protected":false},"author":1,"featured_media":68140,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[11],"tags":[119,1187,1179,116],"class_list":["post-371006","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-news-and-analysis","tag-energy-policy","tag-lanl","tag-los-alamos","tag-washington","prominence-top-story","series-nuclear-negligence"],"_links":{"self":[{"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/posts\/371006","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/comments?post=371006"}],"version-history":[{"count":0,"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/posts\/371006\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/media\/68140"}],"wp:attachment":[{"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/media?parent=371006"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/categories?post=371006"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/nmpolitics.net\/index\/wp-json\/wp\/v2\/tags?post=371006"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}