Table of Contents - Department of Energy · PDF file1.1.2 MST-10 and DX-6 Laboratories ... 6.0...

Table of Contents

PROLOGUE.................................................................................................................................... iEXECUTIVE SUMMARY ..............................................................................................................iii

1.0 INTRODUCTION...................................................................................................................11.1 Facility Description................................................................................................................1

1.1.1 Atlas Project..................................................................................................................21.1.2 MST-10 and DX-6 Laboratories....................................................................................41.1.3 Organizational Structure..................................................................................................5

1.2 Scope, Purpose, and Methodology........................................................................................72.0 ACCIDENT.............................................................................................................................9

2.1 Background...........................................................................................................................92.2 Discovery and Initial Response...............................................................................................92.3 Accident Reconstruction......................................................................................................122.4 Related Events.....................................................................................................................13

3.0 FACTS AND ANALYSIS......................................................................................................153.1 Gasket Design, Fabrication and Installation...........................................................................153.2 Atlas Quality Assurance.......................................................................................................183.3 Procurement........................................................................................................................193.4 Spill Preparedness...............................................................................................................203.5 Hazard Recognition and Authorization Basis.........................................................................233.6 Feedback and Improvement................................................................................................253.7 DOE Oversight....................................................................................................................253.8 Barrier Analysis...................................................................................................................263.9 Change Analysis..................................................................................................................273.10 Causal Factors Analysis.....................................................................................................28

4.0 JUDGMENTS OF NEED.......................................................................................................315.0 BOARD SIGNATURES.........................................................................................................336.0 BOARD MEMBERS, ADVISORS, AND STAFF .................................................................34

ATTACHMENT 1 - Board Appointment Memorandum..................................................................35ATTACHMENT 2 - Barrier Analysis Worksheet............................................................................37ATTACHMENT 3 - Change Analysis Worksheet...........................................................................41ATTACHMENT 4 - Events and Causal Factors Chart....................................................................45

Acronyms and Terminology.....................................................................................Inside Back Cover

This report is an independent product of the Type B Accident Investigation Board appointed by ActingChief Operating Officer for Defense Programs, Ralph E. Erickson.

The Board was appointed to perform a Type B Investigation of this accident and to prepare an investigationreport in accordance with DOE Order 225.1A, Accident Investigations.

The discussion of facts, as determined by the Board, and the views expressed in the report do not assumeand are not intended to establish the existence of any duty at law on the part of the U. S. Government, itsemployees or agents, contractors, their employees or agents, or subcontractors at any tier, or any otherparty.

This report neither determines nor implies liability.

On January 17, 2001, I appointed a Type B Accident Investigation Board to investigate the mineral oil leakand resulting damage at TA-35, Building 125, Atlas Project, at Los Alamos National Laboratory, in LosAlamos, New Mexico that was detected on January 8, 2001. The Board’s responsibilities have beencompleted with respect to this investigation. The analysis, identification of contributing and root causes, andjudgments of need reached during the investigation were performed in accordance with DOE Order225.1A, Accident Investigations.

I accept the report of the Board and authorize release of this report for general distribution.

Ralph E. Erickson DateActing Chief Operating Officer for Defense Programs

Accident Investigation T erminology

Causal Factor - an event or condition in the accident sequence that contributes to the unwantedresult. There are three types of causal factors: direct cause, which is the immediate event(s) orcondition(s) that caused the accident; root cause(s) which is (are) event(s) or condition(s) that, ifcorrected, would prevent recurrence of the accident; and contributing cause(s), which are causalfactors that collectively with other causes increase the likelihood of an accident, but individually didnot cause the accident.

Events and Causal Factors Analysis - include charting, which depicts the logical sequence ofevents and conditions (causal factors) that allowed the event to occur, and the use of deductivereasoning to determine events or conditions that contributed to the accident.

Barrier Analysis - a review of the hazards, the targets (objects) of the hazards, and the controls orbarriers that management systems put in place to separate the hazards from the targets. Barriersmay be physical or management controls.

Change Analysis - the systematic approach that examines planned or unplanned changes in asystem that caused undesirable results related to the accident.

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PROLOGUEInterpretation of Significance

On January 8, 2001, a leak of 6700 gallons of mineral oil was detected at the Atlas Facility, Los AlamosNational Laboratory (LANL). The leak, caused by a failed gasket on a tank, seeped into the basement of thebuilding and resulted in $1,800,000 of damage to experimental equipment in two collocated laboratories. TheAccident Investigation Board concluded that LANL had not effectively implemented the Quality AssuranceProgram developed for the construction of the facility, nor had they adequately conducted a hazard analysisprocess that could have identified controls for the mitigation of such an occurrence. The loss of property in thisaccident is quantifiable, but the loss of the associated research, and the impacts on the involved programs andpersonnel is not. The fact that these losses were preventable through straightforward, reasonable measuresonly adds to the cost of the accident.

There has been a significant amount of programmatic and external pressure on LANL during the design andconstruction of Atlas. DOE and the Laboratory have been under considerable criticism for weaknesses inproject management, facility design, and construction programs. Defense Programs initiated the constructionof Atlas without ensuring that funding would be available for facility operations. Furthermore, the possiblerelocation of Atlas to DOE facilities in Nevada has been under consideration for a period of time. While thesepressures were apparent during this investigation, they do not excuse the failure to adequately address require-ments placed upon the facility. The Department must recognize that despite budgetary concerns, all of itsactivities need to be conducted within the framework of the established requirements and expectations placedupon them. There must always be a balance of resources between programmatic work and the potential risksassociated with the activity. Even in situations such as this accident, where the safety, health and environmentalhazards are limited, the lack of due consideration for collocated activities resulted in substantial impacts thatcould have been readily avoided.

This accident also demonstrates the importance of a defense-in-depth strategy, even for a low hazard activity.The concept of defense-in-depth is three-pronged: (1) actions are taken to avoid the occurrence of an unde-sirable event, but at the same time (2) actions are also taken to mitigate the consequences of the event, shouldit occur anyway. Finally, (3) actions are taken to ensure the integrity of the protective envelope. This accidentcould have been avoided if the Quality Assurance Program had been effectively implemented; it could alsohave been avoided had controls been identified and implemented to protect the vulnerable property andprograms. In this case, neither action was properly conducted.

All DOE and Contractor facilities should ensure that property protection and programmatic impacts are givenappropriate attention in all endeavors. The risks associated with a mission should be understood, controlsshould be developed and implemented, and resources balanced such that government property is protected aswell as the environment and the safety and health of the workers and the public. These are the basic tenets ofboth property management and Integrated Safety Management.

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Overview

The Department of Energy (DOE) Office ofDefense Programs, within the National NuclearSecurity Administration (NNSA), conducted aType B Accident Investigation of a 6,700-gallonmineral oil leak from the First Article Assembly,a test tank associated with the Atlas facility atTechnical Area (TA) 35. TA-35 is located atthe Los Alamos National Laboratory (LANL),Los Alamos, New Mexico. The oil leak resultedin approximately $1,800,000 in damages toproperty in the basement of the building andcleanup costs for the leak of $95,000. A fivemember Accident Investigation Boardcomposed of subject matter experts from DOEHeadquarters and Field Offices conducted theinvestigation January 17 to February 16, 2001.

Atlas is a pulsed power facility designed toperform high energy-density experiments insupport of weapon-physics and basic-researchprograms. Atlas can provide 27-32 Mega-amperes (MA) of electrical current to a target ina cylindrically symmetric geometry. Electricalcurrent in this range allows fielding of large-scaleexperiments that employ design, engineering andexperimental skills analogous to full scale nuclearweapons testing. Specifically, Atlas is a short-pulse, high-current generator designed to drivehydrodynamic experiments to conditionsrelevant to stockpile stewardship. Theseexperiments will enable the study of the responseof materials to (1) strong shock waves and ultra-high pressures in large volumes, and (2)converging geometry with enhanced diagnosticaccess. Among other uses, this will allow thestudy of strength at high strain rate, friction, spall,hydrodynamics in complex geometry, and shocksin strongly coupled plasmas.

Executive Summary

Consistent with the direction provided by DOE O225.1A, Accident Investigations, the purposes ofthe investigation were to (1) determine whathappened, (2) why it happened, and (3) what couldbe done to prevent recurrence – not to determinefault or fix blame. The scope of the Board’sinvestigation was to review and analyze thecircumstances of the accident to determine itscauses. The protection of property is a contractualrequirement of DOE implemented through theDepartment of Energy Acquisition Regulation(DEAR), although it is not part of the IntegratedSafety Management DEAR Clause. Therefore, thisinvestigation focused on the accident from a projectmanagement perspective. However, theinvestigation did include an evaluation of theadequacy of the safety management systems ofLANL and DOE as they related to the oil leak.The Barrier Analysis results from the investigationwere linked to the five core functions of IntegratedSafety Management.

Accident

On January 8, 2001, upon arriving at work at 6:00a.m., a Mechanical Technician discovered oil onthe floor in the Atlas machine High Bay area locatedin Building 125 at TA–35. Initial inspection of thebuilding revealed that mineral oil leaked from theFirst Article Assembly, which holds 11,515 gallons.Approximately 6,700 gallons leaked onto the HighBay floor, of which approximately 500 gallonsseeped into the basement area. The dripping oildamaged several laser systems, associated ultra-fast optics, and electronics located in the basement.The damage to equipment in the basement isestimated to be $1,800,000.

The cleanup costs are $95,000 for the High Bayand basement areas. LANL determined that there

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were no injuries or environmental impact as a resultof this accident or the associated cleanup.

On January 17, 2001, Ralph E. Erickson, ActingChief Operating Officer for Defense Programs, U.S. Department of Energy, established a Type BAccident Investigation of this accident in accordancewith DOE Order 225.1A, Accident Investigations.

Results and Analysis

During the initial response to the event, Atlas facilitypersonnel determined that the leak was due to afailed Rear Tri-Plate Gasket that was used to jointwo tank sections together in the First ArticleAssembly. The gasket, which is 83 inches long,spans a three-inch gap between the two tanks. Atear in a lower corner of the gasket, about six incheslong, provided a leak path of about 2.7 in2. NeitherLANL nor the Board were able to determine theexact time of the onset of the leak, but based on thefact that some minor leaking was still occurring atthe time of discovery, it most likely began overnightbetween Sunday and Monday, January 7 and 8,2001.

Subsequent evaluations by the Board, incooperation with LANL subject matter experts inmaterials science, determined that the failed gasketdid not meet the physical properties specified in thedesign and procurement packages when the FirstArticle Assembly was fabricated. More specifically,the gasket material did not have a nylon fabric insertas required, and therefore did not meet the tensilestrength specification. Both the nylon fabric andthe tensile strength had been explicitly called out inthe procurement package. It was also determinedthat the gaskets had not been delivered to the facilityin the manner specified by the procurement package,they had not been inspected upon receipt at theLaboratory, nor had they been inspected sinceinstallation.

The Board reviewed the design and specificationsof the Rear Tri-Plate Gaskets in comparison withthe intended application. The Board determined

that the design was based on engineeringassumptions that were not consistent with theapplication, and the gasket specifications used forthe procurement did not contain sufficient detail toensure the gasket received was appropriate for theapplication. Furthermore, the assumptions used inthe design were not translated into specifications tobe used during the assembly of the tanks.

The design and construction of the Atlas machinewere governed by a quality assurance (QA)procedure written specifically for this application.However, the Board determined that the QAprocedure had not been adequately implementedwith respect to the gaskets. It was apparent to theBoard that a high level of attention had been paid tothe major components of the machine, such as theMarx Units, electrical capacitors, and relatedelectrical components, but much less attention waspaid to the gaskets, even though they were assignedthe same Quality Grade Level. The Boarddetermined that implementation of the QA programwas not adequate to ensure that all componentswere properly evaluated.

The Board determined that the authorization basisestablished for the facility, including the FacilitySafety Analysis, its associated Facility Safety Plan,and related documents did not comply withrequirements promulgated by LANL for theconsideration of property damage andprogrammatic impact during the identification offacility hazards. Consequently, the implementingdocuments, such as the Spill Preparedness Plandeveloped for the facility, did not establish measuresthat would mitigate consequences to facility orcollocated property and programs. Furthermore,line management did not effectively or fully implementthe programs established by these documents.

The Board also reviewed the initial response to theleak by both facility personnel and LANL’sEmergency Management and Response personnel.The Board concluded that all actions taken wereappropriate and timely, and identified no issuesrequiring corrective actions.

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The Board reviewed recent, related events that itconsidered as precursors to this accident. Ofparticular note was an event that occurred at thesame facility one month before this leak occurred.While no leak resulted from the accident, it directlyfocused the attention of the Atlas personnel andcollocated personnel on the potential for propertyand programmatic impacts, should a leak occur.However, identified corrective actions have beenintentionally delayed until after construction iscompleted and normal operations established.

Conclusion

The Board concluded this accident was preventable.All components did not receive the level of attentionspecified by their assigned Quality Grade Levelsdue to significant weaknesses and inconsistenciesin the implementation of the Quality Assuranceprogram. The basis of the design for the Rear Tri-Plate Gaskets was not consistent with theapplication, nor were design assumptions carriedforward into the fabrication and installationspecifications. Furthermore, processes for therecognition, evaluation, and mitigation of hazardsdid not comply with LANL and DOE requirements,and consequently were not capable of protectingthe collocated laboratories.

There were significant and closely related precursorevents that were identified by both LANL and theBoard. However, LANL failed to proactivelyrespond to those events, and has delayedimplementing the lessons learned into the facility’sdesign and operation. The Board concluded thatthe potential for property damage and programmaticimpacts on collocated activities was known andunderstood by facility personnel. However, LANLfailed to acknowledge that risk within the analysesand preparations supporting the facility.

A fully implemented QA program, coupled withcomprehensive and fully implemented hazardanalyses and spill preparedness programs wouldhave either prevented or mitigated the leak withoutthe resulting property damages. The Board

understands the need of Defense Programs and itsContractors such as LANL to undertake some riskin attaining its mission in the stewardship of thenation’s nuclear weapons program. However, therisks associated with the mission should beunderstood, controls should be developed andimplemented, and resources balanced such thatgovernment property is protected as well as theenvironment and the safety and health of the workersand the public. These are the basic tenets of bothproperty management and Integrated SafetyManagement.

Causal Factors and Judgmentsof Need

The accident investigation process is designed tolead the Board to the determination of the causesof the accident, from which the judgments of needare then derived. The direct cause is the immediateevent or condition that caused the oil leak. Rootcauses are events or conditions that, if corrected,would prevent recurrence of this and similaraccidents. Contributing causes are events orconditions that collectively with other causes increasethe likelihood of the oil leak but that individually didnot cause the accident (contributing causes aretabulated in section 3.10, and are cross-referencedto the root causes and judgments of need).Judgments of Need (JON) are managerialcontrols and safety measures believed necessary toprevent or minimize the probability of a recurrence.

DIRECT CAUSE: A gasket on a tank containinginsulating mineral oil failed, allowing the oil to leakonto and damage equipment in two basement laserlaboratories.

ROOT CAUSES: The Physics Division failed toimplement established processes for QualityAssurance in the design, fabrication and assemblyof the First Article Assembly. The Physics Divisionfailed to conduct a comprehensive process forhazard recognition and mitigation, includingconsideration of property protection, in accordancewith established laboratory requirements

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No. JUDGMENTS OF NEED Related Causal FactorsLANL needs to ensure institutional requirements forthe recognition and evaluation of property and co-tenant impacts, and resulting controls, are effectivelyimplemented.

• Physics Division did not ensure that theSpill Preparedness Plan developed forAtlas was properly scoped to addresspotential leakage during non-operationalperiods and protection of property. (CC2)

• Physics Division did not ensure thatrequirements of the Spill PreparednessPlan were effectively implemented. (CC 3)

• Physics Division did not implementLANL requirements requiring theconsideration of property protection andimpact on co-tenants in development ofFacility authorization basis, FacilitySafety Plans and hazard analysis. (CC 4)

• The FMU did not effectively implementtheir responsibility to ensure that tenantoperations do not adversely affect otherbuilding tenants. (CC 5)

• Physics Division did not implement aneffective Feedback and ImprovementProgram incorporating lessons learnedfrom precursor events. (CC 7)

JON 2 LANL needs to develop and ensure implementationof an institutional Quality Assurance processapplicable to all capital projects per DOE 0 414.1A or10 CFR 830.120, as appropriate.

• Physics Division did not ensureeffective implementation of the Atlasproject Quality Assurance requirements.(CC 1)


JON 1

LANL needs to ensure that facility spill prepared-ness, prevention, and mitigation plans provide forproperty protection as well as personnel andenvironmental protection, and that they are effec-tively implemented. Specific to Atlas, the planneeds to address the following:

• Total inventory of oil in the Atlas facility;• Static as well as operating conditions;• Provisions for leak monitoring and inspection;• Spill response training;• Secondary containment; and• Impacts on collocated tenants.

• Physics Division did not ensure that theSpill Preparedness Plan developed forAtlas was properly scoped to addresspotential leakage during non-operationalperiods and protection of property. (CC2)

• Physics Division did not ensure thatrequirements of the Spill PreparednessPlan were effectively implemented. (CC3)


LANL needs to develop a Preventive Maintenanceprogram for the Atlas facility, including periodicinspection of gaskets using specific performancecriteria.

JON 3

JON 4 • Physics Division did not develop andimplement a Preventative MaintenanceProgram for the First Article Assemblyand Atlas Machine. (CC 6)

• Design specifications in drawings forthe procurement of the Rear Tri-PlateGasket were less than adequate. (CC 8)

• Design assumptions for the Rear Tri-PlateGasket were less than adequate. (CC 9)

• Physics Division did not ensureeffective implementation of the Atlasproject Quality Assurance requirements.(CC 1)

LANL needs to evaluate the implication of design,fabrication, and Quality Assurance shortcomings ofthe First Article Assembly and apply lessonslearned to the Atlas machine.

JON 5

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The Department of Energy (DOE) Office ofDefense Programs, within the National NuclearSecurity Administration (NNSA), conducted aType B Accident Investigation of a 6,700 gallonmineral oil leak in the Atlas facility at TechnicalArea (TA) 35. TA-35 is located at the LosAlamos National Laboratory (LANL), LosAlamos, New Mexico. The oil leak resulted inapproximately $1,800,000 in damages toproperty in the basement of the building andcleanup costs for the leak of $95,000. A five-member Accident Investigation Boardcomposed of subject matter experts from DOEHeadquarters and Field Offices conducted theaccident investigation January 17 to February16, 2001. The Board Chair was Dr. DouglasMinnema of the Office of Technical Support,Defense Programs, DOE/NNSA. Theinvestigation was performed consistent with thedirection provided by DOE O 225.1A,Accident Investigations. The Barrier Analysisresults from the investigation were linked to thefive core functions of Integrated SafetyManagement.

On January 8, 2001, upon arriving at work at6:00 a.m., a Mechanical Technician discoveredoil on the floor in the Atlas machine High Bayarea located in Building 125 at TA–35. Initialinspection of the building revealed that mineraloil leaked from the First Article Assembly, whichholds 11,515 gallons of oil. Approximately6,700 gallons leaked onto the High Bay floor,of which approximately 500 gallons seeped intothe basement area. The dripping oil damagedseveral laser systems, associated ultra-fastoptics, and electronics located in the basement.LANL determined that there were no injuriesor environmental impact as a result of thisaccident or the associated cleanup.

Introduction

On January 17, 2001, Ralph E. Erickson, ActingChief Operating Officer for Defense Programs,DOE/NNSA, established a Type B AccidentInvestigation Board for this accident in accordancewith DOE O 225.1A, Accident Investigations (seeAppendix A for the Appointment Memorandum).

1.1 Facility Description

LANL occupies approximately 43 square miles ofDOE land situated on the Pajarito Plateau in theJemez Mountains of Northern New Mexico. Theclosest population centers are the communities ofLos Alamos, White Rock, and San IldefonsoPueblo. The closest metropolitan center is SantaFe, population approximately 70,000, located 35miles away.

As technologies, U. S. priorities, and the worldcommunity have changed, LANL’s original missionhas evolved from primarily designing nuclearweapons to the following five areas: (1) stockpilestewardship, (2) stockpile management, (3) nuclearmaterials management, (4) non-proliferation andcounter-proliferation, and (5) and environmentalstewardship. LANL’s mission today is to applyscience and engineering capabilities to problems ofnational security.

LANL currently consists of 49 active TechnicalAreas (TAs). Technical Area 35 includes multiplefacilities that house physics experiments operatedby the Physics (P) Division and several othertechnical divisions. Building 125 houses the AtlasProject operated by P-22, an Optics LaserLaboratory operated by the Condensed Matter andThermal Physics Group of the Material Science andTechnology Division (MST-10), and a smaller laserlaboratory operated by the Machine ScienceTechnology Group of the Dynamic Experimentation

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Division (DX-6). In addition, this building containsa machine shop, a glass laboratory, other smallsupport shops, and office space to support theresearch efforts.

1.1.1 Atlas Project

Atlas is a P-Division experimental facility withinBuilding 125. Building 125 was built for anotherproject in the 1970’s and has been used for severalexperimental systems since then. The conceptualdesign of Atlas was approved in 1994. Constructionis essentially complete at this time and in January2001, LANL submitted a Project Critical Decision4 (CD-4) request to Defense Programs tocommence operations.

Atlas is a pulsed-power machine designed toperform high energy-density experiments in supportof weapon-physics and basic research programs.Atlas can provide 27-32 Mega-ampere (MA) ofelectrical current to a target in a cylindricallysymmetric geometry. Electrical current in this rangeallows fielding of large-scale experiments thatemploy design, engineering and experimental skillsanalogous to full scale nuclear weapons testing.Specifically, Atlas is a short-pulse, high-currentgenerator designed to drive hydrodynamicexperiments to conditions relevant to stockpilestewardship. It will enable the study of the responseof materials to strong shock waves and ultra-highpressures in large volumes in converging geometrywith excellent diagnostic access. Among other uses,this will allow the study of strength at high-strainrate, friction, spall, hydrodynamics in complexgeometry, and shocks in strongly coupled plasmas.

All safety evaluations have concluded that Atlas willbe a low hazard, non-nuclear, non-acceleratorfacility. All construction and operational decisionshave been guided by this determination. OutsideArchitect/Engineer firms with guidance and oversightby the LANL Project Management Organization incollaboration with the Atlas design team designedthe building and modifications to accommodateAtlas.

Atlas contains 24 sets of maintenance units (eachmaintenance unit contains four Marx Units) locatedin 12 tanks, which are filled with approximately160,000 gallons of dielectric mineral oil for electricalinsulation. The maintenance units are oriented in acircle around a central target chamber. Each of the12 tanks is attached to two Vertical TransmissionLine (VTL) Tanks. These tanks house the Tri-PlateAssembly Transmission Lines. The Marx Units areused to store a large amount of electrical energy(see Figures 1 and 2). When discharged, thiscapacitor bank delivers a high current pulse throughTri-Plate Assembly transmission lines to a cylindricalload in the central target chamber. The load receivesa strong inwardly directed force due to the magneticfield generated by the current pulse. This causes itto deform plastically and move inward while mostof its material remains in the solid state. In a fewmicroseconds, it can be accelerated to a velocity of10 millimeters per microsecond, which isapproximately the escape velocity from earth. Thishighly uniform imploding cylinder can be studieddirectly or can impact a target designed to explorethe physical phenomena of interest.

In addition to the Atlas machine, there is anothertank in the same room that is referred to as the FirstArticle Assembly (see Figure 3). This assembly issimilar to the 12 tanks in Atlas and includes the FirstArticle Maintenance Unit (MU) Tank holding theMarx Unit and the associated VTL Tank that housesthe Tri-Plate Assembly. The oil capacity of thestandard configuration of First Article Assembly is11,515 gallons, with one Marx Unit installed. TheFirst Article Assembly is used for the testing ofindividual Marx Units. This testing is part of thequality acceptance testing of the electricalcomponents of the Marx Units and the full functionof the units prior to use in the Atlas machine. Similartesting, using the First Article Assembly, is also partof the Atlas maintenance activities.

The MU Tanks containing the Marx Units in theAtlas machine and in the First Article Assembly areconnected to their VTL Tanks by gasketedconnections. The Rear Tri-Plate Gaskets are U-shaped, 0.38-inch thick, 83-inch high, 23-inch wide

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Figure 1. The Atlas machine at LANL. In the background is the First Article Assemble where the leakoccured.

at the bottom, with a 7-inch wide vertical opening(see Figure 4). The gasket serves as the pressureboundary for the 3-inch gap between the FirstArticle MU Tank and VTL Tank, subject only tothe static pressure of oil contained within theconnected tanks. The failure of this Rear Tri-PlateGasket in the First Article Assembly resulted in thesubject oil leak.

Prior to the procurement of the First ArticleAssembly, a Prototype Assembly was designed andconstructed that included a tank for the switch/cableheader assembly and a half-length VTL Tank. ThisPrototype Assembly was used for electrical testingof components in late 1997 and in 1998. ThePrototype Assembly used a similarly designed gasket

with the same material properties specified for thegaskets in the Atlas machine and First ArticleAssembly. The only differences were minor changesin the gasket dimensions to allow for more ease infabrication. The Prototype Assembly has beendecommissioned, however the Rear Tri-PlateGasket from the assembly was recovered for theBoard to evaluate.

A 40,000-gallon storage tank, located on the southside of Building 125, can store oil from the FirstArticle Assembly or the Atlas machine. The oildistribution system includes a transfer capability tothe Atlas machine and First Article Assembly andincludes provision for heating and filtering the oil.

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LANL has completed preparations for operationof the Atlas facility. A Laboratory-directedReadiness Assessment has been performed anddetermined that the facility is ready to operate.LANL has submitted a request to Defense Programsfor approval of Project CD-4, authorization to beginoperations. At the time of the oil leak, the twelveAtlas tanks and the First Article Assembly werefilled with mineral oil. The Atlas system had beenoperated for acceptance testing as part of the CD-4approval process.

1.1.2 MST-10 and DX-6Laboratories

There are other activities collocated in Building 125,but in particular two laboratories were directlyimpacted by the accident. The MST-10 Optics

Figure 2. Schematic of the Atlas High Bay area, showing the relative locations of Atlas.

Laser Laboratory occupies about 1,300 ft2 andhouses on-going experiments in the east basementarea of the building. These experiments are laserbased to develop optical reflectivity and surfacesecond harmonic capabilities and examine thephysics of these processes. The projects in progressat the time of the oil leak and impacted by theaccident were: Melting Dynamics in Metals, Ultra-Fast Dynamics in Correlated Electron Material,Ultra-Fast Scanning Tunneling Microscopy,Terahertz Spectroscopy of Condensed Matter,Plasma Dynamics in Gases, Solid Target PlasmaPhysics, and High Energy Density Hydrodynamics(HEDH) Diagnostics. The Optics Laser Laboratoryhas been in this basement location since 1987 (seeFigures 2, 5, and 6).

The DX–6 laser laboratory is located in a corner ofthe west end of the Building 125 basement area,and occupies about 400 ft2. This lab is used for

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research and development of electron sources andis operated in support of the LANL science-based,stockpile stewardship program. Equipment in thislab includes lasers, optics, vacuum systems, andsupporting electronic components. Thisexperimental set-up has not been used for over twoyears due to funding constraints (see Figure 2).

The basement area of Building 125 was originallybuilt and configured to supply laser pulses to laseramplifiers in the basement. In the mid-1980’s theamplifiers were removed, otherwise the basementlaboratory remained the same. The basement isideal for laser operations due to its stable foundation,minimal temperature variation, and remote location.

Figure 3. The First Article Assembly , where the leak occured, is composed of the Maintenance UnitTank and the V ertical T ransmission Line T ank (note oil on floor).

1.1.3 Organizational Structure

The Regents of the University of California (UC)manage LANL under a management and operatingcontract with DOE/NNSA. UC has managed theLaboratory since its inception in 1943. The DOE/NNSA Los Alamos Area Office (LAAO), a partof the Albuquerque Operations Office (AL),administers the contract with UC and overseescontractor operations at the site. The DeputyAdministrator for Defense Programs, NNSA, is theresponsible Program Secretarial Officer for LANL.The responsible program office within DefensePrograms is the Office of Facilities Managementand ES&H Support.

Both Building 125 and the Atlas machine are ownedby P-Division. The construction of Atlas was theresponsibility of P-26, Atlas Construction Group.

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Figure 4. The interior of the Maintenance Unit T ank, showing the location of the Rear T ri-PlateGaskets as installed.

As of January 2, 2001, P-26 was dissolved and P-22, Hydrodynamics and X-Ray Physics Group,assumed operational responsibility of the Atlasmachine. Many of the P-26 personnel wereincorporated into P-22, maintaining continuity offacility knowledge. Building modifications weremanaged by PM-3, Construction ProjectManagement. The Associate LaboratoryDirectorate for Nuclear Weapons provides fundingfor both the construction and operation of Atlas.

Management of Building 125 is the responsibility ofFacility Management Unit (FMU) 77, a direct reportto the P-Division Director and a peer of the P-22Group Leader. FMU-77 is responsible for overallarea and building management, including utility lines,electrical panels, and mechanical rooms. FMU-77is responsible for permitting work that exceeds thelimits specified in the Facility Safety Plan, includingoperations that could adversely affect other tenants.FMU-77 also provides services such as ES&Hsupport, hazard analysis coordination, and

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addressing co-tenant concerns. The lineorganizations of the building tenants, such as P-22/Atlas Group and MST-10/Optics Laser Group, areresponsible for their experimental processes, safetyresponsibilities, operational equipment in thebuilding, and the physical space occupied by theequipment. They are responsible for their owntechnical work activities and procedures, jobspecific employee training, and physical security andmaintenance of their equipment. Roles andresponsibilities of each organization aredelineated in Facility-Tenant Agreementsand the Integrated Safety ManagementSystem Description. On October 2, 2000,the P-26/Atlas Project Group and theMST-10/Optics Laser Group signedFacility-Tenant Agreements with FMU-77.The Group Leader of MST-10 reports tothe MST Division Director, a peer of thePhysics Division Director.

During the period when Atlas constructionand testing were underway, DefensePrograms was considering whether theAtlas machine would be operated atLANL, moved to Nevada, or not operatedat all. Consideration has been given tomoving the Atlas machine to the Nevada

Test Site (NTS) after constructioncompletion and initial test operations atLANL. In mid-August 2000, DefensePrograms requested a detailed plan for therelocation of Atlas to NTS. As late asmid-September, 2000, it was uncertain asto whether funds would be allocated tooperate the facility in Los Alamos ormaintain the facility in a cold standby/non-operating mode. The present plan is tooperate at LANL for the next year forphysics experiments with a decision on thelocation for future operations dependenton the outcome of the NationalEnvironmental Policy Act review at NTSand other processes.

1.2 Scope, Purpose, andMethodology

The Type B Accident Investigation Board began itsinvestigation on January 17, 2001, and completedthe onsite investigation on February 16, 2001. TheBoard reviewed and analyzed the circumstances ofthe accident to determine its causes. Theinvestigation was performed in accordance with

Figure 5. Overview of the MST-10 Optics Laser Laboratoryin the basement of Building 125, where much of thedamage occured.

Figure 6. Laser optics table in the MST-10 Optics LaserLaboratory with mineral oil damage.

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DOE O 225.1A, Accident Investigations. Theprotection of property is a contractual requirementof DOE implemented through the Department ofEnergy Acquisition Regulations (DEAR), althoughit is not part of the Integrated Safety ManagementDEAR Clause. Therefore, this investigation focusedon the accident from a project managementperspective. However, the investigation did anevaluation of the adequacy of the safety managementsystems of LANL and DOE as they related to theoil leak. The Barrier Analysis results from theinvestigation were linked to the five core functionsof Integrated Safety Management.

The purposes of this investigation were to (1)determine what happened, (2) why it happened,and (3) what could be done to prevent recurrenceof similar accidents occurring at TA-35 and acrossthe DOE complex.

The Board conducted its investigation using thefollowing methodology:

• Inspecting and photographing the accidentscene and individual items of evidence relatedto the oil leak;

• Gathering facts through interviews, documentand evidence reviews, and inspection of theaccident scene;

• Reviewing emergency response;

• Overseeing physical testing of gasket material;

• Analyzing facts and identifying causal factorsusing events and causal factors charting analysis,barrier analysis, and change analysis; and

• Developing judgments of need for correctiveactions to prevent recurrence based on analysisof the information gathered.

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Accident

On January 8, 2001, a leak of approximately6,700 gallons of mineral oil was discovered inRoom A-100 (High Bay) of Building 125 in TA-35. The leak covered the floor of Room A-100, and an estimated 500 gallons of the oilleaked to the basement of the building wheretwo laboratories are located. The oil drippedonto laser systems and associated opticalinstruments, laser tables, microscopes andelectronic equipment located in the basementlaboratories, causing permanent, irreparabledamage to the equipment. Total damage to theaffected equipment has been estimated at$1,800,000. The cleanup costs for the oil leakare $95,000.

The source of the mineral oil leak was found tobe the First Article Assembly containing 11,515gallons of mineral oil. A gasket between theFirst Article MU Tank and its connecting VTLTank failed, permitting approximately 6,700gallons of oil to escape. The First ArticleAssembly is located in the northeast section ofBuilding 125, Room A-100 that also houses theAtlas machine. The MST-10 Optics LaserLaboratory, Room A-16, where most of theproperty damage occurred, is located under thesoutheast corner of this room (see Figures 2, 5,and 6).

2.1 Background

The First Article Assembly (see Figure 7), usedfor testing of individual banks of electricalcomponents and Marx Units, is collocated withAtlas in Building 125. The First Article Assemblywas completed and filled with dielectric mineraloil in October 1999, and has been utilized for367 tests of facility electrical components sincethen. The first half of the tests were conducted

with a plate attached to the First Article MU Tankand without the VTL Tank. The other half of thesetests were conducted with the subject gasket andVTL in place. The last tests using the First ArticleAssembly were performed on August 11, 2000.At the time of the accident, the First ArticleAssembly was filled with oil and ready for anymaintenance or other testing needed to support theAtlas machine.

During the construction phase of the Atlas machine,the floor area of the High Bay under the machinewas stripped of the lead-based paint and resealedwith epoxy paint. The stripping and repainting underthe machine was performed to allow the installationof grout pads under the Marx Tanks. Also, theepoxy seal of the floor and the sealing of the pipepenetrations were performed for oil spill mitigation.The floor area on the east side of the High Bay wasnot sealed during the construction phase due tostorage of equipment in this area and scheduleimpacts. The stripping and repainting process wouldhave limited the access to the High Bay area anddelayed scheduled Atlas machine constructionactivities. The First Article Assembly is located onthe unsealed floor area of the High Bay.

2.2 Discovery and InitialResponse

On Monday, January 8, 2001, at 6:00 a.m. aMechanical Technician arrived at work anddiscovered oil on the floor in Room A-100 (HighBay) of Building 125 at TA-35. The leak occurredsometime during the weekend. The employee whodiscovered the leak made a series of calls to theEmergency Management and Response DutyOfficer, the P-22 staff and management, the FMU-77 Facility Manager, and the P-22 Group Leaderto notify them of the leak. Responding P-Division

2.0

10

employees, who are extremely knowledgeable ofthe Atlas machine operations and associatedhazards, entered the building and determined thesource of the leak to be the First Article Assembly.They concluded that the gasket between the FirstArticle MU Tank and its associated VTL Tank hadfailed (see Figure 8). The initial respondersattempted to initiate a transfer of the remaining oil inthe test tank to the storage tank, but were unable tolocate a key for the system controls. They initiatedan inspection to determine the extent of the oil leak.A small amount of oil was found to have leakedpast the High Bay (east) door that was protectedby a flexible boom. This oil was contained withinthe building. Also, a small amount of oil (several

Figure 7. Schematic of the First Article Assembly , identifying the major components.

gallons) was found outside of the west door of theHigh Bay. The responders positioned a portablebarrier around the oil to prevent further leakage.This oil was cleaned up, and LANL determinedthat there was no environmental impact.

The responders then proceeded to the basement toinspect for possible leakage. They discovered thatoil was seeping down through the concrete floorand around floor penetrations onto the laboratoryareas in the basement. Oil was observed drippingonto lasers, optical instruments, laser tables,microscopes, and electronic equipment. Attemptswere made to position plastic covers to protect theequipment, however, the equipment in the spill area

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had already been exposed to the oil. Personnelfrom the Optic Laser Laboratory arrived and madean inspection of the laboratory equipment. Theydetermined that the equipment in the laboratory hadsustained significant damage. An inventory of theequipment and an initial damage estimate of$3,250,000, based on 100% loss were preparedby the MST-10 staff. This estimate was later refinedto the current estimate of $1,800,000.

The initial responders from P-Division focused onmoving the oil in the High Bay from the unsealedareas over the Optics Laser Laboratory (in thebasement) to the sealed area under the Atlas machineand the trench on the north side of the High Bay.

Within the first hour after the leak discovery, thekey was located and the remaining oil in the FirstArticle MU Tank was transferred to the storagetank. The First Article MU Tank was then used asa storage unit for oil pumped from the floor. Thetear in the gasket occurred mid-way in the tank andthe remaining tank provided approximately a 5000gallon capacity for oil.

The Emergency Management and ResponseIncident Commander mobilized response teams forcleanup and offsite transport of the leaked oil.Electrical power for the facility, except for lighting,was locked-out to mitigate electrical shock hazardduring cleanup operations. The P-22 staff continuedcleanup efforts until relieved by the cleanup responseteam. The cleanup activities were performed duringnormal work hours through the afternoon of January10, 2001. Final cleanup of the building wascompleted on the morning of January 11, 2001 andcontrol of Building 125 was returned to the FMU-77 Facility Manager.

The Emergency Management and ResponseIncident Commander indicated that there were nounexpected problems with the emergency responseand cleanup efforts. The Board concluded that theinitial response activities were appropriate andproperly completed.

Figure 8. This tear in the right Rear T ri-Plate Gasket of the First Article Assembly created a 2.7 in 2

providing the leak path for the mineraloil.

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2.3 Accident Reconstruction

In order to reconstruct the accident, the Boardgathered relevant information associated with thefailed gasket and its configuration in the First ArticleAssembly. The First Article Assembly consists ofthe First Article MU Tank, Marx Unit, VTL Tank,and the enclosure for the Dummy Load (see Figure7). Two Rear Tri-Plate Gaskets connected the FirstArticle MU Tank and the VTL Tank (see Figure 4).

The Board closely examined the condition of theseRear Tri-Plate Gaskets. A six-inch tear in the rightgasket along the First Article tank edge wasobserved. The tear created an opening ofapproximately 2.7 in.2 and was identified as thesource of the mineral oil leak (see Figure 8).Numerous cracks, 6- to 12-inches long andapproximately 0.25 inches deep, were identifiedalong the metal/gasket interfaces (see Figure 9). Theoutside surface of the left Rear Tri-Plate Gaskethad a large number of surface cracks and one majortear. The Board also noted that the Rear Tri-Plate

Figure 9. The right Rear T ri-Plate Gasket and one of the backing bars after removal. The gasketdisplayed significant deterioration along borders where the backing bars were attached

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Gaskets bulged outward because of the hydrostaticpressure of the mineral oil.

The exact time and date of the leak could not beconfirmed; however, based on the 2.7 in.2 openingin the gasket, Atlas personnel estimated that it couldtake as little as two to three hours for the tank todrain to the bottom of the tear. An Atlas ProjectMechanical Technician discovered the leak onMonday at 6:00 a.m. on January 8, 2001. P-22Atlas personnel observed the oil still flowing shortlyafter the discovery, so the rupture may haveoccurred earlier on Monday morning.

The Board also noted that the First Article MU Tankand VTL Tank interfaces were not coplanar, theinterface surfaces of the tanks were not rounded,and the First Article MU Tank was slightly bulged.The Board took various measurements of theassembly to compare them with the design basisand specifications. More detailed facts concerningthe failure of this Rear Tri-Plate Gasket weregathered through material testing. The results ofthese evaluations are discussed in Section 3.1 ofthis report.

The Board inspected the floor of the High Bay todetermine the sources that led to the oil entering thebasement area. Cracks, pipe chases, and expansionjoints were noted in the east portion of the flooring.To provide spill containment, some booms andberms were installed around the doors andequipment. Flexible booms had been installed atthe west and south doors and at the east roll-updoor. It was noted the east door boom was notfully attached to the floor. At the west end area,metal berms had been installed around the mineraloil supply piping and the fire protection loop thatpenetrated into the basement. Foam sealant hadbeen applied around the penetrations and betweenthe berms and floor interface. From discussionswith P-22 personnel, it was determined that thissealant failed and some oil flowed down the fireprotection loop penetrating into the DX laboratoryarea.

2.4 Related Events

The following related events have been identified:

• On November 28, 2000, a full “12 tank” Atlaspulsed-power performance test was conducted.The system was configured to deliver ~28 MAto the target area. Nine microseconds after peakcurrent, an electrical breakdown occurred at anylon insulator, causing damage to thetransmission line and tank. No oil loss resulted,although a similar failure at a different locationmight have made a penetration in the oil tank.Corrective actions included routine cleaning andevaluation of the insulating oil and evaluation ofpotential oil spills. The impact on the OpticsLaser Laboratory in the basement in case of afuture oil spill was a major concern to MST-10after this incident. Corrective actions wereinitiated, including a commitment by P-22 toseal the High Bay floor over the Optics LaserLaboratory. A report titled “Informal Analysisof Atlas Transmission Line Breakdown”documented this event.

• On August 3, 2000 (estimated by P-22personnel), while filling the First ArticleAssembly from the oil storage tank, the pumpwas left on and overfilled the tank. The excessoil (estimated at 500 gallons) spilled onto theHigh Bay floor. The oil was cleaned up and nocritique or incident report was filed due to thesmall quantity of the oil spilled and the absenceof consequences. Oil level detectors weresubsequently installed on the First ArticleAssembly and the Atlas machine that turn offthe oil pumping system and prevent overfilling.

• On November 17, 1997, LANL discovered aflooded sub-basement in TA-35, Building TSL-27, that resulted from the freeze induced ruptureof a chiller line. This caused $3,200,000 indamage to the facility and to equipment usedfor Nonproliferation and International Securityoperations. The resulting DOE Type BInvestigation found that line management did notperform adequate assessments to determine the

14

consequences to mission should equipment failand did not learn from previous accidents.

• LANL issued a Price-Anderson AmendmentAct (PAAA) non-compliance report to DOEon October 19, 2000 describing non-compliance with quality assurance requirementsfor the Laboratory. Two quality issues werereported:

1. Failure to establish the institutionalrequirement for the procurement process,and

2. Weakness in implementation of the LANLQuality Assurance Program at the working

level, including procurement, inspection andacceptance testing, and document andrecord management.

LANL has prepared a corrective action planthat is being implemented for the non-compliance. Additionally, in December 2000,the Associate Laboratory Director for NuclearWeapons issued a Directive detailing the qualityassurance for nuclear weapons activities. ThisDirective requires an assessment of QApractices by March 9, 2001 and expectsimplementation to begin by June 1, 2001. Theresearch performed by the Atlas Program fallsunder this Directive.

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3.1 Gasket Design,Fabrication and Installation

The Board performed various measurements tocompare the as-found condition of the FirstArticle Assembly with the design, fabrication andinstallation specifications. These includedspecifications for dimensions, tolerances, surfacefinish, and material composition for the metal andgasket components. According to the designdrawing, the Rear Tri-Plate Gaskets were to beconstructed of the following:

1. Material: Nitrile (Buna N) Polymer,Nylon fabric insertion 15 oz

2. Hardness: 60 plus or minus 5 Duro–ShoreA

3. Tensile Strength: 1000 psi

4. Finish: Smooth

5. The gaskets were to be shipped flat.

For the First Article Assembly, the followingspecifications were noted:

1. First Article MU Tank and Rear Tri-PlateGasket interfaces required an 0.125-inch x45° chamfer all around inside corner.

2. VTL Tank interfaces were required to havea 0.06-inch radius at its edges.

3. Drawings and supporting design calculationsare based on the First Article MU Tank andVTL Tank interfaces being coplanar.[Although the Rear Tri-Plate Gaskets wereintended to permit some offset, nospecification for the offset distance wasgiven.]

No torque specifications were documented for thebolts that secured the Rear Tri-Plate Gaskets inplace. Determination of the required torque toassure the gaskets would seal properly was part ofthe installation plan for the Prototype and First ArticleAssemblies. [However, during installation, 30 ft-lbwas verbally specified.]

The Board, with the assistance of P-22 personnel,inspected the as-found condition of the First ArticleAssembly, took a variety of measurements, andremoved the Rear Tri-Plate Gaskets. In addition,the Board, with the assistance of LANL materialsscience subject matter experts, evaluated two RearTri-Plate Gaskets. One gasket was from thePrototype Assembly that was used for tests in 1997and 1998; the other was the failed gasket removedfrom the First Article Assembly. These laboratoryanalyses were performed by the Polymer Materialsand Coatings Group of MST and were observedby members of the Board. (Refer to memoranda inaccident investigations records, “Infrared Analysisof Gasket Material,” J. Schoonover, et al., Feb 6,2001; “Results of Mechanical PropertyMeasurements of Atlas Gasket Materials,” E. Orler,Feb 7, 2001; and “Results of Density Measurementsof Atlas Gasket Materials,” K. Wilson, Feb. 7,2001). The Board made the following observationswith respect to the gaskets:

1. There was no nylon fabric reinforcement in theFirst Article Assembly Rear Tri-Plate Gaskets.The Board noted that there was a difference incharacteristics between the gaskets taken fromthe Prototype Assembly and the First ArticleAssembly. There was evidence of fiber in thePrototype Gasket, but there was no evidenceof fibers in the First Article Assembly Gasket.The P-22 personnel made similar observationson the day of the leak discovery.

Facts and Analysis3.0

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Gasket strength characteristics were similar tothose of un-reinforced rubber. The Young’smodulus for the Prototype Assembly Gasketranged from 4000-9300 psi, depending on thedirection of the applied stress during testing.This range is apparently related to the orientationof the nylon reinforcement. The Young’smodulus for the First Article Assembly Gasketwas not significantly dependent on orientation.However, the modulus varied significantly whenexposed in mineral oil. The modulus of materialexposed to the oil was 370-440 psi comparedto 1100-1270 psi for the sample not exposedto the oil.

4. The First Article Assembly Gaskets showedsignificant degradation due to exposure to themineral oil. Density measurements wereperformed on the Prototype Assembly and FirstArticle Assembly Gaskets. Tests wereconducted on samples taken from the lowestportion of the gasket exposed to the oil andfrom the top portion of the gasket that was notexposed to the mineral oil. The densities of thetwo types of gaskets are not the same. ThePrototype Gasket had an average density of1.21 to 1.23 g/cm3 for all portions, whereas thedensity of the First Article Assembly was 1.42g/cm3 when exposed to oil and 1.54 g/cm3 whennot exposed to oil. When combined with thetensile strength test results, the Board concludedthat exposure to oil had resulted in significantdegradation of the physical properties of thegasket material.

With respect to the installation of the Rear Tri-PlateGaskets in the First Article Assembly, the Boardmade the following observations:

1. The Rear Tri-Plate Gaskets were shipped rolledand secured to a pallet. This is noteworthy asthe rolling of the gaskets could introduceadditional stress outside of their designparameters.

2. The Prototype Assembly Gasket and the FirstArticle Assembly Gaskets were of similar, butnot identical, chemical composition. FourierTransform Infrared Spectroscopy wasperformed on samples from the First ArticleAssembly and Prototype Assembly. The resultsshowed a presence of Nitrile, the componentidentified in the drawing. Differences wereobserved in hydroxide (OH) content, but noconclusions could be made. There was nospectral evidence indicating that the gasketswere made of Neoprene or Viton. Intervieweesacknowledged that the material specificationsfor the Rear Tri-Plate Gaskets were takendirectly from a manufacturer’s material list for“Nitrile-Nylon Inserted Diaphragm.” TheBoard concluded that some of thesespecifications, such as Nylon Fabric Insertion15-ounce and Tensile strength 1000 psi, wereunclear as procurement requirements and mayhave been interpreted differently by variousmanufacturers of the gaskets. The Nitrile (BunaN) Polymer specifications did not provide arequirement for Nitrile content. Nitrile is acopolymer of butadiene and acrylonitrile, andits content varies in commercial products from18% to 48%. The exact percentage of Nitrilewas not quantified, but appeared to be of similarmagnitude in both samples. As the Nitrilecontent increases, resistance to petroleumbased oils and hydrocarbon fuels increases. TheBoard determined that the two gaskets’materials were different, but both contained theNitrile component specified in the requirements.

3. The Rear Tri-Plate Gaskets did not meet TensileStrength requirements. Tensile measurementswere performed on the Prototype Assemblyand First Article Assembly Gaskets, includingsamples taken from the lowest portion of thegasket exposed to the oil and from the topportion of the gasket that was not exposed tothe mineral oil. The Prototype Gasket materialhad a pronounced yield point. In contrast, thetensile strength of the First Article AssemblyGasket material was much lower than thePrototype Gasket. The First Article Assembly

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2. The First Article MU Tank interface edges werenot ground to a chamfered edge. This designfeature was intended to reduce stressconcentration on the gasket.

3. The VTL Tank interface was not machined to arounded edge. As with the chamfered edge ofthe MU Tank, this feature was intended toreduce stress concentration on the gasket.

4. Tank interfaces were not coplanar. The offsetmeasurements ranged from 0.35 to 0.85 inches.

The last three observations above need furtherdiscussion to explain their significance. The Boardwas provided with Atlas design calculationsdeveloped to determine the maximum stresses onthe Rear Tri-Plate Gasket as a result of thehydrostatic pressure from the mineral oil. Atlasengineers used an established formula from Roark’sFormulas for Stress and Strain, 5th Edition.According to Roark, the formula can be usedprovided that:

• The maximum deflection of the plate (gasket) isnot more than one-half the thickness.

• The edge conditions are those of a rectangularplate with two long fixed edges; two short edgessimply supported.

• Forces on the flat plate are oriented in a directionnormal to the plane of the plate.

Contrary to these assumptions, the Boarddetermined that:

• The deflection in the gasket (caused by thepressure of the oil) exceeded one-half of thethickness of the gasket. The gasket retained thisdeflection even after removal from the FirstArticle Assembly.

• The edge conditions selected for the gasketdesign calculation do not accurately representthe installed conditions of the gasket. The edgeconditions of the installed gaskets are more

complex than are those of a rectangular platewith two long fixed edges; two short edgessimply supported.

• The pressure from the mineral oil was not in adirection normal to the plane of the gasket, sincethe First Article MU Tank and VTL Tankinterfaces with the gasket were not coplanar.The offset measurements between the FirstArticle MU Tank and the VTL Tank rangedfrom .35 to .85 inches. (This condition wouldalso violate the assumption regarding deflectionof the gasket.)

Based on the differences between the designassumptions and the installed configuration of thegasket, the Board concluded that the design basisfor the gasket did not accurately reflect the actualstresses in the gasket. Of special concern are thecorner areas where the horizontal and verticalbacking bars meet, which is the region where theFirst Article Assembly Rear Tri-Plate Gasket failed.The stress concentration factor in these corner areascould be much greater than the value used in theAtlas project calculations.

The Board found that the gasket calculations andthe associated specifications were used for both thetwo gaskets in the First Article Assembly and the24 gaskets in the Atlas machine. Furthermore, theBoard determined that the assumptions used for thedesign of the gaskets were not incorporated intospecifications for their installation. For example,neither the allowable gasket deflection nor theallowable deviation from coplanar alignment of theMU and VTL Tanks were specified in assemblydrawings or procedures.

The Board also measured torque readings for thebacking bar mounting bolts. The values ranged from4 ft-lb to 21 ft-lb at the time of removal, but theBoard could not make a conclusion concerning thetorque at installation based on the torque readingsat removal.

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Conclusion

Although the same specifications were provided forthe Prototype Assembly and First Article AssemblyGaskets, the tests described above and physicalinspection show that the two materials are notcomparable, especially with respect to tensilestrength. In addition, the strength of the First ArticleAssembly Gasket was further reduced whenexposed to the mineral oil and also reduced by nothaving the specified nylon insert. As a result, thetensile strength of the First Article Assembly Gasketwas lower than required by the specifications andthis factor contributed to the material failure andsubsequent oil leak.

From this analysis the Board concluded thefollowing:

The Rear Tri-Plate Gaskets installed on the FirstArticle Assembly did not meet design andprocurement specifications for material compositionand tensile strength.

• The Rear Tri-Plate Gaskets installed on the FirstArticle Assembly did not meet shipping andinstallation specifications.

• Design assumptions for the Rear Tri-PlateGaskets did not accurately represent the FirstArticle MU Tank and VTL Tank interface designand as-built conditions.

• Design specifications in drawings did not containadequate detail and clarity to ensure theprocurement of the appropriate gasket.

• Of significant importance, the Board concludedthat the Rear Tri-Plate Gaskets used on the Atlasmachine should be re-evaluated by LANL todetermine if a similar failure could occur. LANLshould confirm the Atlas Rear Tri-Plate Gasketsare adequate for their intended application.

3.2 Atlas Quality Assurance

An Atlas Quality Assurance Project Plan (QAPP)was prepared in January 1996 and incorporatedinto the Project Execution Plan. The ProjectExecution Plan designated Atlas as a ManagementLevel 3 (ML-3) project and defined the qualityassurance requirements to be applied consideringthe graded approach. The QAPP established fourmethods for acceptance of items and services thatcan be used either singly or in combination:

1. Evaluation of supplier’s Certification ofConformance;

2. Source inspection/surveillance, post-installationinspection;

3. Receiving inspection; and

4. Post-installation testing.

A supplemental Quality Assurance plan entitledAtlas Special Facilities Equipment QualityAssurance Program Plan was prepared inOctober 1997 as a subset of the Atlas QAPP. Thepurpose of this plan was to define quality assurancerequirements for Atlas special facility equipment,not including the exterior facility. This plan definedQuality Grade Levels (1-4) based on risk to theproject if a failure should occur in the part. QualityGrade Level 1 is the most rigorous, and QualityGrade Level 4 is the least rigorous. The failed gasketin this accident was defined as a Quality Grade Level2 item. A Quality Grade Level 2 designation wasassigned to structures, components, and systemswhose failure or malfunction of the specific item alonewould result in a major condition adversely impactingthe Atlas project such as a major impact to costand/or schedule, potential noncompliance withstatutory requirements, temporary, or minor damageto the environment, or safety significant items forthe protection of workers.

The quality requirements for Quality Grade Level 1and 2 Purchased Products specified in the SpecialFacilities Equipment QAPP included:

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• A Certificate of Conformance,

• Test data, and

• 100% Independent Verification of drawingattributes or sampling inspection based on anacceptable quality history.

The quality requirements for Quality Grade Level 1and 2 Assembled on Site Products specified in theSpecial Facilities Equipment QAPP included:

• Written work and verification instructions, and

• Independent verification of critical attributes.

A contractor for LANL developed the SpecialFacilities Equipment QAPP. The contractor alsoprovided specialists knowledgeable in the area ofquality assurance to the Atlas project. Thesepersonnel were tasked with implementing the qualityassurance requirements in the plan. These QAspecialists left the project in mid-1999. At this pointin the project, no one was specifically assignedresponsibility for defining and enforcing qualityrequirements. This was shortly before receipt ofthe failed gaskets on the First Article Assembly.

A Certificate of Conformance, dated August 1999,was received from the manufacturer of the FirstArticle Assembly Rear Tri-Plate Gasket. No receiptinspection or independent verification of drawingattributes was performed for this gasket. No recordof work instruction or independent verification forthe assembly of the test tank and associated gasketswere produced.

Conclusion

The Board concluded that LANL did not adequatelyimplement the applicable quality assurance plans.Specifically, the project did not have an assignedQA manager and staff; receipt inspections of keycomponents were not performed; self-assessmentsof the QA implementation were not performed; andno assembly instructions were prepared and utilized

for the First Article Assembly. As a result of notfully implementing the quality assurance plans, a non-conforming gasket was improperly installed in theFirst Article Assembly that was the direct cause ofthe accident.

3.3 Procurement

The Special Facilities Equipment QAPP defines thefollowing procurement requirements for QualityGrade Level 2 items:

• Supplier must be on approved supplier list,

• Certificate of Conformance required,

• Test data shall be requested,

• 100% Independent Verification of drawingattributes or sampling inspection based on anacceptable quality history,

• Items shall be inspected, and/or tested andaccepted, in accordance with the qualityrequirements,

• Quality Manager shall conduct randomassessments of the Atlas project, and

• A minimum of one management assessment shallbe conducted annually to verify the adequacyof the QAPP.

The First Article Assembly equipment was procuredunder two subcontracts. Subcontractor A suppliedthe First Article MU Tank Assembly for the MarxUnits and Subcontractor B provided the VTL Tank,stand-off insulators, center Tri-Plate Tank Gaskets,and the Rear Tri-Plate Gasket (the gasket thatleaked). Both of these subcontracts were solicitedand awarded by the LANL Business OperationsDivision Procurement Group. During the fabricationprocess, the Atlas Project Engineer visited theproduction facilities to evaluate the quality of theproducts, perform inspections, and make anyneeded adjustments. During these site visits, the

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Rear Tri-Plate Gasket was not available forinspection, since it was procured from asubcontractor to Subcontractor B.

The First Article MU Tank was received at LANLin May 1999 and the VTL Tank and associatedparts were received in August 1999. Certificatesof Conformance, dated August 1999, were receivedfor each of the items procured from SubcontractorB. A Subcontractor B engineer signed theCertificates of Conformance for the gasket, eventhough it was manufactured by a subcontractor toSubcontractor B. No inspection or testing wasperformed upon receipt at LANL on the Rear Tri-Plate Gasket or other procured articles for the FirstArticle Assembly.

The electrical components of the Marx Units thatare housed in the First Article MU Tank areimportant elements for the proper functioning of theAtlas machine. These components were assigneda Quality Grade Level 2 in accordance with theSpecial Facilities Equipment QAPP, the samedesignation assigned to the First Article Assemblycomponents. However, the inspection andacceptance testing were much different. Theelectrical components for the Marx Units werepurchased under a separate procurement. LANLimplemented an onsite, rigorous testing protocol andacceptance criteria to ensure that the capacitors metthe prescribed reliability budget for a design life of3,000 shots. The capacitors are a special-manufacture item that have a potential for failureand were designated as a special emphasis area bythe LANL Design Engineer. The QAPP requiredindependent verification, inspection, and testing.These were implemented.

Conclusion

Besides the issues already identified related to theimplementation of the QA program in general(section 3.2), the Board concluded that the RearTri-Plate Gaskets for the First Article Assemblywere treated less rigorously than other componentsof the same Quality Grade Level during LANL’s

procurement, receipt, and installation efforts.Because the gaskets were not inspected or testedlike the electronic components, the non-conformingRear Tri-Plate Gaskets were not identified prior toinstallation in the First Article Assembly.

3.4 Spill Preparedness

LIR 404-50-01.1, Water Pollution Control,requires that a Spill Prevention Control andCountermeasures (SPCC) Plan be developed andimplemented prior to an aboveground storage tank(AST) being placed into operation. If the ASTsupports experimental equipment such as a MarxTank, the LIR advises that the experimentalequipment be included in the SPCC. The FacilityManager, safety and environment responsible linemanager, and supervisors are to ensure that anyrequirements identified be included in a HazardControl Plan. According to the LIR ImplementationStatus Report of 02/01/01, ESH-18 determined thatthis LIR was implemented.

Prior to issuance of the LIR, TA-35 personnelidentified a need to develop an SPCC Plan toaddress the hazard of the planned outdoor oil storagetank to fulfill a requirement of 40 CFR Part 112,Oil Pollution Prevention. At the time, the outsidestorage tank was not complete, and information wasnot available to complete the SPCC document.Therefore, its development was delayed, butmeanwhile the P-Division personnel saw the needto prepare a document to address the storage oflarge quantities of oil in Building 125, and thepotential for its release to the environment. Theycontracted for the development of the SpillPreparedness Plan dated May 1999. Thisdocument identified the potential for a major spillthat could flood the building floor and flow into thebasement, and suggested methods for directing oilinto the basement to prevent its escape to theenvironment. Of important note is that this documentaddressed the static, non-operational as well as theoperational aspects of potential spills, and providedmitigating and preventive measures. It also identifiedthe First Article Tank as a potential spill source.

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The plan contained numerous requirements,including:

• A written inventory of available spill controlequipment shall be maintained and checkedmonthly by operations personnel.

• Employee training will be conducted at leastannually to provide instruction on the operationand maintenance of equipment and proper spillresponse measures.

• Training must include the protocol used to reportspills so that immediate countermeasures canbe initiated. Personnel involved in spill responsewill be instructed on safety precautions andtrained in how to use available spill controlmaterials. Such training will include periodicspill response equipment tests and spillequipment deployment drills. (A sample log todocument equipment testing and drills wasincluded in the plan.)

• Project personnel will be properly trained toperform basic maintenance inspections forleakage from equipment, piping, and oil drumstorage. (A sample inspection form wasincluded in the plan.)

• At the end of each day, temporary containmentbooms will be placed around HV MaintenanceUnit [First Article Assembly] in a manner toprovide secondary containment in case of anunattended leak.

• Regular maintenance inspections will beperformed on the Atlas machine, the HVMaintenance Unit, supply lines (including acrossbasement ceiling), R & D operations, and oildrums.

• General operator observations should includea check for leaks, secondary containmentcondition and general safety condition at thesite.... . Walk around inspections will beperformed quarterly by the FM using a formsimilar to inspection forms in Appendix A.

• The HV Maintenance Unit will have some typeof overflow protection for initial filling.

• It is likely that an oil spill on the first floor couldmigrate to the basement through cracks andimproperly sealed utility sleeves; all these areaswill be sealed properly.

The Physics Division did not implement thiscomprehensive set of spill preparednessrequirements.

Subsequently, efforts were initiated in July 2000 tocalculate the maximum foreseeable oil spill andensure it could be contained within Building 125.This volume was estimated at 29,000 gallons, basedon a leak from one Marx Unit Tank, and includingthe volume of oil shared by all tanks. P-26 personnelconcluded this volume could be contained withinthe building using 2-inch barriers if all potential leakpaths were sealed. Plans were initiated to seal theremainder of the floor of the High Bay as projectschedule permitted. Sealing the remainder of thefloor has not been completed to date.

In July 2000, P-Division issued an SPCC to addressthe requirements of 40 CFR Part 112. Thisdocument only addressed the 40,000 gallons of oilcontained in the outside AST. No mention orconsideration of the 160,000 gallons of oil in theAtlas machine and the 11,515 gallons of oil in theFirst Article Assembly is provided in the SPCCPlan. In addition, a revised, one page, SpillPreparedness Plan (TA-35-125) was published byP-26 in November 2000, and includes the followingprovisions:

• All potential exit paths have been sealed againstuncontrolled oil flow from the defined area intothe environment.

• A floor coating has been applied to seal anyhidden cracks in the concrete floor structureand as an added benefit this encapsulates theexisting lead base floor covering as well.

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This plan assumed that any release of oil from Atlasinto Building 125 could be totally contained withinthe building. The plan states that the floor area inthe Atlas High Bay can contain the 29,534 gallonsof oil from a spill. It recognizes that the buildingbasement is available and would contain the entiremachine capacity should additional volume benecessary. No consideration or recognition ofproperty damage or disruption of co-tenants isprovided. Requirements such as training, temporaryspill containment measures, and equipmentinspection contained in the May 1999 plan werenot incorporated in the November 2000 version.As noted by the Board during inspection of thefacility, the entire floor has not been sealed.Furthermore, the sealing of penetrations was foundto be ineffective in preventing oil from leaking intothe basement.

As discussed earlier, an operational event thatdamaged one of the Atlas transmission line tanks inNovember 2000 led to discussions between theFMU-77 Group, the Atlas Group, and theresearchers in the basement Optics LaserLaboratory (MST-10) regarding the potential foran oil spill into the basement. It became clear thatthe entire High Bay floor had not been sealed andthat additional acceptance testing operations wouldoccur before any sealing activities could take place.The potential for damage to the basement laserlaboratory equipment as a result of both oil and dust/debris from full power shots was recognized anddiscussed. The Atlas Group believed that they couldcontrol a spill during the remaining tests andcommitted to sealing the remainder of the floor aftercompletion of testing. Additional requirements forthe placement of booms along the sealed portion ofthe floor during test shots were implemented toprevent oil flow over the unsealed portion of thefloor should a spill from the Atlas machine occur.However, no consideration of a static, non-operational oil leak was addressed in thesediscussions, and the First Article Assembly was notidentified as a possible spill source.

In this present accident, the floor was challengedwith approximately 6,700 gallons, significantly less

oil than the calculated maximum 29,534 gallons ofavailable containment. Even with this reducedvolume, oil leaked past the building barriers andalso reached the basement. The volume for themaximum foreseeable oil spill was recalculated whilethe Board was onsite and the revised number is32,938 gallons. The spill prevention process doesnot address this additional volume.

Conclusion

Based on these considerations, the Board concludedthe following:

• Booms and berms installed in the building werenot designed for the protection of propertylocated in the building basement.

• Booms and berms installed in the building weredesigned to contain oil in the building to preventenvironmental releases.

• Spill Preparedness Plans prepared for the facilitytook credit for the basement as secondarycontainment for a spill to prevent environmentalrelease.

• Assumptions utilized in the Spill PreparednessPlans were not adequate, and were notimplemented.

• P-Division delayed taking corrective actions forrecognized spill preparedness weaknesses toavoid impacting acceptance testing schedulesfor Atlas.

• No routine program for inspecting gasketcondition has been implemented for either theFirst Article Assembly or the Atlas machine.

• Because the controls (sealed floors, booms, leakdetection devices, and inspection of equipment)identified in the various spill preparedness planswere not implemented or failed as designed,the oil was not contained and leaked into thebasement area causing property damage.

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3.5 Hazard Recognition andAuthorization Basis

The Atlas Project has been categorized as a non-nuclear low hazard activity in accordance withLANL LIR 300-00-05.1, Facility HazardCategorization. LANL LIR 300-00-07.1, Non-nuclear Facility Safety Authorization, describesfacility safety authorization as the affirmation by linemanagers that facility and activity level controlsadequately protect workers, the public and theenvironment. A secondary purpose of authorizationis to protect property. It specifies that theAuthorization Basis for non-nuclear low-hazardfacilities will be the Facility Safety Plan (FSP). TheFSP is prepared at the FMU level and shall describeas a minimum the facility and its activities, identifyand analyze their hazards, and establish facility-levelcontrols. Readiness to commence low-hazardactivities within the FMU is verified by theperformance of a Readiness Assessment conductedby the Laboratory. Laboratory implementationguidance for the Facility Safety Plans states that “Theoperations of each tenant are reviewed for theirimpact on the operations of the other tenants….”

The FSP for FMU-77, which includes Building 125,was approved on September 25, 1999. The FSPincludes descriptions of facilities within FMU-77,the hazards presented by these activities andoperating limits to control the hazards. The FSPcontains a discussion of the electrical hazards of theAtlas Marx banks and High Voltage Capacitors,but does not address the potential for oil spill or itspotential impact on other building tenants. TheBoard noted that the previous revision of the FSPcontained an operating limit requiring additionalanalyses by the FMU for “the use or storage of oiland other low toxicity liquid chemicals in containersgreater than 60 gallons or of a total volumeexceeding 1000 gallons.” This limit, which wouldhave required more analysis of the >160,000 gallonsat Atlas, and other LANL requirements were notcarried forward to the latest revision of the FSP.The reason provided to the Board for the removalof these requirements was feedback from facility

tenants, internal assessments, and institutionalchanges in the FSP requirements.

The FMU-77 FSP requires analyzing changes inwork process, room usage, or proposed newoperations. LANL requirements documents definehazard as “Any source or situation with potential tocause injury or harm to workers or the public, harmto the environment or incurred liability, or damageto or loss of property.” Hazards and situations orcircumstances in which they could cause harm mustbe identified and evaluated to determine whethercontrols are needed to reduce the risk to anacceptable level. Controls identified by the FSPprocess are implemented using the Hazard ControlPlan (HCP). The HCP developed for the Atlasactivities only addresses safety hazards that includehigh voltages, elevated work platforms, and slipperysurfaces. Oil spill mitigation and control is referencedto the Atlas Spill Preparedness Plan (previouslydiscussed in Section 3.4). No consideration ofproperty damage or loss is provided.

The Atlas facility organization was transitioning fromthe construction and startup phase to operationalstatus at the time of the accident. The First ArticleAssembly has been effectively operating for 18months, but does not have supporting operationalprograms such as a Preventive MaintenanceProgram in place. Physics Division has delayeddevelopment of programs necessary to supportoperations, such as Preventive Maintenance andprocedures until after the approval to beginoperation is received.

A LANL-directed Readiness Assessment (RA) toconfirm readiness to commence Atlas operation wascompleted by LANL on January 4, 2001. The RAconcluded that Atlas was prepared to safelycommence operation. Several issues were listedas Observations in the RA that addressed the lackof operating procedures, maintenance requirements,and health protection monitoring. None of theseissues were identified as pre-start findings. The RAdid not address the identification and mitigation ofpotential oil spills or the hazard evaluation of the oilstored in the Atlas facility. The Board noted that

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the RA had not established prerequisites forperformance of the facility.

Hazards associated with operations of the Atlasfacility are identified and addressed in the FacilitySafety Analysis (FSA) for the Atlas Pulsed-Power Facility, November 1, 2000. Thisdocument identifies potential hazards and evaluatestheir potential effect on the public, worker and theenvironment. The potential for a leak of mineral oilfrom the Atlas machine is addressed. The mostsevere potential consequences identified were tothe environment and were categorized as “substantialcontamination of the originating facility/activity, minoronsite contamination, no offsite contamination.” Theanalysis recognized that a piping break could resultin a leak into the basement, and that a large leakwould create an operational problem but would notpresent a significant offsite hazard. Potentialconsequences for collocated tenants and propertywere not considered.

Facility-Tenant Agreements are required for allfacilities. A Facility-Tenant Agreement has beenestablished for FMU-77 management and Building125 tenants that include P-26 and MST-10. Theagreement outlines the roles and responsibilities asdefined in the LIR. The FMU-77 Facility-TenantAgreement also includes the duties of the FacilityManager, the responsibilities of the individualemployees, and the approved FMU-77 policies andprocedures. Based on the agreement, the FacilityManager (FM) shall concur with all changes intenant operations or configuration that couldadversely affect other tenants or the physical facility.The FMU shall also monitor the tenant operationsto determine if they meet the FSP and Facility-Tenant Agreement requirements. For known life-threatening hazards and potential majorenvironmental contamination incidents, the FM andtenant are required to agree that resources will benegotiated to ensure mitigation.

Although recommendations were developed in the1999 Spill Preparedness Plan, FMU-77 did notensure implementation of these recommendations.The FSA identified monitoring as a control to

mitigate the spill hazard, but the FMU-77 did notensure this control was in place.

Conclusion

Based on these considerations, the Board concludedthe following:

• Hazard analyses and mitigation measuresassumed that any leak would occur duringmachine operation, not when the machine wasshutdown or the building unoccupied.

• The potential for property damage was notaddressed in the development of the FacilitySafety Plan, the Facility Safety Analysis, andthe scope of the RA.

• Hazard analyses performed for the facilityidentified that the potential for a spill wouldoverflow to the basement, but mitigationmeasures to protect property located in thebasement were not identified and implemented.

• The facility hazard analysis did not consider thepotential impact of facility hazards on collocatedtenants in the building.

• Since property damage was not identified as ahazard in the analysis documents, appropriatecontrols were not identified to prevent damageto the collocated tenants. However, if thecontrols identified in the spill control plan werein place, the property damage may have beenavoided.

The Board also concluded that if a PreventativeMaintenance Program was in place for the FirstArticle Tank operations and were further developedfor the Atlas Machine, the deterioration of the gasketmight have been discovered prior to failure.

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3.6 Feedback and Improvement

The Board determined that throughout the timeframeof the Atlas project LANL had severalopportunities to identify and respond to lessonslearned from related events. Section 2.4 discussedfour events that were directly related to this accident.Some of those events focused direct attention onthe potential hazards to collocated programs andproperty. Another represented a self-identifiedprogrammatic breakdown in the lab-wide QAprogram that contains the same issues identified forthis accident. In addition, the RA made severalobservations about the lack of operatingprocedures, maintenance requirements, and healthprotection monitoring. However, these observationswere not elevated to a level that would promptappropriate and timely corrective actions.

The Board noted from both interviews anddocuments that the facility personnel were awareof the potential for property damage andprogrammatic impacts to collocated activities.However, the response to these concerns was nottimely, and was never incorporated into the formalprocess for the identification, evaluation, andmitigation of these hazards.

Conclusion

The Board concluded that there had been multipleopportunities for LANL to recognize and correctthe situations that resulted in this accident before itsoccurrence. However, lessons learned fromprevious events were not incorporated in a proactiveand timely manner. Even when corrective actionswere identified, they were intentionally delayed soas to not impact project schedule.

3.7 DOE Oversight

DOE provides oversight of Physics Divisionconstruction and project activities through theLAAO Project Management Group, which

provides oversight of facility construction and projectcompletion. The LAAO Facility Representatives(FR) provide oversight of operational activities.

The Project Management Group personnel havebeen closely involved with execution of the Atlasproject. Their oversight focused on budget andschedule execution of the First Article Assemblyand the Atlas machine, and a review of the projectCD-4 package for approval. No assessments offacility performance were conducted by DOE tosupport CD-4.

LAAO operational oversight of Atlas has beenlimited to review of facility startup plans andresponse to occurrences. The LAAO ProjectManager consulted the FR Team Leader on the planfor facility startup and the contractor RA. The FRTeam Leader provided input to the RA scope andTeam makeup, and concurred with the level of RAand startup authority. No operational assessmentsof the Atlas facility operations or of the LANL-directed RA of Atlas have been performed by DOE.

Shortcomings in the utilization and effectiveness ofthe LAAO FR Program were identified in a previousaccident investigation (Type A Investigation of theMarch 16, 2000 Plutonium-238 Multiple IntakeEvent at the Plutonium Facility, Los AlamosNational Laboratory, New Mexico) and in aLAAO FR Program Self-Assessment performedAugust 2000. An Action Plan was developed inresponse to a Judgment of Need from the Type AInvestigation, and implementation is in progress.Corrective actions for the LAAO FR Program Self-Assessment are under development and areexpected to closely parallel those from the Type AAccident Investigation.

In December 1999, the LAAO FR Programdeveloped a staffing plan to ensure that resourcesare appropriately applied to facilities with the highestrisk. The Atlas facility, characterized as a non-nuclear, low hazard facility in P-Division, is currentlynot a high priority facility for FR coverage. Availableresources are applied to higher risk facilities andare available to the Atlas facility on an as-needed

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basis. Additional oversight of lower risk facilities,such as Atlas, is planned, as additional resourcesbecome available.

Conclusion

The DOE oversight of the Atlas project did notidentify the programmatic breakdown of the Atlasproject QA processes or the weaknesses of thefacility hazard analysis processes. However, theBoard concluded that the level of oversight providedwas consistent for the level of hazard identified forthe facility. Furthermore, the Board evaluated thecorrective actions underway to respond to thejudgments of need identified in the recent Type Aaccident investigation at the LANL PlutoniumFacility, and concluded that if implemented fully, thesecorrective actions should improve the oversight atother facilities such as Atlas. Therefore, nojudgments of need were identified in this area.

3.8 Barrier Analysis

Barrier analysis is based on the premise that hazardsare associated with all tasks. A barrier is anymanagement or physical means used to control,prevent, or impede the hazard from reaching thetarget (i.e., persons or objects that a hazard maydamage, injure, or harm). The results are integratedinto the Change Analysis Worksheet, Attachment3. Attachment 2, Barrier Analysis Worksheet,contains the complete barrier analysis performedby the Board.

The Board reviewed engineered containment(gaskets, berms, sealed floor, and leak detectiondevices) and management controls (Inspection,Hazard Control, Spill Prevention Plan, FacilityHazard Analysis, and Quality Assurance) inidentifying barriers and assessing their performance.

Physical barriers that either failed or were missinginclude:

• Containment: Gaskets were used as part ofthe primary containment boundary, rather thanbolting the First Article MU Tank to the VTLTank, introducing a potential gasket failure intothe design.

• Gaskets: The Rear Tri-Plate Gasket did notmeet design specifications and failed under thestatic pressure of the oil.

• Berms: Installed berms were intended tocontain any leakage. The sealing around someberms did not contain the leak and some bermswere not installed.

• Sealed Floor: A sealed floor with effectivesealing around floor penetrations would havelessened the leak into the basement. The eastside of the High Bay area had not been sealed.

• Leak Detection Devices: No leak detectiondevice with alarm capability was installed toprovide notification of the leakage.

Management System barriers that either failed orwere missing include:

• Inspection: A periodic inspection could haveidentified potential bulges or cracks in thegasket. No inspection frequency of the gasketshad been developed.

• Hazard Control Plan, Spill Prevention Plan, andFacility Hazard Analysis: The potential for aleak and overflow to the basement had beenrecognized, but no actions to protect propertyin the basement had been identified andimplemented.

• Quality Assurance: An effective QA programmay have detected the deteriorating gasket, theflawed design and/or the inadequatespecification.

• Avoidance: Keeping high-value equipment outof vulnerable areas in the basement would havelessened the property damage.

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• Feedback and Improvement: P-Division didnot take prompt action on lessons learned fromprecursor events.

Table 3-1 Consolidated Barrier Analysis and ISMSLink presents the Board’s summary of the physicaland management barriers consolidated fromAttachment 2. The physical and managementbarriers are also linked to the five core functions ofIntegrated Safety Management.

Table 3-1. Consolidated Barrier Analysis and ISMS Link

3.9 Change Analysis

The change analysis process examines planned orunplanned changes that caused undesirable resultsrelated to the accident. This process analyzes thedifference between what is normal, or expected,and what actually occurred prior to the accident.The results of the change analysis are integrated intothe Change Analysis Worksheet to support the

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development of casual factors. The Events andCausal Factors Chart, Attachment 4, contains thecomplete documentation of the Change Analysis.

Conditions differing from the ideal situation thatcontributed to the oil leak were: an improper gasketinstalled on the First Article Assembly; QualityAssurance Program requirements were not fullyimplemented for the First Article Assembly; flangesof the First Article MU Tank and connecting VTLTank were not coplanar; and the gasket was notshipped in the specified “flat” configuration.Unsealed cracks and penetrations existed in the floornear the First Article Assembly. The First ArticleAssembly has been effectively operating for someeighteen months, but does not have supportingoperational programs such as a PreventiveMaintenance Program in place.

The Facility Hazard Analysis assumed that anyleakage would occur as a result of machineoperation when the building was occupied. Yet,the leak occurred on a static tank over a weekendwhen no workers were in the building, and wasundetected until the following Monday morningbecause there was no level monitoring or leakdetection system installed to provide an alarm.High-value equipment was located in a vulnerablearea, in a building occupied by multiple tenants fromdifferent organizations. The potential for oil to leakinto the basement had been recognized, andbasement space was credited to help contain a

potential leak; however, no mitigation plans toprotect the laser laboratory equipment had beendeveloped.

3.10 Causal Factors Analysis

A causal factors analysis was performed inaccordance with the DOE Workbook, ConductingAccident Investigations, Rev. 2. Causal factorsare the events or conditions that produced orcontributed to the occurrence of the accident andconsists of direct, root and contributing causes.

The direct cause is the immediate event or conditionthat caused the oil leak.

Root causes are events or conditions that, ifcorrected, would prevent recurrence of this andsimilar accidents.

Contributing causes are events or conditions thatcollectively with other causes increase the likelihoodof the oil leak but that individually did not cause theaccident.

A summary of the Board’s causal factor analysis ispresented in Attachment 4, Events and CausalFactors Chart. The Board’s summary of CausalFactors follows.

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DIRECT CAUSEA gasket on a tank containing insulating mineral oil failed, allowing the oil to leak onto and damage equipment in twobasement laser laboratories.

ROOT CAUSESRC 1 Physics Division management failed to implement established processes for Quality Assurance in the design,

fabrication and assembly of the First Article Assembly. (CC1, CC8, CC9)RC 2 Physics Division management failed to conduct a comprehensive process for hazard recognition and

mitigation, including consideration of property protection, in accordance with established laboratoryrequirements. (CC2, CC3, CC4, CC5, CC7)

No. Contributing Cause DiscussionCC1 Physics Division did not ensure

effective implementation of theAtlas project Quality Assurancerequirements.

• The Rear Tri-Plate Gaskets installed on the First ArticleAssembly did not meet design and procurement specificationsfor material composition and tensile strength.

• The Rear Tri-Plate Gaskets installed on the First ArticleAssembly did not meet shipping and installation specifications.

• Design assumptions used in specifying the Rear Tri-PlateGaskets for the First Article Assembly and Atlas machine donot accurately represent the First Article MU Tank and VTLTank interface design and as-built conditions.

• A Quality Assurance plan had been developed that wasapplicable to the Atlas and First Article Assembly design andconstruction, however, key elements of the plan were notadequately implemented, including:a. The project lacked a QA Manager and staff,b. Receipt inspections of key components were not performed,c. No self-assessments of QA implementation were performed,d. No assembly instructions were prepared and utilized for the

First Article Assembly.• The Rear Tri-Plate Gaskets for the Atlas First Article Assembly

were treated less rigorously than other Quality Grade Level 2components.

CC 2 Physics Division did not ensurethat the Spill Preparedness Plandeveloped for Atlas was properlyscoped to address potentialleakage during non-operationalperiods and protection ofproperty.

• Booms and berms installed in Building 125 were not designedfor protection of property located in the building basement.

• Booms and berms installed in Building 125 were designed tocontain oil in the building to prevent environmental release.

• Spill Preparedness Plans prepared for the facility took credit forthe basement as secondary containment for a leak to preventleakage to the environment.

• Hazard analyses and mitigation measures for the facilityassumed that any leak would occur during machine operation,not when the machine was shutdown and the building wasunoccupied.

• The potential for property damage was not addressed indevelopment of the Facility Safety Plan and Facility SafetyAnalysis.

• Assumptions utilized in development of the facility SpillPreparedness Plan were less than adequate.

CC 3 Physics Division did not ensurethat requirements of the SpillPreparedness Plan wereeffectively implemented.

• Booms and berms installed in Building 125 for spillcontainment did not function as intended.

• The first floor of Building 125 was not completely sealed.

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CC 4 Physics Division did notimplement LANL requirementsfor the consideration of propertyprotection and impact on co-tenants in development of theauthorization basis, FacilitySafety Plans and hazard analysis.

• There was no leak detection and alarm instrumentation installedon the Atlas facility or Building 125.

• Hazard Analyses performed for the facility identified thepotential for a leak that would overflow to the basement, butmitigation measures to protect property located in the basementwere not identified and implemented.

• Hazard analyses and mitigation measures for the facilityassumed that any leak would occur during machine operation,not when the machine was shutdown and the buildingunoccupied.

• The potential for property damage was not addressed indevelopment of the Facility Safety Plan and Facility SafetyAnalysis.

• The facility hazard analysis did not consider the potentialimpact of facility hazards on collocated tenants in Building125.

CC 5 The FMU did not effectivelyimplement their responsibility toensure that tenant operations donot adversely affect other buildingtenants.

• The facility hazard analysis did not consider the potentialimpact of facility hazards on collocated tenants in Building125.

CC 6 Physics Division did not developand implement a PreventativeMaintenance Program for theFirst Article Assembly and AtlasMachine.

• No routine program for inspection of gasket condition has beenimplemented for either the First Article Assembly or the Atlasmachine.

• The Atlas facility organization was transitioning from theconstruction and startup phase to operational status at the timeof the accident.

• Physics Division has delayed development of programsnecessary to support operations, such as PreventiveMaintenance and procedures until after the approval to beginoperation is received.

CC 7 Physics Division did notimplement an effective Feedbackand Improvement Programincorporating lessons learnedfrom precursor events.

• The facility Feedback and Improvement Program did noteffectively apply lessons learned from precursor events.

• A month prior to this accident, an event occurred at the Atlasfacility that directly focused attention on potential propertydamage and co-tenant concerns, but response was delayed andless than adequate.

• The facility did not effectively implement lessons learned froma previous property damage accident investigation at TA-35, inconsidering vulnerability of property located in basements.

• Pre-requisites for performance of the facility ReadinessAssessment were not established.

CC 8 Design specifications in drawingsfor the procurement of the RearTri-Plate Gasket were less thanadequate.

• Design specifications in drawings did not contain adequatedetail and clarity to ensure the procurement of the appropriategasket.

• Design specifications for the Rear Tri-Plate Gaskets are thesame for the First Article Assembly and the Atlas machine.

CC 9 Design assumptions for the RearTri-Plate Gasket were less thatadequate.

• Design assumptions used in specifying the Rear Tri-PlateGaskets for the First Article Assembly and Atlas machine donot accurately represent the First Article MU Tank and VTLTank interface design and as-built conditions.

• Design assumptions for the Rear Tri-Plate Gaskets are the samefor the First Article Assembly and the Atlas machine.

No. Contributing Cause Discussion

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Judgements of Need4.0

Judgments of need (JON) are managerialcontrols and safety measures believed necessaryto prevent or minimize the probability of arecurrence. They flow from the Causal Factorsand are directed at guiding managers in the

development of corrective actions. Attachment 4,Events and Causal Factors Chart, summarizes theBoard’s causal factors and associated judgmentsof need.

No. JUDGMENTS OF NEED Related Causal FactorsJON 1 LANL needs to ensure institutional requirements

for the recognition and evaluation of property andco-tenant impacts, and the resulting controls, areeffectively implemented.

• Physics Division did not ensure that theSpill Preparedness Plan developed forAtlas was properly scoped to addresspotential leakage during non-operationalperiods and protection of property.(CC 2)

• Physics Division did not ensure thatrequirements of the Spill PreparednessPlan were effectively implemented.(CC 3)

• Physics Division did not implement LANLrequirements requiring the consideration ofproperty protection and impact on co-tenants in development of Facilityauthorization basis, Facility Safety Plansand hazard analysis. (CC 4)

• The FMU did not effectively implementtheir responsibility to ensure that tenantoperations do not adversely affect otherbuilding tenants. (CC 5)


JON 2 LANL needs to develop and ensureimplementation of an institutional QualityAssurance process applicable to all capital projectsper DOE 0 414.1A or 10 CFR 830.120, asappropriate.

• Physics Division did not ensure effectiveimplementation of the Atlas projectQuality Assurance requirements. (CC 1)


JON 3 LANL needs to ensure that facility spillpreparedness, prevention, and mitigation plansprovide for property protection as well aspersonnel and environmental protection, and thatthey are effectively implemented. Specific toAtlas, the plan needs to address the following:• Total inventory of oil in the Atlas facility;• Static as well as operating conditions;• Provisions for leak monitoring and inspection;• Spill response training;• Secondary containment; and• Impacts on collocated tenants.

• Physics Division did not ensure that theSpill Preparedness Plan developed forAtlas was properly scoped to addresspotential leakage during non-operationalperiods and protection of property.(CC 2)

• Physics Division did not ensure thatrequirements of the Spill PreparednessPlan were effectively implemented.(CC 3)


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No. JUDGMENTS OF NEED Related Causal FactorsJON 4 LANL needs to develop a Preventive

Maintenance program for the Atlas facility,including periodic inspection of gaskets usingspecific performance criteria.

• Physics Division did not develop andimplement a Preventative MaintenanceProgram for the First Article Assemblyand Atlas Machine. (CC 6)

JON 5 LANL needs to evaluate the implication ofdesign, fabrication, and Quality Assuranceshortcomings of the First Article Assembly andapply lessons learned to the Atlas machine.

• Design specifications in drawings for theprocurement of the Rear Tri-PlateGasket were less than adequate. (CC 8)

• Design assumptions for the Rear Tri-Plate Gasket were less than adequate.(CC 9)

• Physics Division did not ensure effectiveimplementation of the Atlas projectQuality Assurance requirements. (CC 1)

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Board Signatures5.0

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Board Member, Advisors, and Staff6.0

Chairperson Douglas M. Minnema, DOE/NNSA/DP-45

Member Gene E. Runkle, DOE/NNSA/AL/OSS

Member James Slawski, DOE/NNSA/DP-45

Member William Ortiz, DOE/NNSA/AL/KAO

Member Larry Hinson, DOE/SRS/HLW-OD

Advisor Ralph Fevig, PE, CSP, DOE/NNSA/AL/ISRD

Advisor Steve Fattor, DOE/NNSA/AL/SPD

Legal Advisor Michele Reynolds, DOE/NNSA/AL/OCC

Technical Writer Robin Phillips, SAIC

Administrative Support Arminda Roberts, DOE/NNSA/AL/ISRDCynthia Doughty, SAICSandra Robinson, SAIC

Laboratory Observer Phillip Thullen, Deputy Director, ES&H Division, LANL

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ATTACHMENT 1BOARD APPOINTMENT MEMORANDUM

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What were the barriers? How would the barrier perform? Why did the barrier fail? How did the barrier affect theaccident?

Containment Gaskets were used rather than boltingthe transmission line to ease thealignment of the First Article MU Tankand the VTL Tank.

The gasket is more prone tofailure than bolting the transmis-sion line to the tank.

With the introduction of the gasket,a potential failure in the gasket wasintroduced into the design.

Gasket The gaskets were designed to containthe oil in the First Article Assembly.

The material in the gasket did notmeet design specification. Thegaskets were not transported andinstalled as specified.The gasket design may not havebeen adequate.

Since the gasket did not meet thespecifications, the gasket failedunder the static pressure of the oiland the oil leaked causing theproperty damage.

Berms and booms The berms were installed to contain aleak.

They were designed to contain oilwithin the building and preventenvironmental impact.The berms intended to prevent oilfrom leaking to the basement didnot work.They were not adequatelydesigned to protect property inthe basement.

Because of the failures of theseberms, the oil was not containedand leaked into the basement area.

Sealed Floor A sealed floor with effective sealingaround floor penetrations would havelessened the leak into the basement.

The entire area of the first floorhad not been sealed.

Since the floor was not sealed, theoil leaked through cracks, expansionjoints, and floor penetrations.

Leak detection devices A leak or excess flow device wouldalarm a central station warning of apossible leak and summon emergencyresponse.

There was no leak detectiondevice with alarm capabilityinstalled. No surveillance in lieuof a leak detection device wasperformed.

The leak or excess flow devicecould have provided earlier re-sponse to the leak.

Target: EquipmentHazard: Oil Leak

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Inspection

Hazard Control Plan, SpillPrevention Plan, and FacilityHazard Analysis

Quality Assurance

A Preventive Maintenance program ofroutine inspection or replacement couldhave identified potential bulges orcracks that existed in the gasket.

These plans and analysis wouldidentify the potential hazard andassociated control to prevent the leak.

An effective QA program may havedetected the incorrect gasket andinstallation.

The Atlas project was in transi-tion from a construction andacceptance-testing phase to anoperational phase. No mainte-nance program for the gasketshad been developed. The gasketwas designed to last the entire 10-year anticipated life of Atlas.

Identified potential for spill tobasement and took credit forbasement as secondary contain-ment.Developed Spill PreparednessPlan to limit consequences ofspills and did not implement.Considered only operationalconditions, not leak from idlemachine.Did not evaluate property damageas a consequence from a leak tobasement.

There was no acceptance testingof the gasket.No installation instructions for thegasket, therefore it was notdiscovered that the gasket and itsinstallation did not meet designspecifications.No acceptance inspection of FirstArticle Assembly Tanks (cham-fered & rounded edges).

Visual inspection of the gasketsmay have identified the incipientcracks so that the oil could havebeen drained and the gasketreplaced.

The controls identified in the May1999 Spill Preparedness Plan couldhave mitigated the accident.

Because the gasket and its installa-tion did not meet design specifica-tions, the gasket failed and the leakresulted.

Hazard: Oil Leak Target: Equipment

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Hazard: Oil Leak

Avoidance

Oversight

Feedback and Improvement

Keeping high-value equipment out ofthe basement would have lessened theproperty damage.Draining tanks when not in use wouldhave minimized potential hazard.

Oversight organization would ensurethat LANL and Atlas met DOE andinstitutional expectations.

Facility would incorporate lessonslearned from previous events andoperating experience to improve Facilityactivities.

Co-tenants & property protectionwere not considered in develop-ment of safety plans, safetyanalysis, or associated controls.

Oversight was focused on Budget& Schedule.

Lessons learned from November2000 event and other precursorswere not incorporated into Facilityprocesses.

Safe work practices LIR guidance todevelop controls for propertyprotection was not implemented.

With emphasis on Budget andSchedule, weakness in QA programwas not recognized.

November 2000 event focusedattention to potential propertydamage in the basement area andco-tenant concerns and actionswere delayed.

Target: Equipment

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Accident Situation

Non-conforming gasketinstalled on First ArticleAssembly.

Hazard of oil leaking fromAtlas machine to basementwas recognized but notadequately mitigated. HazardAnalysis did not addressproperty damage.

Spill Preparedness Plan tookcredit for space in basementas secondary containment toassure that an oil leak wouldbe contained within thebuilding and have noenvironmental impact.

No Preventive Maintenanceprogram including inspectionof the gaskets had beenimplemented.

Evaluation of Effect

Improper gasket failed, resulting inoil leak that caused accident.

When leak occurred, there were noeffective barriers to prevent oil fromreaching laser equipment inbasement.

When oil leak occurred, there wasno identified method to prevent oilfrom impacting laser equipment inbasement.

Inspection of the gaskets wouldhave likely identified the deteriora-tion that had occurred in thegaskets prior to failure.

Difference

Improper gasket had insufficientresistance to stress.

Actions were not developed andimplemented to protect laserequipment in basement. Contin-gencies for an unattendedmachine were developed in May1999 Spill Preparedness Plan thatcould have limited damage hadthey been implemented.

November 2000 Revision of SpillPreparedness Plan did notaddress protection of equipmentin basement, nor did it proposemethods to limit leakage tobasement.

No Preventive Maintenance orinspection process existed.

Prior, Ideal, or Accident-Free Situation

Ideal - Proper gasket installed.

Ideal - Hazards Analysis & MitigationProcess identifies and developsmitigation for identified hazards,including potential for propertydamage.

Ideal - Spill Preparedness Plan wouldaddress protection of laser equipmentin basement.

Ideal – Implemented PreventiveMaintenance program that requiredperiodic inspection of gaskets.

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Accident Situation

Quality Assurance Program notfully implemented for First ArticleAssembly.

Laboratory containing valuablelaser equipment was located in avulnerable location, under theAtlas machine, where the potentialfor an oil leak existed.

The flanges of the First Article MUTank and VTL Tank were out ofalignment by .35 to .85 inches.

Facility assumed that any oil leakwould occur during machineoperation when facility wasoccupied and personnel availableto respond.

Poor coordination betweenmultiple tenants in same buildingfrom different organizations.

Unsealed cracks and penetrationsexisted in the building floor in thearea of the First Article Assembly.

Prior, Ideal, or Accident-FreeSituation

Ideal – Quality Assurance Programfully implemented.

Ideal – High value equipmentwould not be located in a vulner-able area. Lessons learned fromprevious Type B property damageAccident Investigation imple-mented.

Ideal – Flanges of First Article MUTank and VTL Tank that wereconnected by the gasket wouldhave been aligned, as assumed indesign calculations.

Ideal – Potential for oil leak wouldbe evaluated both for periods ofoperation and non-operations.

Ideal – Fully coordinated consider-ation of all building tenants andaggregate hazards.

Ideal – The entire building floorwould have been sealed.

Difference

Receipt inspection of gaskets andquality verification of installationnot performedDegree of rigor applied to FirstArticle Assembly was not com-mensurate with Quality Level 2significance assigned by Designer.

Laboratory containing laserequipment remained in a vulnerablelocation in the basement underAtlas, despite the concern that anoil leak could impact the laboratory.

Design of gasket did not accountfor any additional stress caused bymisalignment of gasket.

Leak occurred over weekend whenno operations were in progress andbuilding was unoccupied.

Control of aggregate hazards fromall tenant’s activities was noteffective.

LANL sealed floor directly underAtlas machine but delayed sealingremainder of floor due to scheduleconsiderations.


Consistent Quality AssuranceProgram implementation (such asrigor applied to high-tech electricalcomponents) would have identifiedthe non-conforming gasketmaterial.

When oil leak occurred, the laserequipment was in the leak path andwas impacted by the leaking oil.

Stress on gasket was not accu-rately accounted for by design.

No one was available to detect leakand initiate response to stop leakand protect vulnerable equipment.

Concerns over potential leak thatcould damage laser laboratory inbasement were not fully consid-ered and adequately addressed byprimary tenant group.

Building floor directly over laserlaboratory was not sealed, allowingoil leakage from the operating floorto the basement.

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Accident Situation

The building, containing ~ 170,000gallons of oil, contained in theAtlas machine and First ArticleAssembly had no leakage detec-tion and alarm capability.

Atlas facility was in transition fromconstruction and testing tooperations.

Prior, Ideal, or Accident-FreeSituation

Ideal – A leak detection system tomonitor for leakage and providealarm capability to a monitoringstation at all times would havebeen incorporated into systemdesign.

Ideal – Project Execution Plan pre-requisites for CD-4 complete,including:O & M ManualSA and Hazard Control Plan

Difference

No provision for detection ofchanges in level or leakage fromthe oil containment vessels. Noalarm capability for leaking tanks.

O & M Manual not completeHCP & SA does not considerunmonitored operations.


The leak from the First ArticleAssembly occurred at someunidentified time over a weekendand was not discovered untilpeople arrived at work on Mondaymorning. There was no earlywarning system that could havepermitted personnel to respondand mitigate the leak.

No inspection program in place.Unrecognized “static” hazard.

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ATTACHMENT 4EVENTS AND CAUSAL FACTORS CHART

49

ACRONYMNS AND TERMINOLOGY

AL Albuquerque Operations OfficeAST Above-ground Storage TankCFR Code of Federal RegulationsCOC Certificates of ComplianceCD-4 Critical Decision 4DEAR Department of Energy Acquisition RegulationDOE Department of EnergyDX Dynamic Experimentation DivisionDX-6 Machine Science Technology GroupEH Office of Environment, Safety and HealthES&H Environment, Safety and HealthFM Facility ManagerFMU Facility Management UnitFR Facility RepresentativeFSP Facility Safety PlanHEDH High Energy Density HydrodynamicsHV high voltageJON Judgment of NeedLAAO Los Alamos Area OfficeLANL Los Alamos National LaboratoryLIR Laboratory Implementing RequirementsMA Mega-ampere (one million amperes)M&O Management and OperatingMST-10 Condensed Matter and Thermal Physics GroupMST Materials Science and Technology DivisionMU Maintenance UnitOH hydroxideOSHA Occupational Safety and Health AdministrationP Physics DivisionP-22 Hydrodynamics and X-Ray Physics GroupP-26 Atlas Construction GroupPAAA Price-Anderson Amendments Act of 1988PM Preventive MaintenanceQAPP Quality Assurance Program PlanRA Readiness AssessmentSPCC Spill Prevention Control and CountermeasuresTA Technical AreaUC University of CaliforniaVTL Vertical Transmission Line

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