Friday, December 09, 2005

Lessons learned from CREM incident

Letter to LANL Newsbulletin
Dec. 5, 2005

Lessons learned from CREM incident

On Feb. 25, during an all-hands meeting with Department of Energy Secretary
Samuel Bodman and Senator Pete Domenici, the former laboratory director
answered a question by stating that there was an ongoing effort to document
"lessons learned" from the way that the DX Division CREM incident was
handled and investigated. Has this inquiry come to completion? Is a final
report available? If not, what is the status of the effort? If it was
discontinued, why?

I pose this question in the interest of improving the Laboratory's capacity
to document lessons from past mistakes. These will be valuable lessons to
pass to the next contractor of the Laboratory.

--Bernard Foy

Editor's Note: As part of the transition to a new contract, Director Bob
Kuckuck plans to discuss last year's Lab-wide [suspension of operations]
with the new contractor in the context of lessons learned. As part of the
discussion, Director Kuckuck will give to the new contractor a summary of
the [suspension of operations]: what led to it (and it's more than the DX
CREM incident), how incidents were investigated, how the Lab stood up (self
assessments and corrective actions), lessons learned and recommendations.
Director Kuckuck has asked his external Senior Advisory Group (SAG) to do a
lessons learned study for him. Interviews are being conducted with several
associate directors, division leaders and staff members. The SAG will bring
their observations forward to the director for discussion so that he will
be able to advise the new contractor and the National Nuclear Security
Administration on lessons learned and recommendations.

My question is:

What will the new contractor do when they receive a completely whitewashed version of the now well-known events, a version in which UC and LANL management is completely exonerated of any wrong-doing?

Doug; the answer to your question is obvious. It depends who the new contractor is! If UC, the whitewash will be added to the stack of previous UC whitewashes. If LM/Sandia, hopefully it will hit the circular file. Installing good management does not depend on understanding, in detail, the many ways to screw things up.
I suggest that the SAG talk to people where "on the ground" at the time of the CREM incident, instead of just speaking with various lab managers. By this I mean John Horne and other staff who were involved and who have first-hand knowledge of the event.

Speaking only to LANL management (who were to a very large extent part of the problem that led to the shutdown) will guarantee that the report produced will be nothing but a complete whitewash.
Just a note here: I wish to inform everyone that I, for one, have NOT been contacted in any way by the present (nor the past, for that matter) administration of the Lab, even though I am here at the Lab (in X-Division) at least two days a week as a Lab Associate.

I am available to Lab management (SAG or anyone else), to DOE/NNSA, to Congress, to the press--should any of them care whatsoever to hear what I have to say.

In receive mode, but not holding my breath,

P.S. Let's add to that list of people who MIGHT (but probably don't) care to hear from me: LockMart and Bechtel. (As to UC...well, fuggedaboudit.)

Don’t feel bad Brad they don’t want to talk to me either. You already proved the Admiralty wrong with your Physics Today article. Todd and I proved them wrong with regard to their wild cowboy/renegade claims. Ever since Admiral Butthead went non-linear they have been trying to rebuild their credibility. That can’t be done as long as people keep sabotaging them with facts. Anything that these people publish will be the same conglomeration of lies that constituted Nanos’ congressional testimony. As long as people like Domenici, Richardson, Barton, and others have their careers on the line you will never get an admission of the truth on these matters.

The worst part of this is that LANL has learned nothing from the occurrences of 2004.
During a recent CREM reduction (within the last three weeks) a LANL employee received his CREM statement and found that he had five items on his statement when he actually owned only one. Not only that, but the one item that he owned wasn’t on the statement. While all of the items were eventually found the discrepancy proves that LANL still does not effectively track and account for CREM. This is the same type of database error that led to the catastrophe of 2004. With only a minor change in fortune this person could have become the focus of a witch-hunt similar to that which we faced in July of 2004. Nothing has really changed.
LANL staff - if you, like me, find this "management response" inadequate, give me a call at 5-4462 or send me e-mail. I plan to contact the director about it. We deserve better.
-Bernard Foy
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