Radiation Accident:

Incident at Clear Air Force Station, Alaska

NSIAD-86-9: Published: Nov 7, 1985. Publicly Released: Nov 7, 1985.

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Pursuant to a congressional request, GAO investigated the conduct of the Air Force and its contractor in responding to the 1983 radiation accident at Clear Air Station, Alaska, to determine whether: (1) the contractor fulfilled all the required services in compliance with the terms of the contract; (2) Air Force actions in administering the contract were beyond reproach; and (3) affected employees have been afforded the best available medical evaluation, treatment, and follow-up they are entitled to under law.

GAO noted that, according to Air Force and contractor investigation reports, the accident occurred because of the inadvertent actions of a contractor technician. Upon investigation, GAO found that: (1) the technician's action resulted in the workers' exposure to radiation because the equipment was not laid out and operated as required by the contract; (2) contractor noncompliance with contract specifications and problems in contract management practices allowed the accident to go undetected for 8 minutes; (3) there was some delay in providing medical services to the victims immediately following the accident; and (4) the contractor reduced staffing in key control rooms below the minimum manning requirement. GAO also found that: (1) maintenance technicians on duty were not fully qualified to perform in their assigned positions; (2) the quality assurance evaluators (QAE) monitoring the contract were neither technically trained in radar operation nor had prior experience in procurement procedures or contract administration; and (3) although there was some delay in providing medical evaluations to the victims in the 24 hours following the accident, the victims have received extensive medical evaluations since the accident.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: DOD/IG considered action on this item complete as of November 28, 1986. The Space Command is working with military assignment systems to provide better qualified QAE. A separate directorate was established on July 18, 1986, for the QAE program. DOD/IG is to visit all operating sites at least once every year for a review of procedures and training.

    Recommendation: The Secretary of the Air Force should direct the Commander of the Space Command to ensure that only trained QAE, fully qualified in evaluating contractor compliance with technical specifications, are assigned, especially in highly technical areas such as the operation and maintenance of communication and electronic equipment.

    Agency Affected: Department of Defense: Department of the Air Force

  2. Status: Closed - Implemented

    Comments: This recommendation had a DOD/IG action completion date of November 28, 1986. As of November 1986, the revised QAE checklist provided for a continuous review of training records.

    Recommendation: The Secretary of the Air Force should direct the Commander of the Space Command to review the contractor's technician assignment practices to ensure that technicians are fully trained and qualified in the monitoring and control rooms they are assigned to.

    Agency Affected: Department of Defense: Department of the Air Force

  3. Status: Closed - Implemented

    Comments: Action on this recommendation had a DOD/IG completion date of February 9, 1987. Air staff officials met with Space Command personnel on March 6, 1986, and reviewed the revised contractor statement of work and agreed that it was satisfactory to correct manning requirements.

    Recommendation: The Secretary of the Air Force should direct the Commander of the Space Command to require the contractor to comply with minimum manning requirements in monitoring and control rooms, in accordance with the statement of work.

    Agency Affected: Department of Defense: Department of the Air Force

  4. Status: Closed - Implemented

    Comments: Action on this recommendation had a DOD/IG completion date of November 28, 1986. A revised tracker transmitter configuration proposal was approved by Sacramento ALC and Space Command. The modification was completed on April 11, 1986, making the waveguide and monitoring and control room circuitry compatible.

    Recommendation: The Secretary of the Air Force should direct the Commander of the Space Command to change the waveguide layout, wiring, and automatic switching functions to properly align prime transmitters with corresponding radars.

    Agency Affected: Department of Defense: Department of the Air Force

  5. Status: Closed - Implemented

    Comments: Action on this recommendation was considered complete on May 12, 1986. According to the Department of Defense Inspector General (DOD/IG), all site commanders have verified that current procedures are in accordance with technical orders, and a special interest item has been developed for use during IG inspections to ensure that sites are complying with current procedures.

    Recommendation: The Secretary of the Air Force should direct the Commander of the Space Command to conform the safety system interlocks to specifications and follow all technical order procedures for entering and exiting the radome.

    Agency Affected: Department of Defense: Department of the Air Force

  6. Status: Closed - Implemented

    Comments: This recommendation was considered finalized as of February 9, 1987. Nine sites had been inspected and found to be satisfactory. Actions on this recommendation are to be continued indefinitely.

    Recommendation: The Secretary of the Air Force should conduct a survey of technical order compliance and safety procedures at other radar installations to determine if similar problems may exist. If noncompliance with technical orders or other problems are identified, corrective actions should be taken.

    Agency Affected: Department of Defense: Department of the Air Force

 

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