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entitled 'Nuclear Safety: DOE's Investigation of Phosgene Gas 
Contamination Was Inadequate, but Experts Conclude That Worker Safety 
and facilities Are Not Threatened' which was released on May 31, 2007. 

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Report to Congressional Addressees: 

United States Government Accountability Office: 

GAO: 

May 2007: 

Nuclear Safety: 

DOE's Investigation of Phosgene Gas Contamination Was Inadequate, but 
Experts Conclude That Worker Safety and Facilities Are Not Threatened: 

GAO-07-712: 

GAO Highlights: 

Highlights of GAO-07-712, a report to congressional addressees 

Why GAO Did This Study: 

More than 700,000 tons of uranium are stored at two Department of 
Energy (DOE) sites where uranium enrichment took place and where two 
facilities are being constructed to treat depleted uranium. Some of the 
storage cylinders for uranium came from the Army more than 50 years ago 
and may originally have contained phosgene, a toxic gas used as a 
chemical weapon in World War I. In September 2005, DOE’s Inspector 
General issued an alert warning that residual phosgene, if present, 
could threaten the safety of people and the treatment facilities. 

GAO was directed to review DOE’s investigation of possible phosgene 
contamination of uranium storage cylinders. GAO consulted a panel of 
experts to assess the adequacy of DOE’s investigation and whether 
possible phosgene contamination could threaten the new treatment 
facilities under construction. 

What GAO Found: 

According to members of GAO’s expert panel, although DOE adequately 
demonstrated that the public would not be harmed if small amounts of 
phosgene escaped from the storage cylinders, it neglected to explicitly 
document its analysis of worker safety in its investigation of possible 
phosgene contamination. DOE’s regulations and guidance call for 
thorough safety analyses of newly identified hazards, such as possible 
phosgene contamination, to protect workers and the public. Yet DOE 
assumed, without explicitly documenting, that existing worker safety 
procedures were adequate to protect workers from the possible presence 
of phosgene. After GAO identified the need for DOE to support this key 
assumption, DOE provided supplemental information on worker safety; 
GAO’s panel agreed that this supplement sufficiently supported DOE’s 
position. In addition, although DOE’s guidance calls for independent 
review of investigation results, DOE officials supervising the phosgene 
investigation also served as reviewers. This lack of independent review 
may have contributed to weaknesses in the investigation. 

The experts GAO consulted agreed that, for two reasons, the facilities 
under construction in Ohio and Kentucky would not be threatened by 
possible phosgene contamination of uranium storage cylinders. First, at 
the start of treatment operations, cylinders containing depleted 
uranium will be placed inside pressure vessels designed to withstand 
and contain any leak from a cylinder. If phosgene were present, it 
would not affect either the pressure vessels or the treatment 
facilities. Second, during subsequent steps, any phosgene that may be 
processed with the depleted uranium would be destroyed by the extreme 
heat and water vapor applied during the treatment process. 

Figure: Uranium Storage Cylinders at Paducah, Kentucky: 

[See PDF for Image] 

Source: Uranium Disposition Services. 

[End of figure] 

What GAO Recommends: 

GAO recommends that the Secretary of Energy strengthen DOE’s review 
process for safety investigations to include reviewers who are 
independent of the investigations being done and can provide objective 
evaluations of the methods used and the findings and conclusions 
reached. 

DOE agreed that workers and the public were not at risk but did not 
believe that its investigation had flaws. DOE did not comment on our 
recommendations. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-712]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Gene Aloise at (202) 512-
3841 or AloiseE@gao.gov. 

[End of section] 

Contents: 

Letter: 

Scope and Methodology: 

Results in Brief: 

Background: 

DOE's Investigation of Possible Phosgene Contamination Did Not 
Adequately Document Analysis of Worker Safety: 

Possible Phosgene Contamination of Uranium Storage Cylinders Does Not 
Threaten Depleted Uranium Conversion Facilities: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Comments from the Department of Energy: 

Appendix II: GAO Contact and Staff Acknowledgments: 

Table: 

Table 1: GAO's Expert Panelists, Titles, and Affiliations: 

Figures: 

Figure 1: Uranium Storage Cylinders at DOE's Paducah Site: 

Figure 2: Cylinder with an Open Hole: 

Figure 3: Steps to Convert Depleted Uranium Hexafluoride to Uranium 
Oxide, with Impact on Phosgene, If Present: 

Abbreviations: 

DOE: Department of Energy: 
UDS: Uranium Disposition Services: 
USEC: U.S. Enrichment Corporation: 

United States Government Accountability Office: 
Washington, DC 20548: 

May 31, 2007: 

The Honorable Byron L. Dorgan: 
Chairman: 
The Honorable Pete V. Domenici: 
Ranking Minority Member: 
Subcommittee on Energy and Water: 
Committee on Appropriations: 
United States Senate: 

The Honorable Peter J. Visclosky: 
Chairman: 
The Honorable David L. Hobson: 
Ranking Minority Member: 
Subcommittee on Energy and Water Development: 
Committee on Appropriations: 
House of Representatives: 

The Honorable Mitch McConnell: 
United States Senate: 

From the 1940s, one of the missions of the Department of Energy (DOE) 
and its predecessors was to enrich uranium as a source of nuclear 
material for defense and commercial purposes. Before it can be 
enriched, uranium is combined with fluorine to form uranium 
hexafluoride, a substance dangerous to human health and the environment 
because it is radioactive and forms potentially lethal compounds if it 
comes in contact with water. The enrichment process results in two 
principal products: (1) enriched uranium hexafluoride, which can be 
further processed for specific uses, such as nuclear fuel or weapons, 
and (2) depleted uranium hexafluoride, a material that can be converted 
into a more stable form for storage and other applications. Both 
processes--uranium enrichment and depleted uranium conversion--involve 
hazardous materials and processes that can harm the public, workers, 
and the environment. DOE therefore requires specific safety procedures 
to be in place at uranium-processing sites. Uranium-processing 
activities took place at three sites near Paducah, Kentucky; 
Portsmouth, Ohio; and Oak Ridge, Tennessee,[Footnote 1] where over 
700,000 tons of uranium hexafluoride is currently stored. At the 
Paducah and Portsmouth sites, DOE is constructing two new facilities to 
convert depleted uranium hexafluoride into a more stable compound, 
uranium oxide, for long-term storage. 

Between 1945 and the mid-1950s, the Atomic Energy Commission, a DOE 
predecessor, acquired from the U.S. Army Chemical Warfare Service more 
than 2,500 of the approximately 63,000 steel cylinders in which it now 
stores uranium hexafluoride. The Army previously stored other chemicals 
in these 2,500 cylinders, including a toxic gas called phosgene, which 
was used as a chemical weapon during World Wars I and II. Phosgene can 
immediately endanger health or life, even in quantities as small as 2 
parts per million. If inhaled, the gas damages the lungs, causing them 
to fill with fluid and potentially leading to death by suffocation or 
heart failure. DOE's records from 1946 indicate that some of the 
storage cylinders it received from the Army tested positive for 
phosgene; the records do not indicate, however, which cylinders tested 
positive, how much phosgene was present, or whether DOE removed the 
phosgene before using the cylinders to store uranium hexafluoride. 

In September 2005, DOE's Inspector General issued an urgent letter, 
called a management alert, to DOE regarding the possible presence of 
phosgene in the cylinders received from the Army. The alert warned that 
the possible presence of phosgene in uranium storage cylinders had 
significant implications for the safety and health of workers and the 
public. In response to the Inspector General's alert, DOE identified 
2,509[Footnote 2] cylinders suspected of containing phosgene, 
immediately suspended regular maintenance activities around these 
cylinders, implemented precautions to protect workers from the 
potential phosgene hazard, and began an investigation of phosgene 
contamination of the 2,509 cylinders. This investigation was conducted 
collaboratively by DOE and a contractor, Uranium Disposition Services 
(UDS), which was tasked with analyzing and reporting on possible 
phosgene contamination and also with maintaining the storage cylinders 
and constructing the facilities to convert depleted uranium.[Footnote 
3] In April 2006, DOE completed its investigation,[Footnote 4] 
concluding that phosgene, if present, would not react with uranium 
hexafluoride and that the uranium storage cylinders would not contain 
enough residual phosgene to harm the public outside site boundaries, 
that is, no closer than 200 meters from the cylinders.[Footnote 5] DOE 
also concluded that the small quantity of residual phosgene it deemed 
safe for the public would also pose no harm to workers, who would be 
protected under existing safety procedures, and not threaten the 
depleted uranium conversion facilities at Portsmouth, Ohio, and 
Paducah, Kentucky. 

Given the potential safety risks, the Conference Report accompanying 
the Fiscal Year 2006 Energy and Water Development Appropriations 
Act[Footnote 6] directed us to provide an independent review of 
possible phosgene contamination of DOE's uranium storage cylinders. 
This report discusses (1) the adequacy of DOE's investigation of 
potential harm to workers and the public from phosgene contamination of 
the storage cylinders and (2) whether possible phosgene contamination 
of storage cylinders could threaten the depleted uranium treatment 
facilities after conversion operations begin at the Portsmouth and 
Paducah sites. 

Scope and Methodology: 

To determine the adequacy of DOE and UDS's investigation of potential 
harm to workers and the public from possible phosgene contamination of 
uranium storage cylinders, we reviewed the DOE Inspector General's 
workpapers and interviewed officials to understand their preliminary 
findings. We also interviewed officials at the Defense Nuclear 
Facilities Safety Board and U.S. Enrichment Corporation (USEC). To 
identify what actions DOE and UDS were required to take to address 
worker and public safety in light of the possible presence of phosgene, 
we reviewed federal safety requirements set out in the Code of Federal 
Regulations[Footnote 7] and DOE guidance.[Footnote 8] In addition, we 
spoke with senior DOE safety officers to clarify the requirements and 
expectations of DOE safety investigations. To learn what actions DOE 
and UDS took to address the potential presence of phosgene, we reviewed 
DOE's Phosgene Characterization Study and supporting documents and 
interviewed DOE and UDS officials who conducted the investigation. To 
determine the reliability of the data DOE and UDS used in determining 
whether cylinders posed harm to workers or the public, we reviewed a 
stratified random sample of 250 cylinders from the 2,509 cylinders in 
question and reviewed all the available records for each cylinder. We 
visited the cylinder storage yards at the Paducah and Portsmouth sites 
to view some of the cylinders in our sample and to examine cylinder 
records. We found that DOE and UDS had generally interpreted the 
cylinder record information correctly and consistently and that their 
data were sufficiently reliable. 

To assess DOE and UDS's scientific assumptions and conclusions in their 
investigation of possible phosgene contamination, we assembled a panel 
of experts from outside DOE to review DOE's final report and supporting 
documents. To select experts, we used an iterative process (often 
referred to as the "snowball sampling" technique) to identify 
scientists outside DOE who had experience or expertise in phosgene, 
nuclear material, or both. Through recommendations by knowledgeable 
government agency officials, we first identified a small number of 
experts. We asked these experts to participate in the panel and to 
provide names of other experts with knowledge of phosgene or nuclear 
material. We continued soliciting names until we determined that we had 
appropriate coverage of the topic areas. We did not limit our search to 
government agencies but solicited recommendations for experts from 
government, private, academic, and international organizations. The 
scientists we identified with the necessary expertise were all 
government scientists. Table 1 lists the resulting panel of seven 
experts. 

Table 1: GAO's Expert Panelists, Titles, and Affiliations: 

Name: Dr. Frederic Berg; 
Title: Supervisory Research Chemist; 
Affiliation: U.S. Army Edgewood Chemical and Biological Center. 

Name: Dr. John F. Kalinich; 
Title: Principal Investigator, Research Biochemist; 
Affiliation: Armed Forces Radiobiology Research Institute. 

Name: Dr. Tadeusz Kleindienst; 
Title: Research Physical Scientist; 
Affiliation: U.S. Environmental Protection Agency, National Exposure 
Research Laboratory. 

Name: Dr. Urmila Kodavanti; 
Title: Research Biologist; 
Affiliation: U.S. Environmental Protection Agency, Experimental 
Toxicology Division, Pulmonary Toxicology Branch. 

Name: Dr. David McClain; 
Title: Research Biochemist; 
Affiliation: Armed Forces Radiobiology Research Institute. 

Name: Dr. Alfred Sciuto; 
Title: Research Physiologist, Branch Chief; 
Affiliation: U.S. Army Medical Research Institute of Chemical Defense. 

Name: Mr. William Troskoski; 
Title: Senior Chemical Engineer; 
Affiliation: Nuclear Regulatory Commission, Office of Nuclear Materials 
Safety and Safeguards. 

Source: GAO. 

[End of table] 

Panelists were given DOE and UDS's final report on the investigation 
and the report's attached supporting documents, in addition to 
information we collected on uranium enrichment from scientists at USEC 
who work directly with the uranium enrichment process. DOE and UDS 
officials reviewed these documents for completeness and accuracy. The 
panelists met to discuss their own analyses and conclusions and 
continued discussions via e-mail and telephone calls. 

To determine whether possible phosgene contamination of uranium storage 
cylinders could threaten the depleted uranium treatment facilities, we 
assessed documentation on the facilities' operations and interviewed 
officials at UDS and the Nuclear Regulatory Commission. The expert 
panel we assembled reviewed the conversion process and discussed 
whether the facilities would be threatened by phosgene and how the 
conversion process would affect phosgene. Finally, to corroborate the 
information we gathered, we interviewed officials at UDS and the 
Nuclear Regulatory Commission who are familiar with the conversion 
facilities and the equipment used to process the uranium storage 
cylinders. We performed our work in accordance with generally accepted 
government auditing standards from March 2006 through April 2007. 

Results in Brief: 

The experts we consulted confirmed that DOE and UDS's investigation of 
possible phosgene contamination was flawed because, among other things, 
it did not explicitly document that phosgene would not harm workers 
near the storage cylinders. It was not until February 2007, after we 
brought this weakness to DOE and UDS's attention that they provided 
supplemental information that addressed worker safety. Until then, DOE 
and UDS believed, but did not explicitly document, that existing worker 
safety procedures were adequate to protect workers from the possible 
presence of phosgene. Regulations governing how DOE and its contractors 
should conduct operations involving hazardous materials explicitly call 
for the contractor to prepare documented safety analyses that establish 
hazard controls necessary to ensure adequate protection of workers, the 
public, and the environment. The regulations require DOE to take 
appropriate action to address a newly identified hazard, such as 
possible phosgene contamination. Our panelists agreed that DOE and 
UDS's investigation demonstrated that phosgene would not be present in 
quantities that could harm members of the public passing by or living 
near the DOE sites--at a distance of 200 meters or more from the 
cylinders--where uranium is stored or treated. 

The experts also agreed, however, that DOE and UDS failed to document 
that the same quantities of phosgene that would not harm the public 
would also not harm workers directly involved in handling and 
maintaining the cylinders. Although DOE and UDS officials stated that 
they systematically analyzed the potential consequences to workers of 
phosgene in uranium storage cylinders, they did not explicitly document 
their analysis or conclusions, creating a weakness in their 
investigation. In particular, we found no record of their assumptions, 
analysis, or results. DOE and UDS officials reasoned that because the 
uranium hexafluoride in the cylinders was more dangerous than the 
possible presence of phosgene, the existing safety procedure--known as 
"see and flee"--was adequate to protect workers from phosgene. 
Specifically, "see and flee" directs workers to evacuate the area when 
they see any sign of a cylinder rupture. DOE guidance instructs DOE and 
its contractors to document all support for safety investigations to 
allow independent reviewers to assess the adequacy of analyses and 
conclusions. DOE's guidance also calls for independent review of 
investigation results by officials who are not directly involved in the 
investigation. In this case, however, reviewers may have been too 
familiar with the investigation to provide a review that was 
sufficiently independent to identify and correct this weakness. In 
February 2007, DOE and UDS issued a supplement to the original 
investigation report, which supported their earlier assertion that 
existing safety procedures would protect workers near the uranium 
storage cylinders from residual phosgene, and our expert panel 
concurred. In our view, DOE and UDS were fortunate that their 
undocumented assumptions proved correct and existing safety procedures 
had been sufficient to protect workers throughout the investigation. 

The experts with whom we spoke agreed that any phosgene present in 
uranium storage cylinders would not threaten the depleted uranium 
conversion facilities under construction at Portsmouth and Paducah, for 
two reasons. First, at the start of the conversion process, cylinders 
containing depleted uranium hexafluoride will be placed inside pressure 
vessels, where their contents will be heated and liquefied. According 
to our expert panel and officials from DOE and UDS, the pressure 
vessels are designed to withstand and contain any leak from a cylinder, 
so that if phosgene were present, it would not affect either the 
pressure vessels or the facilities. Second, during subsequent steps in 
the conversion process, any phosgene that was processed with the 
depleted uranium hexafluoride would be destroyed. Specifically, our 
expert panel and DOE and UDS officials all agreed that the extreme heat 
would destroy phosgene. In addition, the water vapor added during the 
process would react with any phosgene present to form compounds, 
including carbon dioxide, that would not threaten the facilities. 

We recommend that DOE better ensure that its safety investigations 
follow agency guidelines and are technically adequate, in particular, 
by making use of reviewers who are independent of the investigations 
being done and who will provide objective evaluations of the 
investigations' methods and resulting findings and conclusions. 

DOE commented on a draft of this report and generally agreed with our 
conclusions that neither workers nor the public would have been at risk 
from potential phosgene contamination. DOE did not comment on our 
recommendations. DOE took exception to our findings that its 
assessments of worker safety and of the fate of phosgene in the 
enrichment process were inadequately documented, stating that explicit 
documentation was unnecessary. Our panel of technical experts, however, 
concluded that without explicit documentation of these critically 
important analyses, DOE could not adequately demonstrate that workers 
would not be harmed by the potential presence of phosgene. DOE also 
took issue with our finding that its review of the investigation was 
not sufficiently independent, stating that its investigation was 
reviewed by four officials who had no direct connection to the 
investigation. Nevertheless, according to documents previously provided 
to us by DOE, we believe that two of these officials, who had approved 
investigation plans and provided direction to the investigation, were 
not sufficiently independent to provide an objective review of the 
quality or results of that investigation. 

Background: 

Created in 1977 from diverse agencies, DOE manages the nation's nuclear 
weapons production complex, cleans up the environmental legacy of 
nuclear weapons development, and conducts research in both energy and 
basic science. DOE carries out its work at numerous sites and 
facilities around the country, primarily through organizations that 
manage the facilities and implement program and project activities 
under contract to DOE. The department has established an extensive 
network of field offices to directly oversee the work of these 
contractors. DOE's Portsmouth/Paducah Project Office, under the Office 
of Environmental Management, is responsible for cleanup and depleted 
uranium conversion at the Portsmouth and Paducah sites. 

The United States began processing uranium--a radioactive heavy metal 
that is mined and extracted from ore--before the Manhattan Project gave 
rise to the first atomic bomb in the 1940s. Subsequently, DOE and its 
predecessor agencies continued to process uranium as fuel for 
commercial nuclear reactors. A key step in this process is uranium 
enrichment, which increases the concentration of uranium-235, the form 
of uranium that undergoes fission to release enormous amounts of 
energy.[Footnote 9] Uranium enrichment involves combining uranium with 
the chemical fluorine to form uranium hexafluoride. Radioactive and 
extremely corrosive, uranium hexafluoride reacts with water and can 
burn the skin, eyes, and internal organs. 

Uranium hexafluoride and depleted uranium hexafluoride (the material 
left over after uranium enrichment) are currently stored in steel 
cylinders. In all, approximately 700,000 tons of uranium hexafluoride 
is stored in about 63,000 cylinders at storage yards on the Paducah and 
Portsmouth sites (see fig. 1). A cylinder surveillance and maintenance 
program includes regular inspections to check the integrity of cylinder 
walls, valves, and plugs; replacement or reattachment of nameplates 
(which are vital for cylinder identification and tracking); and repair 
of any defective valves or plugs. 

Figure 1: Uranium Storage Cylinders at DOE's Paducah Site: 

[See PDF for image] 

Source: DOE Inspector General. 

[End of figure] 

Ultimately, DOE plans to convert the stored depleted uranium 
hexafluoride into uranium oxide, a more stable chemical form for long- 
term storage. UDS is constructing two depleted uranium hexafluoride 
conversion facilities, one each at Paducah and Portsmouth. Scheduled to 
begin operating in 2008, the facilities together will be able to 
process a total of about eight cylinders of depleted uranium 
hexafluoride per day. DOE estimates that once the conversion facilities 
begin operating, it will take approximately 25 years to convert its 
existing stockpile of depleted uranium hexafluoride. 

Historically, because of national security concerns, DOE and its 
predecessors have not been externally regulated for worker or nuclear 
facility safety; rather, DOE relies on its own internal system of 
oversight and controls to hold its contractors accountable. DOE's 
primary approach to regulating its contractors to ensure public health 
and safety and the safety of workers at nuclear facilities is to 
incorporate the requirements of DOE regulations and directives, 
including policies, orders, and standards, into contracts. Among other 
requirements, DOE regulations require nuclear facilities to maintain a 
master document, called a documented safety analysis, that analyzes 
hazards and describes the controls necessary to ensure that workers, 
the public, and the environment are adequately protected. The 
documented safety analysis and hazard controls are referred to as a 
safety basis. The contractor must submit a safety basis to DOE for 
review and approval; update the safety basis to keep it current and 
reflect changes in the facility itself, its work, or the hazards 
present; and submit the updated document (or a letter stating that 
there have been no changes) to DOE once a year thereafter. If a new 
hazard is discovered, the regulations direct contractors to take 
immediate steps to ensure the facility's safety and to notify DOE. In 
addition, the contractor must conduct and submit to DOE a safety 
evaluation of the new hazard. 

An October 2000 report by DOE's Office of Environment, Safety, and 
Health informed DOE that some 30-inch diameter cylinders acquired from 
the Army, now used to store uranium hexafluoride, previously contained 
phosgene. A chemical not found in nature, phosgene, or carbonyl 
chloride (COCl2), was used as a chemical weapon in World War I and 
stockpiled by the U.S. Army Chemical Warfare Service in World War II; 
at present, it is used to make plastics, pesticides, and even 
pharmaceuticals. At room temperature, phosgene is a colorless gas 
heavier than air, with an odor of musty hay; in the presence of 
moisture, it may form a white cloud. According to the National 
Institute for Occupational Safety and Health, phosgene presents an 
immediate threat to life and health at a concentration of about 2 parts 
per million. When the chemical comes in contact with moisture on the 
skin or in the respiratory tract, it reacts to form hydrochloric acid, 
which, like uranium hexafluoride, burns human tissues.[Footnote 10] 
With uranium storage cylinders used in the conversion process, DOE's 
Inspector General raised a concern that some 30-inch cylinders could 
possibly contain phosgene and could enter the depleted uranium 
conversion facilities for processing. 

After DOE's Inspector General issued its warning about possible 
cylinder contamination from phosgene, DOE and UDS conducted an 
investigation to determine the extent to which the cylinders received 
from the Army were contaminated. For each cylinder, they applied one of 
three criteria to establish that the cylinder could contain no more 
than a trace amount of phosgene. First, they found that if past 
practices to prepare storage cylinders for use in the uranium 
enrichment process had been consistently followed, these practices 
should have eliminated any phosgene that might have been present. These 
practices included cleaning the cylinders--washing their interiors with 
corrosive chemicals and rinsing them with water--and pressure testing 
them to ensure they were structurally sound. DOE had documents 
demonstrating that 176 of the 2,509 cylinders had been cleaned or 
pressure tested after DOE received them from the Army. DOE was 
therefore able to clear these 176 cylinders of suspicion on the basis 
of this first criterion. Second, DOE and UDS calculated that if the 
storage cylinders had been filled with and emptied of uranium 
hexafluoride at least once, any residual phosgene in the cylinders 
should have been reduced to quantities too small to harm the public. 
DOE cleared 2,296 cylinders on the basis of this second 
criterion.[Footnote 11] Third, DOE and UDS determined that if a 
cylinder had a hole in it--for example, where a valve was removed from 
the cylinder and the resulting hole was left uncovered--residual 
phosgene would have dissipated completely from the cylinder. DOE 
cleared another 12 cylinders with open holes, on the basis of this 
third criterion. Finally, DOE and UDS sampled and analyzed the contents 
of the last 25 cylinders and did not detect phosgene at or above the 
residual quantity they deemed safe for the public. 

DOE's Investigation of Possible Phosgene Contamination Did Not 
Adequately Document Analysis of Worker Safety: 

DOE and UDS's investigation of possible phosgene contamination was 
flawed because, among other things, it did not explicitly document that 
phosgene would not harm workers near the uranium storage cylinders. 
Under federal regulations and DOE guidance, DOE and its contractors are 
to assess safety risks to workers and the public. Although DOE 
considered worker safety, it did not explicitly document its analysis 
or conclusions. It did adequately assess and document its conclusions 
for public safety. In response to our review, DOE and UDS provided 
supplemental information that the experts we consulted found sufficient 
to support DOE's initial assertion that existing safety procedures had 
protected workers from harm throughout the investigation. 

DOE Did Not Explicitly Document Its Analysis of the Safety Risk to 
Workers from Possible Exposure to Phosgene: 

According to the experts we consulted, the original investigation was 
flawed because DOE and UDS did not explicitly document that workers 
would face no harm from small quantities of phosgene that could be 
present in uranium storage cylinders. Federal regulations and DOE 
guidance direct DOE and its contractors to analyze safety risks to 
workers, the public, and the environment to ensure that they are 
adequately protected from hazardous materials and conditions. To do so, 
each DOE facility must maintain a comprehensive documented safety 
analysis that details potential hazards and appropriate safety 
procedures to mitigate those hazards. If a new hazard is discovered 
that is not addressed in the existing documented safety analysis, 
federal regulations direct DOE and its contractors to take action to 
place or maintain the facility in a safe condition until a safety 
analysis is completed and submitted to DOE for approval. 

According to DOE guidance and senior regulatory officials, a safety 
analysis conducted in response to a new hazard must analyze appropriate 
accident conditions, derive or identify procedures sufficient to ensure 
the safety of workers, and demonstrate the adequacy of those procedures 
to maintain the work environment at an acceptably low level of risk. In 
addition, guidance specifies that safety analyses should be well 
documented to allow independent reviewers to assess the adequacy of the 
analysis and its conclusions. The officials stated that the analysis 
should be rigorous, include quantitative and qualitative reasoning, and 
identify and defend assumptions. 

In this case, DOE and UDS conducted an investigation of the possible 
presence of phosgene contamination in uranium storage cylinders because 
they recognized the possibility that workers and the public might be in 
danger if phosgene were present in the cylinders. For example, if an 
accident occurred in the uranium storage cylinder yard and a cylinder 
containing phosgene ruptured, workers and the public could suffer 
serious harm if they inhaled phosgene gas.[Footnote 12] Through their 
investigation, DOE and UDS demonstrated that only small amounts of 
phosgene could be present in the uranium storage cylinders. All members 
of our expert panel reviewed and concurred with this finding. 
Nevertheless, the expert panel raised concerns that DOE did not specify 
whether or how workers conducting operations directly adjacent to the 
cylinders would be protected from harm if phosgene accidentally escaped 
from a cylinder. 

When we related our expert panelists' concerns about the possible 
effects of phosgene on workers, DOE and UDS officials stated that they 
had assessed worker safety during the investigation and decided that 
workers would not be harmed by the possible presence of small amounts 
of phosgene. DOE and UDS officials stated that the first- response 
safety procedure to protect workers from uranium stored in the 
cylinders--termed "see and flee"--calls for immediate evacuation of the 
area around a ruptured cylinder. They reasoned that since this 
procedure was sufficient to protect workers against large quantities of 
uranium hexafluoride if a cylinder ruptured and the contents escaped, 
it would also be sufficient to protect workers from small amounts of 
phosgene. 

DOE and UDS did not, however, explicitly document or support their 
inference that workers would be protected by the "see and flee" safety 
procedure. During their investigation, DOE and UDS considered worker 
safety and inferred that "see and flee" would protect workers from the 
possible presence of phosgene. Contrary to guidelines, however, they 
did not document a thorough analysis demonstrating that "see and flee" 
was adequate to protect workers until we brought the matter to their 
attention. Although DOE and UDS officials stated that they had 
systematically analyzed the potential consequences of the presence of 
phosgene in uranium storage cylinders to worker safety, they were 
unable to provide any documentation of their analysis, such as 
assumptions, reasoning, or results. The phosgene investigation did 
undergo review, but the lack of documentation of DOE and UDS's 
consideration of worker safety made it impossible for reviewers to 
assess the adequacy of this consideration and thus allowed a key 
element of the investigation to pass without inspection. 

In addition, DOE's review of the phosgene investigation may not have 
been sufficiently independent. Senior DOE regulatory officials stated 
that reviewers should not be involved in the investigation under 
review; in this case, however, officials involved in the investigation 
also served as reviewers. DOE reviewers may have been too familiar with 
the project to provide a sufficiently independent assessment of the 
investigation. DOE's review allowed a weakness--the unsupported 
inference that existing safety procedures would protect workers--to 
persist in DOE's investigation of possible phosgene contamination. Thus 
DOE and UDS believed, without explicitly documenting, that existing 
worker safety procedures were adequate to protect workers from the 
possible presence of phosgene.  

Ultimately, in February 2007, DOE and UDS issued a supplement to the 
original investigation report, which documented the assumptions, 
reasoning, and calculations used to reach the conclusion that existing 
safety procedures would protect workers from the possible presence of 
phosgene. All members of our expert panel agreed with the conclusions 
presented in the supplement. Therefore, the supplemental information 
showed that, throughout the investigation, workers were protected from 
harmful phosgene exposure by existing safety procedures. 

In addition, we identified two other weaknesses in DOE and UDS's 
investigation of possible phosgene contamination, which they addressed 
during our review. Specifically: 

˛ DOE and UDS assumed, but did not explicitly document, that any 
phosgene introduced into the uranium enrichment process would be 
destroyed. DOE and UDS did not identify this assumption or support it 
with evidence or analysis during the investigation. This is a key 
assumption because if the uranium enrichment process did not destroy 
phosgene, the gas could have passed through the process and into 
hundreds of thousands of cylinders containing enriched uranium 
hexafluoride and could still be present today. Scientists knowledgeable 
about the uranium enrichment process and the experts we consulted all 
confirmed that DOE and UDS's undocumented assumption was correct-- 
phosgene, if introduced into the uranium enrichment process, would have 
reacted with other chemicals in the process and been destroyed, or it 
would have been purged from the process with other waste gases. After 
we discussed this weakness with DOE and UDS, they provided supplemental 
information demonstrating that phosgene would not survive the uranium 
enrichment process. We reviewed the supplemental information and found 
that it adequately supports DOE and UDS's assumption. 

˛ DOE and UDS used records to determine that 181 cylinders had been 
pressure tested, which would have eliminated any phosgene that may have 
been present, but records for 6 cylinders lacked sufficient information 
to meet this criterion. According to DOE and UDS's definition of the 
pressure-test criterion, a cylinder must have information showing that 
(1) it underwent a pressure test and (2) the cylinder was under DOE's 
control at the time of the test. If a test had been performed while the 
cylinder was still in the Army's possession, it could have subsequently 
been used to store phosgene. During our review, we identified one 
cylinder that did not have sufficient information to prove that DOE had 
performed the pressure test. After discussing this weakness with DOE 
and UDS officials, UDS conducted its own review of all 181 cylinders 
and found 5 additional cylinders that also had insufficient information 
to meet the pressure-test criterion. The available information for all 
6 cylinders, however, did meet the definition of another criterion, and 
as a result, DOE and UDS concluded that the cylinders posed no harm. 

These two weaknesses created potential vulnerabilities in DOE and UDS's 
investigation of possible phosgene contamination because if phosgene 
had survived the enrichment process, or if the six cylinders could not 
have passed a different criterion, many cylinders could still contain 
unknown amounts of phosgene today. 

DOE Did Document Its Analysis of the Safety Risk to the Public: 

According to the experts we consulted, DOE and UDS conclusively 
demonstrated that the presence of small amounts of phosgene in storage 
cylinders would not harm the public. DOE and UDS followed federal 
regulations and agency guidelines by identifying possible accident 
conditions and applying and documenting a qualitative and quantitative 
analysis consisting of three main steps. First, DOE and UDS determined 
that the closest the public would be to cylinders possibly containing 
phosgene was 200 meters--the shortest distance between the storage site 
boundary and the cylinders. Second, DOE and UDS calculated the maximum 
amount of phosgene that could be released from a cylinder without 
harming a person standing 200 meters away. To do this, DOE and UDS used 
emergency-response planning guidelines that specify the maximum 
airborne concentration of phosgene that nearly all individuals could be 
exposed to for up to 1 hour without experiencing more than mild, 
transient health effects (such as coughing and eye irritation) and 
perceiving only an objectionable odor.[Footnote 13] They then applied a 
computer model to predict the dispersion of phosgene gas from a 
ruptured cylinder and determined that 1.2 grams was the maximum amount 
of phosgene that could be present in a cylinder without harming a 
member of the public 200 meters away. Third, DOE and UDS determined 
that none of the cylinders could contain phosgene in excess of this 1.2 
gram amount. Specifically, DOE and UDS reviewed cylinder records to 
document that the cylinders: 

˛ had been washed or pressure tested after DOE acquired them; 

˛ had been filled and emptied of uranium hexafluoride at least once, 
which would have removed enough phosgene that only a residual amount 
(less than 1.2 grams) could remain; or: 

˛ had open holes (for example, where a valve had been removed; see fig. 
2), which would have allowed any phosgene to diffuse harmlessly over 
time. 

DOE and UDS determined that if any one of these criteria were met, the 
amount of phosgene that could remain in a cylinder was 1.2 grams or 
less. For cylinders that did not meet these criteria, DOE and UDS 
sampled the contents to test for phosgene. On the basis of these 
procedures, DOE and UDS determined that phosgene could not be present 
in quantities that would harm the public. 

Figure 2: Cylinder with an Open Hole: 

[See PDF for Image] 

Source: Uranium Disposition Services. 

[End of figure] 

DOE and UDS documented their assumptions, reasoning, calculations, and 
results from this analysis and reported them in their April 2006 
investigation report. According to the experts we consulted, DOE and 
UDS's analysis conclusively demonstrated that the public would not be 
harmed from any phosgene that could be present in uranium storage 
cylinders. 

Possible Phosgene Contamination of Uranium Storage Cylinders Does Not 
Threaten Depleted Uranium Conversion Facilities: 

In September 2005, DOE's Inspector General warned that the introduction 
of phosgene into the conversion process could possibly have 
catastrophic safety consequences. At that time, neither the Inspector 
General nor DOE and UDS knew how much phosgene could be in a cylinder. 
In the investigation prompted by the warning, however, DOE and UDS 
demonstrated that no more than 1.2 grams of phosgene could be present 
in a cylinder. DOE and UDS determined that this small quantity of 
phosgene, if introduced into the conversion facilities, would not cause 
a safety concern, and the experts we consulted concurred. 

The experts, as well as DOE and UDS officials, cited two main reasons 
for concluding that the conversion facilities would not be threatened 
if 1.2 grams or less of phosgene were present in the uranium storage 
cylinders. First, during the conversion process, the cylinders will be 
placed in pressure vessels (called autoclaves) that will heat their 
contents to approximately 200 degrees Fahrenheit. (Fig. 3 summarizes 
the conversion process and what would happen to any phosgene present.) 
According to UDS officials and experts we consulted, these autoclaves 
are designed to withstand any cylinder ruptures and to contain the 
contents of the cylinders, regardless of whether phosgene is present. 
Specifically, the autoclaves are designed to withstand pressures up to 
200 pounds per square inch and temperatures exceeding 200 degrees 
Fahrenheit, and their interiors are treated with a protective coating 
that resists heat and corrosive chemicals. They would therefore 
withstand any depleted uranium hexafluoride or phosgene that might leak 
from a ruptured cylinder into the interior of the autoclave. 
Furthermore, if a cylinder did rupture, according to UDS officials, 
sensors in the autoclave would detect any depleted uranium hexafluoride 
released. These sensors would alert workers, who could then shut down 
the autoclave and follow safety procedures for cleaning it out. 

Second, once the gaseous depleted uranium hexafluoride and phosgene, if 
present, left the autoclave and entered the conversion unit, high 
temperatures and water vapor applied during conversion would destroy 
any phosgene, in addition to converting the uranium hexafluoride to 
uranium oxide and hydrofluoric acid. According to UDS officials, the 
conversion unit will heat the depleted uranium hexafluoride and 
phosgene to temperatures exceeding 800 degrees Fahrenheit as water 
vapor is added. Because phosgene reacts with water and begins to 
dissociate into carbon monoxide and chlorine gases below 800 degrees 
Fahrenheit, any phosgene would separate and react with the water vapor, 
forming carbon dioxide and hydrochloric acid, neither of which would 
threaten the conversion equipment. According to UDS officials, the 
carbon dioxide would be vented from the conversion system with other 
gases through exhaust stacks. The hydrochloric acid would also react 
with the water vapor and be purged from the system. Thus, any residual 
amounts of phosgene that may be introduced into the depleted uranium 
conversion process would be destroyed and would not threaten any part 
of the conversion facilities. 

Figure : Steps to Convert Depleted Uranium Hexafluoride to Uranium 
Oxide, with Impact on Phosgene, If Present: 

[See PDF for image] 

Sources: GAO and DOE. 

[End of figure] 

Conclusions: 

In view of DOE's long history of processing highly radioactive and 
other dangerous materials for use in defense and civilian endeavors, 
protecting workers, the public, and the environment is an integral part 
of accomplishing DOE's missions. In doing so, DOE has guidelines for 
addressing potential hazards to workers and the public, which include 
an independent review of safety analyses. Nevertheless, DOE and UDS's 
investigation of possible phosgene contamination of uranium storage 
cylinders did not follow guidelines for adequately documenting a safety 
analysis of the potential harm to workers that phosgene contamination 
might present. Furthermore, we do not believe that DOE had an adequate 
internal review process for assessing this investigation, a process 
that should have but did not identify weaknesses. Specifically, the 
review should have been conducted by reviewers who were independent of 
the investigation and who could have provided an objective evaluation 
of the investigation's methodology, findings, and conclusions. Although 
the assumptions DOE used in reaching its judgment on possible phosgene 
contamination turned out to be reasonable in this case, DOE may not be 
so fortunate the next time. The same process weaknesses, if undetected 
in other situations, could have dangerous consequences. The discovery 
of the possible presence of a potentially hazardous or lethal safety 
condition, such as phosgene contamination, demands a better planned and 
managed review process and assurance that guidelines are followed. 

Recommendations for Executive Action: 

To ensure the comprehensiveness and technical adequacy of 
investigations of potentially unsafe situations at DOE's nuclear 
facilities, we recommend that the Secretary of Energy ensure that 
safety investigations benefit from a review process that (1) includes 
reviewers who are sufficiently independent of the investigations being 
done and (2) provides objective evaluations of the methodologies being 
used and the findings and conclusions reached. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to DOE for review and comment. In a 
written response, DOE's Chief Operating Officer for Environmental 
Management agreed with our conclusion that neither workers nor the 
public would have been at risk from potential phosgene contamination of 
depleted uranium cylinders but took exception to our findings of 
inadequacies in DOE's investigation. DOE did not comment on our 
recommendations. DOE's comments on our draft report are included in 
appendix I. DOE also provided the February 2007 supplement to its 
investigation that was previously provided to us. We did not, however, 
reproduce the supplement because our draft report already discussed its 
contents. 

In its written comments, DOE expressed the view that three basic 
assertions in our draft report were incorrect, inaccurate, or 
misleading. Specifically, DOE took issue with our findings that DOE's 
assessment of worker safety was flawed, DOE's reviewers of the 
investigation were not sufficiently independent, and explicit 
information on the fate of phosgene in the enrichment process was not 
included in the investigation. 

Regarding worker safety, DOE agreed that its investigation did not 
specifically document that potential phosgene contamination would not 
increase health consequences to workers. Nevertheless, DOE argued that 
explicit documentation was unwarranted because it was so obvious to 
those involved in the investigation that the existing safety management 
plan fully protected workers, and the investigation was written by 
technical experts for review and approval by technical experts. We 
disagree. Our expert panel, which consisted of nationally recognized 
technical experts on phosgene or nuclear material, was unable to 
independently draw the same conclusions as DOE because of the lack of 
explicit documentation in DOE's investigation regarding the effects on 
worker safety of potential phosgene contamination. In our view, this 
fact calls into question DOE's contention that it was "obvious" that 
the existing safety management plan fully protected workers. 

Furthermore, we are concerned about the seemingly lax attitude 
portrayed in DOE's comments about the need for adequate documentation 
of important safety analyses. DOE asserted that the absence of explicit 
documentation of the analysis and results of its investigation does not 
jeopardize worker safety, just as the presence of explicit 
documentation would not ensure worker safety. Nevertheless, DOE's own 
standard for reviewing and approving safety documents states that 
hazards analyses should be both "clearly characterized" and 
"understandable."[Footnote 14] Our expert panel found DOE's analyses to 
be neither clearly characterized nor understandable until DOE issued a 
February 2007 supplement to its original report. DOE stated in its 
comments that such a supplement would have been unnecessary had DOE 
officials been allowed to communicate directly with our expert panel. 
GAO's standards of evidence, however, require that the experts we rely 
on be independent and objective. To help ensure their independence and 
objectivity, the experts on our panel did not interact directly with 
DOE or UDS officials, but the experts did review information provided 
by those officials about the investigation's details. We worked closely 
with DOE and UDS officials to ensure that the information provided to 
the expert panel fairly, accurately, and sufficiently described the 
steps DOE and UDS had taken. We also disagree with DOE's 
characterization of the February 2007 supplement as "simple." In fact, 
without it--that is, on the sole basis of the documentation from DOE 
and UDS's original investigation--our expert panel was not convinced of 
the adequacy of DOE and UDS's worker safety analyses. Thus we maintain 
that the information and analyses included in the February 2007 
supplement should have been included in the original investigation 
report. 

As our draft report noted, we and our expert panel agree that the 
assumptions DOE used in reaching its judgment on possible phosgene 
contamination turned out to be reasonable in this case. Nevertheless, 
the fact that DOE was fortunate this time does not reduce the need for 
future DOE hazards analyses to be adequately documented to sufficiently 
demonstrate that workers and the public will not be harmed by potential 
risks to their safety. In our view, by questioning the need for 
explicit documentation of its analyses, DOE is contending that those 
outside the department should believe DOE's conclusions on the basis of 
trust rather than on the basis of rigorous, scrupulously documented 
analyses. We feel that, given the potentially deadly results of a 
phosgene release, workers, the public, and Congress deserve better than 
simply being asked to take DOE's conclusions on faith. 

Regarding DOE's independent review of the investigation, DOE stated in 
its comments that four high-level, technically qualified officials who 
had no direct connection to the investigation provided an independent 
review of its findings. DOE's argument, however, is misleading because 
two of these reviewers were also named on a list provided to us by DOE 
during our review as staff who provided input on the direction of the 
investigation and who were involved in reviewing and approving 
investigation plans. In our view, staff who have provided direction to 
an investigation are not sufficiently independent to provide an 
objective review of the quality or the results of that investigation. 

Finally, regarding our finding that explicit information on the fate of 
phosgene in the uranium enrichment process was not included in DOE and 
UDS's investigation, DOE noted that uranium enrichment facilities are 
operated by USEC, which analyzed the fate of phosgene in the enrichment 
process and concluded that the gas would not survive. DOE stated that 
it was neither necessary nor appropriate for DOE to repeat USEC's 
assessment. Contrary to DOE's assertion, our draft report did not argue 
that DOE should duplicate USEC's analysis of the fate of phosgene in 
the enrichment process. Instead, we believe that DOE should have, at a 
minimum, noted in its investigation that USEC had performed such an 
analysis and summarized its results. We agree, and our draft report 
noted, that the February 2007 supplement sufficiently documents the 
conclusion that phosgene would be destroyed in the enrichment process. 
Nonetheless, as with DOE's analysis of worker safety, we continue to 
believe that a supplement should not have been necessary at all, 
because the information and analyses explained in the February 2007 
supplement should have been included in the original investigation 
report. 

We are sending copies of this report to the Secretary of Energy. We 
will also make copies available to others upon request. In addition, 
the report will be available at no charge on the GAO Web site at 
http://www.gao.gov. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-3841 or AloiseE@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. GAO staff who made major contributions to 
this report are listed in appendix II. 

Signed by: 

Gene Aloise: 
Director, Natural Resources and Environment: 

[End of section] 

Appendix I: Comments from the Department of Energy: 

Department of Energy: 
Washington, DC 20585: 

May 10 2007: 

Mr. Ryan Coles: 
Assistant Director: 
Government Accountability Office: 
441 G Street, NW: 
Washington, D. C. 20548: 

GAO Report Entitled "DOE'S Investigation Of Phosgene Gas Contamination 
Was Inadequate, But Experts Conclude That Worker Safety And Facilities 
Are Not Threatened" - (Report GAO-07-712): 

Dear Mr. Coles: 

The Department of Energy (DOE) agrees with the Government 
Accountability Office's (GAO) conclusions that neither workers nor the 
public would have been at risk by the possibility of small amounts of 
phosgene remaining in 30 inch cylinders that were previously used in 
Chemical Warfare Service. DOE takes exception to GAO's allegations of 
inadequacies and/or flaws in the DOE investigation. We are disappointed 
that you were not able to include more of our significant comments in 
the draft report. 

There are three basic assertions in the Government Accountability 
Office draft report on the Department of Energy investigation of 
potentially contaminated storage cylinders that are incorrect, 
inaccurate, or misleading. The issues are summarized below and are 
addressed in greater detail in Sections 1 through 3 of Attachment 1. 

Assessment of Worker Safety: 

In the initial sections of the draft report, GAO stated that DOE simply 
assumed that existing worker safety procedures were adequate to protect 
workers from any potential contamination. In fact, long before GAO 
began their review of this issue, DOE explicitly assessed the potential 
risk to workers using widely accepted chemical hazard measures and 
initial determinations of the maximum possible phosgene contamination. 
DOE concluded the possibility of phosgene in the absence of uranium 
hexafluoride increased the risk to workers and imposed additional 
administrative controls. These controls included the immediate measures 
taken to isolate the suspect cylinders, restrict cylinder movements, 
minimize the operational events that have the potential to breach a 
suspect cylinder, minimize the number of personnel in the vicinity of a 
suspect cylinder and other administrative controls documented in the 
investigation report. 

A timeline detailing the various analyses supporting the worker safety 
is provided as Attachment 2 of this response. 

In the safety document "Justification for Continued Operations while 
Resolving the Potential Presence of Phosgene in Selected 30-inch 
Cylinders" (DUF6-G-JCO-001, November 30, 2005), DOE specified that 
"Personnel working in the cylinder storage yards containing the suspect 
cylinders will be trained to recognize actual or suspected off-nominal 
conditions and on evacuation and emergency notification procedures." 
This action was carried out. Workers were briefed when the initial 
concern was raised and provided routine status of the investigation. 
The JCO states that the UDS Safety Management Programs provide the 
necessary controls to safely address the potential phosgene issue, a 
conclusion based on an expert understanding of the relative risks of a 
small amount of phosgene (if present) in a large amount of uranium 
hexafluoride. For additional protection beyond the existing protection 
provided by the standard safety measures developed for activities 
around uranium hexafluoride, interim compensatory measures were 
implemented to further minimize the risks associated with the suspect 
cylinders. The appropriate response practices required were those 
already in place for existing hazards and this was understood by the 
workers. When cylinder sampling occurred, specific activities required 
by workers were reviewed with them (to obtain their input) and the 
final instructions were signed by all workers involved in the 
activities. These documents are part of the Phosgene Characterization 
Study reviewed by GAO. 

The absence of explicit documentation of the calculations and reasoning 
leading to the DOE worker safety assessment in the Phosgene 
Characterization Study does not jeopardize worker safety just as the 
presence of explicit documentation of the assessment would not ensure 
worker safety. The GAO continues to assert that the DOE study did not 
explicitly address worker safety in spite of DOE providing a supplement 
to the study (see Attachment 3) that convinced the GAO expert panel 
that workers were not at risk. 

The worker safety assessment, documented in supporting information 
provided to GAO, clearly demonstrated that the exceedingly low risk 
from potential phosgene contamination was overwhelmed by the risk of 
the much larger quantities of uranium hexafluoride. This early worker 
safety determination allowed DOE to focus its subsequent investigations 
on assessing the potential risk to the public in the event phosgene 
contamination actually existed. The GAO report states: 

"...DOE and UDS issued a supplement to the original investigation 
report, which documented the assumptions, reasoning, and calculations 
used to reach the conclusion that existing safety procedures would 
protect workers from the possible presence of phosgene. All members of 
our expert panel agreed with the conclusions presented in the 
supplement." 

Independent Review: 

The GAO stated that the independent reviewers of the DOE study also 
supervised the investigation and thus were too familiar with the 
investigation to identify the alleged weaknesses identified by GAO. In 
fact, the DOE report was reviewed by at least four, high level, 
technically qualified DOE officials who had absolutely no role in 
supervision of the investigation. 

The development and implementation of the investigation was strictly 
the responsibility of the DOE Portsmouth-Paducah Project Office and was 
supported by their contractors and DOE Oak Ridge where some of the 
suspect cylinders were located. The independent reviewers did not 
supervise or otherwise direct any aspects of the investigation. The GAO 
report states that: 

"...DOE and UDS's analysis conclusively demonstrated that the public 
would not be harmed from any phosgene that could be present in uranium 
storage cylinders." 

Also, in the previous quotation above, the GAO report states that their 
expert panel agrees that the small amounts of possible phosgene 
contamination represent no increased risk to the health and safety of 
the workers under any circumstances. These conclusions of the GAO 
expert panel suggest that independent review of the Phosgene 
Characterization Study did not fail to identify significant flaws. 

Phosgene Fate in Enrichment Facilities: 

GAO stated in their draft report that the DOE assumed but did not 
explicitly document that any phosgene introduced into the uranium 
enrichment process would be destroyed. In fact, the enrichment 
facilities are operated by a commercial firm, the United States 
Enrichment Corporation (USEC). The management alert on potential 
phosgene contamination was promptly forwarded to USEC. They conducted 
an analysis of the potential consequences for their operations and 
concluded that there are none. In response to the GAO assertion that 
explicit information on the fate of phosgene should be included in the 
Phosgene Characterization Study for the convenience of their expert 
panel, DOE provided a supplement addressing the topic. The supplement 
is provided as Attachment 3 of this response. 

DOE, based on the experience and knowledge of their own experts, agreed 
with the USEC determination and that it was neither necessary nor 
appropriate to repeat the USEC assessment of the fate of hypothetical 
phosgene in enrichment facilities. The GAO and their expert panel also 
agreed with the USEC conclusions and the GAO report states that: 

"...phosgene, if introduced into the uranium enrichment process, would 
have reacted with other chemicals in the process and been destroyed, or 
it would have been purged from the process with other waste gases." 

Please be assured, our first commitment is to the health and safety of 
our workers and the public. 

Sincerely, 

Signed by; 

Ines R. Triay, Ph.D. 
Chief Operating Officer for Environmental Management: 

Attachments: 

cc: 

W. Murphie, PPPO/LEX: 
J. Zimmerman, PPPO/LEX: 
R. Holland, EM CBC: 
J. Craig, EM CBC: 
T. Brown, MA-62: 

Response to the GAO Review of the DOE Investigation of Potential 
Phosgene Contamination: 

1. Assessment of Worker Safety: 

In its report, the GAO stated that "DOE and UDS assumed, without 
explicitly documenting, that existing worker safety procedures were 
adequate to protect workers from the possible presence of phosgene" 
(emphasis added). This is not correct. DOE and UDS declared, in the 
positive Unresolved Safety Question (USQ) issued on November 8. 2005, 
that the presence of phosgene could increase risk of health 
consequences to both workers and the public. This was stated again in 
the Justification for Continued Operations (JCO), dated January 5, 2006 
in which additional controls were established on cylinder yard 
operations to further reduce the risk to workers and the public. Both 
of these documents were provided to GAO during their review. 

These controls retrained in place until: 

* DOE and UDS demonstrated that 1.2 grams of phosgene would not result 
in increased health consequences to a member of the public. 

* DOE and UDS determined that the existing safety management program 
was sufficient to protect workers if no more than 1.2 grams of phosgene 
were present in individual 30 inch cylinders. 

* Criteria were developed for demonstrating that cylinders could 
contain no more than 1.2 grams of phosgene. 

* The characterization of all 30 inch cylinders was completed in 
accordance with the criteria established above. 

* CYlinders that could not be cleared based on cylinder records were 
sampled to verify that phosgene was not present at a level above 1.2 
grams. 

Although the final report did not specifically document that 1.2 grams 
would not increase health consequences to workers. the data contained 
in the calculations provided to GAO on April 19, 2006 show that the 
ratio of phosgene to uranium hexafluoride vapor in the cylinder head 
space is almost two orders of magnitude below the ratio required to 
cause increased health consequences to workers. 

The GAO report repeatedly makes the assertion that undocumented 
conclusions are assumptions. This is not correct. GAO concluded that it 
was not until February 2007, after the matter was brought to the 
attention of DOE by the GAO, that DOE adequately demonstrated that 
there would be no increased health consequences for workers. In 
reality, the fact that the existing safety management plan fully 
protected workers from small quantities of phosgene was so obvious to 
those involved in the investigation, including the independent 
technical reviewers, that explicit documentation in the Phosgene 
Characterization Study was unwarranted. 

The GAO asserted that because the DOE did not explicitly document its 
analysis of safety risk to workers in the Phosgene Characterization 
Study that the investigation was flawed. In fact, explicit 
documentation in the study was not deemed necessary by the authors or 
reviewers that approved the report. DOE repeatedly reminded GAO during 
their investigation that the study in response to the DOE Inspector 
General management alert was written by technical experts for review 
and approval by technical experts. 

The GAO report makes statements such as "DOE and UDS officials. decided 
that workers would not be harmed by the possible presence of small 
amounts of phosgene. " or "they reasoned that since this procedure was 
sufficient. " In point of fact, the ERPG levels for phosgene, hydrogen 
fluoride, and uranium hexafluoride that were used to "decide or reason" 
are established by the American Industrial Hygiene Association and are 
considered consensus standards throughout the country. DOE takes 
exception to the implication that DOE's conclusions were based on 
anything less than valid data and quantitative analyses. 

The GAO investigation process prohibited direct communication between 
their panel of experts and the personnel performing the DOE phosgene 
investigation. DOE and UDS believe that the questions related to 
assessment of worker safety could have been resolved with GAO's panel 
of experts if direct communication had been allowed. Evidence to 
support this belief is presented by the fact that a simple supplement 
to the original report was all that was necessary to convince GAO's 
expert panel that workers would not be affected by the presence of 1.2 
grams of phosgene in a 30 inch cylinder containing uranium 
hexafluoride. 

2. Independent Review: 

GAO asserts in their report that the DOE review of the phosgene 
investigation may not have been sufficiently independent. DOE considers 
this claim is without merit and reflects a misunderstanding of the DOE 
review process. 

The DOE study was authored by UDS, a DOE prime contractor. Before 
submitting the report to DOE it was reviewed by UDS management as well 
as a technical expert from Areva (a UDS member company). This technical 
expert was not affiliated with the project in any way. When the final 
draft study was submitted to DOE it was first reviewed by the DOE 
Federal project director and DOE Portsmouth-Paducah Project Office 
staff. Following local review, the report was reviewed by the EM Chief 
Operating Officer, Deputy Assistant Secretary for Safety Management and 
Operations and the Chief of Nuclear Safety (Office of the 
Undersecretary of Energy). In total, at least 3 different reviews were 
conducted by persons who had no direct connection to the DUF6 project. 
None of the reviewers beyond the local level supervised the phosgene 
investigation as stated by GAO. 

3. Phosgene Fate in Enrichment Facilities: 

The GAO asserted that, "DOE and UDS assumed but did not explicitly 
document that any phosgene introduced into the uranium enrichment 
process would be destroyed". Uranium enrichment activities in the US 
are carried out by the United States Enrichment Corporation (USEC), a 
publicly traded company. Both UDS and DOE notified USEC management of 
the IG Alert when it was received. U SEC officials conducted their own 
internal investigation into possible consequences of phosgene in UF6 
cylinders and concluded (correctly) that there were no consequences to 
their operations or potential health consequences to their workers or 
the public. UDS and DOE personnel are familiar with the operating 
principles of the enrichment plants including, in some cases, the 
classified aspects of the process and with that knowledge agreed with 
the USEC conclusions. DOE and UDS disagree that it was necessary or 
appropriate for DOE to repeat the assessment of USEC to validate a 
conclusion that they find entirely consistent with their knowledge of 
the enrichment process. 

Timeline for DOE Activities Performed to Assess and Effect Worker 
Safety due to the Potential Presence of Unknown Quantities of Phosgene 
in UF6 Storage Cylinders: 

Documentation of the activities described in the following timeline was 
provided to the GAO investigators during their site visit or as part of 
DUF6-G-RGN-008, Phosgene Characterization Study. 

September 30, 2005: 

Department of Energy Office of the Inspector General issued the 
management alert that identified the potential for the presence of 
phosgene in 30-inch UF6 Cylinders, This report was received on October 
3, 2005. 

October 5, 2005: 

Cylinder Yard crew was briefed. 

The daily order and end-of-day briefing in the narrative logbooks for 
cylinder yard supervisors dated October 5, 2005 document that the 
phosgene issue was discussed with the cylinder yard crews. 

Per procedure, UDS-GFP-001, Portsmouth Cylinder Yard Management, and 
UDS-GFP-002, Paducah Cylinder Yard Management, the cylinder yard 
supervisor maintains a narrative logbook for the purpose of process 
control and event reconstruction. At a minimum, the narrative logbook 
contains entries for the following: 

* Changes in cylinder storage area operating mode or condition 
(shutdown due to weather, equipment failure, etc.) 

* Force report (personnel reporting for work each shift). 

* Record of general UF6 cylinder related activities such as number of 
cylinder inspections, relocations, as-found and as-left conditions, and 
maintenance activities performed. This record supplements the cylinder 
information database (CID) record but does not replace any CID entry 
requirements. 

* Yard maintenance performed. 

* Status changes in safety-related or important equipment. 

* Occurrences of reportable events. 

* Actions that breach operational safety limits. 

* Security incidents. 

* Out-of-specification process results. 

* Shift relief. 

* Personnel changes. 

* Illness or injuries occurring during the shift. 

* Training activities. 

The logbooks provide a documented record of the phosgene issue and 
implementation of immediate actions. These forms of communication are 
required by DOE Order 5480.19, Conduct of Operations Requirements for 
DOE Facilities. Documentation of the daily orders was provided in 
Attachment F of DUF6-G-RGN-008, Phosgene Characterization Study. 

October 6, 2005: 

UDS issued an Occurrence Reporting and Processing System (ORPS) report 
and notifications were made. 

The ORPS report EM-PPPO-UDS-PORTDUCON-2005-0003, Management concern 
involving storage of Uranium Hexafluoride (UF6) Cylinders, was issued 
to inform management of the issue and to track progress on resolution 
of the issue. The ORPS report noted that all work on the 30A cylinders 
was suspended and that ETTP (Bechtel-Jacobs Corporation) and UDS had 
initiated the Unreviewed Safety Question (USQ) process with a Potential 
Inadequacy in the Safety Analysis (PISA). 

October 7, 2005, 

As part of Daily Order 06-0004, the cylinder yard manager provided a 
briefing that included a presentation consisting of the following: 

* photographs of the UF6 service modification performed on the 
cylinders, obtained from the U.S. Army Chemical Warfare Service t6 
allow workers to identify the potential variations, 

* data indicating the presence of phosgene, 

* immediate actions which included suspending work on 30A cylinders, 

* future actions, 

* preliminary findings in the investigation, and: 

* Material Safety Data Sheets for phosgene. 

In addition, the daily orders noted the development of a phosgene 
binder. The binder was located in the break room used by the cylinder 
yard crew. Any existing information and all updates to the 
investigation were placed in the binder for any of the workers to read. 
Documentation of the daily orders was provided in Attachment F of DUF6- 
G-RGN-008, Phosgene Characterization Study. 

November 8, 2005: 

UDS issued a positive Unreviewed Safety Question Determination (USQD) 
identifying a PISA in both the Paducah and Portsmouth cylinder yards. 
At the time of preparation of the USQD, cylinder records and other 
information had not yet been collected and fully reviewed to 
demonstrate that the maximum quantity of theoretical phosgene in the 
cleared cylinders did not exceed the 1.2 grams found to present no 
significant hazard to the public or workers. 

The USQD was positive for three determination questions. 

1) The potential presence of phosgene increased the consequences of an 
accident previously evaluated in the existing safety basis. 

The basis as revised to account for the phosgene USQD notes that during 
a cold cylinder breach: 

"The site facility worker is protected by SMPs [Safety Management 
Programs] and the risk is not evaluated against ERPG [Emergency 
Response Planning Guidelines] limits. The credited control for the site 
worker is `see and flee'. This control is based on the `white smoke' 
produced by the reaction of UF6 and moisture in the air to produce HF 
and UO2F2. While in a cold cylinder breach, the quantity of white smoke 
is much less than that of a liquid cylinder breach, nevertheless, the 
reaction can be visibly seen. The odor threshold for HF is 0.04 ppm 
while that of phosgene ranges from 0.4 to l. S ppm depending upon the 
sensitivity of the worker. Phosgene has a distinctive odor similar to 
that of fresh mown hay or moldy hay. In the event where phosgene and 
UF6 are both present in the cylinder, 'see and flee' is still a viable 
control since the worker will see the white smoke. 

In the case of the seven [sic] unmodified cylinders at Portsmouth, 
workers can be trained to recognize the smell of phosgene, however, 
since the odor threshold is above the permissible exposure limit, 
training the workers to recognize the smell of phosgene is not 
adequate. Based on current industry practices, it is likely that the 
worker will smell the phosgene and be able to fee, and it is probable 
that the worker will fee and have health damage due to the exposure 
prior to odor threshold; however, the exposure does not necessarily 
result in a fatality. Therefore, the presence of phosgene does not 
change the '.see and fee' control, however, additional training is 
required for the worker to identify the odor of phosgene as an 
additional measure to the visible white smoke and HF odor and 
additional protective measures such as alarms are required to 
adequately protect the worker and allow for emergency response, thus, 
protecting the public." 

Therefore, the effect of phosgene on the cylinder yard workers and the 
hypothetical on-site worker was evaluated and additional controls and 
training were deemed necessary to protect the workers when performing 
work associated with the 30A cylinders. 

2) The PISA concluded there were higher consequences from a malfunction 
of the cylinder wall. 

The basis as revised to account for the phosgene USQD notes the 
following: 

"The cylinder wall is [a] designated design feature in both the 
Portsmouth and Paducah cylinder yard DSAs [Documented Safety Analyses]. 
If the cylinder wall were to malfunction and jail, the resulting breach 
would be equivalent to a cold breached cylinder event. By applying the 
air modeling data provided in the attachment, the ERPG-3 limit is 
exceeded.for both the hypothetical on-site worker and the public. 

If the cylinder wall were breached as a malfunction, the consequences 
to the facility worker, on-site worker, and public would increase due 
to the effects of phosgene in the air." 

Therefore, the effect of phosgene during a cylinder wall failure was 
evaluated for the facility worker and determined that additional 
controls would be required to protect the facility worker, on-site 
worker, and public. Again, this determination was made prior to 
collecting and reviewing cylinder records and other information to 
demonstrate that the maximum quantity of theoretical phosgene in the 
cleared cylinders did not exceed the 1.2 grams found to present no 
significant hazard to the public or workers. 

3) The potential presence of phosgene reduced the margin of safety. 

The basis as revised to account for the phosgene USQ notes the 
following: 

"The Paducah and Portsmouth cylinder yard DSAs do not have specific 
measured parameters that can be associated with the effect due to 
phosgene in the cylinders. However, the potential presence of phosgene 
increases the consequences to the worker during a majority of the event 
scenarios listed in the site DSAs. Due to the significant impact to the 
worker, on-site worker and the public, the margin of safety has been 
reduced due to the potential presence of phosgene." 

Therefore, the effect of phosgene was evaluated for the facility worker 
and determined to increase the consequences to the facility worker 
during the accident scenarios deemed possible in the approved 
documented safety analysis and hazard analysis for the cylinder yards. 
(Subsequent analyses demonstrated that cleared cylinders would not 
exceed the 1.2 grams of theoretical phosgene found to present no 
significant hazard to the public or workers. The small number of 
cylinders that did not satisfy the clearing criteria were sampled and 
found to contain no detectible phosgene.) 

Overall, the USQD documented the results of the investigation and 
clearly shows that UDS and DOE considered the facility worker, on-site 
worker, and the public during the evaluation. Since the USQD was 
positive, UDS and DOE determined that additional controls were 
necessary to provide sufficient protection to the facility worker if 
phosgene was found in a cylinder. A record of the approved USQ-019, 
Potential Presence of phosgene in 30-inch UF6 Cylinders, was provided 
to the GAO for inclusion in their investigation. 

November 28, 2005: 

The cylinder yard manager issued a standing order, FY 06-02, 
documenting the following items relative to the 30A cylinders: 

* No vehicles are permitted on the cylinder yard. 

* No maintenance or movement of 30A model cylinders is permitted unless 
directed by facility manager. 

* No radiological surveys of 30A model cylinders are permitted unless 
directed by the facility manager. 

* Entrance into the cylinder yard or any activities is with the 
explicit permission of the facility manager. 

The standing order was initialed by the cylinder yard crew documenting 
that they had been provided this information. 

Documentation of the standing orders was provided in Attachment F of 
DUF6-G-RGN-008, Phosgene Characterization Study. 

December 19, 2005: 

DOE approved DUF6-G-JCO-001, Justification for Continued Operations in 
the Paducah and Portsmouth UF6 Cylinder Storage Yards While Resolving 
the Potential Presence of Phosgene in Selected 30-inch Cylinders. This 
Justification for Continued Operations (JCO) documents the hazard 
analysis results from the DOE and UDS analysis of the postulated 
accidents scenarios. 

The JCO states the following: 

"The existing UDS SMPs provide the necessary controls to safely address 
the potential phosgene issue. Additional administrative controls have 
been implemented based on the specific cylinder surveillance and 
maintenance program activity to be performed and the potential cold 
breach accidents." 

The potential presence of phosgene did not result in any new design 
basis accidents from those in the Documented Safety Analysis. It was 
determined that the procedures supporting the existing Safety 
Management Program were adequate for safely managing the potential 
presence of phosgene. However, based on the hazard analysis of the 
design basis accidents, additional compensatory measures were 
implemented to provide protection beyond the current procedures. 

All facility workers were briefed to the JCO and the interim 
compensatory measures. Documentation of the briefings was provided in 
Attachment F and G of DUF6-G-RGN-008, Phosgene Characterization Study. 

January 11, 2006: 

DOE approved the revised JCO which was updated to include sampling 
activities. All facility workers were briefed on the changes. The final 
JCO was provided as Attachment E of DUF6-G-RGN-008, Phosgene 
Characterization Study. 

UDS approved the work package to begin sampling the suspect cylinders 
at Portsmouth. Facility workers were briefed on the work flow and 
instructions, activity hazard analysis, radiological work permits, 
implementation of the JCO, and equipment to be used. In addition, 
facility workers were provided with Material Safety Data Sheets for all 
chemicals used in the sampling activity. The complete work package was 
provided as Attachment F of DUF6-G-RGN-008, Phosgene Characterization 
Study. 

January 12, 2006: 

Sampling activities were started and completed at the Portsmouth 
facility. No phosgene was detected in the cylinders. Activities are 
noted in the Portsmouth sampling work package number WA-PO-06-0001, 
Perform Sampling of 10 Cylinders (2.5-ton 30 inch) Suspected of 
containing Phosgene, which was provided as Attachment F of DUF6-G- RGN-
008, Phosgene Characterization Study. 

January 26, 2006: 

UDS approved the work package to begin sampling the suspect cylinders 
at Paducah. Facility workers were briefed on work flow and 
instructions, operation of the equipment to be used, implementation of 
the JCO, activity hazard analysis, and radiological work permit. 
Documentation of the facility worker briefing was provided in 
Attachment G of DUF6-G-RGN-008, Phosgene Characterization Study. 

Sampling activities were initiated. 

February 6, 2006: 

Paducah cylinder yard operations completed sampling activities. No 
phosgene was detected in the cylinders. Activities are noted in the 
Paducah sampling work package number WA-PA-06-0001, Sampling of Suspect 
30-inch Diameter Cylinders for Phosgene at Paducah, which was provided 
as Attachment G of DUF6-G-RGN-008, Phosgene Characterization Study. 

[End of section] 

Appendix II: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Gene Aloise, (202) 512-3841 or AloiseE@gao.gov: 

Staff Acknowledgments: 

In addition to the individual named above, William R. Swick, Assistant 
Director; James Ashley; Ellen W. Chu; Ryan T. Coles; Doreen Feldman; 
Cindy Gilbert; Cynthia Grant; George Hinman; Wyatt R. Hundrup; Alison 
O'Neill; Laina Poon; Keith Rhodes; Sushil Sharma; and John Stradling 
made key contributions to this report. Also contributing to the report 
was Jena Sinkfield. 

(360673): 

FOOTNOTES 

[1] DOE processed uranium at the site near Oak Ridge, Tennessee until 
1985. This site is now being decontaminated and decommissioned, and 
storage cylinders have been moved to other sites, such as Portsmouth. 
Since 1992, uranium enrichment activities have been performed by U.S. 
Enrichment Corporation (USEC), a private company that was created in 
1992 as a wholly owned government corporation and then privatized in 
1998. 

[2] DOE's Phosgene Characterization Study reported 2,544 cylinders that 
were suspected of containing phosgene. Thirty-five of those cylinders 
were removed from consideration because they were not relevant; for 
example, some were not the type of cylinder in question. We chose not 
to report on these 35 cylinders, reporting instead on the 2,509 
relevant cylinders. 

[3] In addition to DOE and UDS officials, officials from Bechtel Jacobs 
Corporation were involved in investigating possible phosgene 
contamination of uranium storage cylinders formerly stored at DOE's Oak 
Ridge site. 

[4] Department of Energy, Depleted Uranium Conversion Project, Phosgene 
Characterization Study, DUF6-G-RGN-008, rev. 1 (Washington, D.C.: April 
2006). 

[5] DOE and UDS determined that, should a cylinder rupture, 1.2 grams 
or less of residual phosgene present in a cylinder would not harm 
people standing 200 meters or more from the ruptured cylinder. 

[6] H.R. Rep. No. 109-275, at 150 (2005). 

[7] 10 C.F.R. part 830, subpart B: Safety Basis Requirements. 

[8] Department of Energy, DOE Standard: Review and Approval of Nuclear 
Facility Safety Basis Documents (Documented Safety Analyses and 
Technical Safety Requirements), DOE-STD-1104-96, Change Notice No. 1, 
May 2002; Implementation Guide for Use in Addressing Unreviewed Safety 
Question Requirements, DOE G 424.1-1, October 2001; and Implementation 
Guide for Use in Developing Documented Safety Analyses to Meet Subpart 
B of 10 C.F.R. 830, DOE G 421.1-2, October 2001. 

[9] Natural uranium, the raw material required for the uranium 
enrichment process, comprises several isotopes--forms of the same 
element with different atomic weights. Uranium ore consists mostly of 
uranium-238 and less than 1 percent uranium-235, the fissile isotope 
used in nuclear reactors and nuclear weapons. To be usable as reactor 
fuel, uranium must be enriched so that the proportion of uranium-235 
exceeds 1 percent; commercial nuclear fuel is typically enriched to 3 
to 5 percent. 

[10] The severity of a chemical's toxic effect depends on a person's 
total exposure to that chemical, that is, the concentration of the 
chemical multiplied by the duration of exposure. For phosgene, exposure 
to a concentration of 30 parts per million for 1 minute (or 3 parts per 
million for 10 minutes) damages the lungs, exposure to 150 parts per 
million for 1 minute causes the lungs to fill with fluid, and exposure 
to 300 parts per million for 1 minute or more can kill. 

[11] DOE and UDS originally identified 182 cylinders that met the first 
criterion and 2,290 cylinders that met the second criterion. During our 
review, however, 6 cylinders were found to not meet the first 
criterion; they were subsequently cleared of suspicion by DOE under the 
second criterion. As a result, 176 cylinders met the first criterion, 
and 2,296 met the second. The next section discusses this difference in 
more detail. 

[12] The uranium hexafluoride stored in the cylinders is also very 
dangerous to workers, but safety procedures are in place to protect 
workers from uranium hexafluoride if a cylinder were to rupture. 

[13] These emergency response planning guidelines were developed by the 
American Industrial Hygiene Association, a nonprofit organization 
founded in 1939 that serves the needs of environmental health 
professionals practicing industrial hygiene in industry, government, 
labor, academic institutions, and independent organizations. 

[14] Department of Energy, DOE Standard: Review and Approval of Nuclear 
Facility Safety Basis Documents, DOE-STD-1104-96, May 2002. 

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