II. MAJOR TECHNICAL ACTIVITIES OF THE BOARD DURING 1994 A. HEALTH AND SAFETY MANAGEMENT OF DEFENSE NUCLEAR FACILITIES A significant result of the last major reorganization of the Department of Energy in 1993 was that the roles and responsibilities of the offices involved in nuclear safety were not clearly delineated. In May 1994, the Board imposed a reporting requirement on DOE (pursuant to 42 U.S.C. 2286b(d)) requiring the Department to provide a brief summary description of the basic safety management system that DOE currently has in place for satisfying its responsibilities under the Atomic Energy Act to protect or to minimize danger to life and property. The Board requested DOE to describe how safety is considered throughout the life cycle of defense nuclear facilities, including the major stages of design, construction, operation, and decommissioning. DOE was also requested to clearly define the nuclear safety responsibilities of the various line and internal oversight organizational elements. In its October 1994 response, DOE described the objectives, tasks, and safety considerations for each phase of the system life cycle, as well as the general transition, interface, and information flow requirements among the phases. The response provides a systems-oriented framework for DOE to examine its safety management program critically. Additionally, the Department revised its Manual of Functions, Assignments and Responsibilities. The Board views these steps as positive measures toward strengthening the Department's safety management program, and is now assessing the effectiveness with which this manual has been implemented by headquarters and field organizations. In response to budgetary restrictions, the Secretary announced a plan in December 1994 to review the structure of the Department. This effort, to be performed by both DOE employees and independent experts, should afford a valuable opportunity to address systematically the subject of health and safety responsibilities of individuals and organizations within the Department. Because of the clear opportunity for the Department to improve its health and safety management, the Board intends to monitor this effort during 1995. B. SAFETY ASPECTS OF THE ASSEMBLY, DISASSEMBLY, AND TESTING OF NUCLEAR WEAPONS DOE is responsible for maintenance and support of the active nuclear weapons stockpile, retaining the capability to resume nuclear testing (in accordance with Presidential direction), dismantlement of nuclear weapons, and associated research and development. The nature of DOE's weapons mission in these areas has changed from its former thrust toward design, production and testing to an emphasis on dismantlement, stockpile maintenance, decommissioning, and safe storage. DOE has defined its adjustments to these changes in two program initiatives: (1) Stockpile Management, which deals with the retention of capability to maintain the systems in the U.S. nuclear weapons stockpile; and (2) Stockpile Stewardship, which deals with retention and development of the technological tools necessary to maintain confidence in the safety, reliability, and performance of U.S. nuclear weapons and their associated components. The thrust of these initiatives is to move toward a smaller, but fully capable nuclear weapons complex. DOE's efforts to adapt the nuclear weapons complex to reflect changes in the U.S. national security posture have resulted in new areas needing safety attention. The Board has taken action on four fronts to help ensure that such changes do not degrade nuclear safety. These four areas of primary focus in 1994 were: (1) the adequacy of technical staffing, (2) the evaluation of facility and process readiness, (3) the conduct of ongoing operations, and (4) ensuring that the safety of operations is standards-based. Adequacy of Technical Staffing: The Board continues to note the close relationship between the recruitment, training, and retention of well-qualified personnel and nuclear safety. This issue is an especially crucial one in a "downsizing" environment. The continued need for technically competent personnel in the weapons complex was addressed by the Board in its 1993 Recommendation 93-6; Recommendation 93-3 addressed this issue DOE-wide. The Board issued Recommendation 93-6 to highlight the need to retain access to and capture the unique knowledge of individuals who have been engaged for many years in assembly, disassembly, and testing of nuclear weapons, so as to avoid future safety problems. The Board noted that many individuals are being lost from the defense nuclear system, due to retirement incentives, layoffs, and other downsizing activities, and that these individuals possess information that is not presently documented. Retention of this information is essential if DOE is to maintain the capability to safely manage and maintain the weapons stockpile, and conduct dismantlement activities. The Secretary accepted Recommendation 93-6 in February 1994, stating that the Department shared the Board's concern about ensuring capability to conduct nuclear weapons testing operations and dismantle nuclear weapons safely. In May 1994, the Secretary notified the Board that 45 additional days were needed to develop an integrated and effective approach. In its response to the Secretary, the Board stressed that some aspects of the recommendation have a high degree of urgency, emphasizing that impending early retirement of weapons experts in DOE and the National Laboratories would exacerbate an already inadequate staffing situation. The Board noted that technical competence in DOE's defense activities was already below a level necessary for continued safety, and urged an aggressive approach to supplement the Defense Programs organization with additional, technically competent personnel. In July 1994, the Department submitted an Implementation Plan generally acceptable to the Board. A specific element of the plan committed to an immediate review of staffing of specific organizational elements of DOE's weapons complex and the need for additional, technically qualified personnel. Unfortunately, the initial efforts to assess staffing were unsatisfactory. In September 1994, the Board wrote to the Department, stating that the initial report did "not address either of the explicit requirements of the commitment (i.e., the status of current staffing and recommendations for additional staff)." However, discussions between the Board and the Secretary led to a commitment by DOE in late 1994 to: (1) allow the Headquarters staff to be supplemented immediately with ten additional personnel for nuclear safety-related activities; (2) conduct a comprehensive technical staffing review to identify where technical resources were lacking; and (3) determine how to focus additional resources. In general, DOE's progress on meeting the commitments in its implementation plan for Recommendation 93-6 has been limited, due in part to the staffing inadequacies highlighted by the Board. In its September letter, the Board informed DOE of a number of deficiencies. As a result of the Board's letter, DOE assigned senior DOE managers to better coordinate implementation of Recommendation 93-6. Their efforts did result in some additional progress, but at year-end, implementation of Recommendation 93-6 was still substantially behind schedule. The potential safety impact of a delay in meeting the objectives of Recommendation 93-6 is significant. During 1994, the Board also made inquiries as to the availability of technically qualified former military personnel to perform duties within the weapons complex. This topic was the subject of a meeting between members of the Board and the Deputy Secretary of Defense in July 1994. At that meeting, the members also specifically addressed the importance of assigning a senior military officer to the position of DOE Deputy Assistant Secretary for Military Applications and Stockpile Support (DASMASS) for a period longer than the customary two-year tour. That officer should be a technically competent manager with a background in nuclear weapons and/or nuclear facilities. They also addressed the need for the Department of Defense to continue its attention to the selection of highly qualified individuals of sufficient stature and commitment to critical positions as an essential element in ensuring the continuing safety of the defense nuclear complex. Evaluation of facility and process readiness: The readiness of facilities in the weapons complex to operate safely was a topic of significant Board attention throughout 1994. Particular emphasis was placed on conduct of appropriate readiness reviews. For specific weapon assembly and disassembly operations, the Nuclear Explosive Safety Study (NESS) along with the Qualification Evaluation (QE) processes are utilized to independently assess readiness. In December 1993, the Board called for an independent review of the NESS process. Subsequently, a review of the NESS process was conducted by an independent team composed of nuclear safety professionals from the Department of Defense and the DOE National Weapon Laboratories. Completion of this review in May 1994 led to the development of a NESS Corrective Action Plan, which addressed program deficiencies, a number of which were taken care of by DOE immediately by issuing interim guidance instructions. The remaining corrective actions are being integrated with the implementation of an earlier Recommendation 93-1, and are scheduled for completion by June 1995. Throughout 1994, the Board exercised oversight of the majority of NESSs performed by DOE for operations at the Pantex Plant and at the Nevada Test Site. Oversight reviews were focused on the adequacy of interim guidance issued by DOE, and on field compliance with the guidance and with the requirements of DOE Order 5610.11 (which addresses nuclear explosive safety). Guidance for readiness reviews of weapons operations was developed by DOE in response to Recommendation 92-6. The guidance calls for a Qualification Evaluation (QE) to be performed after certification of readiness by contractor and DOE line management. The QE, performed by a team of National Weapon Laboratory personnel, assesses the adequacy and correctness of the procedures for weapon assembly or disassembly, and verifies that safety considerations have been addressed. The Board provided DOE with suggested improvements to DOE's guidance paper, and at year-end, DOE was in the process of responding to the Board's comments. The Board observed and reviewed implementation of the QE process at the Pantex Plant. On-going efforts to implement the process resulted in the identification of improvements required by both the DOE Amarillo Area Office and the DOE Albuquerque Operations Office. The lessons learned from reviews performed in 1994 are to be used by DOE to upgrade future QEs. Recommendation 93-6 called for maintaining safety-related nuclear testing expertise to ensure that if testing is required in the future, it can be resumed safely. In support of this effort, and in response to Recommendation 92-6, DOE developed a Test Readiness Assessment (TRA) program. DOE uses full-scale exercises as a primary means to achieve test readiness. The Board provided several observations on the conduct of testing exercises where the intent of Recommendation 93-6 was not being met, and DOE committed to strengthen the exercise program in the areas identified by the Board. Conduct of Ongoing Operations: Detailed review of the ongoing operations at facilities in the weapons complex received high priority in 1994. These reviews included, for example, standards-based evaluations of: conduct of operations, radiological controls, operational safety, maintenance of safety-related systems, and quality assurance. One such review performed at the Y-12 Plant in Oak Ridge disclosed systemic problems with criticality safety and conduct of operations; these were addressed by the Board in Recommendation 94-4. These problems are discussed in detail in Section I.E.1. At the Pantex Plant, the Board continued to monitor DOE's progress in implementing a satisfactory level of conduct of operations, pursuant to its corrective action plan issued in response to the Board's November 1993 reporting requirement. Standards-based Operations: During 1994, DOE completed its analysis of the differences between the safety requirements applicable to nuclear explosives facilities and those which are applicable to other defense nuclear facilities, as called for in the Department's Implementation Plan for Recommendation 93-1. This analysis, coupled with the analysis called for in a December 1993 Board letter regarding the Nuclear Explosive Safety Study (NESS), led DOE to conclude that the guidance and requirements contained in its 5610 series of orders (on Nuclear Explosive Safety) needed improvement. The Department developed a plan to improve the requirements applicable to nuclear explosive facilities, which were set forth in orders and the NESS program. DOE also committed to developing an action plan for upgrading and expediting order compliance self-assessments at facilities that assemble, disassemble and test nuclear weapons. Progress in achieving these improvements in order compliance self- assessment has been inconsistent, with some facilities showing substantial improvements (e.g., Los Alamos National Laboratory) and others lagging behind (e.g., Lawrence Livermore National Laboratory and the Nevada Test Site). On the other hand, the Board was encouraged by DOE's commitment to extend the applicability of selected safety orders and to enhance the set of DOE standards. C. SAFELY MANAGING SURPLUS NUCLEAR MATERIALS AND WASTES 1. Safe Disposition of Surplus Nuclear Materials Recommendation 94-1, issued in May 1994, called for an accelerated schedule for stabilizing and repackaging unstable special nuclear materials and spent fuel. DOE's Plutonium Vulnerability Study, a detailed and wide-ranging evaluation of the safety of plutonium stored in DOE facilities, reached conclusions similar to those reached by the Board. However, the Board has concluded that the risks posed by those materials are more serious than appears to be recognized by DOE, and that DOE's schedules for stabilizing and repackaging need to be accelerated in the interests of worker and public safety. Recommendation 94-1 specifically called on DOE to: o bring stored plutonium metal and oxide at all sites into conformance with the DOE plutonium storage standard within approximately eight years; o process the plutonium and trans-plutonium solutions in the Savannah River Site's F-Canyon within 2-3 years into forms safer for interim storage; o repackage plutonium metal in contact with plastic at all sites within 2-3 years; o process possibly unstable plutonium residues at Rocky Flats within 2-3 years into forms suitable for interim storage; o process deteriorating irradiated fuel at the Savannah River Site within 2-3 years into forms suitable for interim storage; o place deteriorating irradiated fuel from the K-Basins at the Hanford Site in a stable configuration within 2-3 years; o establish a research program to help choose among candidate processes for conversion to interim forms and longer-term disposition; and o maintain facilities that may be needed for future handling and treatment of such materials. The Department's initial Implementation Plan, submitted in December 1994, was not acceptable to the Board. DOE agreed in general terms with the Board's objectives but declined to commit itself to the recommendation's timetable for taking specific actions. Meanwhile, the Board's sense of urgency was reinforced by further developments after the recommendation was issued. As postulated by the Board, high concentrations of hydrogen gas have been found in the headspace of drums containing plutonium residues at Rocky Flats. Radiography of these drums during 1994 showed that the residues were contained in plastic bottles, rather than in sealed stainless steel cans, as called for by good practice. The Board has concluded that substantially increased action is required to implement Recommendation 94-1. Recommendation 94-1 recommended that storage of all plutonium metal and oxide conform to the then-draft DOE plutonium storage standard. DOE subsequently issued the standard (in December 1994) requiring that plutonium oxide be thermally stabilized before packaging for storage, and that containers used to store plutonium metal or oxide be sealed, structurally adequate, corrosion-resistant, and free of organic materials. This will require repackaging thousands of items stored at Rocky Flats, the Los Alamos and Lawrence Livermore National Laboratories, the Hanford Site, and the Savannah River Site. DOE has identified several sites where it is known or suspected that plutonium metal is in contact with plastic, creating the potential for producing radiolytic hydrogen. These sites include Rocky Flats (approximately 250 items), the Savannah River Site (12 containers), and the Mound Site (number of items not known). Currently, thirteen of the plutonium items that were originally packaged in contact with plastic at Rocky Flats have been repackaged. DOE has proposed processing the plutonium solutions remaining in F- Canyon systems at the Savannah River Site to metallic form within two years. It is planned that the trans-plutonium solutions will be vitrified in F-Canyon within the next five years, but the Board is concerned that continued storage of this highly radioactive material in a liquid form poses potential risks to the public. The Board is working with DOE to explore alternatives that would lead to this material being stabilized sooner. In addition, DOE is developing plans to stabilize the remaining uranium, neptunium, and plutonium solutions being stored in H-Canyon and F-Canyon. The Board will continue to monitor these plans to ensure that these materials are stabilized safely and in a timely manner. In January 1995, DOE formally withdrew the Implementation Plan for Recommendation 94-1, in response to the Board's dissatisfaction. A revised Plan is scheduled to be delivered to the Board in February 1995. The Board expects that DOE will make firm commitments for an aggressive schedule to accomplish the stabilization called for in Recommendation 94- 1. 2. Accelerated Waste Characterization at the Hanford Site The Board continues to urge DOE to accelerate the pace of the program for characterizing and processing the contents of high level nuclear waste tanks at the Hanford Site. In its 1990 Recommendation 90-7, the Board stated that the schedule for characterizing tanks containing ferrocyanide compounds needed to be greatly accelerated. Its Recommendation 93-5 expanded upon Recommendation 90-7, stating that DOE should complete all safety-related characterization of high-level waste tanks at the Hanford Site within three years, with the characterization of the high priority tanks being completed in the first two years. Recommendation 93-5 also called for the characterization program to be integrated into the systems engineering program for the Tank Waste Remediation System at the Hanford Site to ensure the data necessary to select treatment and immobilization methods will be available when needed. The Secretary of Energy accepted these recommendations. The Implementation Plan for Recommendation 93-5 was accepted by the Board in March 1994. Sampling and analysis of the contents of high-level waste tanks are far behind schedule. The schedule problems involve both the characterization strategy and its subsequent execution. DOE has not been able to develop a technically defensible strategy for efficiently characterizing the high-level waste tanks. Mechanical problems and poor sample recovery have plagued the contractor's core sampling equipment. The contractor is operating to a schedule that will not complete safety- related characterization of watch list tanks until two years after the Implementation Plan commitment, and the remaining tanks one year later than committed. DOE is analyzing the situation to see if the goals of Recommendation 93-5 can be achieved with substantially less sampling and analysis. Thus far, no technically sound plan of action has emerged, and DOE has not convinced the Board that it can meet the goals of Recommendation 93-5. 3. Storage of Spent Nuclear Fuel During 1994, the Board continued its 1993 activities in review of storage of spent nuclear fuel storage at the Idaho National Engineering Laboratory (INEL), the Savannah River Site, and the Hanford Site. In the past year, 189 fuel containers were successfully moved from an old, structurally unstable location to a newer and more structurally competent storage basin at the Idaho Chemical Processing Plant. The Board considers these and other actions being taken to manage vulnerabilities at INEL to be a DOE safety improvement. The K-East Basin at the Hanford Site contains more than a thousand tons of deteriorating, irradiated nuclear fuel. The fuel is substantially corroded and the basin is heavily contaminated. These degraded conditions result in increased waste generation, higher personnel exposure, and greater difficulty in the handling, storage and disposal of the fuel. The K-East Basin has leaked on several occasions, and is likely to leak again. In addition, analysis shows that in a severe seismic event, the basin may not remain intact. Contaminated water released from the basin could migrate to the nearby Columbia River. As part of its Recommendation 94-1, the Board called for the deteriorating fuel in the Hanford Site's K-East Basin and fuel storage basins at the Savannah River Site to be placed in a stable configuration for interim storage within two to three years. DOE's current planning calls for packaging the K-East Basin fuel and the associated fission product sludge, and removing it from the basin by 1999. Defense-related fuel in the Savannah River Site basins is scheduled for processing by 2004, with the bulk of the most deteriorated fuel being processed by 1997. DOE is currently re-evaluating its commitments under Recommendation 94-1, in an effort to improve these schedules. 4. Low Level Waste Management In September 1994, as part of its Recommendation 94-2, the Board recommended that DOE complete a complex-wide review of the low-level waste issue, with the objectives of establishing the dimensions of the low- level waste problem and identifying necessary corrective actions to bring operations into compliance with applicable safety standards. In preparation for the substantial increase in low-level waste projected from cleanup programs, the Board recommended that DOE's Implementation Plan include a program for forecasting future burial needs. The Board urged that more immediate steps be taken to complete performance assessments for all active low-level waste burial sites, as required by DOE Order 5820.2A. The Board also recommended that DOE issue instructions to ensure that performance assessments are based on total inventories of low-level waste (past, present, and future) emplaced or planned for a burial site and that performance objectives be achieved for the composite of all low-level waste disposal facilities on the site. The Secretary of Energy accepted Recommendation 94-2 in October 1994 and committed to undertake a complex-wide baseline assessment of DOE's low-level radioactive waste disposal requirements and practices. The Department also recognized the importance of assessing cumulative impacts to the public health and safety due to total waste inventories and all low-level waste disposal facilities on a site. At year-end, DOE was in the process of developing its Implementation Plan. D. SAFETY ASPECTS OF CONDUCT OF OPERATIONS 1. Conduct of Operations DOE's requirements regarding conduct of operations at its facilities are set forth in DOE Safety Order 5480.19, which establishes the expectation that operational formality at defense nuclear facilities be on a par with that used by the commercial nuclear industry. In June 1994, as part of DOE's annual report for Recommendation 92-5, the Department provided a brief description of the operational status and plans for future use of facilities in the defense nuclear complex. The report did not present significant new initiatives regarding requirements for conduct of operations. Recent reportable occurrences and observations made during site visits by the Board's staff members, and DOE's August 1994 report of its review of conduct of operations, indicate slow and uneven progress in implementing Departmental requirements. The status of implementation of DOE 5480.19 as stated in the June 1994 report, is too optimistic since significant deficiencies exist in the implementation of this order throughout the complex, more than four years after its issuance. An example of deficient conduct of operations practices is provided by recent observations at the Y-12 Plant in Oak Ridge. Although DOE and the operating contractor at the Y-12 Plant at the Oak Ridge Site have made some improvements in conduct of operations over the past two years, several violations of Operational Safety Requirements (OSRs) and Compliance Schedule Agreements (CSAs) during 1994 indicated an unsatisfactory level of conduct of operations. In September 1994, during a routine site review, members of the Board's staff observed several violations of nuclear criticality safety limits in Y-12 storage vaults and brought these violations to the attention of contractor management and the DOE Facility Representative. Neither the DOE nor contractor personnel present took the actions required by the applicable criticality safety procedure. Proper actions were taken only after members of the Board's staff notified the DOE Y-12 Site Office Manager. As a result of these violations, contractor management curtailed Y-12 activities and began a comprehensive site-wide review of compliance with all CSAs. That review identified more than 1300 CSA noncompliances. Contractor management subsequently shut down all operations at Y-12 pending correction. This apparent breakdown of administrative controls and other conduct of operations problems at Y-12 were key factors leading the Board to issue Recommendation 94-4, calling for DOE to fully evaluate compliance with OSRs and CSAs, determine root causes of identified violations, review the nuclear criticality safety program, and establish actions to resolve the nuclear criticality deficiencies at Y-12. The Board also urged DOE to compare the level of conduct of operations at Y-12 to the level expected by DOE in implementing the Board's Recommendation 92-5. DOE accepted Recommendation 94-4 in mid-November, and is developing an implementation plan in parallel with improving criticality safety, conduct of operations, and other administrative safety programs before resuming Y-12 operations. During 1995, the Board intends to monitor DOE's efforts to resume operations at Y-12. On the other hand, some notable examples exist where the right mix of management attention, resources, and staffing expertise has been brought together to implement an effective conduct of operations program. Examples include the startup of the Replacement Tritium Facility and the restart of F-Canyon, both at the Savannah River Site; and the restart of Building 559 at Rocky Flats. At these facilities, line managers were personally committed to the program and involved in finding and correcting problems, and communicated their strong support and expectations to subordinates. Sufficient numbers of experienced operations personnel were assigned to the facilities, and DOE field organizations were staffed with knowledgeable managers and facility representatives who were committed to enforcing the correct standards. 2. Readiness of Facilities to Operate In response to Recommendation 92-6, DOE issued a new order, DOE Order 5480.31, in September 1993, establishing requirements for starting or resuming operations and the readiness review process. An associated standard, DOE-STD-3006-93, which was issued in April 1994, provides detailed guidance for planning and conducting readiness reviews at defense nuclear facilities, other than those involved in nuclear explosives activities. The issuance of these requirements and standards is a positive action toward assuring nuclear safety throughout the operating complex. The Board has monitored implementation of the new order across the complex. Some examples of the results of the Board's oversight appear below. o In early 1994, the Board reviewed preparations for increased storage of pits in Zone 4 at the Pantex Plant, finding, among other things, that DOE and contractor line management had not achieved an adequate state of readiness before conducting an Operational Readiness Review (ORR) for pit storage, according to the requirements of DOE Order 5480.31. The premature ORR revealed practices needing improvement. Thus, contrary to the original intent, the ORR team functioned as an adjunct to line management, rather than as an independent check of readiness. o This practice, which effectively nullifies the safety benefits of an independent check, was observed in a number of other cases. The Board raised this issue in a letter to the Department in April 1994. In August 1994, DOE responded by committing to provide further training to line management personnel on the readiness review process and to revising DOE Order 5480.31 to more clearly define actions in certifying readiness to operate. o At Rocky Flats, DOE completed an Environmental Assessment for limited use of Building 707 to stabilize plutonium-bearing residues, and found no significant environmental impact. Although an ORR had been completed more than two and a half years earlier, DOE decided a reassessment was warranted. In July 1994, DOE completed that additional ORR for limited operations in Building 707. The Board reviewed the preparations for renewed calcining operations and based on its staff's report, concluded that the ORR was conducted satisfactorily, and so informed DOE in August 1994. DOE authorized resumption of the limited operations in Building 707 in December 1994. o At the Idaho National Engineering Laboratory, the Board and its staff monitored preparations to restart the de-nitrator process at the Idaho Chemical Processing Plant. In June 1994, DOE completed an ORR. The Board found that preparations by line management and conduct of the ORR adequately demonstrated readiness to restart operations. o The Board also monitored the process of establishing readiness to resume operation at various facilities at the Savannah River Site, including the F-Canyon, FB-Line, and the In-Tank Precipitation facilities. Preparations for restart of both F-Canyon and FB-Line in 1994 included ORRs conducted by DOE Headquarters, which identified several issues requiring resolution before restart. o As previously stated, the Oak Ridge Y-12 Plant management had shut down most nuclear operations in late 1994 because of numerous noncompliances with safety requirements. During this hiatus, DOE chose to conduct a number of important nuclear operations at Y-12, including support for inspections by the International Atomic Energy Agency, receipt of highly enriched uranium from Kazakhstan (the SAPPHIRE project), and receipt of certain components of nuclear weapons disassembled at the Pantex Plant. In each of these cases, the Y-12 contractor prepared a special activity package describing the additional controls and actions that would be taken to ensure safety of these high priority activities during the shut-down period. The Board evaluated the review and approval process and subsequently reviewed the proposed operations. In each case, the Board saw no undue risk to health and safety of the public or workers. o In early 1994, the Board reviewed the readiness of the LANL TA-55 Plutonium Facility to proceed with production of plutonium oxide pellets in support of NASA's Cassini Mission to Saturn. LANL and DOE did not conduct full operational readiness reviews prior to restart. They relied on what they believed to be adequate experience of the operators from previous campaigns for fabrication of similar pellets. However, to review whether the higher throughput rate required for Cassini posed a significant risk, the Board held two public meetings in March 1994. Subsequently, in reviewing compliance with procedures and safety limits, LANL management suspended production operations for two and a half months to make operational improvements. Production operations began again in late July 1994. E. SAFETY ASPECTS OF MANAGING THE DEFENSE NUCLEAR FACILITY SYSTEM LIFE CYCLE 1. Systems Engineering Implementation The Board has become increasingly aware that DOE does not treat interacting operations at individual sites or combinations of sites as a system whose components mutually affect each other. This point is commonly overlooked in planning of facilities, operations, and programs, and more often that not leads to unworkable results. A systems-based process attempts to optimize the solution of a complex problem by breaking the problem into component parts and then engineering component parts in the context of the whole. For example, preparation of the high level waste in the tanks at the Hanford Site for geologic disposal will require characterization, pre-treatment, vitrification, and packaging. Engineering the solutions for these complementary functions must be done in the context of the system objective; namely a stabilized waste form suitable for disposal. During 1994, the Board reviewed systems engineering activities at several facilities including: the control of safety bases for operations at the Pantex Plant; improvements to be made in the OSR surveillance process at the TA-55 facility at LANL; and the remediation of high level waste at the Hanford and Savannah River Sites and at the Idaho National Engineering Laboratory (INEL). Systems engineering activities related to the disposition of special nuclear material and spent nuclear fuel at the Hanford Site , INEL, the Savannah River Site, and Rocky Flats were also reviewed by the Board in the past year. To date, reviews have shown that these various DOE activities have been largely unsatisfactory. In general, the Board has noted that DOE has not consistently taken a formalized systems approach to solving safety, technical, and managerial problems. A complex-wide DOE standard that formalizes the method would help. The need for better guidance on systems engineering was apparent during a number of the Board's reviews in 1994. Several examples are provided below. On two occasions, in April and May, the Board informed DOE of what it considered to be inadequacies in design basis information involving systems serving safety functions, configuration management, and flow-through of technical requirements to operational procedures at the Pantex Plant and at LANL. Subsequently, DOE elected to curtail operations at the Pantex Plant and at LANL's TA-55 facility for extended periods. As part of the Tank Waste Remediation System (TWRS) at the Hanford Site, DOE announced its intention to build additional one-million gallon, double-shell tanks as major elements of the Multi-functional Waste Tank Facility (MWTF). The Board's review of the process of design of these tanks, both in the managerial and technical areas, resulted in the issuance of Recommendation 92-4 calling for a systems engineering approach to the design, construction, operation, and eventual decommissioning of the MWTF. DOE has made some progress toward use of systems engineering for project development within the TWRS. However, at the end of 1994, it was still not being fully used by DOE. It was not used to decide whether new tanks are really needed, how many there should be, and how large they should be. The use of systems engineering by DOE's Office of Spent Nuclear Fuel (EM-37) has evolved from a series of DOE- sponsored workshops, site meetings and site activities during 1994. This has resulted in the development of functional requirements at a high enough level to ensure some consistency across the defense nuclear complex. However, during a recent visit to the Savannah River Site, it was observed that both ongoing and planned contractor projects supporting the storage and processing of spent fuel are not linked to the Spent Nuclear Fuel Systems Engineering Program. The situation resembles that with the TWRS described above. There seem to be no near-term plans to integrate the Spent Nuclear Fuel Systems Engineering Program with current spent nuclear fuel projects in the field. Failure to use a systems approach in planning can lead to greatly increased cost, delays, inferior solutions to problems, and even inability to solve some problems. The Board will continue to emphasize the need for a systems engineering approach in these and other projects in the complex. As part of its efforts to streamline project development, DOE is revising DOE Order 4700.1, dealing with systems management. The Board has reviewed initial drafts of the revised order and has provided its comments to DOE regarding needed improvements to address the problems noted above. All these activities are ongoing and have had or will have significant impact on operations or decommissioning of numerous DOE facilities. 2. Seismic and Other External Hazards Mitigation During 1994, the Board's review of seismic hazards focused on the design adequacy of key facilities in DOE's nuclear materials storage and waste management. Reviews continued of the design basis adequacy of the In-Tank Precipitation Facility (ITP), the H-Area Waste Tank Farms, and the Defense Waste Processing Facility (DWPF) at the Savannah River Site; the Tank Waste Remediation System at the Hanford Site; the spent fuel storage basins at the Idaho Chemical Processing Plant; and Building 371 at Rocky Flats. The adequacy of the Chemistry and Metallurgy Research Laboratory (TA-3) and the Plutonium Facility (TA-55) at Los Alamos National Laboratory were also reviewed, and a November 1994 letter was accordingly sent to DOE requesting a report concerning design practices at LANL. Based on its review of the seismic aspects of DOE's efforts to consolidate the large inventory of plutonium and highly enriched uranium at Rocky Flats into a single building, the Board concluded that DOE's ongoing activities to better identify and respond to potential hazards from natural phenomena were not well integrated. The activities were not logically structured or sufficiently encompassing in either detail or scope to assure protection of public health and safety. In September 1994, the Board issued Recommendation 94-3, calling for a systems approach to the design basis for Building 371 at Rocky Flats and the safety concerns associated with the increased storage of special nuclear material in this facility. The Secretary has accepted the Board's recommendation, and the Department is currently developing an Implementation Plan. Since the types and magnitudes of potential earthquakes act as important driving forces on facility design and modification decisions, the Board continues to monitor efforts to characterize earthquake ground motion at the Hanford Site, INEL, LANL, Rocky Flats, the Oak Ridge Reservation, and the Savannah River Site. The Board has raised questions regarding the emphasis DOE places on probabilistic methods for characterizing earthquake ground motion, without concurrently reconciling that methodology to the analytical procedures used successfully in the commercial nuclear power program. Probabilistic methods have been changing rapidly, with new and untested assumptions and extrapolations being introduced. Validation of these models will require time and experience. The Board is examining and has questioned the use of probabilistic methods in lieu of the deterministic approach used by the commercial nuclear industry. The Board intends to continue to work with DOE on these matters during 1995. 3. Criticality Safety In Recommendation 93-2, the Board recommended that DOE retain its program of criticality experiments to improve the criticality data base and to serve in training the community of criticality engineers. The Department responded positively to this recommendation. DOE chose the Los Alamos Critical Experiments Facility (LACEF) for this purpose and formed a Nuclear Criticality Steering Committee to provide guidance in responding to Recommendation 93-2. DOE identified projected funding and experiments for execution through Fiscal Year 1995 and summarized the significant accomplishments in an annual report on the status of the program. The Board will continue to review the adequacy of future funding for criticality experiments and criticality engineer training, as well as the operation of the LACEF in general. In late September 1994, after draining low-concentration plutonium solution from a storage tank, an operator in Building 771 at Rocky Flats drained solution from another tank, outside the scope of the procedure. As a result, about five liters of highly concentrated plutonium solution were collected in a potentially unsafe geometry. Although criticality did not occur, this action defeated the controls that had been put in place to prevent a nuclear criticality accident. Following this event, the Rocky Flats plant contractor suspended tank draining operations as well as a number of other operations that involve the handling of special nuclear material. In November 1994, the Board requested that DOE address the issues raised in Board Recommendation 94-4 as applicable to this criticality infraction and provide a report within 60 days. At the end of the year, the suspension was still in effect, and DOE was preparing its response to the Board's request for a report. 4. Safety Analysis of Site Operations The Board continued to review the technical adequacy of Safety Analysis Reports (SAR's) of DOE facilities. During 1993, the Board's review of analyses of potential aircraft crashes at defense nuclear facilities indicated that the methodologies employed in these studies vary significantly from site to site. It was seen that the differences resulted from lack of uniform guidance by DOE. Within the past year, DOE has initiated the development of a consensus standard to address this deficiency. In October 1993, the Board requested that DOE prepare a report providing additional information on several technical issues concerning military overflights of the Pantex Plant and the methodology used for evaluation of the impact of an aircraft crash into the Pantex Plant Zone 4 storage magazines. The Board reviewed DOE's report and questioned the validity of the Pantex Plant's analysis in a letter to the Department in June 1994, and requested that a safety evaluation be conducted using methodology prescribed in DOE Order 5480.21, Unreviewed Safety Questions. DOE addressed the issues raised by the Board and found errors in the calculations of the probability of an aircraft crash into Zone 4. A cooperative activity by DOE, the City of Amarillo, the U.S. Air Force, and the Federal Aviation Administration (FAA) resulted in an agreement to reduce the number of aircraft overflights of the Pantex Plant significantly during the next five years. The Board has reviewed safety analyses for several other DOE defense nuclear facilities, including separations facilities, and the high-level waste storage and processing facilities at the Savannah River Site (SRS). Several of these facilities are scheduled to begin operations in 1995. The Board conducted several reviews of the safety of the F-Canyon and FB-Line. These reviews resulted in the implementation of additional safety measures and the upgrade of existing safety analysis documentation. Some of the specific measures include: (1) isolation of Tank 17.1, which contains highly radioactive americium and curium solutions, to reduce the risk of release to the environment; (2) upgrade of capabilities to monitor the activity of cooling water to reduce the risk of a release to the environment; (3) reclassification of the process vessel vent system to provide additional controls to prevent the accumulation of flammable gas; and (4) modification of the 3rd and 4th level ventilation systems at the FB-Line to prevent unmitigated releases during a fire. The F-Canyon restarted second plutonium cycle operations in February 1995 and the FB- Line is scheduled to restart in April 1995. The Board reviewed the safety analysis for the In-Tank Precipitation (ITP) Facility and questioned the adequacy of several key assumptions related to the rates of benzene generation and the degree of mixing. These assumptions had led to a DOE conclusion that a flammable vapor mixture could not form in the tank headspace under either normal or abnormal conditions. In response to the Board's questions, DOE implemented a program to validate the assumptions made in the safety analysis. This program includes the development of a computer simulation of the tank headspace to determine the degree of mixing during normal and abnormal conditions (e.g., loss of ventilation). The results of this analysis will be validated by a test program prior to initial startup of the ITP, scheduled in July 1995. The Board has monitored the startup test program for the Defense Waste Processing Facility (DWPF) and has reviewed the safety of process operations. The design and classification of safety systems that control and prevent the formation of flammable vapor mixtures in several process operations were questioned. In response to the Board's questions and DOE's own independent oversight findings, DOE reassessed the design and classification of these safety systems. The need for several significant upgrades has been identified (e.g., backup inert gas purging systems). These will result in a significant reduction of the risk to the workers and public. Board reviews also led to comprehensive reassessment of the facility, integration of required research and development efforts, and significant improvements in conduct of operations, operator training, control system design, and mitigation of process hazards. DWPF is scheduled to start up in December 1995. DOE has explored the concept of risk acceptance in its safety management programs. This is a potential departure from the deterministic approach based on engineering disciplines traditionally used in safety assessments in the commercial nuclear industry as well as in the military weapons safety program. The Board has held numerous discussions with DOE about the use of risk assessment and its acceptance in safety management, particularly where data for probability estimates are lacking. The Board continues to encourage DOE to make maximum use of deterministic analysis coupled with defense-in-depth mitigation of accidents and hazards, while looking to risk determination as additional confirmatory information for use in the Department's safety management programs.