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[DOE LETTERHEAD]
February 7, 1995
The Honorable John T. Conway
Chairman
Defense Nuclear Facilities Safety Board
625 Indiana Avenue, N.W.
Suite 700
Washington, D.C. 20004
Dear Mr. Conway:
The enclosure is a preliminary report in response to your letter of November 25, 1994, concerning the Defense Nuclear Facilities Safety Board's Recommendation 94-4. As you suggested, our review of criticality safety related infractions at the Rocky Flats Environmental Technology Site has been expanded. Your requested delivery date for the report has not permitted completion of that review, but the enclosure includes the field information available to date. The late receipt of this information in Headquarters has not yet permitted a detailed review, so the reported information should be treated as pre-decisional. A final report will be provided upon completion of the review.
This report contains contractor privileged information, but may be placed in public reading rooms if Attachment eight of Enclosure three is omitted.
Sincerely,
Thomas P. Grumbly
Assistant Secretary for
Environmental Management
Enclosure [excludes Attachment eight of Enclosure three, as cited above]
RESPONSE TO THE DEFENSE NUCLEAR FACILITIES SAFETY BOARD (DNFSB) RECOMMENDATION 94-4
INTERIM REPORT
January 18, 1995
[DOE LOGO]
TABLE OF CONTENTS
RESPONSE TO THE
DEFENSE NUCLEAR FACILITIES SAFETY BOARD (DNFSB)
RECOMMENDATION 94-4
The purpose of this paper is to provide a response to the issues and concerns raised in the Defense Nuclear Facilities Safety Board (DNFSB) Recommendation 94-4 which covers deficiencies in criticality safety and Conduct of Operations a the Oak Ridge 6-12 Plant as applicable to the criticality safety limit infraction in Building 771 at the Rocky Flats Environmental Technology Site.
Background
On the evening of October 6, 1994, the Building 771 Production Manager reported to the Building 771 Shift Manager that solution draining activities outside the scope of authorized work had been conducted on the backshift on September 29, 1994. As a result, Building 771 nuclear operations were terminated, and an Occurrence Report was filed by the Shift Manager. Subsequent inquiry into the incident identified one employee who deliberately initiated the activity outside the authorized scope of work and two supervisory employees who not only did not stop the activities, but assisted in completing the unauthorized activities and then concealed them for seven days.
This unauthorized operation was reported in occurrence notification report RFO-EGGR-771OPS-1994-0062. Standing Order 34 was issued by EG&G Rocky Flats, Inc., on October 7, 1994, as a precautionary measure to immediately suspend movement, transfer, and operations involving fissile material at the Rocky Flats Environmental Technology Site. Standing Order 34 was subsequently revised to clarify suspended activities and to formalize restart requirements.
On November 25, 1994, the DNFSB Chairman, John T. Conway, requested in a letter to Thomas P. Grumbly that DOE provide a report that addresses the issues and concerns raised in Recommendation 94-4 as applicable to the Rocky Flats Building 771 criticality safety limit infraction. EG&G Rocky Flats and the Department of Energy/Rocky Flats Field Office (DOE/RFFO) had initiated and completed a number of activities as a result of the Occurrence Report and Standing Order 34 at the time this request was made. Many of these activities provide a direct response to the DNFSB specific recommendations.
During the period in which this report was being prepared, a second occurrence in Building 771 was reported (Occurrence RFO-EGGR-771OPS-1995-0003). Similar to the initial incident, this second occurrence constituted a violation of procedures and Conduct of Operations. On December 29, 1994, a technical staff engineer closed five pencil tank sight glass valves while performing a USQD valve line-up walkdown and verification. Management approval was not obtained prior to closing the valves nor was any notification made to management after the valves were closed. When questioned later, the technical staff engineer readily admitted closing the valves and stated he had intentions of notifying supervision of his actions. The same five pencil tank sight glass valves were re-opened on December 31, 1994, by a process specialist while performing a RCRA inspection. The valves, in the closed position, were not consistent with RCRA inspection requirements therefore, the process specialist opened them. Although, management approval was not obtained prior to opening the valves, the shift manager was later notified by the process specialist of his actions. This incident is believed to share root causes with the original event. Additional corrective actions were initiated and are considered throughout this response.
This paper is organized to first list each specific part of Recommendation 94-4 followed by the EG&G Rocky Flats and DOE/RFFO associated response. Each recommendation has been modified, shown in italics, to make it specific to Building 771 and the Rocky Flats Environmental Technology Site (the Site). Each related response provides a brief description and references documents enclosed with this paper that provide more detailed information related to the subject.
Recommendation 94-4 (1)
DOE determine the immediate actions necessary to resolve the nuclear criticality safety deficiencies at the Y-12 Plant (Building 771), including actions deemed necessary before restarting curtailed operations and any compensatory measures instituted. These actions should be documented, along with an explanation of how the deficiencies remained undetected by MMES (EG&G) and DOE (line and oversight).
EG&G Response 94-4 (1)
The immediate action was the termination of liquid transfer operations in Building 771, submission of Occurrence Notification Report RFO-EGGR-771OPS-1994-0062, 771 Operations (Enclosure 1) and issue of Standing Order 34 to suspend movement, transfer, and process operations involving fissile material on the site. Enclosure 2, J.A. Geis letter JAG-193-94 to D. W. Ferrera, "Basis for Standing Order 34," November 2, 1994, provides some clarification guidance and includes the original and two revisions of Standing Order 34. The Standing Order is revised as restart approval is obtained for the suspended activities. A comprehensive Root Cause Analysis and Generic Implication Study was initiated and completed on November 28, 1994. Enclosure 3, A. H. Burlingame letter AHB-275-94 to Mark N. Silverman, "Root Cause Analysis and Generic Implications of the Unauthorized Draining of a Process Line in Building 771, November 28, 1994," completed the report and forwarded it to DOE/RFFO. The lack of acceptance of Conduct of Operations principles is identified as the first of four generic implications (Enclosure 3, Attachment 2, page 1). An excerpt from this section states "One of the major improvements at Rocky Flats over the past few years has been to introduce a standards-based approach to work performance. That approach is embodied in the site's Conduct of Operations Program. Information gathered in response to the Building 771 event indicates that there are some personnel in Building 771 and other former production buildings who are not prepared to adhere fully to Conduct of Operations principles and practices. These employees generally believe that they cannot rely on management outside of their work groups to assure their safety and well-being and that they must rely on their own resources and process knowledge to accomplish work and improve their working conditions. As a result, operations personnel sometimes state that they have more faith in the "process knowledge" of experienced personnel in their building than in strict adherence to new procedures to assure their safety. The root cause report includes immediate, short-term, and long-term corrective actions that cover the site including Building 771. An evaluation of the delay in reporting the incident is included in the report.
After the critique of the events of the second occurrence in Building 771 on December 31, 1994, it was concluded that actions in progress but not yet completed from the Root Cause Analysis for the initial draining event were germane to this incident, and that the occurrence was continuing evidence of the failure by building personnel to embrace the concepts of Conduct of Operations. To ensure adequate control of workforce behavior while working toward a full implementation of Conduct of Operations, additional controls including increased levels of supervision and mentoring were instituted in the building.
In parallel with the root cause analysis, each director responsible for an activity involving movement, transfer, and process operations with fissile material suspended by Standing Order 34 was required to prepare a restart plan. The process for restart was initiated with directions1 to use the minimum Core Requirements from Attachment 2 of DOE Order 5480.31, Startup and Restart of Nuclear Facilities, as guidance for the preparation of plans. The process ensures completeness and consistency for each plan but permits grading the restart prerequisites to address actions identified in the root cause as applicable to the specific activity. The process uses the existing EG&G Rocky Flats, procedure (Admin 10.01) that implements DOE Order 5480.31 to provide consistent format of the restart plans.
A Safety Review Board subcommittee was established by the President of EG&G Rocky Flats, consisting of senior managers not associated with any of the restart programs to review the restart plans and provide appropriate recommendation to the Safety Review Board. These managers have significant, broad-based, and relevant experience which is being used to process, and operation of the subcommittee. The Safety Review Board submits the recommendation to the EG&G Rocky Flats President who has final authority prior to submission to the Manager, DOE/RFFO. The restart of suspended operations require approval by the DOE/RFFO manager.
The restart plans are based on an Internal Review, Readiness Assessment or Operations Readiness Review as defined in DOE Order 5480.31. The restart plans focus on the causes and generic implications specified in the root cause analysis. As of January 13, 1995, the following restart plans have been or are planned to be submitted to DOE/RFFO:
The restart of operations specified in 1, 2, and 3 have been approved by DOE/RFFO. Restart Plan number 4, which requires an Operational Readiness Reviews (ORR), is being prepared. The plan will be included in the final report following review, comment, and approval by DOE. Additional restart plans for other suspended activities are in preparation and/or internal review by the Safety Review Board and its subcommittee.
DOE/RFFO Response 94-4 (1)
The Site took prompt, appropriate, and conservative actions as a result of the Building 771 event to curtail activities Site-wide until the implications of the event could be addressed. The unauthorized draining of tanks was discovered by EG&G management (Shift Manager) on October 6, 1994, at approximately 7:30 p.m. The Sift Manager immediately terminated operations involving fissile materials in Building 771, posted the affected glovebox as criticality infraction, and notified DOE and EG&G management. On October 7, 1994, at 7:30 a.m., a critique was held on the event and attended by the RFFO Manager and the President of EG&G Rocky Flats. Immediately after the critique, EG&G suspended movement and handling of all fissile materials site wade.
DOE/RFFO has a formal process for overseeing the contractor restart process for all curtailed activities (Enclosure 8). The process includes walkdowns of spaces involved in the operations; reviews of operating procedures; criticality, nuclear, and operational safety analyses; and interviews of contractor operating and management personnel. DOE/RFFO review of the root cause determined it was adequate to support the restart of drum movements. HSP 31.11 repack, and thermal stabilization in Building 707. These activities had undergone extensive review (HSP 31.11 and Thermal Stabilization), or were deemed very low risk (drum movements). In addition, DOE/RFFO focused restart reviews for these activities on the problem areas identified in the root cause to ensure that the problems identified were not applicable or corrective actions were in place. The DOE/RFFO comments on the root cause will be addressed as part of the restart process for liquid stabilization in Building 771 (Enclosure 9). The root cause analysis will be further reviewed by a group of independent technical experts commissioned by DOE/RFFO. The results of this review and any actions will be submitted in the final report.
Recommendation 94-4 (2) (a)
DOE perform the following for defense nuclear facilities at the Y-12 Plant Rocky Flats Environmental Technology Site):
An evaluation of compliance with Operational Safety Requirements (OSRs) and Criticality Safety Approvals (CSAs), including a determination of the root cause of any identified violations. In performing this assessment, DOE should use the experience gained during similar reviews at the Los Alamos plutonium facility and during the recent "maintenance mode" at the Pantex Plant.
Editors Note: A combination of EG&G Rocky Flats, Inc., Criticality Safety Evaluations and Nuclear Material Safety Limits (NMSLs) or Criticality Safety Operations Limits (CSOLs) are equivalent to the Criticality Safety Approvals at the Y-12 Plant.
EG&G Response 94-4 (2) (a)
The reports covering similar reviews at the Los Alamos Plutonium Facility2 and during the maintenance mode at the Pantex Plant3 were reviewed to determine applicability to the Building 771 incident. The common issue in each report and the Building 771 incident is related to Conduct of Operations. As stated in the letter submitting the root cause ...."the fundamental and direct cause of this (Building 771) incident, that is the willing and knowing violation of the principles of Conduct of Operations and the subsequent non-disclosure of such violation for a period of seven days."
The process established by EG&G Rocky Flats and DOE/RFFO to completed a comprehensive root cause analysis (Enclosure 3) and prepare detailed restart plans, described in responses to Recommendation 94-4 (1), cover the issues raised in the Recommendation 94-4 item 2 (20 and referenced reports.
The Conduct of Operations in addressed in core requirement 12 of DOE Order 5480.31, which requires the implementation status of DOE Order 5480.19, "Conduct of Operations Requirements for DOE Facilities," and is addressed in each of the restart plans (Enclosures 4,5,6, and 7). The infrastructure for Conduct of Operations was established for Buildings 559 and 707. The issue is the acceptance of the fundamentals of Conduct of Operations by site personnel, which is also addressed in each restart plan.
Another corrective action identified during the root cause analysis (Enclosure 3) was the need to enhance training on Nuclear Criticality Safety. This corrective action is included in the restart plans as part of prerequisites to meet core requirements 1, 2, and 3 in Attachment 2 of DOE Order 5480.31 covering procedures, training and qualification, and level of knowledge of operations and support personnel. The DOE Order 5480.31 core requirements 4 and 5 addressed in the restart plans cover the facility safety documentation, and reconfirm the condition and operability of safety systems including Limiting Conditions of Operation (LCO) and Operational Safety Requirements (OSR's). The restart plans also require review, reaffirmation, and/or revision to existing criticality safety limits. The specific criteria, methodology, and deliverables are described for each DOE Order 5480.31 core requirement in the restart plans (Enclosures 6, 7, 8, and 9).
DOE/RFFO Response 94-4 (2) (a)
Ensuring compliance to OSRs (which include criticality safety limits) is the highest
priority of DOE/RFFO Facility Representatives. Facility Representatives observe activity
performance and contractor management response on a daily basis.
When criticality safety limit violations or OSR out of tolerance conditions are
identified, they are reported per DOE Order 5000.3B, which includes the requirement for a
root cause analysis. RFO facility representatives and ES&H personnel attend all
critiques involving OSR violations and most critiques involving potential criticality
safety problems. Also, the RFFO process for overseeing the re-start of curtailed
activities requires RFFO personnel to independently assess the adequacy of compliance to
the OSRs.
Recommendation 94-4 (2) (b)
A comprehensive review of the nuclear criticality safety program at the Y-12 Plant (Rocky Flats Environmental Technology Site), including: the adequacy of procedural controls, the utility of the nuclear criticality safety approvals, and a root cause analysis of the extensive level of non-compliance found in recent reviews.
EG&G Response 94-4 (2) (b)
EG&G Rocky Flats, Inc. has two site wide procedures, (NSM-03.12) "Nuclear Material Safety Limits and Criticality Safety Operating Limits Surveillance" and (NSP-010) "Monthly Criticality Safety Assessment," which are required controls for all buildings containing special nuclear materials (SNM). Procedure NSM-03.12 is a prerequisite to performing any activity involving movement or handling of fissile material. The Building 771 incident was not a result of inadequate nuclear criticality limits, controls, or approvals, but a deliberate violation of limits applied for the activity. Some additional actions were identified in the root cause analysis (Enclosure 3), including additional criticality training.
The Nuclear Criticality Safety Committee (NCSC) at the site has been collecting a number of documents covering assessments, concerns, evaluations, letters, etc., that are related to nuclear criticality safety. The NCSC was in the process of reviewing this information to identify the causal factors of recurring deficiencies within the criticality safety program at the time of the Building 771 incident. This activity was placed on hold while NCSC members participated in the root cause analysis of the Building 771 incident. Subsequently, a dedicated team of knowledgeable people from EG&G and Los Alamos National Laboratory has been assembled to complete a review of the criticality safety program deficiencies. The review and resulting corrective actions will be provided in the final report. Preliminary findings of this group include issues associated with the operations/criticality safety interface and the over utilization of administrative controls. Actions which related to restart activities will be incorporated as appropriate into the restart plans at the time of identification. The restart plans (Enclosures 4, 5, 6, and 7) address the criticality safety concerns related to the specific activities.
DOE/RFFO Response 94-4 (2) (b)
The site nuclear criticality safety program was evaluated during the Buildings 559 and 707 Operational Readiness Reviews. The reviews included process specific and programmatic elements. In view of the Building 771 event, DOE/RFFO has requisitioned a team of experts in the nuclear safety field to perform an independent review of the nuclear criticality safety program at the Site which will focus on the implementation of nuclear criticality safety program elements site-wide. The review is scheduled for February 1995, and a final report will be issued and included in the final report.
Recommendation 94-4 (2) (c)
A comparison of the current level of Conduct of Operations to the level expected by DOE in implementing the Board's Recommendation 92-5.
EG&G Response 94-4 (2) (c)
EG&G Rocky Flats implementation of the "conduct of operations" as related to the Board's recommendation 92-5 is "formality of operations." This includes readiness reviews prior to operation, training and qualification of operations and support personnel, Safety Analysis Reports, Limiting Conditions of Operations, criteria for meeting safety goals, and Conduct of Operations as required per DOE Order 5480.19. Each of the restart plans addresses the formality of operations by using the Attachment 2 Minimum Core Requirements of DOE Order 5480.31. The determination for restart (e.g., internal review, readiness assessment, or operational readiness review) is made based on the criteria in DOE Order 5480.31 and direction from DOE/RFFO. The completion of the restart plans (Enclosures 4, 5, 6, and 7) provides objective evidence of the formality of operations.
Included in each restart plan are additional compensatory measures such as added management oversight, independent reviews, and meetings with personnel to discuss the incident and lessons learned. Buildings 559 and 707 have demonstrated a higher level of adherence to the formality of operations through an intensive mentoring program for Conduct of Operations. The mentoring program is now being extensively applied to Building 771 to significantly upgrade the culture of adherence to the program infrastructure. This is being accomplished by assigning full time to Building 771 personnel who were instrumental in establishing the Conduct of Operations culture in Buildings 559 and 707.
In addition, a team of internal consultants were assigned to work with specific managers in Building 771 to improve performance in Conduct of Operations. This assignment involved extensive floor level appraisal of behaviors in Building 771. They provided instruction and recommendations to key management personnel regarding needed improvements in Conduct of Operations behavior. The team of consultants assumed the role of mentor to designated managers in Building 771. In this role, the team identified performance measures for each manager, established baselines of performance, evaluated trends, and defined goals for performance in each area. The team worked directly with managers in identifying and removing barriers to performance. The team developed periodic reports on performance and evaluated trends to assist the Operations Manager and Director in identifying problems and resolutions.
Internal consultants have also been working with Support Services (particularly the Steam Plant), SNM Consolidation (particularly Building 371), and Waste Management (particularly Building 776) to facilitate maturing Conduct of Operations in those areas.
DOE/RFFO Response 94-4 (2) (c)
The level of Conduct of Operations implementation is continuously monitored by DOE Facility Representatives. Facility Representatives observe building activity performance and contractor management response to Conduct of Operations issues on a daily basis.
DOE/RFFO has approved the contractors implementation plans for DOE 5480.19. Buildings 707 and 559 have fully implemented the order. In order to accelerate this implementation schedule in Building 771, the contractor has provided additional mentors in Building 771 along with stronger management team.
RFFO is implementing a Conduct of Operations Assessment Program to systematically assess contractor performance on a site-wide level. Implementing procedures for the assessment program are scheduled to be completed and included in the final report.
Recommendation 94-4 (2) (d)
Development of plans, including schedules, to address any deficiencies identified in the analyses conducted above.
EG&G Response 94-4 (2) (d)
The corrective actions identified as a result of the root cause analysis and generic implications (Enclosure 3) have been assigned to the responsible organization and entered into the Plant Action Tracking System (PATS) to ensure completion. The corrective actions are divided into three categories: immediate, short term, and long term. Immediate means before restart of activities suspended by Standing Order 34 (Enclosure 2); short term means as soon as practicable within 6 months, and long term means as soon as practicable within 12 months.
The restart plans (Enclosures 4, 5, 6 and 7) provide specific criteria, addressing the Attachment 2 Minimum Core Requirements of DOE Order 5480.31. These criteria will be met and verified prior to the restart of the activity. The combination of corrective actions and restart plans provides the response to this recommendation.
DOE/RFFO Response 94-4 (2) (d)
Plans and schedules will be initiated to address any deficiencies identified in Site reviews. DOE/RFFO monitors contractor commitments and tracts external DOE/RFFO commitments utilizing the RFFO Commitment Tracking System.
Recommendations 94-4 (3) and 94-4 (4)
DOE evaluate the experience, training, and performance of key DOE and contractor personnel involved in safety-related activities at defense nuclear facilities within the Y-12 Plant (Rocky Flats Environmental Technology Site) to determine if those personnel have the skills and knowledge required to execute their nuclear safety responsibilities (in this regard, reference should be made to the critical safety elements developed as part of DOE's response to the Board's Recommendation 93-1).
Editors Note: We believe the reference to be to Recommendation 93-3 rather than 93-1 to match the topic and concern.
DOE take whatever actions are necessary to correct any deficiencies identified in (3) above in the experience, training, and performance of DOE and contractor personnel.
EG&G Response 94-4 93) and 94-4 (4)
The restart plans (Enclosures 4, 5, 6, and 7) provide specific criteria for the training and qualification for the supervision and assigned workers for each of the activities. The training programs consist of the Training Users Manual (TUM) and approved Training Implementation Matrix (TIM) per DOE Order 5480.20. The training also includes building, functional, and job specific training and qualification. Demonstration of performance and completion of qualification for nuclear operations will occur during the startup plans for each activity.
Specific experience, training level and performance of the criticality safety staff has been addressed by the following steps:
Significant progress has been made:
The actions taken have resulted in a more stable program with sufficient resources to correctly monitor the necessary contractor staff, respond to mission requirements and, ultimately, Safety Order-driven requirements.
With respect to Criticality Safety Staff training from external sources, LANL Criticality Safety Staff participation in site program efforts is ongoing. This cooperative effort is evidenced by participation in the Waste Management Program restart as well as the continuing programmatic efforts in support of Building 771 liquid stabilization criticality safety evaluations, and on the team created by the NCSC to review the existing criticality safety program and to propose improvements.
EG&G Rocky Flats has previously addressed the DNFSB Recommendations 91-1, 92-7, and 93-3 by establishing the following programs and documents maintained by the Human Resource Department:
Upon initial hire and with all subsequent promotions, employees are required to meet minimum education and experience guidelines. These guidelines increase progressively with each salary grade. Waivers to these guidelines are granted occasionally by Human Resources only upon management documentation that the employee can perform the job.
In order to fill a position either internally or externally, a Position Staffing Requisition must be initiated by management and approved by title, job code, education and experience as outlined in the PIQ. When a new position is required for which no PIQ exists, a new PIQ must be initiated by management and then reviewed and approved by Human Resources.
The combination of the specific information contained in the restart plans and the documentation and process maintained by Human Resources provides the response to Recommendations 3 and 4.
DOE/RFFO Response 94-4 (3) and 94-4 (4)
As discussed in Section (2) (b), DOE/RFFO has requisitioned a team of experts in the nuclear safety field to perform an independent review of the nuclear criticality safety program at the site. Part of the review will assess the adequacy of the site personnel working on criticality safety related activities. The review is scheduled for February 1995, and a final report will be issued by March 1, 1995. Plans and schedules will be initiated to address any deficiencies in this area and entered in the appropriate tracking system.
Summary
The root cause and generic implication report (Enclosure 3) provides a basis for corrective actions that encompass more than Building 771. Following are actions that have been identified, completed, and/or are underway by DOE/RFFO and EG&G Rocky Flats to address the issues and concerns that were raised by the DNFSB Recommendations.
FOOTNOTE:
1 J.A. Geis ltr JAG-179-94 to Distribution, Proposed Prerequisites for Restart of Nuclear Activities, October 11, 1994.
2 John T. Conway ltr to Victor H. Reis, Regarding the Termination of Normal Operations at Los Alamos National Laboratory TA-55, May 20, 1994
3 John T. Conway ltr to Victor H. Reis, Regarding the Change from an Operating Mode to a Maintenance Mode in the Zone R Facilities at the Pantex Plant, April 29, 1994