[DNFSB LETTERHEAD]
March 7, 2003
The Honorable Jessie Hill Roberson
Assistant Secretary for Environmental
Management
U.S. Department of Energy
1000 Independence Avenue, SW
Washington, DC 20585-o 113
Dear Ms. Roberson:
The Defense Nuclear Facilities Safety Board
(Board) recognizes the recent success of the Department of Energy (DOE) and its
contractor in initiating fuel removal from the K-East Basin at the Hanford Site
and accomplishing the milestone in DOE’s Implementation Plan for the Board’s
Recommendation 94-1, Improved Schedule
for Remediation in the Defense Nuclear Facilities Complex, of packaging and removing approximately 957
metric tons of heavy metal from the K-West Basin. Your letters of December 27, 2002, and February 5, 2003, note the
positive effect of improved equipment availability on achieving these important
goals. Lessons learned from the
operational readiness reviews (ORRs) recently performed for the K-Basins Fuel
Transfer System may enable further improvements in efficient operations of
Hanford’s Spent Nuclear Fuel Project.
The Board’s staff recently concluded a
review of the DOE and contractor ORRs for the startup of the K-Basins Fuel
Transfer System. Although the
contractor’s performance during the ORRs showed improvement compared to recent
readiness reviews, DOE’s Richland Operations Office (DOE-RL) still has not
corrected the problem of the contractor declaring readiness prematurely. Additionally, modifications to the ORR
process at Hanford have been made that reduce the independence of the DOE and
contractor ORRs and are not consistent with the applicable DOE directive. The Board’s staff observed that DOE-RL line
management and the DOE ORR team had not received formal training on preparing
for and performing ORRs. Improvements
in the effectiveness of the ORR process could be achieved if appropriate
training were performed, and if a senior advisor/mentor were used in instances
when personnel assigned to lead ORRs possess limited ORR leadership experience.
Startup of the K-East Sludge Water System
and shipment of the first sludge container to T-Plant represent two delayed milestones for
the Spent Nuclear Fuel Project that will require readiness reviews. If the weaknesses in readiness preparation
and determination at Hanford are not addressed in an effective and timely
manner, continuing startup issues could further delay this vital project. The Board requests to be informed of any
efforts to improve readiness preparations and the ORR process at Hanford.
The enclosed report prepared by the Board’s staff discusses the above issues in detail and is forwarded for your information and use as appropriate.
Sincerely,
John T. Conway
Chairman
c:
Mr. Keith A. Klein
Mr. Mark B. Whitaker, Jr.
Enclosure
DEFENSE
NUCLEAR FACILITIES SAFETY BOARD
Staff Issue Report
February 21,
2003
MEMORANDUM FOR:
J.
K. Fortenberry, Technical Director
COPIES: Board
Members
FROM: R.
Rosen, D. Grover
SUBJECT: Operational
Readiness Reviews for Fuel Transfer System, Hanford Spent Nuclear Fuel Project
This report documents the results of a
review by the staff of the Defense Nuclear Facilities Safety Board (Board) of
the operational readiness reviews (ORRs) for the K-Basins Fuel Transfer System
(FTS) at the Hanford Spent Nuclear Fuel Project (SNFP). Reviews of the Fluor Hanford and Department
of Energy (DOE) ORRs were performed during September 25–October 10, 2002, and November 6–14, 2002, respectively, by staff members R.
Rosen and D. Grover, and outside experts D. Boyd and J. King. The staff reviewed the FTS ORR lessons
learned report issued by the SNFP on December 19, 2002. Additionally, the staff discussed readiness
planning for the upcoming contractor ORR for the Sludge Water System during a
SNFP teleconference on February 20, 2003, to determine whether improvements are
likely to be made to the Hanford ORR process.
Background. The
FTS was designed to transfer fuel from K-East to K-West Basin for subsequent
encapsulation and dry storage in multi-canister over-packs. The purpose of the FTS ORRs was to
independently assess the readiness to perform FTS operations. DOE’s Richland Operations Office (DOE-RL)
performed a line management review (LMR) concurrently with the contractor ORR
to assess the readiness of the contractor.
DOE line management is responsible for documenting the contractor’s
actions to verify readiness to commence FTS operations at the K-Basins.
DOE Order 425.lB, Startup and Restart of Nuclear Facilities, establishes DOE’s expectations with regard
to the conduct of readiness reviews.
The Order requires DOE and contractor line managers to develop a Plan of
Action (POA) for their respective ORRs.
The POA must be approved by the startup authorization authority. The POA identifies the breadth of the review
and the ORR team leader. The team
leader develops an implementation plan that is based on the core requirements
in the POA. The team leader also
develops the details of the ORR, including specific criteria concerning each
core objective, and provides direction to the team on the approach to be used
in evaluating the extent to which these criteria are met.
Contractor Line Management’s Readiness
Determination for FTS. Based on lessons learned from recent
readiness reviews at Hanford, Fluor Hanford recently initiated several corrective
actions to improve its process for preparing to declare readiness for new
activities.
These corrective actions included
development of management readiness self-assessment (RSA) forms detailing the
criteria and requirements for evaluating readiness and specific actions that
need to be accomplished prior to declaring readiness. A readiness mentor with experience in starting up new nuclear
activities was assigned to the SNFP to assist in these self-assessments.
These initiatives could aid in project preparations
for readiness, but they were not performed satisfactorily at the SNFP. The readiness mentor was not in place early
enough in the process to be fully effective.
Moreover, the quality of the RSA forms varied widely. The staff's review of these documents
identified several cases of inadequate descriptions and evaluations of the
extent to which criteria had been met.
For example, field verification and validation of surveillance and
maintenance procedures were required but not performed; instead the responsible
organization relied on tabletop reviews of the procedures. During the contractor ORR, it was found that
these procedures could not be performed as written. The result was numerous pre-start findings regarding the
procedure development process at the SNFP.
Some of the RSA forms had been signed off by management without having
been validated.
The project also did not adequately manage
the turnover of some operating systems from construction to operations. Continued delays in completing equipment
acceptance testing, due to equipment malfunctions, severely delayed the
turnover of equipment to the operations organization. As a result, operations personnel were not adequately aware of
system status, preventive maintenance on some equipment was not current, and
Technical Safety Requirement (TSR) surveillance procedures had not been
performed. Subsequent testing of these
systems revealed that two safety-class interlocks were not operable. The construction delays also contributed to
problems with procedure development.
Contractor ORR for FTS.
Fluor Hanford relied primarily on subcontractors to provide subject
matter expertise for its ORR. The team
members had appropriate levels of experience and skill and pursued lines of
inquiry adequate to meet assessment objectives. The breadth of the review was sufficient to identify significant
problems with preparations in areas outside the principal operating equipment
and procedures. The appropriateness of
the depth of the review conducted in problem areas is illustrated by the ORR
findings involving the underlying administrative procedures at Fluor Hanford
and the SNFP. However, the ORR team
facilitated the practice of using the ORR as a method to prepare for
readiness. For example, the team requested
reperformance of the emergency preparedness drill after determining that the
drill controllers had terminated the drill too early to adequately evaluate
recovery actions. In addition, after
maintenance procedures could not be performed as written, the ORR team allowed
the project to verify and validate the procedures during a weekend and then
demonstrate performance again.
The ORR team determined that project
management had prematurely declared readiness, as evidenced by several ORR
prerequisites that had not been completed.
These included the procedure and preventive maintenance problems noted
above. In addition, management’s
assessment of health and safety programs was determined to be inaccurate, the
findings of recent reviews had not been effectively resolved, and deficiencies
identified during the self-assessment process had not been thoroughly
corrected. The staff believes that the
premature declaration of readiness was attributable to the failure of SNFP
management to adequately understand the criteria for readiness.
DOE Line Management’s Review for FTS. The
DOE LMR team concluded that the FTS would be ready for safe operations once
the actions outlined by the contractor ORR had been completed, in addition to
pre-start findings identified by the LMR.
The contractor ORR team and LMR team also agreed that several ancillary
support organizations―including
maintenance, emergency management, procedure development, and nuclear safety―were not at the same level of readiness as
the operations and radiological control groups. One issue identified by the Board’s staff and pursued by the LMR
team near the end of the contractor ORR was the incorrect incorporation of TSRs
into a process standard and the related operating procedure. The equipment used to perform this procedure
was not capable of doing so in a manner consistent with the TSRs. The SNFP developed a change to the TSRs that
allowed for more operational flexibility while remaining within the approved
safety basis. DOE’s LMR team followed
the resolution of its findings and those of the contractor ORR sufficiently to
provide reasonable confidence that the project was prepared prior to
authorizing the start of the
DOE ORR.
DOE ORR for FTS. The
Board’s staff observed the DOE ORR and determined that the team conducted an
adequate review within the scope of the approved implementation plan. In particular, the DOE ORR identified one
key finding involving the determination that the contractor had not established
a staffing plan detailing the minimum number of personnel required to support
safe multi-shift operations. This
deficiency turned out to be significant enough to prevent the SNFP from being
able to transition into two-shift operations until long after startup was
authorized.
Staff Observations on the ORR Process. The
ORR process at Hanford has been modified by DOE-RL in response to the outcome
of recent readiness reviews, including problematic startup activities at
T-Plant. DOE-RL now uses the
contractor’s criteria and approach for those core requirements not specific to
the DOE staff. This use of common
implementation plans limits the DOE ORR team’s ability to fully utilize its
expertise. The result is a reduction in
the independence of both ORR teams.
Lessons learned in the conduct of readiness
reviews from throughout the DOE complex were not included in the POA or
implementation plan process. During the
FTS review, the Board’s staff observed that there had been no formal training
of the DOE-RL line managers or staff on the management of, preparation for, or
conduct of an ORR. Similarly, the DOE
ORR team leader and members had indicated they had received no formal training
in the ORR process, although most of the team had participated in prior
readiness reviews at Hanford. The team
leader did not use the services of a senior advisor/mentor. Many of these issues would be resolved if
the personnel assigned to lead and perform ORRs received training that captured
complex-wide ORR lessons learned.
The ORR process at Hanford, as observed
during the FTS ORRs, resulted in the DOE ORR team leader being constrained to
use the implementation plan developed by the contractor. The Board’s staff noted that the ORR team
did use its own initiative in the evaluation process. However, doing so resulted in deviations from the implementation
plan that were not discussed in the ORR team’s report.
Lessons Learned from ORRs for FTS. The
December 19, 2002, SNFP lessons learned report for the FTS ORRs acknowledged
most of the deficiencies observed by the ORR review team and the Board’s staff,
However, the lessons learned report did not comment on the problem of
contractor management signing deficient RSA forms without validation. In addition, recent discussions with DOE-RI
indicate that the upcoming contractor ORR for the K-East Sludge Water System is
scheduled to start before installation of all system equipment is
complete. Under this approach, the
system could not be tested in its final configuration until after the
contractor ORR. These observations
suggest that future readiness activities at Hanford may suffer from
deficiencies similar to those seen with the FTS.