TRANSMITTED TO M. WHITAKER 12/8/95 DEFENSE NUCLEAR FACILITIES SAFETY BOARD June 13, 1995 MEMORANDUM FOR: G. W. Cunningham, Technical Director COPIES: Board Members FROM: R. Todd Davis SUBJECT: Review of the Department of Energy Operational Readiness Review of the In-Tank Precipitation Facility (May 17-24, 1995) 1. Purpose: This report documents a staff review of the Department of Energy (DOE) Operational Readiness Review (ORR) of the In-Tank Precipitation (ITP) facility. The review was performed by Defense Nuclear Facilities Safety Board (Board) technical staff, T. Davis and T. Arcano, and outside expert, R. West, on May 17-24, 1995. A detailed review of the ORR is provided as an attachment. 2. Summary: The DOE ORR team appeared to adequately characterize the status of the ITP facility. WSRC correction of the 18 pre-start findings and a properly structured startup test plan should provide assurance of operational readiness to restart radioactive operations (non-wash cycle) at the facility. Since ORR prerequisites were not met because final safety documents were not complete (identified as a pre-start finding by the DOE ORR team), it would be beneficial for DOE ORR team members to perform additional reviews in this area after these documents and associated procedures are in place. 3. Background: The ITP facility is a high-level radioactive waste chemical processing facility in which radioactive salt solutions from the Savannah River Site (SRS) tank farms will be separated into high and low activity solutions by precipitation and filtration. The high activity solution will be the feed material for vitrification operations at the Defense Waste Processing Facility (DWPF). The low activity solution will be processed at the saltstone facility. The ITP facility is scheduled to begin radioactive operations in August 1995. DOE Order 5480.31, Startup and Restart of Nuclear Facilities, establishes the actions to be taken and assigns the responsibilities for authorizing the startup or restart of DOE nuclear facilities. DOE Standard DOE-STD-3006-93, Planning and Conduct of Operational Readiness Reviews, provides additional guidance for the development and conduct of ORRs. Because ITP is a new hazard Class 2 facility, a DOE ORR was required to verify the facility's readiness to operate with respect to safety, health, environmental compliance and management. 4. Discussion: a. Overview: The ORR leader and team members met the experience and knowledge requirements of the DOE Order. The team reviewed documents, observed operations, and conducted interviews. The review identified 18 pre-start findings, 8 post-start findings and 15 observations. The following 9 functional areas did not meet the acceptance criteria: emergency preparedness, industrial hygiene, management, maintenance, operations, procedures, radiological protection, safety envelope, and training. The ORR team considered fire protection, configuration management, and training areas to be in good condition. The ORR team concluded that after correction of the noted findings, there will be no major programmatic deficiencies. The team noted that operations were at the level expected for a facility starting up after a major modification. b. Prerequisites: The facility failed to meet the requirements in the Order for start of the ORR in the following two areas: (1) Facility Safety Documentation: DOE Order 5480.31 requires that safety documentation be complete prior to start of the ORR. For ITP, DOE and Westinghouse Savannah River Company (WSRC) have not finalized the Safety Evaluation Report (SER), the Safety Analysis Report (SAR), the Operational Safety Requirements (OSRs), and the associated procedures. Additionally, WSRC has not completed 17 SAR and OSR related action items identified in the Authorization Commitment Matrix. This matrix identifies facility procedures, policies, and testing required to meet the authorization basis. The ORR team recommends that an independent assessment of the final safety documentation be performed prior to startup. The staff believes that appropriate member(s) of the DOE ORR team could perform this review. (2) Closure of Pre-start Findings: DOE Order 5480.31 requires that all actions required for startup be complete with the exception of a manageable list of insignificant pre-start findings that have a well defined schedule for closure. WSRC has a number of open findings to complete with no well defined schedule for closure. c. Significant Findings: In addition to the items listed above, the following significant findings were identified by the ORR team: (1) Shift management was considered to be deficient, especially with regard to maintaining the facility within the safety envelope. During shift turnover briefings and plant evolutions, several instances were observed where operations managers failed to give adequate attention to maintaining plant operations within specified Limiting Conditions for Operations (LCOs). Deficiencies were noted in level of knowledge regarding safety requirements during interviews with shift management personnel. (2) The startup test plan is incomplete. The plan consists only of a schedule of actions and does not include the minimum prerequisite conditions for startup. (3) Operators are qualified and certified without performing all required training. This, combined with an observation about a lack of administrative control for annotating the ITP qualification roster, indicates a problem with the process of identifying qualified personnel and assigning them to tasks. (4) Several procedures require additional information to ensure operators understand and can properly accomplish them. Additionally, procedure revisions are still required to incorporate the anticipated safety documentation changes. (5) Seventeen commitments identified in the Authorization Commitment Matrix (ACM) have not been completed. (6) Access to high radiation areas is not adequately controlled. (7) WSRC has not adequately planned for the effects of contamination and radiation hazards in the filter/stripper building. (8) WSRC has not adequately reviewed the emergency procedure for evacuating the control room and stopping ITP operations to ensure that use of this procedure safely shuts down the facility. (9) Several ITP surveillance procedures do not fully verify equipment operability as described in the OSR bases. (10) The lockout/tagout system does not require an engineering review for all safety related systems. Attachment Detailed Review of the Department of Energy Operational Readiness Review of the In-Tank Precipitation Facility 1. ORR Preparations by WSRC: WSRC promulgated a plan-of-action and an implementation plan as required by DOE Order 5480.31. A Readiness Self-Assessment was performed in mid-1994. A WSRC ORR was conducted in October-November 1994. The staff found that the contractor ORR was more thorough than the previous WSRC reviews, but there were still deficient areas. The WSRC ORR started prematurely and deficiencies in the planning and conduct of the review adversely affected evaluations in several areas. As a result of comments made by the staff, WSRC conducted an expanded review in April-May 1995 primarily in the areas of safety documentation, procedures, conduct of operations, and training. Consequently the DOE ORR team found that WSRC conducted a thorough and satisfactory ORR. 2. Facility Readiness for the ORR: The following prerequisites for the DOE ORR were not met: (1) All actions required for startup shall be completed with the exception of a manageable list of insignificant open pre-start findings that have a well defined schedule for closure; and (2) Facility safety documentation, including definitions of the safety envelope, procedures and administrative control are complete, approved and auditable. Final safety documents for ITP are still being revised. These changes will require modification of the Limiting Conditions for Operations (LCOs) and Surveillance Requirements (SRs) in the Operational Safety Requirements (OSRs). Several discrepancies were also found in the existing OSRs and their associated surveillance procedures. The DOE ORR team considered that the quality of operations observed during the review was at the level expected for a facility transitioning to operation after a major modification. However, the team noted deficiencies in the shift operations management especially with regard to providing adequate attention to maintaining plant operations within limits specified by LCOs. 3. DOE Savannah River (DOE-SR) Readiness Validation: The DOE ORR team found that DOE-SR had conducted a site wide administrative assessment of WSRC compliance with DOE Orders. The DOE ORR team noted that a WSRC adherence assessment of ITP was reported to be satisfactory by the DOE-SR Validation Report; however, there was minimal documentation supporting this assessment as previously noted by the Board's staff. 4. DOE ORR Team and Preparations: The team was led by Joseph King, a nuclear engineer in the Office of Engineering and Operations Support, Defense Programs, DOE. Mr. King has participated in three previous ORRs. He was assisted by three senior nuclear advisors who are retired Navy flag officers with submarine nuclear experience. These advisors have also participated in previous ORRs. The remainder of the team consisted of 20 individuals with each having at least eight years of experience in his field of expertise and/or nuclear engineering. All but four of these team members have been involved in previous ORRs and those four have extensive experience in program assessments. The team met the qualification requirements of DOE Order 5480.31, section 9.b.(5), which requires team members to be technically qualified, thoroughly familiar with the activity being reviewed and have experience or training in performance-based review techniques. Fourteen of the subject matter experts on the ORR team have participated in the recent F-Area ORRs. The team leadership ensured that team members conducting their first review were closely monitored by a more experienced technical expert. The Implementation Plan prepared by the ORR team essentially met the requirements of Section 9.b of DOE Order 5480.31 for setting the approach, methodology and reporting requirements. However, one weakness was that the shift performance approach for most Criteria and Review Approach Requirements (CRADs) did not specify the number and types of operations to be observed. This information was provided in a separate list which did not reference the CRADs. This approach does not demonstrate that sufficient operations were reviewed to provide the basis for judging the facility's readiness. 5. Conduct of the ORR: The review of ITP was divided into three phases. The first phase was a programmatic review for three days. The second phase involved observation of drills and evolutions during five 12-hour shifts over three days. The third phase consisted of level of knowledge interviews to evaluate operators individually. 6. Results of the ORR: The ORR resulted in 18 pre-start and 8 post-start findings, and 15 observations. A finding is a deficiency. Pre-start findings must be corrected and a plan of action for other findings must be approved prior to restart. Observations are comments that will assist in improving operations. No findings were made in the following areas: chemical safety, criticality safety, fire protection and engineering support. a. Document Review: Most of this part of the review was conducted prior to the arrival of the Board's staff. Comments during the remainder of the ORR indicated that this review was extensive and thorough. Deficiencies found during the document review were: Industrial Hygiene Industrial hygiene management has not clearly established program responsibilities to ensure adequate staffing levels (pre-start). Management Key elements of the startup plan have not been finalized and approved (pre-start). Corrective actions for deficiencies identified during operations drills have not been routinely completed and have not been entered into the Management Tracking System (MTS) (post-start). Maintenance Reverse traceability procedures for M&TE found out-of-calibration are cumbersome and result in excessive delays in evaluating instrumentation and interlocks supporting OSRs. Repeat findings of out-of-calibration occurrences of flow calibrators are not being aggressively resolved (post-start). Procedures The procedure for evacuating the control room, EOP-005, needs an engineering and operational analysis to ensure the actions specified provide a safe method of shutting down the ITP systems and components in the event of a control room evacuation (pre-start). Five SOPs and SRs require additional information to ensure operators understand and can successfully accomplish them (pre-start). Procedure revisions related to changes in safety basis documentation that were not resolved and implemented at the time of the ORR must be closely monitored and tracked in order to assure implementation and closeout (pre-start). Quality Assurance The WSRC self-assessment program did not require QA assessment of safety surveillance field activities (post-start). Safety Envelope OSR surveillance requirements do not periodically verify that the exhaust ventilation flow rate from each filter cell is at least 1000 scfm (pre-start). Current safety documentation does not completely address the hazards and risks associated with ITP operations (pre-start). Some surveillance procedures do not provide the necessary assurance that OSR surveillance requirements are met (pre-start). Seventeen safety related commitments from the authorization basis have not been fully implemented (pre-start). Training Operators are qualified and certified without performing all practical factor evolutions. b. Observation of Operations and Facility Tours: The team leader requested a list of evolutions and drills that the facility was capable of performing. At the start of the ORR the DOE team presented WSRC with a selection of drills and operations to be performed. This was an improvement over the evolution and drill selection methodology used on other recent ORRs The ORR team observed a simulated facility startup that extended for the period of performance monitoring. Several problems were seen during this evolution. On several occasions the shift operations management failed to give adequate attention to maintaining plant operations within the limits specified in plant LCOs. Poor turnover of existing or changing requirements, shortcomings in the understanding of the implications of some lockouts/tagouts and a general lack of focus on LCO requirements during shift operations contributed to this failure. The team observed several drills. One drill simulated a fire in the control room building and required the evacuation of the control room and shutdown of the process at local controls. The pre-drill brief did not stress lessons learned from previous performances of the drill. Controllers were not well positioned to observe many actions. Problems with the accomplishment of some actions and the priority of actions required additional study. The control of operators in accomplishing the shutdown was inefficient. Another drill simulated a benzene leak. Although shift response was adequate, some training value was lost when controllers failed to identify several deficiencies during the drill. A drill involving the simulated spill of radioactive material was also conducted. Overall response to the drill was satisfactory except for the recovery of the chemistry technician, which was much slower than it should have been, and the involvement of the industrial hygiene representative was not effective. As noted below a finding was made about weaknesses in the execution of drills that reduced their training effectiveness. An ORR team member evaluated an emergency preparedness drill in November 1994 during which the response was evaluated as inadequate. A remedial emergency preparedness drill was observed in February 1995 and the response was considered adequate. Several surveillances, maintenance actions, job performance evaluations, system or area walkdowns, and shift routine actions were also observed. The team concluded that the performance observed in all drills and evolutions demonstrated an adequate response capability except for the specific problems noted below: Configuration Management A walkdown of seven systems found three discrepancies with the drawings for the emergency purge ventilation process and instrumentation (post-start). The system walkdowns found labeling to be thorough and complete except for the lack of supply sources on labeling in a motor control center contrary to the WSRC Conduct of Operations Manual (post-start). Emergency Preparedness Inspections of the emergency response equipment found that the Self Contained Breathing Apparatus (SCBA) equipment is not available on a consistent basis (post-start). Operations Execution of the lockout/tagout system does not provide for adequate control of system impacts on Limiting Conditions for Operation (LCOs) (pre-start). On several occasions, the shift operations managers (Shift Manger, Shift Technical Engineers, and the Shift Supervisor) failed to give adequate attention to maintaining the plant operations within the limits specified in plant OSRs and LCOs (pre-start). Weaknesses in the execution of the drill program reduce the training effectiveness in maintaining the operators proficiency in facility operations, unusual conditions and casualty control (post-start). Procedures During a drill it was noted that a controlled set of procedures is not located external to the control room in the event of a control room evacuation so that facility management has the information necessary to ensure safety of the facility associated equipment and personnel, and the environment (pre-start). Radiological Protection Physical access control for High Radiation Areas is not in place for the filter/stripper building (pre-start). Contamination control versus ALARA considerations at filter/stripper building exits require resolution (pre-start). Environmental Protection and Waste Management The staging area contingency plan did not include a description of the capability of the fire extinguisher present at the ITP Mixed Waste Staging Area as required by South Carolina regulations (post-start) The drills and evolutions that were observed were sufficient to determine the readiness of the facility to conduct operations. The team's critiques of operations were effective in noting problem areas. However, a significant amount of simulation was required since most operations cannot be performed until radioactive operations are authorized. The drills and evolutions observed were sufficient to determine that personnel, procedures and equipment were adequate to conduct operations using a well structured startup test program. The team correctly noted problems with the shift operations management and the importance of defining the startup test program. The problems noted with the shift management appear to be symptomatic of a general lack of an integrated team approach to shift performance of duties. Additional DOE reviews could verify correction of this deficiency. c. Interviews: About 50 interviews were scheduled to be conducted by team members. The interviewees consisted of a complete cross section of personnel at the facility - operators, supervisors, inspectors, maintenance personnel, managers, engineers, and radcon personnel. Questions asked during interviews were generally of an appropriate level of difficulty and included a range of topics. The interviews lasted about 45 minutes. The few specific findings made by the team concerning the level of knowledge of facility personnel are summarized below. Industrial Hygiene The industrial hygiene professional staff did not demonstrate an adequate working knowledge of ITP operations, processes and systems (post-start). Environmental Protection and Waste Management ITP operators did not demonstrate an adequate level of knowledge regarding waste management procedures (post-start). Several instances of inadequate personnel knowledge were noted during interviews. Shift technical assistants, shift managers and shift supervisors demonstrated weak knowledge of LCO action and time requirements, conditions requiring process shutdown and lacked the ability to walk through LCO actions. Operators were found to have a limited understanding of Lower Explosive Limits and Lower Flammability Limits. Maintenance support personnel knowledge varied and was sometimes marginal concerning basic fundamentals and facility systems. Some maintenance managers were weak in their knowledge of the facility's compliance status with DOE Order 4330.4B, Maintenance Management Program. d. Observations: Although observations are not mandatory for correction, many are important to ensure adequate facility performance. The following observations were identified by the ORR team: Post Maintenance Test Plan in one work request was noted to have an administrative deficiency. Annual area emergency response organization retraining did not include training on weaknesses detected during drills and exercises, changes to plans and procedures, and "lessons learned" in the emergency preparedness training materials for the ITP staff. The Compliance Schedule Approval DOE 5500.3A-CSA-93-127, Planning and Preparation for Operations Emergency Training is not funded and there is no management schedule to complete the ITP job-task-analysis for emergency response organization positions. The High Level Waste Fire Protection Memorandum of Agreement is in draft. An access control equivalency measure for the filter crane stairtower was not in place. Periodic surveillances in the filter/stripper building may result in unnecessary exposures to physical, chemical and radiological hazards. Maintenance personnel demonstrated weaknesses in basic system knowledge for supporting operations, maintenance and emergency conditions. Isokinetic sample line design may preclude representative results. Radiological Controls inspector responsibilities for certain Industrial Health analyses must be defined. Procedures for filter cell operations should be fully validated prior to radioactive operations. Portable radiac equipment storage was not adequate. Several statements in the OSR basis do not accurately reflect the intent of safety documentation. DOE-SR had insufficient documentation to support the adherence compliance assessment of DOE Orders on ITP. There was a lack of administrative control for who was permitted to annotate the ITP qualification roster. The drill team was composed of training personnel only and should include an operations department representative on the team. 7. DOE-SR Evaluation: The team found the Facility Representative program is structured satisfactorily with a qualification program of sufficient rigor to ensure the necessary background for facility representatives to carry out their responsibilities. The team identified this area as excellent. Training requirements matrices that were developed for each DOE employee associated with ITP were considered to be satisfactory. Some training was indicated as being overdue. The ORR found that the DOE-SR managers associated with ITP had sufficient experience and training to meet their operational and safety responsibilities.