NE-ID--BEA-ZPPR-2011-0001 FINAL
Occurrence Report
Between 2003 and 2017 Redesign

Zero Power Physic Reactor


(Name of Facility)

Special Nuclear Materials Storage


(Facility Function)

Idaho National Laboratory Battelle Energy Alliance, LLC


(Laboratory, Site, or Organization)

Name: GUNDERSON, RICHARD A.
Title: NUCLEAR FACILITY MANAGER Telephone No.: (208) 533-8045


(Facility Manager/Designee)

Name: KEEFE, KEVIN O.
Title: FACILITY OPERATIONS STAFF SPECIALIST Telephone No.: (208) 533-7505


(Originator/Transmitter)

Name: Jeffrey L. Garner Date: 09/17/2012


(Authorized Classifier (AC))

  1. Occurrence Report Number: NE-ID--BEA-ZPPR-2011-0001

      ZPPR Workroom Pu Contamination Event in MFC-775

  2. Report Type and Date: FINAL

Date Time
Notification: 11/10/2011 11:21  (ETZ)
Initial Update: 12/21/2011 20:43  (ETZ)
Latest Update: 09/25/2012 17:11  (ETZ)
Final: 01/30/2014 11:36  (ETZ)

Significance Category: OE


  4. Division or Project: BEA

  5. Secretarial Office: NE - Nuclear Energy, Science and Technology

  6. System, Bldg., or Equipment: Clad fuel plates

  7. UCNI?: No

  8. Plant Area: MFC-775 (ZPPR)

9. Date and Time Discovered:     11/08/2011    11:17  (MTZ)

10. Date and Time Categorized:     11/08/2011    13:00  (MTZ)

11. DOE HQ OC Notification:

Date Time Person Notified Organization
11/08/2011 14:13  (MTZ) Kevin Williamson DOE-HQOC

12. Other Notifications:

Date Time Person Notified Organization
12/21/2011 18:35  (MTZ) John Martin DOE-ID
02/06/2012 18:00  (MTZ) John C. Martin DOE-ID
11/09/2011 19:25  (MTZ) John Martin DOE-ID
01/17/2012 10:30  (MTZ) John C. Martin DOE-ID
11/08/2011 11:35  (MTZ) John Martin DOE-ID

13. Subject or Title of Occurrence:

      ZPPR Workroom Pu Contamination Event in MFC-775


14. Reporting Criteria:

6D(3) - Identification of onsite personnel or clothing contamination (excluding anti-contamination clothing provided by the site for radiological protection) that exceeds 10 times the total contamination values identified in 10 CFR Part 835, Appendix D. The contamination level must be based on direct measurement and not averaged over any area. This criterion does not apply to tritium contamination.

10(1) - Any event resulting in the initiation of a Federal Accident Investigation Board, as categorized by DOE O 225.1B, Accident Investigation.
[Note: This reporting criterion may raise the significance category of an occurrence already reported under separate criteria. Multiple reporting criteria should be assigned, when appropriate.]

4B(4) - A facility evacuation, other than a precautionary evacuation or an evacuation due to false alarms or spurious alarms (e.g., due to electronic noise, radon/thoron decay). If the event fell under another reporting criterion, then evacuation should be reported as well by noting multiple reporting criteria for the single occurrence.

1(1) - An Operational Emergency not requiring classification, as defined in DOE O 151.1C, Chapter V, Paragraph 2.

6B(3) - Identification of onsite radioactive contamination greater than 10 times and no greater than 100 times the total contamination values in 10 CFR Part 835, Appendix D, exclusive of footnote 3 to Appendix D, and that is found outside of the following locations: areas routinely posted, controlled and monitored for contamination, areas controlled in accordance with 10 CFR Section 835.1102(c), and, per Section 835.604(a), any non-posted area that is under the continual observation and control of an individual knowledgeable of and empowered to implement required access and exposure control measures. For tritium, the reporting threshold is 10 times the removable contamination values in 10 CFR Part 835, Appendix D.
[Notes:
a) This does not apply to contamination from residual radioactive material meeting applicable DOE-approved authorized limits.
b) This does not apply to legacy radioactive contamination, which is to be reported under a separate criterion below.
c) The exclusion from reporting contamination in a Radiological Buffer Area applies only when the area has been established for a Contamination Area, High Contamination Area or Airborne Radioactivity Area and its exit requirements have adopted guidance from Article 338.2 of DOE-STD-1098-2008.
d) This reporting criterion does not apply to packages monitored in accordance with 10 CFR Section 835.405 that meet DOT contamination limits specified in 49 CFR Section 173.443(a).]


15. Description of Occurrence:

Workers at the Zero Power Physics Reactor (ZPPR) facility were packaging clad plutonium (Pu) fuel plates in the facility HEPA exhausted material handling hood. Two of the fuel storage containers had atypical labels indicating potential abnormalities with the clad fuel plates located inside. A timeout was conducted for management to review the situation. Authorization to proceed was granted based upon past experience. Instructions were given to survey for contamination and if clean, to proceed with processing the material.
A smear of the outside of the fuel storage container indicated no contamination. Upon opening the fuel storage container, the workers discovered a clad Pu fuel plate wrapped in plastic and tape. At approximately 1117, on November 8, 2011 the workers attempted to remove the wrapping there was a release of material powder. Additional survey of the inside of the fuel storage container detected high contamination voiding the radiological work permit. A stop work was ordered by the supervisor when the workroom Continuous Air Monitor (CAM) alarmed and personnel immediately evacuated the facility in an orderly fashion. The event resulted in the contamination of 16 personnel.
ZPPR facility reentry planning, characterization, and decontaminating activities began on November 14th, 2011.
On December 23, 2011, an entry was made into ZPPR workroom to repair the backup hood exhaust fan (EFS-M107B). The fan was found to be operating, an unexpected condition as facility logs showed (EFS-M107A) to be the intended operating exhaust fan. EFS-M107B was tagged out-of-service. The out-of-service condition was due to a partially closed damper which did not provide full exhaust capability to the material handling hood. Operation of the out-of-service fan resulted in a reduced face-flow velocity at the hood where the event occurred and likely contributed to the severity of the accident.
Early January 2012, the U.S. Department of Energy Office of Health, Safety and Security released the Accident Investigation Report: Plutonium Contamination in the Zero Power Physics Reactor Facility at the Idaho National Laboratory, November 8, 2011.
This ORPS report was late because at the time of the event MFC had several ongoing operational events, these operational events delayed completion of this ORPS report.


16. Is Subcontractor Involved? No


Operating Conditions of Facility at Time of Occurrence: Operating Mode: radiation monitoring and ventilation systems operating. Criticality Alarm System operating.


Activity Category:

      03

Normal Operations (other than Activities specifically listed in this Category)


19. Immediate Actions Taken and Results:

ZPPR was immediately evacuated. Personnel were surveyed for contamination, decontaminated if required, and further monitoring of personnel is ongoing. The ECC was manned and operational. Management and DOE were notified. ZPPR facility was roped off. A recovery manager was appointed and a plan was developed for recovery.


20. ISM:

      1) Define the Scope of Work
      2) Analyze the Hazards
      3) Develop and Implement Hazard Controls
      4) Perform Work Within Controls
      5) Provide Feedback and Continuous Improvement


21. Cause Code(s):

A3B2C04 - Previous success in use of rule reinforces continued use of rule
-->couplet - A4B5C11 - Changes not adequately communicated
-->couplet - A6B3C02 - Inadequate content
-->couplet - A4B1C03 - Management direction created insufficient awareness of the impact of actions on safety / reliability
A4B3C11 - Inadequate work package preparation
A4B5C04 - Risks / consequences associated with change not adequately reviewed / assessed
A4B5C11 - Changes not adequately communicated
A4B5C01 - Problem identification methods did not identify need for change
A4B4C05 - Emphasis on schedule exceeded emphasis on methods/doing a good job
A4B1C01 - Management policy guidance / expectations not well-defined, understood or enforced
A3B1C02 - Step was omitted due to distraction
-->couplet - A4B1C03 - Management direction created insufficient awareness of the impact of actions on safety / reliability
A4B1C06 - Previous industry or in-house experience was not effectively used to prevent recurrence
A5B2C08 - Incomplete / situation not covered
A3B1C01 - Check of work was LTA
-->couplet - A4B1C04 - Management follow-up or monitoring of activities did not identify problems
A5B4C01 - Communication between work groups LTA
A2B6C01 - Defective or failed part


22. Description of Cause:

To identify causes to this event, the team used two cause analysis tools, a Barrier Analysis and an Event and Causal Factor Chart.

From the Accident Investigation Board (AIB) the following causes were identified:

Direct: The Board determined that the direct cause of the accident was the cutting and handling of the plastic wrapping around the Pu fuel plate, which released the Pu contaminants.
Root Cause: The management system lacked requirements intended to influence the decision making of the NFM and SS, resulting in a single-point decision to cut the wrapping.
Contributing Causes: The organizational transition resulted in a loss of knowledge and past practices and records that indicated the conditions associated with the fuel plates.

The BEA investigation team concludes that Pu plates with unknown integrity being opened in a hood instead of a contained environment, coupled with insufficient ventilation due to improper ventilation system line-up to the hood likely caused the contamination spread and subsequent contamination of 16 individuals. From a causal standpoint, Idaho National Laboratory (INL) personnel involved in planning and executing the work failed to recognize the hazard of a breached plutonium plate and missed opportunities to identify this hazard either by better understanding of past operations and events and thorough response to abnormal indications as the work was occurring.
INL operations, radiological controls, safeguards, and engineering personnel involved in the work and planning for the work failed to recognize and plan appropriately for the hazard of a breached plutonium plate. The operations procedures, As Low As Reasonable Achievable (ALARA) review, Radiological Work Permit (RWP), and Documented Safety Analysis (DSA) all failed to identify the hazards of a breached plutonium plate and as a result, appropriate mitigations were not in place. Written history of operations and events in the Zero Power Physics Reactor (ZPPR) facility and knowledge of personnel who worked in the facility in the past indicated a potential for cladding breaches in plutonium plates; however, this information was not effectively understood or relayed to those planning and performing the work. In addition, indications of differences between this work evolution and recent plutonium plate surveillances were not evaluated properly due to lack of understanding the hazard including abnormal labeling noted on the clamshells and finding a plate wrapped in plastic. Although personnel at the job site correctly contacted management for direction on the abnormal indications, management incorrectly determined it was safe to move forward. This report also documents weaknesses in operations and engineering understanding of the facility ventilation system, poor ventilation system configuration and status control, inadequate training and knowledge retention of Plutonium hazards and chelation treatment, weaknesses in facility abnormal response procedures, and lack of attention to detail in ensuring operations and maintenance procedures correctly identify and control TSR systems in ZPPR. To identify causes to this event, the team used two cause analysis tools, a Barrier Analysis and an Event and Causal Factor Chart. The cause analysis found the following to be causal to the contamination event emerged from document reviews, personnel interviews, and event reconstruction.
Cause Code: A3B2C04 - Human Performance Less-Than-Adequate - Rule Based Error - Previous success in the use of a rule reinforced continued use of the rule. If a rule for behavior has been used successfully in the past, there is an overwhelming tendency to apply the rule again, even though circumstances no longer warrant the use of the rule.

This cause code is corrected by corrective actions 11-13, 41, 45, 46, 51, 54, 55, 66, 80, 83.

Coupled With: A4B5C11 - Management Problem - Change Management was Less-Than-Adequate - Changes not adequately communicated. Change to processes were not communicated to affected personnel effectively.

This cause code is corrected by corrective actions 11-13, 31-33, 38, 40, 41-46, and 66.

A6B3C02-Training Deficiency-Training Materials was Less-Than-Adequate-Inadequate content-The lesson content did not address all the training objectives. The lessons did not contain all the information necessarily to perform the job. The knowledge and skills required to perform the task or job were not identified.

This cause code is corrected by corrective actions 54, 56, 57, 64, 87, 81.

Discussion of Causes: Management, radiological controls personnel, and operations personnel underestimated the hazards associated with dispersible plutonium. Job planners and workers did not recognize the increase in hazards of working with Pu as compared to dispersible HEU. Personnel relied on their past experience with handling Pu fuel plates even when signs to stop were present.
Additionally, personnel relied upon the fume hood, believing it would provide them protection from exposure. Personnel justified continued operation under the existing safety envelope instead of stopping and assessing the new information and the hazards that could potentially be present. There was a reliance on recent past experience with Pu plates with robust cladding, and a belief that the Pu plate cladding would not fail, particularly when compared to the HEU plates. The depth and breadth of the training provided to personnel, so that they understood the hazards associated with Pu was less than adequate. Additionally, some persons working in the area at the time of the event had no training on the hazards associated with Pu.
The ALARA review and RWP controls were much more focused on external exposure control (i.e. localized shielding, use of tongs, high expected contact dose rates); contamination controls were minimal and only briefly discussed.
The underestimation of hazards extended to the response after the CAM alarmed (SG-1 re-enters area), the emergency response (as seen in the slow decontamination process) and ultimately impacted the medical response (delayed chelation) (MCP-14501, Chelation Therapy states that DTPA is most effective when administered within one hour or less of contamination).

Cause Code: A4B3C11 - Management Problem - Work Organization and Planning was Less-Than-Adequate - Inadequate work package preparations. Thorough scoping and planning were inadequately performed; the work package did not reflect the information gathered from work scoping and planning.
The work package did not accurately reflect the work that was to be completed.

This cause code is corrected by corrective actions 38, 40, 41, 45, 46 and 66.

Discussion of Cause: Despite the procedure reviews and modifications that occurred during the radiological work stand down, the hazards associated with handling Pu plates were not incorporated into the ALARA review, the RWP, or the operating procedures because personnel reviewing the documents, Radiological Engineers, and ZPPR management failed to recognize the hazard associated with handling Pu. Also, work control procedures did not address the hazards present in the facility because management participation in the document review process was less-than-adequate. For the procedures used during this event, the radiological work stand down did not accomplish what it was intended to accomplish. Procedures were reviewed to add new scope, but the new hazards were not properly assessed. As a result, PPE (respiratory protection) was not used because it was not required.
In addition, the engineered control (the fume hood) was not adequate for working with Pu fuel plates.

Cause Code: A4B5C04 - Management Problem - Change Management was Less-Than-Adequate-Risks and consequences associated with a change were not adequately reviewed and assessed. Elements of the process change were not recognized as having adverse impact or increased risk of adverse impact prior to implementing the change.

This cause code is corrected by corrective actions 11-13, 31-33, 38, 40-44, 66.

And Cause Code: A4B5C11 - Management Problem - Change Management was Less-Than-Adequate - Changes not adequately communicated. Change to processes were not communicated to affected personnel effectively (i.e. when ZPPR transitioned from a research facility with an operating reactor to a storage facility managed by Nuclear Operations).

This cause code is corrected by corrective actions 11-13, 31-33, 38, 40, 41-46 and 66.

Discussion of Causes: There exist poor material conditions within ZPPR. The lack of investment in equipment over a number of years has resulted in maintenance problems with old and failing equipment. Poor material/facility condition tends to lead to low expectations and tolerance of maintenance problems. Workers then resort to developing work-arounds to an inability to upgrade/replace/maintain equipment. These are not optimum conditions for performing work with potentially dispersible material, particularly dispersible Pu.
Additionally, during transition of fuel inventory databases, information related to plate history and condition was lost. Additionally, after the ZPPR reactor was shut down and the ZPPR facility transitioned from a Research to Nuclear Operations, corporate knowledge of plate behavior, potential damage, proper handling, and past events was lost. It was unclear if this was intentional (i.e. loss of records) or occurred through retirement, attrition or reassignment to other positions. Previous work practices when handling Pu plates at ZPPR included the use of respiratory protection, CAMs, and much more stringent contamination control measures.

Cause Code: A5B4C01 - Communications Less-Than-Adequate - Verbal Communications Less-Than- Adequate - Communications between workgroups was less than adequate. Lack of communication between work groups (production, technical, or support) contributed to the incident.

This cause code is corrected by corrective actions 11-13, 17-19 and 42-44.

Discussion of Causes: When the ISRC Chairman identified a concern regarding the anticipated failure of Pu fuel plate cladding, communications between the chairman and the MFC Nuclear Operations Director (in 2009 and again in 2010) and Deputy Director in 2011 failed to convey the importance of the problem.
Additionally, when a request to change the BIO was submitted to DOE one and a half months prior to the event, the anticipated failure of Pu plate cladding was not communicated to the operators by either the SS or the NFM. Had it been, it may have made them question the markings and plastic wrapped fuel plates and how to safely handle them. Additionally, the potential for Pu plate cladding failures did not transfer from Nuclear Safety to Radiological Controls to be used in radiological work planning even though personnel from Radiological Controls are on the DSA review team and are represented on the ISRC.

Cause Code: A3B2C04 - Human Performance Less-Than-Adequate - Rule Based Error - Previous success in the use of a rule reinforced continued use of the rule. If a rule for behavior has been used successfully in the past, there is an overwhelming tendency to apply the rule again, even though circumstances no longer warrant the use of the rule.

This cause code is corrected by corrective actions 11-13, 41, 45, 46, 51, 54, 55, 66, 80, 83.

Coupled With: A4B1C03 - Management Problem - Management Methods Less-Than-Adequate-Management direction created insufficient awareness of impact of actions on safety or reliability.
Management failed to provide direction regarding safeguards against non-conservative actions by personnel concerning quality, safety, or reliability when they directed operators to perform work outside the bounds of the work control documents, and when the work had not been properly analyzed for hazards.

This cause code is corrected by corrective actions 11-13, 51, 54, 55, 66, 80, 83 and 88.

Discussion of Causes: The lack of a questioning attitude regarding work being performed under unexpected conditions can be partially attributed to the culture of an expert-based system. Workers tend to conform to existing work practices in the facility and follow the lead of other, more experienced workers. In a number of cases, work was paused when an unexpected condition occurred, but was continued if it could be force-fit under existing work control documents. (The documents did not say that something could not be done; therefore it was okay to proceed.) ZPPR procedures are complex and tend to cross-reference each other (particularly in this case). The focus is on getting the work done (the end justifies the means). When the NFM and SS directed that work continue, the workers stated that they felt confident it was the right decision.

Cause Code: A4B4C05 - Management Problem - Supervisory Methods were Less-Than-Adequate - Emphasis on schedule exceeded emphasis on methods/doing a good job. Accepted standards for methods were not met due to supervisions focus on completing the activity within a certain time frame.
This cause code is corrected by corrective actions 11-13, 51, 52, 54, 55, 66, 80 and 83.

And Cause Code: A4B1C01 - Management Problem - Management Methods Less-Than-Adequate - Management policy guidance / expectations were not well defined, understood, or enforced. Personnel exhibited a lack of understanding of existing policy and/or expectations, or policy/expectations were not well-defined or policy/expectation is not enforced.

This cause code is corrected by corrective actions 11-13, 51, 52, 54, 55, 66, 80 and 83.

Discussion of Causes: There exist some management expectations and leadership issues at ZPPR.
Senior level management says the right things about safety particularly with stop work, but first-line to mid-level management appears to be talking the talk without walking the walk. Personnel had bad experiences with stopping work in the past; however, in this case, they stated that they were comfortable with the decisions to proceed. Although management was told that alternate plates were available and could be used, because they were confident nothing could go wrong with the Pu cladding, they decided to continue work with the marked clamshells and wrapped plates.

Cause Code: A3B1C02 - Human Performance Less-Than-Adequate-Skill Based Error-Step was omitted due to distraction. Attention was diverted to another issue during performance of the task and the individual committed an error in performance due to the distraction.

This cause code is corrected by corrective actions 51, 52, 55, 66, 80, 83 and 88.

Coupled With: A4B1C03 - Management Problem - Management Methods Less-Than-Adequate-Management direction created insufficient awareness of impact of actions on safety or reliability.
Management failed to provide direction regarding safeguards against non-conservative actions by personnel concerning quality, safety, and reliability.

This cause code is corrected by corrective actions 11-13, 51, 54, 55, 66, 80, 83 and 88.

Discussion of Cause: The RWP requires that hands be surveyed for alpha contamination after opening primary containers. Although HPT-1 surveyed OP-1s hands after opening the clamshell, OP-1s hands were not surveyed after opening the plastic covering the fuel plate. Contamination control survey practices, such as frisking the swipe with a portable alpha probe before removing it from the hood and before putting it into the bench-top scaler, indicate a training/experience issue with handling of Pu. OP-1 swiped the inside of the clamshell after the material was seen falling from the bag. All personnel present underestimated how potentially contaminated the flecks might be, and a field probe of the smear was not taken, again indicating an inexperience with Pu handling. Additionally, OP-1 did not use tongs to handle the fuel plate even though the RWP required that tongs be used. The work that the NFM and SS directed OP-1 to perform could not have been accomplished using tongs.
Finally, on October 22, 2011, ZPPR facility management directed that ZPPR exhaust fans be switched in accordance with ZPPR-OI-412 without fully understanding the impact of the actions taken. As such, no exhaust fan was in operation for the workroom south fume hood during the event.

Cause Code: A4B1C06 - Management Problem - Management Methods Less-Than-Adequate-Previous industry or in-house experience was not effectively used to prevent recurrence. Industry or in-house experience relating to a current problem (i.e. the potential of corroded/failed cladding on a Pu fuel plate) that existed prior to the event, but was not assimilated by the organization.

This cause code is corrected by corrective actions 11-13 and 42-44.

Discussion of Cause: There were previous events resulting from failed Pu plate cladding, one in 1970, one in 1991, and there existed several volumes of a ZPPR Suspect Fuel Log. Although this information was available, and readily discovered during the investigation, it was not used to manage operations in ZPPR today.

Cause Code: A5B2C08 - Communications Less-Than-Adequate - Written Communications Less-Than- Adequate - Incomplete / Situation not covered. Details of the written communications were incomplete. Insufficient information was presented. The written communication did not address situations likely to occur during the completion of the procedure.

This cause code is corrected by corrective actions 38, 40, 41, 45, 46 and 66.

Discussion of Cause: Work control documents, including the operating instructions, and the RWP were inadequate and did not provide instructions for the conditions encountered nor did they provide any specific instruction for safely handling Pu fuel.

Cause Code: A3B1C01-Human Performance Less-Than-Adequate-Skill Based Error-Check of work was LTA.

This cause code is corrected by corrective actions 21-31.

Coupled with: A4B1C04-Management Problem-Management Methods Less-Than Adequate-Management follow-up or monitoring of activities did not identify problem.

This cause code is corrected by corrective actions 21-31, 51, 52, 55, 66, 80 and 83.


Discussion of Cause: On October 27, 2011, a ZPPR operator, directed to switch fans 101 and 109 to the A banks, inadvertently switched fan 107 instead of 109. The action resulted in an out of service fan (107B) being placed in service causing substantially reduced airflow through the south fume hood ultimately affecting the hoods ability to contain and control any loose contamination.
Even though the fan was properly labeled as out-of-service, and the status was communicated to operations personnel for over nine months, none of the operators completing the daily rounds between October 27, 2011 and November 8, 2011 or the Shift Supervisor reviewing and approving the daily rounds noticed the discrepancy.
Additionally, when the ZPPR facility is taken into Facility Operations Mode, Form 475 requires that two FMHs and the SS verify all conditions have been met to enter the Facility Operations Mode. During this check, two certified fissile material handlers (ZPPR Operators providing independent verification of readiness for operations) and the Shift Supervisor failed to identify the discrepant condition.

Cause Code: A2B6C01- Equipment / Material Problem-Defective / Failed or Contaminated-Defective or failed part. A part or piece of equipment that lacked something essential to perform its intended function. The degraded performance of a part or a component contributed to the failure of the component, equipment, or system.

This cause code is corrected by corrective actions 20-30.

Discussion of Cause: The damper for fan 107B was not functioning properly which resulted in the exhaust fan providing insufficient airflow through the south fume hood.

The following ISMS core functions were found to be less than adequate:

Define the Scope of the Work:
Procedures were revised without acknowledging the scope increase and understanding the additional hazards associated with Pu fuel.

Analyze the hazards:
Each of the hazards associated with work in ZPPR were identified, analyzed, and categorized, however the analysis of the hazards associated with handling the Pu fuel plates was less than adequate.

Develop and Implement Controls:
For work performed on November 8, 2011, controls were established within ZPPR work control documents. Given lack of hazard identification for a failed plutonium plate, the controls developed and implemented were insufficient.

Perform Work within the Controls:
The hazard was not appropriately identified resulting in insufficient mitigation of the actual hazard and inappropriate controls. The ventilation system was not operational, the controls intended to be in place (south workroom hood ventilation) was not actually in place.

Provide Feedback and Continuous Improvement:
During the Radiological Work Recovery process ZPPR Procedures lacked proper review. For most ZPPR procedures, only one person from operations performed the review and then a team leader signed the review checklist. There is no evidence that representatives from Radiological Controls or Facility Management participated in the validation of the procedures during the review process. As such, a valuable opportunity was missed to ensure that the work being performed in ZPPR considered all the hazards, not just those that operations personnel were accustomed to encountering.
Of 100 surveillances performed, all were deemed satisfactory and only five identified an area that needed improvement. Additionally, some assessment criteria was not assessed because work was not being performed during the assessment, however the assessment was closed.
Similar events had occurred however historical information and awareness of the previous event was not well known among operators and staff assigned to ZPPR.
As a result of this event an INL site wide extent of conditions was performed.
The corrective action number referenced in the Description of Cause (See section 22 above) correlate/match the sequence numbers used in this ORPS report (See section 25 below.)
The corrective action numbers referenced in the description of the corrective actions (See section 25 below) do not correlate/match the sequence numbers used in this ORPS report.


Evaluation (by Facility Manager/Designee):

A Level 1 Causal analysis was performed and all corrective actions are being addressed in the ICAMs system. Immediate actions were taken to suspend all Transuranic work until reviewed and released after approval by the MFC Radiological Manager, the applicable Facility Manager, and as necessary Research Space Manager. Immediate and long term corrective actions (including actions yet to be completed) have had (and will have) a significant positive impact on work performance and enhanced performance of the five ISMS core functions. These corrective actions are time consuming and initially lead to significant work slowdowns at MFC, however the implementation of corrective actions since the initial work slowdown have led to an increase in the safe completion of work at the Materials and Fuels Complex to a rate greater than that before the event.


Is Further Evaluation Required?: No


25. Corrective Actions
Local Tracking System Name: LabWay

        1.
NTS #1: Perform a Root Cause Analysis.
Target Completion Date: 02/15/2012 Tracking ID: AI-06681
        2.
NTS #2: Develop a corrective action plan based on the root cause analysis.
Target Completion Date: 03/02/2012 Tracking ID: AI-06682
        3.
NTS #3: Perform a review of prior self-assessments to identify missed opportunities to identify this noncompliance.
Target Completion Date: 03/08/2012 Tracking ID: AI-06683
        4.
NTS #4: Perform an extent of conditions review to identify potential site-wide issues.
Target Completion Date: 09/30/2012 Tracking ID: AI-06684
        5.
NTS #5: Develop and submit to DOE the initial ESS/JCO for the positive USQ associated with the discovery of the breached plutonium plate jacket which increased the probability of a malfunction of equipment important to safety. (CA 1, JON 1, JON 4)
Target Completion Date: 03/23/2012 Tracking ID: AI-07573
        6.
NTS #6: Reassess the likelihood, severity, and risk of accidents and the effectiveness of hazard controls in current ZPPR BIO. The reassessment will involve facility, engineering, nuclear safety, and independent (non-BEA) personnel. Use the PISA process to identify any positive USQs as a result of the reassessment. (CA 2, JON 1, JON 4)
Target Completion Date: 04/27/2012 Tracking ID: AI-07574
        7.
NTS #7: Develop submit to DOE, and implement upon approval any associated ESS/JCO from CA-2 (NTS #6) (may require several submittals identifying mitigation controls).
Target Completion Date: 10/01/2012 Tracking ID: AI-07575
        8.
NTS #10: Complete a review of the existing and upgraded MFC Documented Safety Analyses (DSAs). The review will consider the hazards, hazard event frequency and consequence judgments. The review will also consider differences between the existing DSAs and any not approved or approved and not yet implemented upgraded DSAs. Use the PISA process to identify any positive USQs as a result of the reassessment. (CA 6, JON 1)
Target Completion Date: 05/03/2012 Tracking ID: AI-07578
        9.
NTS #11: Evaluate, revise, and submit to DOE for approval "INL Unreviewed Safety Questions" (LWP-18001) and/or "MFC Work Plan for Safety Basis Upgrade" (NS-18308) to strengthen requirements associated with application of the PISA process during SAR upgrade activities and SAR annual updates. (CA 7, JON 2)
Target Completion Date: 05/24/2012 Tracking ID: AI-07579
        10.
NTS #12: Implement the revision to the USQ procedure(s) from CA-7 (NTS #11). The due date assumes DOE approval is received by 6/30/2012. (CA 8, JON 2)
Target Completion Date: 11/30/2012 Tracking ID: AI-07580
        11.
NTS #13: Issue a Lessons Learned on the ZPPR event. The Lessons Learned will include discussion on the 1) failure to adequately address ISRC concerns including use of the ICAMS tracking and resolution process or the Resolution of Dissenting Professional Opinion process (LWP-10011), and 2) failure to effectively utilize the PISA process for new information, 3) failure to consider historical information in work planning, 4) failure to adequately address the stop work when unexpected conditions were encountered, 5) lack of an integrated production control schedule process, and 6) Emergency Management response including; bioassay equipment availability, communications with Pu internal dose experts, communications with DOE. (CA 9, JON 2, JON 7, JON 10)
Target Completion Date: 04/20/2012 Tracking ID: AI-07581
        12.
NTS #14: Complete training on the Lessons Learned to affected MFC personnel. Identify expected behaviors for the six identified failures in the training. (CA 10, JON 2, JON 7, JON 10)
Target Completion Date: 05/31/2012 Tracking ID: AI-07582
        13.
NTS #15: Using a Systematic Approach to Training, select appropriate content from the Lessons Learned ZPPR event derived from CA-9 (NTS #13) and deliver via all employee training methods and selected other topcial areas of training to affected INL personnel outside MFC as appropriate. (CA 11, JON 2, JON 7, JON 10)
Target Completion Date: 06/30/2012 Tracking ID: AI-07583
        14.
NTS #16: Revise the charter (CTR-314) for the MFC Issues Screening Team (IST) to add a Nuclear Safety representative to ensure ICAMS issues are considered for PISA and USQ applicability. (CA 12, JON 2)
Target Completion Date: 04/27/2012 Tracking ID: AI-07584
        15.
NTS #17: Evaluate and revise, if needed, the appropriate ATR process (i.e. Issues Screening, Management Review Committee, or appropriate review appliance) to ensure ICAMS issues are considered for PISA and USQ applicability as part of the review work-flow process. (CA 13, JON 2)
Target Completion Date: 04/27/2012 Tracking ID: AI-07585
        16.
NTS #18: Revise the charter (SMC-CTR-033) for the SMC Screening and Management Review Committee to add a safety basis compliance coordinator to ensure ICAMS issues are considered for PISA and USQ applicability. (CA 14, JON 2)
Target Completion Date: 04/20/2012 Tracking ID: AI-07586
        17.
NTS #19: Revise the charter (CTR-207) for the MFC ISRC to 1) redefine reporting requirements for the chairman and 2) identify chairman roles and responsibilities for communicating unresolved issues to senior management including when to formally document concerns or issues that the ISRC identifies (including ICAMS). (CA 15, JON 2)
Target Completion Date: 04/25/2012 Tracking ID: AI-07587
        18.
NTS #20: Revise the procedure (SP-10.1.1.3) for the ATR SORC to 1) redefine reporting requirements for the chairman and 2) identify chairman roles and responsibilities for communicating unresolved issues to senior management including when to formally document concerns or issues that the SORC identifies (including ICAMS). (CA 16, JON 2)
Target Completion Date: 05/11/2012 Tracking ID: AI-07588
        19.
NTS #21: Revise the charter (SMC-CTR-014 for the SMC ISRC to 1) redefine reporting requirements for the chairman and 2) identify chairman roles and responsibilities for communicating unresolved issues to senior management including when to formally document concerns or issues that the SORC identifies (including ICAMS). (CA 17, JON 2)
Target Completion Date: 05/11/2012 Tracking ID: AI-07589
        20.
NTS #22: Empty the ZPPR south fume hood of nuclear material and repair or take hood out of service. (CA 18, JON 5)
Target Completion Date: 08/31/2012 Tracking ID: AI-07590
        21.
NTS #23: Revise and implement the safety analysis process procedures (NS-18101) to strengthen DSA identification and requirements for defense-in-depth SSCs. (CA 19, JON 5)
Target Completion Date: 07/31/2012 Tracking ID: AI-07591
        22.
NTS #24: Review ZPPR Documented Safety Analysis (DSAs) and identify defense-in-depth (DID) SSCs that are performing a credited function. (CA 20, JON 5)
Target Completion Date: 05/31/2012 Tracking ID: AI-07592
        23.
NTS #26: Establish operability/performance requirements for ZPPR DID SSCs that are performing a credited function as found in the DSA in CA-20 (NTS #24). If requirements have been previously established, identify the document containing the requirements. (CA 22, JON 5)
Target Completion Date: 07/31/2012 Tracking ID: AI-07594
        24.
NTS #28: Issue preventative maintenance bases/justifications or surveillance bases/justifications for ZPPR DID SSCs to provide assurance of SSC performance/operability based on the results of CA-22 (NTS #26). If preventative maintenance or surveillances already exist, identify the procedures. (CA 24, JON 5)
Target Completion Date: 10/31/2012 Tracking ID: AI-07596
        25.
NTS #30: Develop and issue preventative maintenance procedures for ZPPR DID SSCs as needed based on the results of CA-24 (NTS #28). (CA 26, JON 5)
Target Completion Date: 12/20/2012 Tracking ID: AI-07598
        26.
NTS #33: Develop and issue surveillance procedures for ZPPR DID SSCs as needed based on the results of CA-24 (NTS #28). (CA 29, JON 5)
Target Completion Date: 12/20/2012 Tracking ID: AI-07601
        27.
NTS #34: Complete an extent of conditions review on DID SSCs for the balance of MFC, ATRC and NMIS. The review will consider 1) proper identification of DID SSCs that are performing a credited function in the Documented Safety Analyses (DSAs), 2) establishment of operability /performance requirements for the DID SSCs, and 3) establishment of appropriate preventive maintenance and surveillances for the DID SSCs. (CA 30, JON 5)
Target Completion Date: 12/20/2012 Tracking ID: AI-07602
        28.
NTS #35: Complete an extent of conditions review on DID SSCs for SMC. The review will consider 1) proper identification of DID SSCs that are performing a credited function in the Documented Safety Analysis (DSA), 2) establishment of operability /performance requirements for the DID SSCs, and 3) establishment of appropriate preventive maintenance and surveillances for the DID SSCs. (CA 31, JON 5)
Target Completion Date: 12/20/2012 Tracking ID: AI-07603
        29.
NTS #36: Revise and implement MFC Nuclear Operations supplemental Laboratory Excellence Requirements (MCP-9600) associated with 1) equipment status (tagging) and 2) tracking essential equipment status (in a database). For tagging, consider the need to identify equipment status where facility rounds are taken and where equipment is operated. (CA 32, JON 5)
Target Completion Date: 05/31/2012 Tracking ID: AI-07604
        30.
NTS #37: Revise and implement INL Laboratory Excellence requirements associated with equipment status (tagging). Revision will consider the need to identify equipment status where facility rounds are taken and where equipment is operated. (CA 33, JON 5)
Target Completion Date: 07/31/2012 Tracking ID: AI-07605
        31.
NTS #38: Implement the equipment deficiency tracking database from CA-32 (NTS #36) to allow MFC senior management to track essential equipment status (including active safety class, safety significant, and defense-in-depth SSC). (CA 34, JON 5)
Target Completion Date: 05/31/2012 Tracking ID: AI-07606
        32.
NTS #39: Develop and implement a process for a single Integrated Priority List (IPL) for MFC that is risk ranked and sortable (e.g., funding profiles, facility). The IPL will address current known facility and equipment needs. (CA 35, JON 5)
Target Completion Date: 08/30/2012 Tracking ID: AI-07607
        33.
NTS #40: Develop a plan to establish an MFC Sustainment Program as part of the MFC Strategic Excellence Plan that will support increasing essential equipment reliability in MFC facilities. The plan will include methods to prioritize risk, identify mitigations and define methods for submitting funding requests. (CA 36, JON 5)
Target Completion Date: 08/30/2012 Tracking ID: AI-07608
        34.
NTS #41: Complete and assessment on active MFC Nuclear Operations PWS to identify those that inappropriately provide work control direction. Revise PWS as necessary. (CA 37, JON 6)
Target Completion Date: 05/31/2012 Tracking ID: AI-07609
        35.
NTS #42: As an interim measure until completion of CA-40 (NTS #44), revise and implement the PWS administrative (SP-20.2.1) to clarify that PWS do not provide work control direction. (CA 38, JON 6)
Target Completion Date: 05/31/2012 Tracking ID: AI-07610
        36.
NTS #43: Complete an extent of conditions review for the inappropriate use of supplemental instruction documents as work control direction for the INL. (CA 39, JON 6)
Target Completion Date: 06/14/2012 Tracking ID: AI-07611
        37.
"NTS #44: Revise and implement LWP-21220 to provide instructions for development and use of supplemental instruction documents used in conjunction with Laboratory Instructions (LIs) including Process Work Sheets (PWS), Experimental Plans, Special Instructions (SI), Engineering Release Letters (ERL), Engineering Directives, and Operating Information Letters (OIL). This revision to LWP-21220 is intended to ensure that the nature and content of supplemental instruction documents are subservient to their governing LI(s) and are not used independently of the LI(s). This revision will provide instructions to ensure the nature and content of supplemental instructions do not create new scope, new hazards and new controls that are not contained within the LI(s). (CA 40, JON 6)"
Target Completion Date: 10/31/2012 Tracking ID: AI-07612
        38.
NTS #45: Complete an assessment of 1) the formats being used by INL organizations for supplemental work instructions to determine if templates need to be established for their use, and 2) use of the Mentor Chair or Qualified Review function at INL in procedure development to assure completeness and quality of laboratory instructions. (CA 41, JON 6, JON 7)
Target Completion Date: 08/30/2012 Tracking ID: AI-07613
        39.
NTS #46: Establish an annual assessment of PWS implementation at MFC. Assessment will look for inappropriate use of PWS as work control. (CA 42, JON 6)
Target Completion Date: 04/20/2012 Tracking ID: AI-07614
        40.
NTS #47: Revise and implement in an MFC Nuclear Operations procedure the use of Mentor/Chairs (M/C) or Qualified Reviewers and an active focused review process to assure completeness and quality of laboratory instructions. The review will consider applicable historical information and lessons learned. (CA 43, JON 7)
Target Completion Date: 07/31/2012 Tracking ID: AI-07615
        41.
NTS #49: Revise and implement INL radiological procedure(s) t0 incorporate (as appropriate) supplemental controls from the MFC timely order MFC-RC-LT-7. The timely order identifies air/contamination monitoring requirements, respiratory protection requirements, and work configuration (e.g., bench top, hood, glovebox) requirements based on activity and isotopes involved. (CA 45, JON 8)
Target Completion Date: 09/27/2012 Tracking ID: AI-07617
        42.
NTS #50: Identify high hazards for each MFC Nuclear Operations facility by utilizing group meetings with operators, radiological control technicians, engineers, researchers, and facility management. (CA 47, JON 7)
Target Completion Date: 07/31/2012 Tracking ID: AI-07618
        43.
NTS #51: Verify the high hazards identified in CA-50 are adequately mitigated for each MFC Nuclear Operations facility in the operating procedures. (CA 47, JON 7)
Target Completion Date: 11/29/2012 Tracking ID: AI-07619
        44.
NTS #52: Establish a requirement to review records and historical data and to consolidate the information into a formal document on nuclear material condition as a part of Special Nuclear Material (SNM) project planning for projects that involve disposition of SNM. (CA 48, JON 7)
Target Completion Date: 06/28/2012 Tracking ID: AI-07620
        45.
NTS #53: Revise and implement radiological control procedure(s) (MCP-15009 and/or LWP-15009) to incorporate supplemental controls from MFC timely order MFC-RC-LT-6. The timely order requires identifying all radiological hazards in the Radiological Conditions section of the RWP and developing limiting conditions for listed hazards (as applicable). The timely order also notes if a radiological hazard is identified that is not listed in the Radiological Conditions section of the RWP, then the RWP is no longer valid for the activity (until revised to address the new hazard). (CA 49, JON 8)
Target Completion Date: 09/27/2012 Tracking ID: AI-07621
        46.
NTS #55: Revise and implement abnormal and alarm response procedures for MFC Nuclear Operations facilities to ensure radiological response is adequately covered. (CA 51, JON 8)
Target Completion Date: 12/20/2012 Tracking ID: AI-07623
        47.
NTS #56: Evaluate air monitoring procedures (MCP-352, MCP-356 or other procedures) for adequacy of instructions on the placement of continuous air monitoring equipment to ensure proper indication of any airborne radiological hazard. Based on the evaluation, revise and implement the procedures as needed to include improved directions for proper placement and use of fixed monitoring, portable monitoring and breathing zone monitoring equipment. Consider need for required periodic review to ensure facility conditions haven't changed. (CA 52, JON 9)
Target Completion Date: 11/29/2012 Tracking ID: AI-07624
        48.
NTS #57: Ensure ZPPR facility air balancing is completed to include current building ventilation air flow analysis. (CA 53, JON 9)
Target Completion Date: 09/27/2012 Tracking ID: AI-07625
        49.
NTS #58: Upon completion of CA-56 and CA-57, re-evaluate radiological air monitoring needs and placement for the ZPPR facility. The evaluations will include building ventilation air flow analysis, air monitoring needs determination and suggested air monitoring equipment and placement. The evaluations will be documented in engineering evaluations in conformance with engineering procedures. (CA 54, JON 9)
Target Completion Date: 12/20/2012 Tracking ID: AI-07626
        50.
NTS #59: Install or verify placement of air monitoring equipment in the ZPPR facility as specified in the engineering evaluations from CA-58. (CA 55, JON 9)
Target Completion Date: 12/20/2012 Tracking ID: AI-07627
        51.
NTS #61: Institutionalize the use of Human Performance Tools at MFC via a formal requirement for MFC management to routinely select specific Human Performance Tools and emphasize their use across MFC. (CA 58, JON 10)
Target Completion Date: 05/31/2012 Tracking ID: AI-07629
        52.
NTS #62: Develop and implement a mentor program at MFC for Foremen and Supervisors. The program will emphasize use of Human Performance Tools including 1) reinforcing procedural adherence and 2) reinforcing use of stop work and the appropriate responses to stop work. (CA 58, JON 10)
Target Completion Date: 07/30/2012 Tracking ID: AI-07630
        53.
"NTS #63: Issue a Lessons Learned on the ZPPR event. The Lessons Learned will include discussion on the 1) failure to adequately address ISRC concerns including use of the ICAMS tracking and resolution process or the Resolution of Dissenting Professional Opinion process (LWP-10011), and 2) failure to effectively utilize the PISA process for new information, 3) failure to consider historical information in work planning, and 4) failure to adequately address the stop work when unexpected conditions were encountered."
Target Completion Date: 04/20/2012 Tracking ID: AI-07631
        54.
NTS #64: Strengthen training on TRU hazards and controls and provide training to all personnel who work with TRU materials at MFC and key personnel who develop/implement controls (e.g., managers, supervisors, technical support). Training should include emphasis on relative potential consequences of injection compared to inhalation and ingestion and possible medical treatment. A retraining interval will be established. (CA 59, JON 10, JON 11)
Target Completion Date: 07/19/2012 Tracking ID: AI-07632
        55.
NTS #65: Perform an extent of conditions review at ATR, SMC, and MFC, and other areas selected by the actionee, regarding the effective use of Time Out and Stop Work human performance tools in accordance with PDD-1004 "Integrated Safety Management System"> Ensure the assessment focuses on the appropriateness of management response to Time Outs/Stop Work taken by work performers. The focus should also include responses by management to Time Outs/Stop Work when procedures cannot be implemented as written. Engage the Human Performance Practitioners at each site to assist with performing the evaluations. (CA 60, JON 10)
Target Completion Date: 07/20/2012 Tracking ID: AI-07633
        56.
NTS #67: Strengthen facility specific training (For MFC facilities) on TRU materials physical characteristics, abnormal conditions, indications of degradation, and recognizing unique hazards associated with facility specific TRU. Selection of the target audience will consider the role of managers and supervisors. A retraining interval will be established. (CA 63, JON 11)
Target Completion Date: 09/27/2012 Tracking ID: AI-07635
        57.
NTS #68: Complete an extent of conditions for inadequacies in facility specific training on TRU materials and associated hazards for INL facilities other than MFC. (CA 64, JON 11)
Target Completion Date: 06/14/2012 Tracking ID: AI-07636
        58.
NTS #69: Develop (or revise) and implement training for radiological controls personnel on the various CAMs used within MFC. Training shall consider a) how the instruments function (e.g., fast and slow response), b) types of CAMs (beta/gamma or alpha), and c) units for the instrument readout. (CA 65, JON 12)
Target Completion Date: 12/20/2012 Tracking ID: AI-07637
        59.
NTS #70: Develop (or revise) and implement training for radiological controls personnel on the various CAMs used within ATR. Training shall consider a) how the instruments function (e.g., fast and slow response), b) types of CAMs (beta/gamma or alpha), and c) units for the instrument readout. (CA 66, JON 12)
Target Completion Date: 12/20/2012 Tracking ID: AI-07638
        60.
NTS #71: Develop (or revise) and implement training for radiological controls personnel on the various CAMs used within SWC and SMC. Training shall consider a) how the instruments function (e.g., fast and slow response), b) types of CAMs (beta/gamma or alpha), and c) units for the instrument readout. (CA 67, JON 12)
Target Completion Date: 12/20/2012 Tracking ID: AI-07639
        61.
NTS #72: Assign radiological engineers at MFC to specialize in the following disciplines: a) continuous air monitors and air sampling, b) personnel contamination monitors and frisking, c) radiation area monitors, criticality monitors and dose rate instruments. (CA 68, JON 12)
Target Completion Date: 07/26/2012 Tracking ID: AI-07640
        62.
NTS #73: Revise and implement the procedure on Alpha 7 CAMs (TPR-7638) to include requirements to label Alpha 7 CAMs with the specific radionuclides established for the instrument along with the associated alarm setpoints. (CA 69, JON 12)
Target Completion Date: 10/25/2012 Tracking ID: AI-07641
        63.
NTS #74: Develop and implement a checklist to support MCP-148, "Personnel Decontamination," and LWP-15015, "Responding to Radiological Emergencies," The checklist will consider items such as segregation, nose blowing, nasal smears, material retention, CAM data etc. (CA 70, JON 12)
Target Completion Date: 07/26/2012 Tracking ID: AI-07642
        64.
NTS #75: Develop radiological operational drills (in coordination with facility training organizations, radiological controls and medical) that include activating the facility Emergency Response Organization (ERO). Incorporate radiological operational drills into the Emergency Management drill schedule. Conduct a radiological operational/ERO drill. (CA 71, JON 12, JON 15, JON A, JON 18, JON D)
Target Completion Date: 10/01/2012 Tracking ID: AI-07643
        65.
NTS #76: Develop a document describing a mentoring program for performance of management (field) observations at MFC and implement the program. The program will include observations on the use of Human Performance Tools. (CA 72, JON 13, JON 14)
Target Completion Date: 05/31/2012 Tracking ID: AI-07644
        66.
NTS #79: Revise and implement documents (Plan-114, EPI-91 and MFC-14 checklist) to ensure someone is identified and appointed to perform on-scene communicator duties when the BED (Building Emergency Director) is unavailable. (CA 75, JON 15)
Target Completion Date: 08/30/2012 Tracking ID: AI-07647
        67.
NTS #80: Develop and implement a process that the ED/EAM can follow in deciding when to activate the EOC/ECC when support is needed even though an Emergency Action Level (EAL) was not met or exceeded. This development will include some table-top walk-through and discussions with senior management involvement to better understand expectations resulting from conservative decision making when considering activation of the Emergency Response Organization (ERO). (CA 76, JON 15)
Target Completion Date: 09/30/2012 Tracking ID: AI-07648
        68.
NTS #81: Conduct a review of the Emergency Preparedness hazards assessment for ZPPR Facility and determine the need for revisions to the assessment and make any need for changes to the Emergency Action Levels (EALs) for that facility. (CA 77, JON 16)
Target Completion Date: 12/20/2012 Tracking ID: AI-07649
        69.
NTS #82: Evaluate the wording of discretionary Emergency Action Levels (EALs) and revise so that the Emergency Action Manager (EAM) actually has discretion in its use. (CA 78, JON 16, JON A)
Target Completion Date: 10/01/2012 Tracking ID: AI-07650
        70.
NTS #83: Evaluate the amount of chelation agents that the INL should have on hand. The evaluation will consider the largest projected accident from Emergency Management characterizations, Facility DSAs, and ability of REAC/TS to provide timely stock. The evaluation will be documented in a technical evaluation (TEV). (CA 79, JON 17)
Target Completion Date: 04/20/2012 Tracking ID: AI-07651
        71.
NTS #84: Based upon the TEV from CA-70 (NTS #83), work with REAC/TS to stock the appropriate amount of chelation agent at the INL, if available. (CA 80, JON 17)
Target Completion Date: 06/22/2012 Tracking ID: AI-07652
        72.
NTS #88: Document the verification and validation of the RadDecay software used by the radiological control organization to decay radionuclides. (CA 84, JON 18, JON B)
Target Completion Date: 05/18/2012 Tracking ID: AI-07656
        73.
NTS #77: Schedule an effectiveness review of the following: 1) work control changes from CA-40 (NTS #44) and CA-43 (NTS #47); 2) radiological control procedure changes from CA-45 (NTS #49) and CA-49 (NTS #53); 3) Human Performance tool usage from CA-57 (NTS #61) and CA-58 (NTS #62); and, 4) field observation program mentoring from CA-72 (NTS #76). (CA 73, JON 6, JON 13, JON 14)
Target Completion Date: 06/25/2012 Tracking ID: AI-07645
        74.
NTS #78: Revise the MFC Management Review Committee (MRC) charter (CTR-313) to require periodic review of management field observation data. (CA 74, JON 13, JON 14)
Target Completion Date: 04/30/2012 Tracking ID: AI-07646
        75.
NTS #85: Evaluate and develop the capabilities at MFC to perform qualitative and quantitative analysis to support timely dose assessments of different sample medias including, but not limited to nasal swabs, swipes, smears, air filters, and emergency bioassay samples in the event of a radiological emergency. The capabilities would include generation of methodologies, staffing trained personnel to perform analyses, and a QA program to ensure valid results. (CA 81, JON 18, JON B)
Target Completion Date: 12/20/2012 Tracking ID: AI-07653
        76.
NTS #86: Evaluate and develop the capabilities at ATR Complex to perform qualitative and quantitative analysis to support timely dose assessments of different sample medias including, but not limited to nasal swabs, swipes, smears, air filters and emergency bioassay samples in the event of a radiological emergency. The capabilities would include generation of methodologies, staffing trained personnel to perform analyses, and a QA program to ensure valid results. (CA 82, JON 18, JON B)
Target Completion Date: 09/28/2012 Tracking ID: AI-07654
        77.
NTS #87: Review, revise as needed, and implement procedures used in radiological emergencies to ensure response actions (including evaluation for medical treatment) are clear identified. The review will consider LWP-15015, "Response to Abnormal Radiological Situations," MCP-148, "personnel decontamination," MCP-14501, "Chelation Therapy,: PLN-114-09, "Emergency Medical Support," and TEV-500, "Technical Evaluation for establishing Levels of Radionuclide Intakes for Consideration of Medical Intervention TEV-500. (CA 83, JON 18, JON B)
Target Completion Date: 09/27/2012 Tracking ID: AI-07655
        78.
NTS #89: Train radiological engineers in the use of RadDecay software. (CA 85, JON 18, JON B)
Target Completion Date: 06/22/2012 Tracking ID: AI-07657
        79.
NTS #92: Address the following concerns of the ISRC Chairman white paper: Leaking sodium plates in MFC-784 (I/O -016801 RWSF potential exposure issue (I/O -016800) Communication issue regarding Nuclear Operations Director unaware of important security upgrades. (CA 87, JON 7)
Target Completion Date: 07/10/2012 Tracking ID: AI-07916
        80.
NTS #93: Revise LWP-14002 (or other appropriate document) to enhance guidance associated with specific actions to be taken by managers and supervisors when work is stopped by work performers. (CA 88, JON 9)
Target Completion Date: 07/30/2012 Tracking ID: AI-07917
        81.
NTS #94: Improve formal guidance documentation regarding communications to affected workers during radiological events. This guidance will include; biological hazards of exposures received i.e. potential dose consequences, any mitigation strategies available, medical and psychological options available, etc. (CA 89, JON 18)
Target Completion Date: 07/30/2012 Tracking ID: AI-07918
        82.
NTS #95: Perform an extent of conditions review of the balance of MFC facilities to ensure facility ventilation evaluations (i.e., air flow analyses and balancing) are complete. (CA 90, JON 9)
Target Completion Date: 12/20/2012 Tracking ID: AI-07919
        83.
NTS #96: As an interim action before completing CA-87, develop and provide documents to MFC employees identifying expectations regarding the Stop Work process and actions to be taken by work performers and management prior to resumption of work. Provide the documents to the MFC staff by 4/4/2012. (CA 91, JON 9)
Target Completion Date: 04/23/2012 Tracking ID: AI-07920
        84.
Implement the ZPPR DSA upgrade. The due date is based on DOE approval within 6 months of submittal. (CA 5, JON 1)
Target Completion Date: 12/19/2013 Tracking ID: AI-07953
        85.
Develop and issue preventative maintenance procedures for ATRC DID SSCs as needed based on the results of CA-28. (CA 27, JON 5)
Target Completion Date: 01/31/2015 Tracking ID: AI-07954
        86.
Perform an extent of conditions on documentation for and placement of air monitoring equipment for INL facilities beyond MFC. (CA 56, JON 9)
Target Completion Date: 08/30/2012 Tracking ID: AI-07956
        87.
NTS #90: Provide training for rad workers on TRU hazards and factors associated with making personal decisions associated with chelation. (JON C, A6B3C02)
Target Completion Date: 02/07/2013 Tracking ID: AI-08057
        88.
NTS #97: Complete an assessment of INL facilities to identify areas where radiological survey equipment should be installed inside contamination areas to support operations. (CA 62, JON 10)
Target Completion Date: 07/31/2012 Tracking ID: AI-08058


26. Lessons Learned:

Submitted on: 04/17/2012
Proper identification of work control hazards through all sources of documentation and experience.

During the planning of a work activity, proper identification of the hazards through all sources of documentation and experience, analysis of the hazards identified, and mitigation of those hazards is paramount to the protection of workers. Additionally, management must respond appropriately to time out, stop work, and questioning attitudes exhibited by work performers.

The investigation identified Integrated Safety Management System (ISMS) core function failures in the areas of defining the scope of work, identifying hazards, developing and implementing hazard controls and performing work within controls. The work planning process did not explicitly evaluate the possibility of a plutonium plate breach as part of the work evolution neither did the nuclear material handling procedures, As Low As Reasonably Achievable (ALARA) review, or Radiological Work Permit (RWP) address the possibility of a plutonium plate breach. Personnel involved in planning and executing the work failed to recognize the increased hazard associated with a breached plutonium (Pu) plate and missed an opportunity to identify this hazard by better understanding past operations and events. Improper response to abnormal indications as the work was occurring, contributed to the failure to identify the increased hazard associated with a breached plutonium plate.

The need to look for and use historical data concerning Pu fuel plates and an identified concern regarding the anticipated failure of Pu fuel plate cladding was not utilized in the work planning process. Additionally, when a change to the facility safety basis was submitted for approval 6 -7 weeks prior to the event, this change to the likeliness of Pu plate failure from beyond extremely unlikely to anticipated failure of Pu plate cladding was not communicated to the operators by facility management.

When a concern was identified by the Independent Safety Review Committee (ISRC) Chairman regarding the anticipated failure of Pu fuel cladding, communications between the chairman and the responsible management failed to convey the importance of the problem in regards to the work activity. This concern was not submitted as a change to the safety basis for over two and one half years. Neither were the additional venues of the INL issues management process or the dissenting opinion resolution process used to help resolve the concern.

The Potential Inadequacy in the Safety Analysis (PISA) process was not effectively utilized when new information was discovered causing a lack of entering the proper USQ process. The USQ process does not apply to the process of upgrading DSAs in response to new requirements or to the use of new or different analytical tools during the upgrade process. However, the USQ process does apply, even during upgrade efforts, when there is reason to believe that the current safety basis might be in error or be otherwise inadequate.

Even though the change in Pu plate breach probability was inserted in the upgraded DSA submitted for approval, actions to fully understand implications of this breach to intended operations in the facility were not robustly handled and consequence judgments of a plutonium plate breach did not appropriately consider differences between the assumed-bounding Pu fire analysis and physical form of Pu in a breached plate that had been subject to oxidation over time.

The Integrated Production Control scheduling process caused a compression in the timeframe to accomplish the pre-work tasks which lead to the lack of a proper review of the work control documents, including the operations instructions for example the Process Worksheet was issued the same day that it was scheduled to work, as was the RWP. This lead to documents that were inadequate and did not provide instructions for the conditions encountered nor did they provide any specific instruction for safely handling Pu fuel. Some work steps did not have an appropriate hazard analysis or accompanying mitigation for loading the material into containers. The routing table and activity parameters did not refer to specific steps of the referenced operating instructions to clearly direct the work activity.

The command and control structure of the Emergency Response Organization (ERO) was not fully established. Personnel had been responding to the event for nearly three hours and had established their own communications chains and command structure. As a result, emergency responders in the Emergency Operations Center (EOC) and Emergency Control Center (ECC) struggled to get clear information, provide needed resources, and ensure that appropriate actions were being coordinated. This did not allow for communications with any type of Pu internal dose experts for guidance in dealing with the event. Resources were not coordinated in an efficient manner to provide clothing, facilitate transportation, and coordinate response between facility personnel and Central Facilities Area (CFA) medical for the response to contaminated personnel. The information provided to the CFA medical was not sufficient to assess the need for medical intervention. Radiological Control informed the medical staff that the material was Pu but did not provide detailed information, i.e., chemical form and solubility class, and the dose consequences of not performing a treatment.

Recommended Actions

1) Need to look for and use historical data in the work planning process.
2) Identified concerns need to be properly followed up to provide resolution to the concern.
3) The integrated control scheduling process needs to be utilized to provide a schedule that is realistic in detailing the work activity.


27. Similar Occurrence Report Numbers:

None


User-defined Field #1:

GC73

User-defined Field #2:


30. HQ Keyword(s):

14E--Quality Assurance - Work Process Deficiency
06H--Radiological - Inadequate Radiological Control Job Planning
06I--Radiological - Radiological Control Training Deficiency
14A--Quality Assurance - Program Deficiency
14B--Quality Assurance - Training and Qualification Deficiency
14D--Quality Assurance - Documents and Records Deficiency
01G--Inadequate Conduct of Operations - Inadequate Procedure
01I--Inadequate Conduct of Operations - Safety System Actuation/Evacuation
12N--EH Categories - Radiological Skin Contaminations/Uptakes/Overexposures
13A--Management Concerns - HQ Significant (High-lighted for Management attention)
13C--Management Concerns - Accident Investigation - Type B (Retired)
01A--Inadequate Conduct of Operations - Inadequate Conduct of Operations (Retired)
01B--Inadequate Conduct of Operations - Loss of Configuration Management/Control
01P--Inadequate Conduct of Operations - Inadequate Oral Communication
01Q--Inadequate Conduct of Operations - Personnel error
01R--Inadequate Conduct of Operations - Management issues
06C--Radiological - Skin Contamination
06D--Radiological - Airborne Radiological Release
06J--Radiological - Inadequate Radiological Control Procedure


31. HQ Summary:

On November 8, 2011, while inspecting material in the Zero Power Physics Reactor (ZPPR) work room, an area Continuous Air Monitor (CAM) alarmed and sixteen personnel were discovered to have contaminated personal effects. When the CAM alarmed, personnel immediately stopped work and exited the area according to procedures and health physics personnel instructions. Personnel were surveyed for contamination and decontaminated, if required. Seven employees had skin contamination. Six personnel had positive nasal smears. Personnel were working in a laboratory hood removing ZPPR fuel plates from one container and preparing the material to be placed in another container suitable for shipping. Management and DOE-ID were notified and the ZPPR area was roped off. The emergency control center was manned and helped coordinate the response efforts. All potentially exposed employees are currently undergoing additional radiological monitoring at the Central Facilities Area Medical Facility. External air sampling and radiological surveys indicate no contamination has been detected outside of the ZPPR facility. A critique was completed on November 9. A recovery manager has been appointed and a plan is being developed for recovery. The USQ determination was positive.


32. DOE Facility Representative Input:

Causal analysis ad corrective actions were developed through the BEA independent Accident Investigation as well as the results of the DOE Accident Investigation Board. Corrective actions have been approved by the DOE-ID Office Manager.

Entered by: MARTIN, JOHN C Date: 10/23/2012


DOE Program Manager Input:Approved.
Entered by: NIYOGI, PRADYOT KDate: 01/30/2014


34. Approvals:
 
Approved by: GUNDERSON, RICHARD A., Facility Manager/Designee
Date:09/25/2012
Telephone No.:(208) 533-8045
 
Approved by: MARTIN, JOHN C , Facility Representative/Designee
Date:10/23/2012
Telephone No.:
 
Approved by: NIYOGI, PRADYOT K, Program Manager/Designee
Date:01/30/2014
Telephone No.: