DNFSB report details safety issues at PF-4

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LANL > Board’s report cites criticality lapses at facility

By John Severance

More details became available this week about the stand-down of activities in the Plutonium Facility at Los Alamos National Laboratory last month that was ordered by lab director Charlie McMillan.

The Defense Nuclear Facilities Safety Board sent a letter and report to Energy Secretary Ernest Moniz, detailing some of the criticality issues surrounding the work being done at PF-4.

“The current pause at PF-4 is aimed at addressing the concerns in the letter and others identified by lab employees and managers,” lab spokesman Fred DeSousa said. “However, the letter is addressed to Secretary Moniz and Acting Administrator (Bruce) Held, so we would respectfully ask that you direct your questions to DOE and NNSA.”

DOE and NNSA officials did not respond to requests for comment.

The report, meanwhile, pointed to a number of issues including a lack of safety personnel and lax control of operating procedures.

The biggest issue is a significant shortage of Los Alamos National Security criticality safety staff has hindered the ability of LANS to address deficiencies at the facility, and the backlog of unresolved criticality safety issues continues to grow.

The board also identified the following non-compliances during its review:
• Most criticality safety controls are not incorporated into operating procedures.
• Operators typically do not utilize written procedures when performing work.
• Fissile material labels do not list parameters relevant to criticality safety (e.g., mass).
• Some fissile material operations lack Criticality Safety Evaluations (CSEs).
• Some CSEs do not analyze all credible abnormal conditions.

After McMillan announced the pausing of activities at PF-4, LANS has committed to provide the Los Alamos Site Office with a comprehensive “get well” plan for criticality safety by Oct. 1.

The report said, “the staff recognizes that achieving compliance with applicable requirements will involve significant time and resources.

“The staff believes this plan should identify the resources and schedule required to achieve compliance milestones. Additionally, the staff notes that long-standing issues, such as staffing shortages in the LANS criticality safety group and CSE compliance, indicate flaws in the federal oversight and contractor assurance systems.”

The DNFSB, meanwhile, made the following recommendations.
• Incorporate criticality controls and limits into procedures;
• Improve conduct of operations including utilization of procedures;
• Evaluate procedures that contain criticality safety controls for designation as Use Every Time procedures;
• Review and approve criticality safety postings to ensure they are accurate and of high quality;
• Enhance criticality safety support for ongoing operations.

The report also pointed out a rather alarming statistic regarding fissile material handler training and certification.
The number of infractions identified in the first six months of 2013 nearly matches the yearly totals from 2012 and 2011 (15 in the first half of 2013, 15 in all of 2012, and 16 in all of 2011).

And of the 15 criticality safety infractions identified in PF-4 this year, nine were identified by LANS personnel, five were identified by LAFO personnel, and one was identified by the Board’s staff during its review.

The report said, “the staff is concerned that the significant proportion of infractions identified by oversight personnel may indicate that facility personnel should be more familiar with and sensitive to criticality safety requirements.

“The overall increase in infractions this year may indicate a half-life of the fissile material handler training and certification effort, which took place after the significant criticality infraction in August 2011. The staff believes that it would be prudent to consider criticality safety refresher training for fissile material handlers.”

Then the report provided an example.

While performing a walk-down of a glove box in Room 429 of PF-4, the staff identified a container of fissile material in a portion of the glove box without an assigned mass limit (i.e., the CSLA did not allow fissile material to be stored in this location). LANS personnel took appropriate actions by evacuating the room and notifying criticality safety staff of the potential criticality safety infraction.

The following day, LANS conducted a critique to discuss and resolve the potential infraction.

At the conclusion of the critique, senior LANS management appropriately determined the configuration resulted in a criticality safety infraction.

Based on this infraction and other recent infractions, LANS paused operations in the room until an extent-of-condition walk-down could be performed.

“During the critique, several fissile material handlers and production managers argued against categorizing the event as an infraction due to the current configuration of the glove box,” the report said. “Specifically, the argument was made that certain requirements did not apply at that time because no liquids were present in the glove box.

“The staff believes this argument may further indicate that facility personnel should be more sensitive to criticality safety requirements.”

Programmatic activities were halted days after a DOE Inspector General report surfaced, detailing issues with PF-4.
McMillan then emailed a memo to employees, detailing the reasoning behind the decision.

“Because of the nature and importance of the work we do, it is important to regularly assess all aspects of our operations to ensure we are executing our procedures and operational processes appropriately,” McMillan said in the memo.

“We expect some areas to return to operational status sooner than others, but we do not expect there to be any significant impacts to mission deliverables as a result of this action. To accomplish our national security missions we work with materials that must be strictly controlled and safely handled.

“Today this material remains safe, secure, and protected. It stays that way in part because of strict adherence to procedures and formality in our operations. Once we have verified that operations can be safely and reliably conducted, the director will allow operations to resume.”