Department of Energy Best Practices Workshop

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ISM at the Savannah River Site

• Department of Energy Best Practices Workshop
• H-Completion Criticality Safety Improvement
• Phil Breidenbach, ManagerEnvironment, Safety and
  Healthand Mike Borders, Manager
• F Disposition Project
• Washington Savannah River Company
• September 12-13, 2006

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Nuclear Safety

• Washington Savannah River Company (WSRC) is
  committed to excellence in all aspects of safety,
  especially nuclear safety.

Savannah River Site
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The Situation in H-Completion

• Too many errors
• Concerns primarily in the area of criticality
  safety

Production Rate
Production rate doesnt matter, success is event
free performance.
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Significant 2005 Events

• Charge of dissolver before a criticality safety
  calculation was complete
• Caused by inadequate communication and an
  inadequate procedure
• Potential transfer to an evaporator of solution
  exceeding allowable grams of Uranium
• Caused by procedure noncompliance and an
  unnecessarily complex procedure

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Improvement Actions

• After the dissolver event

• Immediate actions
• Two-day stand down started June 9
• Added senior engineer with criticality expertise
• Increased involvement of the Criticality Safety
  Committee
• Longer-term actions
• Top-to-bottom review of the H-Completion Project
  (HCP) criticality safety program
• Review of all operating procedures for fissile
  material
• Conducted level of knowledge testing for HCP
  personnel relative to criticality safety
• Reevaluate cross qualification initiatives to
  ensure adequate knowledge and proficiency
• Strengthened the assessment process associated
  with criticality safety
• Authorized funding for implementation of
  engineered controls to replace some
  administrative controls
• Initiated integrated root cause analysis of
  recent events

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Improvement Actions (Contd.)

• After the evaporator event
• Suspended fissile operations July 1
• Management Control Plan approved July 13, which
  described the causes of the problems and the
  actions that would be complete prior to resuming
  fissile operations

Some problems cant be fixed on the run.
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Common Causes

• Inadequate disciplined operations
• Procedure compliance
• Specificity of communication
• Inadequate procedures
• Excessive and unnecessary procedural complexity
• Inadequate defense in depth in procedures
• Inadequate leadership
• Accountability

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Improvement Strategy

• Operational pause to focus on causes and
  corrective actions
• Prioritized system-by-system review
• Operator / First Line Manager (FLM) / System
  Engineer teams formed for every system
• System engineers put on shift to work with
  operators
• Managed as a project from the War Room

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Improvement Actions

• People
• Disciplined operations leadership sessions
  focus on expectations and accountability
• Shift proficiency demonstration
• Senior supervisory watch (SSW)
• Procedures
• Criticality control review
• Procedure review
• Plant
• System walkdowns
• Distributed Control System (DCS) review

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Improvement Examples

• Reduced complexity
• Improved use of DCS
• Increased defense in depth
• Improved DCA

People wont consistently achieve excellence
without excellent defenses.
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Removing Complexity

• Fissile Material Tank Transfer
• Before
• Poor procedure format increasing likelihood of
  calculation error
• After
• Simple table that increases chance of success

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Removing ComplexityBefore

• Calculate the mass balance in Tank 11.2
• RECORD Tank 8.3, 8.3/11.1 (if EU was blended),
  8.3/15.2 (if 15.2 was blended), or 8.3/12.1 (if
  PuCs was blended) and Tank 11.4 Liquid Level
  data.
• Tank 8.3, or 8.3/11.1, or 8.3/12.1, or 8.3/15.2
  lbs transferred to Tank 11.2 from NOP 221-H-4212,
  Step 5.1.5 or NOP 221-H-225, Step 5.3.4, or NOP
  221-H-4218, Step 5.3.4 or NOP 221-H-227, Step
  5.3.4. (B)
• Tank 11.4 initial lbs from NOP 221-H-4212, Step
  5.1.2 or NOP 221-H-225, Step 3.1.7, or NOP
  221-H-4218, Step 3.1.7, or NOP 221-H-227, Step
  3.1.6. (C)
• Final 11.4 weight factor (HN-16B)
• Final 11.4 lbs (D)
• CALCULATE the Tank 11.4 increase.
• Tank 11.4 Increase Final 11.4 lbs (D) Initial
  11.4 lbs (C)
• ( lbs)-( lbs)
• lbs (E)
• 3. CALCULATE the mass balance around Tank 11.2.

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Removing ComplexityAfter
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Improved Use of DCS
Receipt of Low Activity Waste in Evaporator Feed
Tank 8.7
Complexity is an enemy complex administrative
controls fail.
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Increased Defense in DepthGlobal Changes

• Before
• Inconsistent use of Independent Verification and
  Second Person Verification
• FLM engagement not required at key points in
  evolutions
• After
• Independent Verification (IV) in Critical data
  collection
• Second Person Verification (SPV) of calculations
• FLM verification at key transition points

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Improved DCA

• Move from Administrative Controls to Engineered
  Controls
• Created DCS alarms to augment operator rounds /
  administrative actions
• Credited existing alarms versus administrative
  operator actions

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Results

• 17 systems reviewed and released for operations
• 465 procedures reviewed
• 207 procedures containing criticality safety
  steps revised
• 20 procedures eliminated
• Procedural complexity reduced
• Defense in depth increased
• 200 training sessions conducted for 120
  individuals
• Double Contingency Analysis (DCA) improvements
• Credited existing engineered controls versus
  administrative controls
• Created DCS alarms to augment administrative
  controls
• Tightened implementation of DCA controls in
  procedures

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Results (Contd.)
WSRC Independent Review, 11/05 Disciplined
operations in H-Canyon had made a notable
improvement since the last ISME. WGI
Independent Review, 1/06 Significant improvement
was noted in Conduct of Operations within the
H-Completion project since the July 2005 review
DOE OA Review, 2/06 H-Canyon managers and
operators are committed to rigorous and formal
conduct of operations. At the H-Canyon ,
facility management has effectively communicated
its expectations for meeting conduct of
operations requirements. The improvements are
evident.
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Results (Contd.)
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Long-term Improvements

• Continue the shift from administrative controls
  to engineered controls
• Restructure the DCA for event free execution
• Continue the focus on self assessment

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Learning Points

• Production rate doesnt matter success is event
  free performance
• Some things cant be fixed while operating
• People cant consistently achieve excellence
  without excellent defenses
• You have to choose controls wisely
• Complexity is an enemy

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Questions

• Phil Breidenbach
• philip.breidenbach_at_srs.gov
• [phone]
• Michael Borders
• michael.borders_at_srs.gov
• [phone]

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