ORNL is managed by UT-Battelle for the US Department of Energy Enforcement Lessons Learned Unexpected Airborne Release Presented to EFCOG Regulatory & Enforcement Technical Subgroup Debbie Jenkins ORNL Enforcement Coordinator October 21, 2015

2 NNFD – 3525 Uptake Event Summary of Event In August 2014, Personnel were resizing and repackaging highly enriched uranium (HEU) material into an approved shipping container Work was performed on the 2 nd floor mezzanine in a Lexan enclosure Activity was not expected to generate airborne radioactivity and no ventilation was provided June – August 2014 received and repackaged 4 batches

3 NNFD – 3525 Uptake Event Unexpected operational conditions during shearing of 5 th package CAM alarm occurred during shearing operations – CAM was in general vicinity, but not intended to monitor this activity Alarm response was less than adequate –RCT investigated and reset alarm personnel believed there was no airborne risk anomalous operation or radon suspected –Second CAM went into alarm –Material was placed in safe configuration –Two employees remained in the general area conflicting priorities between alarm response and security –First CAM went into alarm again Dose assessment determined that seven personnel received inhalation uptake of HEU –Total committed effective dose below 5 % of the regulatory limit for all personnel

4 NNFD – 3525 Uptake Event Comprehensive investigation initiated to identify causes Direct cause – Unexpected airborne contamination exited shear enclosure and went unrecognized until monitors alarmed Root Cause – Incorrect assumption regarding airborne contamination potential resulted in inadequate planning of work and inadequate contamination control Contributing Causes –Legacy items with little know about specifications –No destructive size reduction previously conducted –SMEs not involved in work planned – missed opportunity –Staff did not immediately exit are upon first alarm –Surface contamination encountered during previous work evolutions did not trigger questions –Personnel authorized to re-enter work area without fully understanding hazards

5 NNFD – 3525 Uptake Event Broad corrective actions focusing on safety culture improvements included the following Radiological Protection –Intensive four-day proficiency training completed for all Rad staff –Procedures were revised to add more clarity on alarm response actions and expectations –Radiological Engineer staffing levels and involvement in work planning increased –RWP development process strengthened –Qualification process for RCTs and supervisors revised to focus on facility-specific competencies –RCT continuing training redesigned to emphasize the need for more realistic and challenging hands-on practice drills Line Organization –Procedures updated and clarified Work control Pre-job briefing Alarm and abnormal response Work Acceptance Prioritization of safety vs. security issues –Staff re-trained to new expectations –Drill program enhanced to include facility specific drills

6 NNFD – 3525 Uptake Event In January 2015, Notice of Intent (NOI) to Investigate was received from OE Call from OE to provide CA clarification Would be recommending CO to OE NOI received Management and Site Office approval of CO request already in place CO request drafted and ready for final review Unallowable cost letter issued Signed CO agreement - $ 112, 500 Notified unofficially that CO would be granted Called OE to notify that a CO would be submitted within a week OE agreed to hold off on document request and scheduling of investigation CO request transmitted to OE Call from OE requesting CA clarification OE Enforcement Specialist communicated that he would be recommending the CO to his management May 20 Jan 16 Jan 29 Feb 12 Jan 20 Jan 23 Friday Tuesday Friday Thursday Draft CO agreement received for review Apr 13

7 NNFD – 3525 Uptake Event Developed 5-page Consent Order Request Acknowledgment of significance of event Mitigating Responses –Compensatory measures –Investigation/corrective action summary Laboratory-Wide Safety Culture Improvement Initiatives –Safe Conduct of Research –Front line supervisor training –Safety mentoring Radiation Protection Program Improvements –Organizational changes –Trending and analysis –Radiation Monitoring –Training and drills –Lessons learned

8 NNFD – 3525 Uptake Event Rationale for why a CO was warranted Demonstrated and consistent history of noncompliance reporting (NS, WSH, Security) Demonstrated history of strong radiological program performance and commitment to continuous improvement Prompt and thorough reporting of circumstances surrounding the release Comprehensive and aggressive investigation of event Timely development of corrective actions addressing not only issues specific to the event, but also underlying cultural issues Transparent communication and interaction with ORNL Site Office regarding the event and path forward