1. Department of Energy Best Practices Workshop H-Completion Criticality Safety Improvement Phil Breidenbach, Manager Environment, Safety and Health and Mike Borders, Manager F Disposition Project Washington Savannah River Company September 12-13, 2006 ISM at the Savannah River Site

2. Nuclear Safety Washington Savannah River Company (WSRC) is committed to excellence in all aspects of safety, especially nuclear safety. Savannah River Site H Area 2

3. The Situation in H-Completion Too many errors ­ Concerns primarily in the area of criticality safety Production Rate Production rate doesn’t matter, success is event free performance. 3

4. 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 4

5. Improvement Actions ­ 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 After the dissolver event 5

6. 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 can’t be fixed on the run. 6

7. 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 7

8. 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 8

9. 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 9

10. Improvement Examples Reduced complexity Improved use of DCS Increased defense in depth Improved DCA People won’t consistently achieve excellence without excellent defenses. 10

11. Removing Complexity Fissile Material Tank Transfer ­ Before Poor procedure format increasing likelihood of calculation error ­ After Simple table that increases chance of success 11

12. Removing Complexity—Before Calculate the mass balance in Tank 11.2 1.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 ) 2.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. 12

13. Removing Complexity —After 13

14. Improved Use of DCS Receipt of Low Activity Waste in Evaporator Feed Tank 8.7 Complexity IndicatorBeforeAfter Total pages2110 Total procedure steps10060 Total criticality safety steps3313 Total criticality safety calculations111 Total attachments for data collection81 14 Complexity is an enemy – complex administrative controls fail.

15. Increased Defense in Depth—Global 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 15

16. 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 16

17. 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 17

18. 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.” Results (Contd.) 18

19. Results (Contd.) 7 Months Time 12 Months Time 19

20. 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 20

21. Learning Points Production rate doesn’t matter – success is event free performance Some things can’t be fixed while operating People can’t consistently achieve excellence without excellent defenses ­ You have to choose controls wisely ­ Complexity is an enemy 21

22. Questions Phil Breidenbach ­ philip.breidenbach@srs.gov ­ (803)952-9897 Michael Borders ­ michael.borders@srs.gov ­ (803)952-4395 22