**\[DNFSB LETTERHEAD\]**

March 18, 2003

The Honorable Linton Brooks

Acting Administrator

of the National Nuclear Security Administration

U.S. Department of Energy

1000 Independence Avenue, SW

Washington, DC 20585-0701

Dear Ambassador Brooks:

The Defense Nuclear Facilities Safety Board (Board) recently observed
the National Nuclear Security Administration's (NNSA) readiness
assessment of the implementation of controls from the *Fire Protection
Basis for Interim Operation* (FP BIO) at the Pantex Plant. A report on
the staff's observations is enclosed for your information and use, as
appropriate. The FP BIO and its implementation are commitments to the
Board under the Department of Energy's (DOE) Implementation Plan for
Recommendation 98-2, *Safety Management at the Pantex Plant*. If
implemented properly, the controls in the FP BIO represent a significant
enhancement to the safety of Pantex operations. However, the NNSA
assessment team concluded that the FP BIO controls had not been
implemented properly.

NNSA's contractor, BWXT Pantex, took immediate action to address the
ineffective implementation of combustible loading controls for the W79
and W87 programs. Recent observations by the Board's staff verified
improvement in the implementation of these controls. Much of this
improvement resulted from a change in implementation philosophy to a
simpler, more conservative approach.

The Board is encouraged by this improvement. However, the findings from
the readiness assessment highlight the problems that accrue from the
ever-increasing use of administrative controls. The Board continues to
be concerned about the effectiveness and reliability of administrative
control programs within the DOE's defense nuclear complex. The
generation of new safety bases in the near future is expected to
complicate the set of administrative controls still further. Board
Recommendation 2002-3, *Requirements for the Design, Implementation and
Maintenance of Administrative Controls* states that, as a minimum,
administrative controls should have attributes that ensure effectiveness
and reliability. The Board understands BWXT has a program underway to
simplify and integrate controls for the current safety basis and planned
safety basis upgrades. As one aspect of the implementation of
Recommendation 2002-3, the Board encourages BWXT to pursue this effort
vigorously. Other DOE defense nuclear sites might benefit from a similar
program.

NNSA's readiness assessment of the implementation of fire protection
controls was essential to identifying significant safety issues and
improving the implementation of important safety controls. NNSA's Pantex
Site Office is to be commended for its decision to perform an
independent validation of the implementation of new safety basis
documents at the Pantex Plant. As DOE sites continue to develop new
safety basis documents in compliance with 10 Code of Federal Regulations
830, *Nuclear Safety Management*, it might be appropriate to require
similar, appropriately tailored assessments to independently validate
the implementation of controls identified in those documents,
particularly where those controls differ significantly from the controls
currently in place. Even when ongoing operations do not change, the
controls relied upon to ensure the safety of those operations are often
modified, expanded, or relied upon to perform new safety functions.

Despite the ability of the Pantex Site Office team to identify
significant problems with the implementation of fire protection safety
controls, as noted in the enclosed report, the Board's staff noted
several issues with regard to the performance of this review. The
ability to conduct thorough readiness reviews takes on added importance
in view of the recent reorganization in which the site offices have been
given more responsibility for conducting readiness assessments without
additional resources with which to conduct those reviews. In order to
maintain the rigor of readiness reviews at an appropriate level, NNSA
should reevaluate its readiness process, especially with regard to the
pertinent expertise, experience and availability of readiness assessment
team members. The findings of the NNSA readiness assessment team also
indicate deficiencies in the BWXT process.

Sincerely,

***John T. Conway***

***Chairman***

c: The Honorable Beverly Ann Cook

The Honorable Everet H. Beckner

Mr. Daniel E. Glenn

Mr. Mark B. Whitaker, Jr.

Enclosure

**DEFENSE NUCLEAR FACILITIES SAFETY BOARD**

**Staff Issue Report**

March 3, 2003

**MEMORANDUM FOR:** J. K. Fortenberry, Technical Director

**COPIES:** Board Members

**FROM:** R. Rauch

**SUBJECT:** Implementation of Fire Protection Controls at the Pantex
Plant

This report documents observations made by the staff of the Defense
Nuclear Facilities

Safety Board (Board) of the National Nuclear Security Administration's
(NNSA) readiness assessment (RA) of the implementation of controls from
the *Fire Protection Basis for Interim Operation* (FP BIO) for
individual weapon programs and special-purpose facilities. Staff member
R. Rauch and outside expert R. West observed the RA on December 9--13
and December 16--19, 2002. Staff members J. Deplitch and A. Matteucci
and outside experts L. McGrew and R. West observed the implementation of
combustible loading controls for W79 and W87 operations on January
7--9,2003.

**Background.** The FP BIO evaluates fire-related accident scenarios for
nuclear facilities at the Pantex Plant and identifies the controls
necessary to ensure the safety of nuclear operations in those
facilities. These controls, as defined in the *Technical Safety
Requirements for Pantex Facilities* (TSRs); encompass fire detection and
suppression systems (including surveillance requirements), facility
structural requirements and other design features; and administrative
controls in such areas as combustible loading and fire department
response. These controls are supplemented by controls developed in a
combustible (material) loading disposition (CLD) document for each
weapon program that define the allowed material and required locations
of combustibles to ensure that timely operation of the deluge
suppression systems can protect the facility. The development,
implementation, and assessment of the FP BIO controls are commitments to
the Board under Recommendation 98-2, *Safety Management at the Pantex
Plant*.

The Pantex Plant contractor (BWXT) implemented controls in the FP BIO in
three phases. Each phase was followed by a contractor RA to determine
whether the controls had been effectively implemented. Phase I involved
seven site-wide administrative controls. Phases II and III consisted of
specific engineered and administrative controls for weapon programs,
transportation, staging, and nuclear material operations. The Pantex
Site Office (PXSO) completed the NNSA RA for Phase I controls in March
2002. PXSO conducted its RA for Phases II and III in December 2002,
after BWXT had made the controls applicable in the TSRs.

**Implementation of Fire Protection Controls.** To assess the
implementation of fire protection controls, the PXSO RA team leader
elected to sample three weapon programs (W79, W87, and W88) and
associated special-purpose facilities. The team identified 2 pre-start
and 19 post-start findings. The RA report noted that the team "was
unable to conclude that BWXT had successfully implemented the \[FP BIO\]
Phase II and III controls due to the number and type of issues
identified in the RA and the limited sampling of active programs." The
RA team found the fire protection controls on the W79 and W87 programs
"to be poorly implemented," whereas the implementation of controls for
the W88 program met expectations. The RA team also expressed concern
regarding the accountability of line management for readiness.

*Complexity of Combustible Loading Controls*―The deficiencies noted in
implementation of the administrative controls related to combustible
loading appear, in part, to be due to the number of controls and their
promulgation by means of numerous directives. The TSR and CLD controls
are incorporated into plant standards, procedures, and general
requirements documents for action by operational and support personnel.
Questions about definitions of allowable combustible materials and the
multiplicity of directives used for issuing controls complicate the
controls' implementation. The following are examples of problems noted
with the flowdown and interpretation of controls:

-   Three cardboard boxes had been staged under a table in a W87 bay for
    some time, contrary to the TSR. The TSR specifies that, in an
    unoccupied facility, combustibles are not to be staged under desks,
    carts, on tables or on the floor to ensure clear sight lines from
    the detectors to the combustible materials. The applicable control
    procedure for combustible material contained a restriction against
    combustibles being stored on the floor, but did not prohibit storage
    under desks, carts, or tables.

-   CLDs occasionally provide specific direction for handling of a
    combustible fuel package. Although most of this information is
    included in general or weapons program procedures, examples were
    found in which this did not occur. The W79 CLD includes direction
    regarding the staging of various components, but this direction was
    not included in the applicable procedures. Thus, operators were
    unaware of the proper locations for storing these combustibles.

-   Inadequately defined terms caused interpretation problems for the
    production technicians. An example was the lack of proper control of
    transient combustibles when technicians misunderstood the definition
    of "under direct control." Another example was the improper
    placement of combustible material for later use within the standoff
    distance from a sensitive component because of a misunderstanding of
    the requirements for "staging" of materials.

Some weapon programs chose to interpret these requirements in a
conservative but simplified manner, and prohibited any transient or
not-in-use combustibles in a facility unless they were containerized or
in contact with personnel. These programs (e. g., WSS) appear to have
been successful at implementation of controls. Other weapon programs
(e.g., W79 and W87) left interpretation of the controls in the TSRs and
various documents to the production technicians. While this approach
allowed more flexibility with regard to the types and locations of
combustibles used in the facilities, the result was ineffective
implementation of controls.

This issue was addressed in letters from the Board dated February 27 and
June 21, 200l.

The initial letter described some combustible loading controls as
burdensome. The June 21, 2001, letter then pointed to the benefits of
streamlining these controls, including reducing training requirements,
improving efficiency, and further improving overall safety by decreasing
the chances for human error. The Board's Recommendation 2002-3,
Requirements for the Design, Implementation and Maintenance of
Administrative Controls, also discusses the importance of effective and
reliable administrative controls. The methods chosen by some program
managers to implement administrative combustible loading controls
ultimately compromised the effectiveness and reliability of these
controls.

Following the NNSA RA, BWXT took action to address the implementation of
combustible loading controls for the W79 and W87 programs. On a
subsequent visit, the

Board's staff noted marked improvement in the adherence of production
technicians to combustible loading controls, especially on the W87
program. This improvement resulted from a change in the approach for
implementing controls to the more restrictive yet simplified approach
used by the W88 program. This rapid response to deficiencies identified
during the FP BIO RA is encouraging. As discussed in the Board's
letters, additional action is needed to reduce the continuing and
potentially increasing burden of numerous administrative controls and
improve their implementation, thereby providing the necessary
reliability and effectiveness for these safety controls.

*RA Processes*―PXSO decided to validate implementation of the FP BIO
controls through the RA process, and intends to use this process to
verify the implementation of controls resulting from the safety
documents being developed under Title 10 of Code of Federal Regulations
Part 830, *Nuclear Safety Management*. The number of problems identified
by the RAs indicates this approach is warranted any time significant new
or modified controls are implemented. Despite the number of issues
identified during the RA, deficiencies were noted with the readiness
process:

-   The limited duration of the review, a lack of adequate support by
    the contractor, and problems with the availability of personnel
    reduced the effectiveness of the NNSA RA. The operational
    observations included visits of 30 to 45 minutes to two or three
    bays or cells for each program. Only two of these visits occurred
    with operations in progress, and neither of these activities
    involved handling of combustible materials.

-   The availability of NNSA RA team members was reduced because of the
    performance of routine work and time lost for personal reasons. With
    a small team of seven members, these losses impacted the quality of
    the RA. PXSO had committed to addressing the lack of dedicated team
    members for RAs by revising the applicable site procedure by
    February 2001, but this revision had not been accomplished.

-   The NNSA team experienced problems in arranging meetings with key
    personnel and obtaining required records and procedures in a timely
    manner. As a result, the team accomplished little for the first two
    days of the assessment (a significant impact for this short review);
    similar problems arose throughout the review.

-   The number and significance of problems identified by the NNSA RA
    with two of three sampled programs indicated that the contractor RA
    process was deficient in identifying and resolving issues. The NNSA
    RA report noted that the contractor RA for the FP BIO was deficient
    in several instances in the identification and subsequent handling
    and correction of deficiencies, but generated no finding for the
    associated core requirement.

**Conclusions.** The controls in the FP BIO are a significant
enhancement to the safety of nuclear operations at the Pantex Plant. The
effectiveness of the deluge systems in protecting against postulated
accident scenarios depends on administrative controls to limit the
amounts and locations of combustibles. As discussed in the Board's
Recommendation 2002-3, it is important that these administrative
controls be effective and reliable. This was not the case for the FP BIO
controls in two of three programs reviewed. Subsequently, BWXT improved
the control on combustible materials for these two programs in response
to the NNSA RA findings.

The generation of new safety bases in the near future is expected to
complicate the set of administrative controls still further. An effort
needs to be made to simplify and integrate the controls for the current
safety basis and planned safety program upgrades to provide assurance of
continued implementation of all controls. It may be noted that BWXT has
initiated efforts to address the elimination of unnecessary, excessively
complex, or inadequate administrative controls and, where possible, to
replace them with appropriate engineered controls. These efforts should
be formalized and pursued vigorously.

Additionally, PXSO and BWXT should consider making improvements in their
readiness review processes. There is a need to improve the thoroughness
of the reviews, to improve the definition of their scope, to minimize
work distractions, and to reduce the effects of various personnel
impacts.