**\[DNFSB LETTERHEAD\]**

July l0, 2003

The Honorable Everet H. Beckner

Deputy Administrator for Defense Programs

National Nuclear Security Administration

U.S. Department of Energy

1000 Independence Avenue, SW

Washington, DC 20585-0104

Dear Dr. Beckner:

The staff of the Defense Nuclear Facilities Safety Board (Board)
recently conducted a review of hoisting and rigging operations at the
Pantex Plant. A number of significant deficiencies were identified by
the site contractor, BWXT Pantex, and the Pantex Site Office following
the recent hoisting occurrence in the mass-properties facility at the
site. The Board's staff noted issues, including improper maintenance of
safety-class hoists and inconsistent training, as discussed in the
enclosed report.

A number of corrective actions are in various stages of planning and
implementation to address the identified issues. Although it is too
early to judge the effectiveness of the proposed corrective actions, the
Board remains concerned and urges prompt attention to this important
safety program.

Therefore, pursuant to 42 U.S.C. § 2286b(d), the Board requests a status
briefing within 120 days of receipt of this letter or when a final set
of corrective actions for the issues noted in the enclosed report has
been clearly defined and funded-whichever occurs sooner.

Sincerely,

***John T. Conway***

***Chairman***

c: Mr. Mark B. Whitaker, Jr.

Enclosure

**DEFENSE NUCLEAR FACILITIES SAFETY BOARD**

**Staff Issue Report**

June 20, 2003

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

**COPIES:** Board Members

**FROM:** J. Shackelford, C. Shuffler

**SUBJECT:** Hoisting and Rigging at the Pantex Plant

This report documents a review of the hoisting and rigging program at
the Pantex Plant, conducted during the week of May 26, 2003. Members of
the staff of the Defense Nuclear Facilities Safety Board (Board) J.
Shackelford and C. Shuffler, together with outside expert R. West,
evaluated the site's hoisting and rigging program, focusing in depth on
the root-cause analysis, corrective actions, and lessons learned from
recent hoist-related occurrences. Other major areas of the review
included the following:

-   The standards and codes required by contract and implemented by the
    contractor for the Pantex Plant, BWXT Pantex (BWXT), in its hoisting
    and rigging program.

-   The hazard and accident analyses performed for Zone 12 bays and
    cells and the safety classification of hoisting and rigging
    equipment.

-   Facility operations, including simulations of pre-engineered
    production lifts.

-   Training and qualification programs for personnel involved in
    hoisting and rigging operations.

-   The procurement, installation, inspection, testing, and maintenance
    of hoisting and rigging equipment, including cranes, hoists, and
    below-the-hook lifting devices.

BWXT's review of the January 2003 hoist brake failure in Building 12-60
revealed several significant deficiencies in the hoisting and rigging
program. In response to the review, BWXT and the Pantex Site Office
(PXSO) established several corrective action programs to address needed
improvements. The Board's staff found these programs to be in various
stages of development, approval, and implementation, but noted that
there is no clear indication that resources and funding are available to
complete them. The staff also identified some additional issues that had
not been addressed.

**Codes and Standards.** The Board's staff reviewed the codes and
standards in the BWXT contract related to hoisting and rigging and found
that the majority of the applicable industry guidance is appropriately
referenced in the standards/requirements identification documents
(SRIDS). However, one significant exception involved American Society of
Mechanical Engineers (ASME) NOG-1, Rules for Construction of Overhead
and Gantry Cranes. Department of Energy (DOE) Guide 420.1-1, Nonreactor
Nuclear Safety Design Criteria and Explosive Safety Criteria, requires
the use of ASME NOG-1 for the construction of safety-significant and
safety-class cranes. The Board's staff observed that this standard was
not referenced in the SRIDS, and that BWXT had not evaluated the
safety-class hoists and cranes at Pantex with respect to the guidance
contained in the standard. BWXT personnel acknowledged the staffs
concern and committed to evaluating the safety-class hoisting equipment
using ASME NOG-1.

**Safety Classification.** BWXT's current authorization basis classifies
the 83 facility hoists used for nuclear explosive operations as
safety-class equipment. The requirements for this equipment are set
forth in Design Feature (DF) 3 of the site Technical Safety Requirements
(TSRs). The DF requires the hoists and cranes to be designed and
installed in accordance with applicable sections of 29 Code of Federal
Regulations (CFR) 1910.179 and the ASME B30 series for load rating,
brakes, and stops.

The current documented safety analyses for Zone 12 facilities, which
have been approved by DOE but not yet implemented by the site, postulate
swinging impacts involving weapons traveling at the maximum horizontal
speed that BWXT calculated that a facility hoist could reach under
normal operating conditions. However, the hoists at Pantex are
pneumatic, with the speed of travel being determined by the inlet
pressure to the hoists. Although the hoists are designed to operate at
lower pressures (i.e., less than 90 psig), the facilities' compressed
air system can deliver significantly greater air pressures (i.e., in
excess of 125 psig) under certain circumstances. To date, the contractor
has been unable to determine the theoretical maximum hoist speeds at
these higher pressures.

BWXT has proposed revisions to the approved, but unimplemented,
authorization basis that would increase the maximum speed used for the
accident analyses, but these revisions cannot be completed until new
weapon response data are provided by the design agencies. The potential
will still exist for the installed equipment to exceed this new, higher
maximum speed. As a result, BWXT is considering engineering
modifications to limit inlet air pressure, thus limiting the hoist
travel speed. The staff observed that no implementation plan has been
approved and funded to design and install any of these modifications.

The Board's staff also noted that the travel stops installed on the
equipment are not rated for the speeds that could be encountered in the
currently postulated scenarios involving a runaway hoist. As a result,
the staff questioned whether the current approved, but unimplemented,
accident analysis is bounding with respect to the limiting impact
scenarios.

**Operations and Training.** The Board's staff reviewed facility
hoisting and rigging procedures and observed operations in the training
bays. Additionally, the staff conducted interviews and discussions with
production technicians, system engineers, site management, and the
training staff concerning appropriate actions on the part of production
technicians during a postulated incident involving a runaway hoist. The
staff noted significant inconsistencies among the responses expected of
production technicians by management, training, and operations personnel
during such an event.

During the January 2003 hoist brake failure in Building 12-60, the
production technicians lost the ability to control the hoist with the
pendant and resorted to guiding a nuclear explosive component into its
fixture manually. BWXT management representatives indicated that they
expected production technicians to depress the stop button on the hoist
pendant while simultaneously dispatching a second technician to close
the emergency shutoff valve supplying air to the hoist. They did not
expect, or desire, production technicians to use other control functions
on the pendant to redirect the hoist. The training staff, however,
indicated that they trained production technicians to use all available
means, including redirecting the hoist with other pendant control
functions, to regain control of a malfunctioning hoist. The Board's
staff interviewed production technicians during two separate simulated
hoisting operations, and received two different responses regarding the
actions each production technician would take during such a scenario.
Further, the Board's staff observed that system engineering personnel
had not evaluated the runaway hoist scenario with respect to expected
equipment performance. The Board's staff noted that BWXT has had more
than 4 months since the actual brake failure incident to implement
appropriate corrective actions and remedy any confusion about the
desired response of production technicians during this type of failure.
BWXT personnel acknowledged this training deficiency and are currently
working to resolve it.

**Review of the Building 12-60 Hoist Brake Failure, Root-Cause Analysis,
and Corrective Actions.** The Board's staff reviewed the operational
aspects, root-cause assessment, and corrective actions associated with
the hoist brake failure in Building 12-60 that occurred on January 10,
2003. The details of this event are documented in Occurrence Report
ALO-AO-BWXP-PANTEX-2003-0002. During the event, the facility hoist
failed to respond to operator actions intended to control a nuclear
explosive unit during lifting operations, and the unit slowly lowered to
a resting position. During the event, operators took actions to secure
the unit safely, and no adverse consequences or damage occurred.
However, the event revealed a number of deficiencies in the hoisting and
rigging program, as well as issues related to root-cause analysis and
corrective actions.

Immediately following the incident, BWXT removed the hoist from service
and performed a root-cause analysis to determine the cause of the
failure. At the time, BWXT system engineers did not have detailed
diagrams and manuals for this safety-class hoist. Therefore, they were
unable to perform a rigorous failure modes and effects analysis (FMEA)
to support the root-cause analysis. As a result, BWXT initially
attributed the hoist failure to deficiencies in the control pendant, a
conclusion later determined to be incorrect. After this initial
(incorrect) root-cause analysis, the pendant was replaced, and the hoist
was returned to service. Following additional questions and discussion
with PXSO and the hoist manufacturer, however, BWXT again removed the
hoist from service for further investigation. When the required drawings
were received from the manufacturer, almost 1 week after the incident,
an FMEA was performed. It showed that the root-cause initially
identified by BWXT was not a credible failure mode.

During follow-up discussions with the manufacturer, BWXT noted that this
type of hoist had been subject to similar failures in other
applications. The manufacturer had determined that a design deficiency
existed in the brake unit. This deficiency allowed a buildup of brake
dust to bind the brake piston in its housing, preventing application of
the brake. The manufacturer reported that a modification was available
to limit the effect of this dust buildup. This modification was
subsequently made to the applicable hoists. Brake inspections of the
failed hoist revealed approximately 1 teaspoon of brake dust in the
unit. BWXT personnel acknowledged that they had not been following the
manufacturer's recommendation to disassemble, clean, and inspect the
brake periodically. The root-cause analysis was subsequently revised to
reflect the fact that the primary cause of the incident was failure to
perform the manufacturer's recommended maintenance, with a secondary,
contributing factor being related to the design deficiency.

BWXT determined that the initial root-cause analysis had been based on
inadequate technical information and had incorrectly identified the
cause of the failure. As a result, an inadequate corrective action plan
had been implemented, and the hoist had been returned to service
prematurely before the actual failure mode had been corrected. BWXT is
currently working to upgrade the methodology supporting its corrective
actions process. The incident also revealed significant weaknesses in
BWXT's program with respect to maintaining adequate technical
information and documentation, as well as communicating with vendors to
ensure that up-to-date information on operating experience is available
for safety-class equipment. Finally, the event highlighted the need for
significant improvements in BWXT's efforts to ensure that all of the
manufacturer's recommended maintenance is either performed or
appropriately evaluated for deferral or exclusion. The current
corrective action plan for the hoist brake failure in Building 12-60
addresses this issue for the safety-class hoists at the Pantex Plant.

**Maintenance and Procurement.** As noted above, BWXT concluded that it
had not adequately implemented the manufacturer's recommended
maintenance activities (or properly justified their omission) for
safety-class hoists. Upon further review, BWXT determined that this
problem existed with other vital safety systems at the site and
indicated that corrective actions were under way to address this issue.

Following a request by the Board's staff, it was found that BWXT did not
have an adequate program for trending equipment failures and
deficiencies. A report on crane and hoist deficiencies for 1998--2002,
generated in response to the staffs request, showed maintenance problems
and deficiencies in a variety of areas. Currently, no formal program
exists to track and trend equipment failures for the safety-class
hoists, but BWXT committed to establishing such a program in a
corrective action plan. Additionally, the Board's staff noted that the
site had only recently incorporated predictive maintenance practices
(e.g., lube oil analysis) into the maintenance programs for vital safety
systems.

An incident that occurred in March 2003, involving the failure of draw
cables for a lifting and rotating fixture, illustrated a deficiency in
the site's procurement process. A cable had failed in an unexpected
manner, with the wire rope pulling out of the swaged end. Subsequent
testing revealed that cables procured during the last 2 years had
continued to fail in this unexpected manner and at loads significantly
below the manufacturer's rating. It was determined that the site had not
implemented the appropriate administrative mechanisms to ensure that the
procured components would meet the required quality control criteria.
BWXT is currently working to resolve this procurement problem.

**Conclusion.** The Board's staff noted a number of significant
deficiencies in the Pantex Plant's hoisting and rigging program. Most of
these issues had been identified by BWXT and PXSO prior to the visit by
the Board's staff. A number of the deficiencies are generic in nature
and applicable to other vital safety systems and program areas. Although
corrective actions have been initiated or are being developed for these
issues, there is no clear indication that resources and funding are
available to complete all of the required actions. In view of the
actions remaining to be accomplished, the Board's staff will continue to
follow resolution of these issues closely.