**\[DNFSB LETTERHEAD\]**

January 17, 2006

The Honorable James A. Rispoli

Assistant Secretary for Environmental Management

U.S. Department of Energy

1000 Independence Avenue, SW

Washington, DC 20585-0113

Dear Mr. Rispoli:

The Department of Energy (DOE) has been planning to retrieve samples of
the highly radioactive soil near underground waste Tank W-1A at the Oak
Ridge National Laboratory to support planning for eventual soil
disposal. Excavation of the soils near Tank W-1A had been attempted by
the contractor, Bechtel Jacobs Company, in 2001 but was suspended due to
the discovery of higher-than-expected radiological contamination.

In early November 2005, the Defense Nuclear Facilities Safety Board
(Board) conducted a review of preparations for sampling the soil
surrounding Tank W-1A. This review was followed by several discussions
among the Board, DOE, and their contractor. The enclosed report provides
observations resulting from this review and is provided for your use.
The Board observed weaknesses in the application of Integrated Safety
Management for this activity, especially in the core functions of
identification and analysis of hazards, and identification and
implementation of controls for worker protection. Based upon discussions
held during December 2005, the Board understands that following the
review, Bechtel Jacobs Company acknowledged that significant additional
work was necessary, and postponed soil characterization startup while
taking steps to address the issues.

Pursuant to 42 U.S.C.§2286b(d), the Board requests a briefing on the
steps being taken to address the observations in the enclosure and
ensure worker protection before Tank W-1A soil characterization
activities are initiated.

Sincerely,

***A. J. Eggenberger***

***Chairman***

c: Mr. Gerald G. Boyd

Mr. Mark B. Whitaker, Jr.

Enclosure

**DEFENSE NUCLEAR FACILITIES SAFETY BOARD**

**Staff Issue Report**

December 21, 2005

MEMORANDUM FOR: J. K. Fortenberry, Technical Director

COPIES: Board Members

FROM: R. Raabe

SUBJECT: Review of Work Planning for Tank W-1A Soil Characterization and
Sampling at Oak Ridge National Laboratory

This report documents a review of work planning for the Tank W-1A soil
characterization and sampling project to be carried out at Oak Ridge
National Laboratory (ORNL). The review was conducted from October 31,
2005 to November 1, 2005, by members of the staff of the Defense Nuclear
Facilities Safety Board (Board), F. Bamdad, D. Burnfield, D. Owen, R.
Raabe, and D. Winters, along with outside expert D. Volgenau. Subsequent
discussions, including a telephone conference among the Board's staff,
the Department of Energy (DOE), and their contractor during December
2005, identified activities planned to correct many of the deficiencies
noted in the report.

**Background.** Tank W-1A collected wastes from analytical facilities
with high radiation levels at OWL, including Building 2026, Building
3019B, and Radiochemical Processing Pilot Plant Building 3019. Tank W-1A
was installed in 1951 and removed from service in 1986. During its
operation, the transfer line to Tank W-1A from Buildings 2026 and 3019
is suspected to have leaked, causing soil and groundwater contamination
around the tank. In 2001, a remediation project was attempted to remove
Tank W-1A and the contaminated soils. After removal of about
three-quarters of the contaminated soils, an area with
higher-than-expected radiological contamination was found. On-contact
dose rates ranged from 400 mrem/hr to 6 rem/hr. The remediation was
suspended, the excavation was backfilled, and the facility was
subsequently declared an inactive waste site. The remediation project is
now being renewed; it will begin with sampling and characterization,
followed by removal of the remaining contaminated soil (about 100 yd^3^)
and Tank W-1A.

The project, being conducted by Bechtel Jacobs Company (BJC), is
currently focused on sampling and characterization of the soil around
Tank W-1A. Key objectives of these activities are to perform
radiological characterization of the soil and to develop a
three-dimensional map showing the locations of soil meeting the
definition of transuranic and low-level waste. Sampling will be
accomplished by retrieving cores of the contaminated soil using a
direct-push drill rig and dual-wall soil sampling system. The soil cores
will be analyzed with gamma spectroscopy and then cut to obtain samples
for more definitive, off-site analyses. At the time of the staffs
review, DOE and B JC personnel indicated that the management
self-assessment was planned for the week of October 31, 2005, the BJC
readiness assessment for the week of November 7, 2005, and the startup
of the project for the week of November 14, 2005. This activity is to be
controlled to be below Hazard Category 3 thresholds for nuclear
material.

**Observations.** The Board's staff made numerous observations during
its review and on-site discussion of work planning for the soil sampling
and characterization project associated with Tank W-1A. The staff found
that the state of the project preparations and work planning was such
that protection of workers could not be ensured. Several core functions
of Integrated Safety Management were not being followed effectively in
planning the work.

BJC had not planned adequately and was not prepared to carry out all the
necessary activities associated with the project. Despite the stated
intention to conduct the BJC readiness assessment during the week of
November 7, 2005, mockup training and dry runs of the various tasks had
not been completed, and the contractor was not prepared for an
integrated demonstration of the full sampling activity to support a line
management declaration of readiness. Such an integrated dry run is
especially important given the potential radiation levels, the potential
for airborne radioactivity, the complexity of the tasks involved, the
multiple subcontractors, and the multiple interfaces at the site.

*Identify and Analyze the Hazards and Implement Controls*―The process
used to identify and analyze the hazards associated with the planned
work was not adequate to ensure that appropriate controls would be in
place to protect workers. The prepared work instructions required
significant improvement to enable safe and successful accomplishment of
the sampling and characterization:

-   The work instructions called for cutting the soil cores for further
    radiological characterization or for size reduction prior to waste
    packaging. Some of the core samples were to be cut on a table under
    a canopy. After the staff expressed concern about conducting such
    activity in the open air, the contractor committed to performing all
    cutting and resizing of soil cores in a glovebox.

-   The activity hazard analyses were generic in nature. They did not
    accurately identify the significant hazards associated with the
    work, nor did they comply with the requirements of the contractor's
    directive, BJC-EH-2010, *Hazard Assessment*. For example, neither
    hazards nor controls associated with a high radiation area were
    identified. Also, hazards associated with individual work steps were
    not evaluated.

-   The work instructions were complicated, lacked specificity, and were
    not worker-friendly. The roles and responsibilities of all
    participating entities were not well defined, the way in which
    independent activities were to be supervised and coordinated was not
    clearly spelled out, and many actions required that workers refer to
    other documents to learn how they were to be accomplished.

-   The activity hazard analyses did not formally examine potential
    undesirable events or what-if scenarios (e.g., drop/damage to the
    high-efficiency particulate air vacuum cleaner or the core samples
    during delivery) for associated hazards and the identification of
    appropriate controls. The staff emphasized the role of a proper
    hazard analysis in the development of controls to prevent scenarios
    or ensure they are adequately mitigated.

-   Material and procedural problems were observed during a field
    demonstration of the drilling equipment to be used for obtaining
    soil samples. Drill rig operators and radiological controls
    personnel participated in the demonstration to illustrate their
    actions during sampling evolutions. It was evident from the
    demonstration that the procedures to be used for the sampling and
    characterization project required further improvement to ensure a
    smooth and safe process. In addition, several mechanical problems
    that developed with the drilling rig and its hardware during the
    demonstration could have exposed workers to hazards unnecessarily.

-   The project instituted a materials inventory control program
    intended to keep the quantity of radionuclides brought to the
    surface below the threshold for Hazard Category 3 per DOE-STD-1027,
    *Hazard Categorization and Accident Analysis Techniques for
    Compliance with DOE Order 5480.23, Nuclear Safety Analysis Reports*.
    The inventory control program uses measured levels of cesium-137 and
    ratios based on previous sampling to estimate the quantity of other
    radionuclides present in the soil. However, there did not appear to
    be any provision in place to confirm or update the ratios in the
    corresponding calculations with the results from more detailed
    off-site analyses.

-   The pre-job as low as reasonably achievable (ALARA) review
    discounted the significance of high radiation readings observed
    during previous excavation work with Tank W-1A because of the
    reduced volume of soil being brought up to the surface. In so doing,
    it failed to account for the potential for hot spots. The Board's
    staff believes the analysis needs to assume material that reads at
    least 10 rem/hr on contact, especially since readings of 6 rem/hr
    have been recorded during previous work.

-   There is the potential of an abnormal event in which a soil core
    with a dose rate exceeding 1 rem/hr cannot be returned to its
    original position in the sampling hole. These soil cores could have
    measurable dose rates as high as 6 to 10 rem/hr. It was not clear
    that the project planning accounted for the possibility of this type
    of occurrence or that this possibility had been analyzed in the
    design of the shielding. Furthermore, it was not clear that the
    thresholds for Hazard Category 3 would not be exceeded if the
    calculation had used ratios corresponding to a core sample
    representative of the dose rate actually detected during the earlier
    work (6 rem/hr).

-   Despite knowledge that the sampling and characterization work could
    be a high-radiation activity with the potential for airborne
    radioactivity, a radiation safety plan (RSP) was not prepared during
    the work planning effort. The contractor's directive, BJC-EH-4000,
    *Radiation Protection Program*, calls for preparation of an RSP if
    necessary to address project-specific radiation protection practices
    when planning for radiological work.

-   The radiation work permits are being used to establish controls for
    the project, and are referred to for controls in the activity hazard
    assessment. This is an improper approach to hazard analysis.
    Radiation work permits are not supposed to establish controls, but
    they should implement the applicable controls identified in the
    activity hazard assessment.

-   The radiation work permits do not require workers to wear
    multiple-whole-body dosimetry. Further, it was not apparent that
    consideration had been given to the use of foot dosimetry. Depending
    upon the position of workers during transport of the soil core, it
    would be quite possible for a no uniform radiation field to exist.
    Article 512 of DOE-STD-1098, *Radiological Control*, defines a
    nonuniform radiation field as occurring "when the dose to a portion
    of the whole body will exceed the dose to the primary dosimeter by
    more than 50 percent and the anticipated whole body dose is greater
    than 100 mrem." Article 512 recommends that multiple dosimeters be
    issued in nonuniform radiation fields. The correct use of mockup and
    worker positioning studies would provide the information needed to
    determine whether multiple whole-body and/or foot dosimetry is
    required.

-   The calculations used in the pre-job ALARA review to determine
    transferable contamination thresholds for requiring respiratory
    protection appear problematic. The calculation for alpha
    contamination was based on plutonium-239; however, the Board's staff
    considers that it would be appropriate to base the calculation on
    thorium-229, since it has a more limiting derived air concentration
    value and has been present in Tank W-1A soil at concentrations close
    to those for plutonium-239. Additionally, the equations and
    calculations appear to be in error.

-   The radiation work permits allow respirators to be donned in either
    a contamination area zone or a high-contamination area zone. This
    practice could lead to potential internal exposures to workers.

-   The contractor plans to use a shield device and transport tool to
    shield and transport the soil cores. The shielding device consists
    of a stainless steel carrier that is approximately 0.25 inch thick.
    It will be used for moving soil cores that have a measurable dose
    rate of at least 5 mrem/hr. The technical basis for the shielding
    device was unclear, as were its specifications, such as the
    tolerance and type of stainless steel to be used. Also, it was
    unclear why the shielding device would not be used for all cores
    having any measurable dose. The transport tool for carrying soil
    cores to ensure that extremities are a distance of at least 30 cm
    from the soil cores had not yet been designed or demonstrated for
    the scheduled management self-assessment. Although the transport
    tool was mentioned in the pre-job ALARA review, the stated intention
    to maintain 30 cm to extremities was not clearly incorporated in
    that review.

-   While the contractor planned to label individual cores with sampling
    location information, there was no plan to include radiation levels.
    Clear labeling of the radiation levels on each core would be useful
    to aid workers in minimizing doses consistent with ALARA, in
    handling/transport of the cores.

-   There was no provision for informing radiological control
    technicians of the expected dose for a particular sample location to
    allow for efficient presetting of dose ranges on the Teletector
    probe. The Teletector probe is used to monitor the radiation levels
    of soil cores as they are being raised. It comprises low-range and
    high-range Geiger-Mueller detectors. Thus, if an improper dose range
    were used (e.g., one of the three ranges for the low-range detector
    used to measure a high-radiation field), the low-range detector
    could become saturated, resulting in an incorrect reading of 0
    rem/hr.

-   The contractor stated that cutting of cores prior to waste packaging
    is necessary to fit pieces into 5- or 1 0-gallon waste drums
    currently planned for use. The contractor could not explain the
    basis for limiting packaging to these smaller drums or for not
    evaluating the use of larger waste drums to minimize the need for
    size reduction of cores. In addition, there were no apparent plans
    to shield the drums while they are being stored in the staging area
    before transport.

-   DOE and contractor personnel were not aware of an August 2005
    memorandum from the DOE Assistant Secretary for Environment, Safety
    and Health that establishes guidance for setting limiting conditions
    for radiological work. They indicated that they would review the
    guidance and use it as appropriate.

*Provide Feedback and Continuous Improvement*―Previous work has been
conducted and technical reports written regarding Tank W-1A; however, it
was not apparent that the Contractor had drawn upon this information to
improve the process for the current project. For example, the applicable
details of an August 2004 Technical Assistance Team report had not been
considered in the work planning for this project. The purpose of that
report was to identify and evaluate alternative solutions for
remediation of the contaminated soils adjacent to Tank W-1A. Project
personnel were not familiar with the details of this report and did not
know whether consideration of its conclusions had been part of the work
planning efforts. The report was not included on the reference list in
the work planning documentation.