TRANSMITTED TO DOE/M. WHITAKER 7/5/95

DEFENSE NUCLEAR FACILITIES SAFETY BOARD

October 6, 1994

MEMORANDUM FOR:     G.W. Cunningham, Technical Director

COPIES:        Board Members

FROM:               Matthew B. Moury, Pantex Program Manager

SUBJECT:       Pantex Site - DNFSB Staff Trip Report - W55 Case Cutting
               Incident

1.   Purpose:  This report documents a review by Defense Nuclear Facilities
     Safety Board (Board) staff member M. Moury and Outside Expert T. Quale
     (Systems Planning Corporation) of a trip on September 12-14, 1994, to
     the Pantex Site near Amarillo, Texas to review the W55 Case Cutting
     Occurrence, AL-AO-MHSM-PANTEX-1994-0137,  attached.

2.   Summary: 

     a.   The investigation conducted by the Mason & Hanger (M&H) into the
          incident was in general a thorough technical review.  The
          corrective action plan, if properly carried out, will correct most
          of the root causes that led to this occurrence.

     b.   The Board staff identified several additional concerns that showed
          the lack of an integrated work control program and less than
          adequate implementation of Department of Energy (DOE) Order
          5480.19, Conduct of Operations Requirements at DOE Facilities, and
          DOE Order 5000.3B, Occurrence Reporting and Processing of
          Operations Information.

3.   Background:   In 1992, the W55 dismantlement operations were suspended
     due to sparks generated during W55 case cutting operations.  A new
     cutting process was developed to eliminate the potential for sparking
     with a new cutting tool.  During a W55 program review on September 1,
     1994, the Board site representative became aware of an incident that
     occurred on July 29, 1994, while testing the new cutting process.  M&H
     conducted an experiment to verify the new cutting device would not cause
     an airborne contamination problem.  Several personnel errors took place
     that led to airborne contamination.  The Board staff reviewed the events
     that led to this occurrence and the corrective actions to prevent
     recurrence.  The review consisted of personnel interviews, document
     reviews, and viewing the case cutting tooling.

4.   Discussion/Observations: 

     a.   The following is a summary of the issues identified during the
          Mason & Hanger review of the incident:

          (1)  Conduct of Operations Issues:  Failure to follow procedures;
               inappropriate changes to procedures; inadequate supervision
               of work; work was perceived to be driven by schedule; and
               the Plan of the Day was not used to control all activities
               in the facility.

          (2)  Procedure Issues:  Work done according to an unapproved
               procedure; Nuclear Explosive Operating Procedure (NEOP) and
               Engineering Instruction (EI) were inadequate to control the
               work; the procedures used for the work had not been reviewed
               by an engineering supervisor and there was no requirement
               for this to be done.

          (3)  Radiological Control Issues:  Failure to follow the
               requirements of the Radiological Work Permit; the Radiation
               Safety Plan used for this work had not been approved.

     b.   Several additional concerns were identified by the Board staff. 
          In combination with the concerns identified above they demonstrate
          the lack of an integrated work control program and less than
          adequate progress in implementing DOE Order 5480.19 and DOE Order
          5000.3B.

          (1)  Procedure Preparation and Use:  The approval processes for
               NEOP's and EI's (Plant Standards 0143 and 0170 respectively)
               do not specify the process for obtaining technical
               concurrence from organizations such as radiation safety,
               industrial health, etc.; although, they do require such
               reviews.  This has resulted in a lack of formality
               concerning these reviews.  For example, the Radiological
               Control Manager said that his organization does not
               routinely provide signature approval of such procedures. 
               
               The Board staff reviewed the EI prepared for the case
               cutting evaluation.  The review revealed several
               deficiencies including incomplete instructions, incorrect
               sequencing of steps that would have resulted in missing
               steps for repetitive work, and the failure to include
               critical instructions in the procedure such as the method
               for cleaning (decontaminating) the case. 

          (2)  Control of Work:  Pantex has not implemented an integrated
               program to control work nor a Conduct of Engineering
               Program.  Such programs have been valuable at other
               facilities in providing proper control of work.  An
               Integrated Work Control Program defines the specific aspects
               of Conduct of Engineering, Conduct of Operations, and
               Conduct of Maintenance necessary to support a strong
               Configuration Management Program and a safe working
               environment.  The Engineering and Design Division Manager
               clearly recognizes the need for, and value of, such programs
               and also the need for compensatory measures until they are
               fully implemented.  However, efforts in this area are only
               just underway.  An Integrated Work Control Program would
               have been valuable in preventing this occurrence. 
               Specifically, it may have prevented the following causal
               aspects of this occurrence.

               (a)  Preparation of an inadequate procedure including
                    failure to specify and obtain a review of the
                    procedure by an engineering supervisor.

               (b)  Failure to designate an overall supervisor for the
                    evolution, to use the Plan of the Day to control the
                    evolution, to use unapproved supporting procedures,
                    and to make unauthorized changes to the procedure.

          There are few, if any, requirements in DOE Orders supporting or
          requiring an Integrated Work Control Program for defense nuclear
          facilities.  However, facilities such as the Rocky Flats
          Environmental Technology Site and the Savannah River Plant have
          found that such a program is a necessary tool in providing a safe,
          high-quality operating environment.  Further, such a program is
          indispensable in the fulfillment of  several of the criteria of
          DOE Order 5700.6C Quality Assurance.  Specifically, Criterion 1
          Program, Criterion 4 Documents and Records, and Criterion 5 Work
          Processes.

          (3)  Radiological Controls:  Conduct of radiological work using
               the principles of DOE Order 5480.19 as invoked by article
               125 of the DOE Radiological Controls Manual (RCM) is weak.  
               During a brief tour of one small section of one bay to
               observe the case cutting equipment, the Board staff observed
               several radiological deficiencies.  These deficiencies
               included out- of-date and incomplete posting and personnel
               handling equipment without first reading the radiological
               posting to determine what controls were required. 

          In response to the generation of airborne radioactivity during the
          subject occurrence, the Radiation Safety Department intends to
          require the use of filter respirators for personnel inside the
          contamination area.  However, personnel immediately outside the
          contamination area would not be required to use respirators. 
          These two areas are only separated by a rope barrier and no
          studies have been performed to determine air flow patterns in the
          bay.  Article 531.1 of the RCM states "Use of respiratory
          protection shall be reduced to the minimum practical by
          implementing engineering controls and work practices to contain
          radioactivity at the source."  Pantex has not performed a formal
          engineering evaluation to determine what measures are available to
          eliminate the need for respiratory protection during this
          evolution. 

          Analysis of bioassay samples of exposed personnel had not been
          completed at the time of the review.  Although these were
          emergent, non-routine samples, no urgency was placed on the
          contractor used by Pantex to expedite analysis.  In fact, at the
          time of the review, about six weeks after the occurrence, the
          Radiological Control Manager had not confirmed that the contract
          with the analysis contractor included a clause to expedite
          emergent samples. 

     c.   This event was not originally classified as an occurrence contrary
          to the requirements in DOE Order 5000.3B section 16 of Appendix I
          or the Pantex Site Specific Criteria for Categorization of
          Reportable Occurrences.  Because the event was not reported using
          the occurrence system, notification of senior DOE officials and
          event investigation was delayed almost four weeks.

     d.   Several technical issues have been raised concerning the safety of
          the cutting process.  The first deals with the rate of the cutting
          operations and the potential for generating sparks in the
          proximity to high explosives.  The second is the potential
          scraping of the HE when the upper shell hemisphere is lifted from
          the unit.  Both issues are currently being reviewed by the Board
          staff.

5.   Follow-up Activities:  The following Board staff actions are planned:

     a.   Review the preparations being made to reperform the case cutting
          experiment, including all corrective actions from the first case
          cutting experiment occurrence.  The Board site representatives
          will monitor the actual operations.

     b.   Perform a technical review of the remaining safety issues with the
          cutting operation before actually dismantling the first unit.