TRANSMITTED TO M. WHITAKER 7/24/96

DEFENSE NUCLEAR FACILITIES SAFETY BOARD

                                             May 8, 1996

MEMORANDUM FOR:       G. W. Cunningham, Technical Director

COPIES:               Board Members

FROM:                 J. Deplitch
                      
SUBJECT:              Report on the Rocky Flats Environmental Technology
                      Site Annual Emergency Preparedness Exercise, READY-
                      96


1.      Purpose:  This report documents Defense Nuclear Facilities Safety Board's
        (Board) staff observations made during the conduct of the Rocky Flats
        Environmental Technology Site (RFETS) Annual Emergency Preparedness Exercise,
        READY- 96, on April 17, 1996, and follow-up reviews.  Board staff observers
        were J. Deplitch, D. Thompson, R. Warther, and M. Sautman.

2.      Summary:  RFETS performed a multiple incident emergency preparedness (EP)
        exercise with the intent of significant offsite participation for the most
        severe incident.  The exercise was intended to fulfill the annual site-level
        exercise requirement.  The exercise involved four incidents: three short
        duration onsite incidents with no offsite consequences and one longer
        duration offsite incident.  None of the three onsite incidents required
        declaration of any emergency or any protective action recommendations.  The
        offsite incident involved a 2,500-gallon fuel fire, two contaminated
        casualties, and 0.05 curies of Plutonium-239 (a hazard of concern only in the
        immediate area of the accident).

  RFETS's performance on this exercise was significantly improved from the
  previous drills and exercises in the past year.  However, there were many
  weaknesses and inconsistencies involving assessment of the hazards,
  determination of emergency action levels, selection of protective actions,
  use of personal protective equipment, contamination control, use of
  radiological instruments, use of procedures/checklists/references, and
  exercise control.  Overall, the Board staff observers considered that RFETS
  marginally demonstrated its ability to respond to an onsite emergency, but
  failed to demonstrate an ability to coordinate with state and local emergency
  response organizations for an offsite emergency.

  Offsite agency participation included activation, manning, and operations at
  the State Emergency Operations Center, Offsite Coordination Center, Joint
  Public Information Center, and RFETS Emergency Operations Center.  Offsite
  organizations also responded to the offsite incident with local fire
  department, hazardous material, medical, and law enforcement personnel and
  equipment.  Except for the Radiological Assistance Teams (requested from the
  Department of Energy), offsite organizations performed few actions to
  respond, assess, control, and mitigate the accident.

  
3.      Background:  The exercise was intended to demonstrate the preparedness of
        emergency response personnel, procedures, facilities, and supporting systems
        for an emergency at RFETS; to demonstrate RFETS's ability to notify,
        coordinate, and support state and local agencies for an offsite emergency;
        and to exercise emergency response capabilities of the state and local
        agencies.  RFETS controlled, evaluated, and critiqued their own participation
        in the exercise, while state and local agencies provided their own control,
        evaluation, and critique of their participation in the exercise.  Department
        of Energy (DOE) Headquarters Office of Emergency Management (NN-60) provided
        limited external evaluation to RFETS's participation in the exercise.

  The RFETS exercise included four simulated incidents.  The first incident
  involved a commercial delivery truck colliding with the northern-most gate
  booth of the West Gate as it exited the site.  The impact caused minor
  injuries to the driver and passenger, leaked antifreeze and transmission
  fluid, and scattered three boxes containing Iodine-123 (20 millicuries each,
  salt form).  One box was opened and the contents partially scattered on the
  ground.  The Iodine-123 was still in its inner container and no contamination
  resulted.  The second incident involved an accident between a 2,500-gallon
  gasoline tanker and a commercial transport truck carrying low-level waste
  from RFETS, just north of the East Gate, on Indiana Road.  As a result of the
  accident, several crates of machine parts and drums of corrosive solvents,
  all contaminated with plutonium, were ejected from the truck trailer; the
  trucks, drivers, and cargo were burned in the fire; and the transport truck
  passenger and an individual, who was following the truck and went to aid of
  the passenger, were injured and contaminated.  The third incident involved
  the Crisis Support Team manager losing consciousness while performing his
  duties in the EOC.  The fourth incident involved a technician dropping a box
  of hydrochloric acid bottles, breaking one bottle.  The technician's leg was
  burned and the fumes produced respiratory difficulty.

4.      Discussion/Observations:  

  The Board's staff observed activities of exercise conduct and control and
  activities at the accident scenes, Incident Command Posts (ICPs), RFETS
  Emergency Operations Center (EOC), Joint Public Information Center, Offsite
  Coordination Center, and State Emergency  Operations Center.  The Board's
  staff also reviewed RFETS emergency action level (EAL) procedures and
  protective action recommendation (PAR) procedures.

     EALs and PARs were determined arbitrarily during the exercise.  The Incident
     Commander did assess the accident and determine a timely EAL and PAR, but the
     EAL and PAR did not coincide, i.e., he declared an Alert and gave an order to
     Shelter for all onsite facilities (corresponding to a Site Area Emergency). 
     The Incident Commander did not refer to available procedures to determine the
     appropriate levels and recommendations.  A later Board's staff review of EAL
     procedures showed that the procedures lacked sufficient detail to clearly
     identify and classify an accident.  Review of the PAR procedures showed a
     clear and logical decision-making process, but decisions were based upon
     default bounding effects and accidents only.  The procedures lacked a broad
     spectrum of potential accidents that can lead to an operational emergency;
     such as, potential accident conditions and observable indications that can be
     identified easily and that trigger specific EALs and PARs.   As written, the
     procedures required accident and consequence assessment before EAL and PAR
     could be accurately determined, otherwise the determination could be overly
     conservative (alarmist) or not adequate to protect the workers and public. 
     For Incidents 1 and 2 the EAL and PAR were overly conservative; for Incident
     4 the PAR was slow.

     The Hazard Assessment Center (HAC) was not effective in collecting and
     evaluating data.  The HAC accepted the Reportable Quantity value for Iodine-123, 10 curies, as the quantity involved with the West Gate incident and did
     not aggressively seek actual accident data.  As a result, unnecessary
     protective actions were initiated and persisted.  The HAC did not have an
     appropriate model for assessing the Iodine-123 hazard and deployed only one
     Field Sampling Team.  The HAC apparently did not understand the difference
     between the reporting chains for Field Sampling Teams and Radiological
     Assistance Teams (under the Radiological Assistance Program) and, therefore,
     had difficulties with collecting and coordinating for the field survey data.

     The ICP had communication and coordination problems.  Duties and
     responsibilities changed several times among the ICP staff, causing redundant
     coordination and communications and delayed responses.  The truck manifest
     for the West Gate incident was available to accident scene responders in
     about ten minutes, but the information was not communicated to decision
     makers for reevaluation of protection actions for nearly an hour.  Also, the
     ICP was located so close to response vehicles with their engines running at
     high idle speed that communications were very difficult.  Very high winds
     exasperated the communications problem.

     Contamination control was poor, particularly during the East Gate incident
     response.  Contaminated responders walked into clean areas with unprotected
     personnel; unprotected personnel walked into contaminated areas, especially
     while treating the casualties.  No measures were taken to control access to
     the contaminated areas, e.g., through designated entry and exit points. 
     During the hydrochloric acid spill incident a worker (other than the
     responders)walked through the spill area.

     The use of personal protective clothing and equipment (PPE) was inconsistent. 
     Responders wore different levels of protection while in the same potentially
     contaminated area.  Some wore self-contained breathing apparatus, while
     others wore full-face respirators with particulate cartridges, partial-face
     respirators with no cartridges, or no respirator protection.  A clear level
     of protection was not prescribed or maintained.  At one time during the West
     Gate incident, the Industrial Hygienist prescribed and incorrectly identified
     the PPE in use as Level A protection.  Gas tight chemical resistant clothing,
     Level A, was not required for the accident hazards, worn by any responders,
     or included with the PPE for the accident responders.  A properly assessed
     level of protection would ensure each responder is adequately protected, but
     not overburdened.

     Radiological measurement instruments were not used properly.  Personnel were
     frisked for contamination too fast and at an inappropriate distance. 
     Thermoluminescent dosimeters and self-reading dosimeters were worn
     incorrectly, i.e., underneath protective clothing.  During the East Gate
     incident, probes were used in a manner that would have made it impossible to
     detect the plutonium contamination.  Air sampler operators were not trained
     to operate the samplers.

     The exercise was well-designed and well-controlled, except for the lack of
     adequate pre-exercise coordination with the local and state jurisdictions
     expected to participate.  This lack of coordination was a major contributor
     to the poor performance and response to the offsite incident. The perceived
     effort on the part of RFETS and offsite agencies for planning and
     participating in the exercise and demonstrating poor overall performance for
     responding to the offsite incident indicates strongly the need for future
     integrated training, drills, and exercises with offsite agencies.

     One major controller deficiency was noted.  During the large fire at the East
     Gate, one controller indicated that the fire was out after fifteen minutes. 
     Another controller stated the fire was still raging one hour after the
     incident.  As a result, there were many misunderstandings about what
     responses should or could occur, on the part of both the players and
     controllers.

     The site has an annual requirement to exercise the response capability of
     each facility and for the site-level emergency response organization elements
     and resources to participate in a minimum of one exercise.  Training and
     drills are performed periodically to develop and maintain specific emergency
response capabilities.  Drills provide supervised, hands-on training for members
of emergency response organizations.  Exercises are used to validate the elements
of the emergency management program.  A site exercise is designed to test and
demonstrate the site's integrated emergency response capability.

Board staff observers used the Federal Emergency Management Agency (FEMA)
evaluation methodology set forth in FEMA-REP-15, "Radiological Emergency
Preparedness Exercise Evaluation Methodology," dated September 1991; and Drills
and Exercises and DOE Emergency Exercise Evaluation Criteria published in the DOE
Emergency Management Guide, dated  December 11, 1991.

Accidents were only categorized: systems and operations, loss of power, fire,
explosion, release of hazard, security, weather/natural phenomena, and
miscellaneous.  Various buildings were identified with the maximum credible
accident hazard and whether it led to a General Emergency or Site Area Emergency
(other quantities and hazards were not addressed).  Various hazards were
identified with quantities that lead to General Emergency or Site Area Emergency. 


The variety of accidents or incidents that can lead to an operational emergency
at RFETS is broad.  Emergency preparedness should include a thorough evaluation
of all potential accidents and hazards and consequence assessments for adequate
planning.  A spectrum of potential accidents ranging from minor to beyond-the-design basis should be postulated and realistically analyzed.  The EAL and PAR
procedures should include the broad spectrum of accidents that can lead to an
operational emergency and provide for a quick identification of appropriate EAL
and PAR.  EALs and the specific criteria used to recognize and categorize events
must be developed for the spectrum of potential operational emergencies
identified by the hazards assessments.  The procedures should include potential
accident conditions and observable indications that can be identified easily,
have been evaluated for potential consequences, and trigger specific EALs and
PARs.  (IAW DOE Order 151.1, DOE Order 5500.2B, DOE Order 5500.3A, and DOE
Emergency Management Guide).

During the after-action critiques a lead controller expressed frustration at the
poor coordination and stated, "we don't plan to do this with the State again."