DEFENSE NUCLEAR FACILITIES SAFETY BOARD

December 22, 1993

MEMORANDUM FOR:     G. W. Cunningham, Technical Director

COPIES:             Board Members

FROM:               Ralph Arcaro, Technical Staff

SUBJECT:            Report on Training and Qualification at the Hanford Site

1.Purpose:  This memorandum describes and provides comment on the status of
training and qualification of federal and contractor employees at the Department
of Energy's (DOE's) Hanford Site.  A DNFSB staff review team consisting of DNFSB
staff members Ralph Arcaro and Charles Keilers and outside experts David Boyd and
Douglas Volgenau performed a review of training and qualification from November
30 to December 2, 1993 to assess the progress and improvements made since a DNFSB
staff review in June 1992, and DOE EM-25 reviews in January and October 1993. 
Observations of Conduct of Operations were also made and are commented on in an
attachment to this report.  The review team received presentations from managers
responsible for training and qualification from both DOE Richland Operations
Office (DOE-RL) and Westinghouse Hanford Company (WHC).  The team also reviewed
facility-specific training and qualification at the T-Plant, K-Basin, Plutonium
Finishing Plant, and 222-S Laboratory facilities.

2.Summary:  The DNFSB review team found little improvement in the state of
training and qualification at DOE-RL and WHC.  It appears the majority of their
efforts aimed at correcting the several training and qualification deficiencies
noted during the DNFSB staff June 1992 review are concentrated on fixing specific
problems and deficiencies rather than identifying underlying issues and
addressing root causes.  

General conclusions of the review and major comments are presented here. 
Supporting comments and other observations are presented in the attachments. 
Attachment 1 provides comments on DOE-RL.  Attachment 2 provides comments on WHC. 
Attachment 3 provides specific comments on the conduct of operations at the
facilities reviewed.

a.DOE-RL:  The primary finding of the review was that DOE-RL continues to
underestimate the importance of training and qualification for both federal and
contractor personnel.  

1.DOE-RL guidance and direction provided to WHC concerning training and
qualification programs continues to be ineffective as evidenced by the nature and
number of deficiencies noted in each of the training and qualification programs
at the four facilities evaluated.

2.In August 1993, DOE-RL management moved the site training organization out of
the Human Resources Division.  The organization, now named the Office of
Technical Training and Education, now reports directly to the DOE-RL Manager. 
However, this change has not had the desired effect of elevating training
priority to any significant degree.  The following deficiencies have contributed
to this situation:

a)Although the Director of the OTE reports directly to the DOE-RL Manager,
discussions with individuals at DOE-RL indicate the OTE does not effectively
invoke the authority of the Manager to ensure needed training and qualification
improvements are implemented.

b)The OTE has not received sufficient support from DOE-RL line management at the
facility level to effect broad-based improvement.  DOE-RL line management is not
proactive in enhancing training programs through day-to-day guidance and
direction at all facilities.

c)The OTE has issued a directive prescribing the OTE oversight of contractor
training and qualification programs.  No comparable directive applicable to DOE-
RL line management exists.

      3. The DOE-RL Facility ("Site") Representative program is still not
         making a positive impact on improving contractor training,
         qualification, and conduct of operations programs.  The principle
         reason for its ineffectiveness appears to be the sluggish
         restructuring of the program that has hindered its maturation.

   b. WHC:  The WHC management has continued with training improvements since
      the June 1992 DNFSB staff visit.  However, at the four facilities
      reviewed, major deficiencies continue to exist:

      1. Improvements are exceedingly slow.  None of the four facilities have
         fully implemented the requirements of DOE Order 5480.20, Personnel
         Selection, Qualification, Training, and Staffing Requirements at DOE
         Reactor and Non-Reactor Nuclear Facilities.  Three of the four
         facilities have not yet developed all training materials necessary
         for program implementation.

      2. At T-Plant, K-Basins, and the 222-S Analytical Laboratory, the
         contractor has not technically justified compensatory measures for
         allowing continued facility operation with operators and supervisors
         trained and qualified to a non-compliant program.

      3. DOE-RL reported improvement in accelerating approval of the Training
         Implementation Matrices (TIMs).  However, review of two of the
         matrices showed they did not contain sufficient detail to allow the
         approving authority to objectively determine their merit.  For
         example, The T-Plant TIM gives a false indication of a near fully
         compliant program.  DNFSB staff review revealed that the TIM's
         compliance claim is based on a facility-level training procedure
         that is not fully implemented.

   c. Conduct of Operations:  DNFSB reviewers observed several training,
      operations, and maintenance evolutions that provided an opportunity to
      evaluate the conduct of operations at two of the facilities.  The
      observations made by the DNFSB review team, detailed in Attachment 3 of
      this report, indicate that conduct of operations at Hanford requires
      significant improvement.

3. Background:  Members of the DNFSB staff and several Outside Experts
   performed a site-wide review of training and qualification at the Hanford
   Site in June 1992.  The primary concerns resulting from the review involved
   DOE-RL management's lack of commitment to training and qualification, lack
   of formalized training for DOE-RL employees, and deficient contractor
   training and qualification programs at the four facilities visited.  The
   Board transmitted these and other concerns to DOE in a letter dated July 6,
   1992 forwarding the staff's trip report.

   Since the June 1992 visit, the DNFSB staff has been monitoring the efforts
   of DOE, DOE-RL and WHC in the training and qualification upgrade efforts. 
   A DOE (EM-25) assessment in January 1993 of training and qualification
   improvement efforts at Hanford, particularly the Tank Farms, identified
   several findings indicating that WHC had not achieved significant progress
   in upgrading the training at the Tank Farms.  A follow-up review conducted
   by EM-25 in October 1993 noted that progress in effectively addressing the
   concerns from the January 1993 visit had been minimal.  Additional concerns
   in the training area were documented.  The highest concern was that DOE-RL
   and WHC operations management were not taking an active role in training.  

   In order to assess the current status of the training and qualification
   programs, discussions were held with DOE-RL and WHC management and four
   facilities were visited.  The facilities visited included the Plutonium
   Finishing Plant (PFP), 222-S Laboratory, K-Basins and the T-Plant.  At the
   facilities, discussions were held with the facility management, records were
   reviewed and conduct of evolutions was observed.  

4. Future Staff Actions:  Given the lack of significant progress in improving
   training and qualification at the Hanford Site, the staff will closely
   monitor DOE-RL's and WHC's actions in response to this review and those
   performed by EM-25.  The staff will intensify its evaluation of the
   effectiveness of the improvements initiated by the Richland Operations
   Office as well as line management and oversight organizations at DOE
   Headquarters.  The staff will also concentrate efforts on Hanford as the
   Department implements DNFSB Recommendations 92-7 and 93-3 to improve
   training and qualification across the defense nuclear facilities complex. 
   The staff intends to include training, qualification, and conduct of
   operations topics in all future site visits of an operational nature to
   ensure the staff stays abreast of all improvement actions.  A decision to
   perform a specific follow-up review of training, qualification, and conduct
   of operations will be made based on progress made by DOE-RL and WHC.                                                    Attachment 1

   Comments Concerning DOE Richland Operations Office (DOE-RL)

1. DOE-RL Office of Training and Education:  There has been little progress
   since June 1992 in the effective oversight of Westinghouse Hanford Company
   (WHC) site training and qualification programs.  This appears to be
   principally the result of a lack of senior program management attention to
   this important area.  The following observations are provided:

   a. In August 1993, DOE-RL formed an organization entitled the Office of
      Training and Education (OTE), which is responsible for coordinating DOE-
      RL training and qualification programs and for oversight of contractor
      training and qualification programs.  The director of this office
      reports directly to the Manager, DOE-RL.  This office appears to be
      primarily the renaming and repositioning of an existing organization
      that had been a subordinate within the Human Resources Division of
      DOE-RL.  This organization is not empowered with the authority of the
      Manager to ensure training and qualification requirements are
      effectively implemented.

   b. The OTE is understaffed.  Only four DOE employees (and approximately
      eleven contracted personnel) are assigned full time to the Office.  The
      OTE Director is forced to take on many tasks that would otherwise be
      delegated, distracting him from maintaining the focus of the
      organization.  This issue was initially reported by DOE Headquarters in
      a 1990 audit.  It has not yet been addressed.

   c. A DOE-RL implementing procedure (RLIP) or implementing directive (RLID)
      has not been written to establish the OTE function, vision and goals,
      organizational structure and responsibilities, standards, and
      implementing strategies.  A mission and functions statement was
      developed for use within the group, but this statement does not define
      responsibilities, authorities, and relationships between OTE with other
      DOE-RL divisions concerning training matters.  RLIP 3410.TEB, Training
      Management Plan, was the corresponding procedure for the OTE predecessor
      organization, but this procedure has not been modified to reflect an
      increased emphasis on training and education at DOE-RL.

   d. There was little evidence that DOE-RL senior program management is
      involved in fulfilling the requirements of DOE Orders 5480.18A,
      Accreditation of Performance-Based Training for Category A Reactors and
      Nuclear Facilities, and 5480.20, Personnel Selection, Qualification,
      Training, and Staffing Requirements at DOE Reactor and Non-Reactor
      Nuclear Facilities, regarding the oversight of contractor training
      programs.  The OTE developed a procedure for conducting training and
      qualification assessments of the contractor; however, this directive was
      not applicable to DOE-RL line management.

   e. An OTE-originated DOE-RL letter of November 23, 1992 to WHC summarized
      concerns in the DNFSB staff trip report of the June 1992 review.  A
      comparison of the DOE-RL letter with the DNFSB staff report revealed
      that in many cases, the specific deficiencies, rather than the broad-
      based issues and underlying issues, were communicated to WHC as concerns
      to be addressed.  Root causes were not effectively investigated to
      design lasting corrective actions.

   f. The OTE organization is responsible for the training of DOE-RL (federal)
      employees.  An effective program to train those individuals tasked with
      contractor oversight on the specifics of the various facilities does not
      exist.  This requirement was well articulated in DNFSB Recommendation
      93-3.  A program to identify and implement training requirements for
      DOE-RL technical positions is in its infancy and therefore was not
      reviewed in detail.

   g. The cost of training for federal employees is administered by a
      "billback" system in which appropriate program funds are used to pay for
      training when an employee enrolls.  This system is designed to
      discourage no-shows at planned training.  However, it was reported that
      this method has also resulted in reluctance on the part of line managers
      to commit federal employees to training.  It is not clear whether this
      reluctance results from a perception that the training is not valuable
      or cost effective, or a perception that management is not committed to
      training.

2. DOE Facility Representatives:  A revised DOE-RL Facility ("Site")
   Representative program is in the early stages of implementation and is not
   yet capable of providing effective facility performance monitoring.  The
   following observations are provided:

   a. DOE-RL has taken the position that the "Facility Representative"
      described in DOE Order 5000.3B, Occurrence Reporting and Processing of
      Operations Information, and DOE Order 5480.19, Conduct of Operations
      Requirements for DOE Facilities, must be the applicable Division
      Director.  The Division Director is the "Facility Representative," but
      carries out the Facility Representative duties and line management
      oversight through "Site Representatives" designated for each major
      facility or group of lesser facilities.  This is inconsistent with the
      Guidance promulgated in DOE-STD-1063-93, Establishing and Maintaining a
      Facility Representative Program at DOE Nuclear Facilities, and the
      Facility Representative Programs at other major DOE sites.  This lack of
      conformity to established standards may be diluting the responsibility
      of the Facility Representatives, and may be contributing to the lack of
      effectiveness of the Facility Representative Program at DOE-RL that has
      been noted repeatedly during reviews and assessments.

   b. A new implementing directive (RLID 1300.1A) for the "Site"
      Representative (SR) Program was issued in October 1993.  The lines of
      authority and the duties and responsibilities for a SR are extensively
      defined in this directive.  DOE-RL has recently hired a number of people
      to serve as SRs under their new program and has instituted an incentive
      program for advancement to paygrade GS-14 upon completion of the SR
      qualification requirements.  Some of the selected people had previously
      served as SRs and others are newly assigned.  All individuals but one
      are in training.  Those individuals currently serving as SRs, but not
      selected for the new program, are continuing to perform as SRs until the
      new people gain sufficient experience.  Their status is undefined and as
      a result, there is little incentive for them to perform. These factors
      are contributing to the ineffectiveness of the SR program, which may be
      significantly hindering the ability of DOE-RL to oversee the WHC.

   c. Facility-specific SR qualification requirements have not yet been
      determined for all facilities.

   d. Two experienced SRs assigned to the Plutonium Finishing Plant (PFP) are
      performing SR duties, but have not completed qualification.  Neither is
      slated to be retained as a SR under the new program, therefore they are
      not continuing SR training.  An individual assigned to PFP as a new SR
      is not located at PFP, as he is awaiting security clearance. 
      Alternatives such as the use of escorts or limited access are not being
      used to maximize this individual's time in the facility prior to full
      assignment.

   e. No full- or part-time SR is assigned to the Processing and Analytical
      Laboratory complex.

3. Training Implementation Matrices:  The failure of DOE-RL to review and
   approve facility Training Implementation Matrices (TIMs) in a timely manner
   was noted in the June 1992 DNFSB staff visit.  TIMs are required of WHC to
   schedule implementation of DOE Order 5480.20.  Since the June 1992 visit,
   there has been much effort on the part of DOE-RL to process the TIMs in a
   timely manner and as a result, a number have been approved.  

   Two of the TIMs that had been determined to be adequate by DOE-RL were
   reviewed.  In a number of cases, WHC had inaccurately indicated that an
   Order requirement had been met.  As submitted, the two TIMs reviewed by the
   DNFSB staff did not contain sufficient evidence of compliance to allow an
   objective, accurate review by DOE.  DOE-RL indicated that compliance
   verification reviews were scheduled for a later date.  However, in the
   interim, the contractor may not be working toward compliance with all
   requirements.                                                    Attachment 2

     Comments Concerning Westinghouse Hanford Company (WHC)

1. Site-Wide Training and Qualification:  In early November 1993, WHC
   reorganized the organization responsible for site-wide training.  A new
   manager was assigned and the position is now a level 2 manager, reporting
   directly to the WHC president.  The following observations are provided:

   a. Under the new organization, training representatives are matrixed
      directly to facility line management.  This appears to be having a
      positive effect on the training programs; however, it is too early to
      fully evaluate the long term effectiveness of the overall training
      program. 

   b. Because of the number of facilities in standby, and the rapidly changing
      mission at Hanford, WHC intends to request long term, permanent
      exception from the requirements of Department of Energy (DOE) Order
      5480.18A, Accreditation of Performance-Based Training for Category A
      Reactors and Nuclear Facilities, regarding Training Program
      Accreditation.  Exemption letters for the PUREX and Plutonium Finishing
      Plant (PFP) facilities have already been submitted.

   c. WHC management considers that many of the identified deficiencies from
      the various DNFSB staff and EM-25 visits have been corrected or
      addressed.  However, it appears that the majority of the effort aimed at
      correcting the several training and qualification deficiencies is
      concentrated on fixing the specific deficiencies rather than identifying
      underlying issues and addressing the root causes.  

   d. Facility training and qualification programs are currently being
      upgraded.  In the interim, there has been little or no effort to define
      the present qualification status of the supervisors and operators who
      are conducting various operations and evolutions on a regular basis.  No
      real consideration has been given to the use of compensatory measures to
      ensure continued safe facility operation.  The safety of continued
      operations in some facilities can not be ascertained as the training and
      qualification status of supervisors and operators, currently conducting
      operations in these facilities, has not been verified.

2. T-Plant:  The T-Plant training program was not included in the June 1992
   DNFSB staff review.  The current mission of T-Plant includes providing
   decontamination services, providing facilities for liquid waste transfer car
   certification and repair, providing characterization, segregation, and
   repacking of containerized waste, providing storage and surveillance for
   pressurized water reactor irradiated fuel elements, and performing
   fabrication and repair for stack continuous air monitors and area monitors
   for the Hanford Site.  The facility is currently performing some portions of
   its mission.  This low hazard facility is the only one at the Hanford Site
   with these capabilities.  

   The members of the review team observed on-the-job training (OJT), pre-job
   briefs, and preventive and corrective maintenance evolutions.  Observations
   and comments of an operational nature are included in Attachment 3.  The
   following observations regarding the training and qualification programs are
   provided:

   a. Facility management is in the process of formulating an upgraded
      training and qualification program.  Two of five operator certification
      packages have been completed, but significant changes are planned to
      incorporate Job Performance Measures.  Development of the qualification
      requirements will be completed by September 1995.  T-Plant management
      has not addressed how it will upgrade operators qualified before the
      issuance of the new certification packages incorporating Job Performance
      Measures.

   b. Supervisors and operators are conducting operations in the facility. 
      None are qualified to the requirements of WHC-CM-5-34, which implements
      DOE Order 5480.20, Personnel Selection, Qualification, Training, and
      Staffing Requirements at DOE Reactor and Non-Reactor Nuclear Facilities. 
      Their certification to conduct these operations has not been verified. 
      No effective measures to compensate for their qualification status have
      been taken.

   c. Although the T-Plant Training Implementation Matrix (TIM), which
      schedules implementation of the new training program, is nearing final
      approval, DNFSB staff review indicated a number of errors in the stated
      compliance with requirements.  The T-Plant TIM asserts compliance with
      many of the requirements of DOE Order 5480.20 based on the existence of
      the T-Plant training procedure, WHC-CM-5-34.  This assertion is
      misleading because the training program procedure is not fully
      implemented.

   d. The upgraded training and qualification program's supervisor training
      requirements were not at an increased depth to reflect the added
      responsibility of their positions as required by DOE Order 5480.20. 
      This requirement of DOE Order 5480.20 is not addressed in the T-Plant
      TIM.

   e. The planned facility continuing training program does not contain many
      of the program elements required by DOE Order 5480.20.

   f. There are no facility-specific knowledge requirements for the Facility
      Manager.  The Facility Training Manager has not completed qualification
      as an Operations Supervisor as required by WHC-CM-5-34.  He has not been
      assigned a formal qualification program for this qualification.

   f. An examination that had been administered to an operator was reviewed. 
      The exam consisted of multiple choice questions of reasonable
      difficulty.  There were no questions that related the individual's
      fundamentals knowledge to operator requirements.

   g. An on-the-job evaluation (OJE) of a trainee performing various plant
      surveillances was reviewed.  The following comments are provided:

      1. The OJE guide did not include written criteria for determining
         successful demonstration of knowledge requirements contrary to the
         guidance in DOE-STD-1012-92, Guide to Good Practice for On-the-Job
         Training.

      2. The T-Plant Surveillance Course (No. 450020) was not reflective of
         the most recent change to its companion procedure (Daily
         Surveillance Procedure DO-040-001).

      3. Both the trainee and the instructor demonstrated deficient knowledge
         of air flow fundamentals.

3. K-Basins:  These facilities consist of K-East (KE) and K-West (KW) basins
   and are being used for the long term storage of spent reactor fuel.  Concern
   about the storage conditions at these basins has been well documented.  A
   plan is in place to commence encapsulation of the KE fuel in June 1994.  The
   K-Basins have previously been identified as having an inadequate level and
   quality of operator training, engineering support, and conduct of
   operations.  An October 1993 training assessment, conducted by DOE-RL,
   confirmed the existence of major weaknesses in the K-Basins training and
   qualification programs.  

   The DNFSB review team toured the facility and observed a routine
   surveillance and preventive maintenance procedure.  Observations and
   comments of an operational nature are included in Attachment 3.  The
   following observations regarding the training and qualification programs are
   provided:

   a. An effective training and qualification program does not currently exist
      for the K-Basins.  The existing supervisors and operators were qualified
      under a previous program and perform some functions of a routine nature
      on a daily basis.  Their level of training has been determined to be
      inadequate by a number of assessments.  In spite of this, facility
      management has not done an assessment to determine which individuals
      should be certified to take particular actions in the facility.  There
      is no listing of which people are certified to perform actions in the
      K-Basin facilities.

   b. The facility management has undergone a number of changes over the last
      year in an attempt to improve the training conditions.  A new Facility
      Manager was assigned in August 1993.  WHC has formed a new separate
      organization for the K-Basins.  The past instability in the management
      of the facility has slowed the improvement and correction of identified
      weaknesses.

   c. A new Facility Training Manager was assigned in early 1993.  His efforts
      have centered around formulating an effective training and qualification
      program.  Some progress has been made in improving the level of
      knowledge of operators.  In 1993, all operators but one have completed
      a five week fundamentals training course.  For most, it was the first
      formal training since a several-day briefing on conduct of operations
      principles was held about two years ago.  Beyond this briefing, formal
      operator training had ceased when the N-Reactor was shutdown.  This
      improved level of attention has not been placed on supervisor
      fundamentals training.  Facility management does plan to have
      supervisors complete either a five or eight week course in fundamentals
      prior to the start of KE fuel encapsulation, currently scheduled to
      start in June 1994.

   d. The major KE training emphasis is towards preparation for fuel
      encapsulation.  Qualification packages for fissionable material handler
      certification are under preparation.  Materials for facility-specific
      classroom type training and on-the-job training (OJT) are not yet
      developed.  Operator certification is to consist of classroom,
      examination, OJT and OJE processes.  Not all of these have been defined. 
      Considering the current maturity of the training program, completion of
      the certifications required for the start of encapsulation in June 1994
      is ambitious and may not be realistic.

   e. The K-Basins Operations Training Plan was reviewed.  The following
      comments are provided:

      1. Examination requirements are ambiguous.  Although examinations are
         required, it is not clear at what point in the qualification process
         trainees will be examined.

      2. Qualification/Certification training requirements are labeled as
         "TBD."

      3. Engineering and Facility Management training requirements have not
         been identified.

   f. A positive initiative of the new Facility Manager was to arrange for
      cross facility experience training in work control procedures for some
      of his people at the Fast Flux Test Facility.  Experience training in
      the conduct of operations area is also planned for sometime in the
      future.

   g. A continuing training program that meets the requirements of DOE Order
      5480.20 has not been developed.

   h. Facility-specific training programs for the technical staff and
      maintenance personnel have not been developed.

   i. Recently, new air cooled chillers were installed in the K-Basins.  An
      OJT checklist was developed to be used for operators to demonstrate
      competency in performance and knowledge requirements regarding operation
      of the chillers.  The one operator who had completed the certification
      had been evaluated and certified by an operator who had not been
      officially approved to operate the chiller.

4. 222-S Laboratory:  The 222-S Laboratory training program was not included in
   the June 1992 DNFSB staff review.  The 222-S Laboratory is part of the
   Processing and Analytical Laboratory (PAL) and is engaged in providing
   analytical chemistry and process development services.  The 222-S Laboratory
   is a low-hazard facility.

   Like the other Hanford facilities visited, the 222-S Laboratory is in the
   early stages of developing a training and qualification program consistent
   with DOE Order 5480.20.  The following observations were made:

   a. The PAL does not have a permanently assigned training manager for
      Laboratory training.  This situation contributes to a lack of
      integration between operations and training organizations.  For example,
      the acting training manager does not attend meetings of the PAL
      manager's direct reports.  

   b. The following observations were made during an OJT session concerning an
      analytical procedure:

      1. The applicable procedure was not on hand and used for reference
         during the steps observed.

      2. Detailed written criteria for successfully passing the OJT were not
         available, contrary to the guidance in DOE-STD-1012-92, Guide to
         Good Practice for On-the-Job Training.

      3. Operators aids were used which were not formally logged and
         authorized in an operator aid system in accordance with DOE Order
         5480.19, Conduct of Operations Requirements for DOE Facilities.

   c. A scheduled ventilation test required the temporary evacuation of the
      radiologically controlled area for two periods of over an hour each.  No
      training or work was planned during the delays.  The PAL management was
      not conditioned to take advantage of this otherwise non-productive
      period to maximize training time.

   d. A review of an individual's training record revealed that during two
      weeks of OJT, he had successfully demonstrated knowledge of over 60
      procedures by discussion alone.  None of the procedures were actually
      performed or simulated.

   e. The DNFSB  team reviewed and observed a portion of the laboratory
      technologist training course.  This course consists of two weeks of
      classroom training and five weeks of OJT conducted in portions of the
      lab at PUREX.  The course covers seven analytical and seven operational
      procedures.  The following comments are provided:

      1. The location at PUREX is not conducive to oversight by managers at
         222-S.  

      2. A review of chemistry fundamentals is not included in the course.

      3. An OJT checklist is not used to track trainee qualification for the
         analytical procedures.  Furthermore, qualifications for the
         operational procedures are signed off based on discussion early in
         the course rather that based on performance to verify mastery.

      4. Standards for demonstrating proficiency with course procedures are
         different from the standards for acceptance when actually performing
         the procedures.  The analytical acceptance band is tighter in
         training, but only 70 percent of the student's results need be
         within the tighter band.

   f. Chemical technologists are qualified to individual procedures rather
      than a position as intended by DOE Order 5480.20.

5. Plutonium Finishing Plant (PFP):  The PFP training program was included in
   the June 1992 DNFSB staff review.  Continuing improvements have been made to
   correct deficiencies noted in the trip report of the staff review.  However,
   the recently announced PFP mission to prepare the facility for
   decontamination and decommissioning includes actions with significant but
   not yet fully defined training impacts, such as reducing the scope of
   operations and reconfiguring the staff to support interim actions.

   a. Observation of classroom instruction on pressure differentials and air
      flows associated with glove boxes indicated that the instructor lacked
      an understanding of fundamentals, did not have satisfactory knowledge of
      related systems, and was not proficient in presenting the subject
      matter.  Similar comments regarding this same instructor were made
      following the June 1992 DNFSB review.

   b. DNFSB staff review of a general plant operations written examination
      revealed it did not meet the guidance contained in DOE-STD-1011-92,
      Guide to Good Practice for the Design, Development, and Implementation
      of Examinations:

      1. A disproportionate number of questions (approximately 40%) covered
         a single topic (hazardous waste handling).

      2. No time limit was specified for taking the exam.

      3. Multiple choice questions had only three choices for answers and the
         number of possible correct choices was not specified.

   c. Classroom instructors have not completed training and qualification on
      facility systems and lack knowledge of these systems.

   d. Because OJT evaluators have been moved out of the operations
      organization, proficiency of OJT evaluators is no longer being tracked.

   e. Specific standards are not provided for instructing and evaluating
      trainees in OJT requirements, contrary to the guidance in DOE-STD-1012-
      92, Guide to Good Practice for On-the-Job Training.  The PFP training
      organization is preparing Job Performance Measures to provide a more
      consistent, less subjective method to evaluating trainee performance.

                                                    Attachment 3

          Comments Concerning Conduct of Operations at
                      T-Plant and K-Basins

T-Plant

1. The performance of a weekly preventive maintenance procedure on a PCM-1B
   (personal whole body radiation monitor) was observed.  Although a lengthy
   pre-job brief was conducted and documented, the extent appeared excessive
   since the operator had performed this weekly cleaning, inspection, and
   functional test on numerous occasions.  A number of deficiencies were noted
   in a review of the work package.  For example: no approval signatures
   appeared on the procedure to be used and the work package specified only
   that "the attached procedure" be used; the work package included a data
   sheet, but did not reference a particular procedure; an incorrect revision
   of the Radiation Work Permit was specified. This work package is routinely
   approved for use for a whole month.  There is no requirement for
   verification of procedural or permit changes prior to each use.  The
   technician failed to perform one of steps required by the procedure. 

2. The requirements to conduct pre-job meetings/briefings are not formalized. 
   The need to conduct these briefings, as required by WHC-CM-1-6, was
   determined from the root cause analysis of an off-normal occurrence in
   August 1992.  Direction for conducting these meetings consists of a brief
   computer note from the Facility Manager.

3. A member of the DNFSB review team attended a pre-job brief for encapsulation
   of asbestos in preparation for removal.  The work package reviewed specified
   a procedure for an encapsulation method different than that which was
   actually to be used for the job.  The intended method (double-wrap plastic)
   was described in an asbestos-removal procedure that was neither included nor
   referenced in the work package.

4. During a training evolution at T-Plant, the trainee and instructor noted a
   radiological area posting had fallen from its support.  Although the trainee
   and instructor both recognized the condition as deficient, no action was
   taken to correct the situation.

5. A T-Plant surveillance procedure observed during a training evolution
   required the operator to record the status of a trouble light.  The
   associated data sheet for the procedure did not provide a space to record
   the information.  The instructor and trainee indicated no intent to initiate
   a procedure change until prompted.

6. Discussion with an instructor and trainee indicated inconsistencies in the
   way operators read gauges when the indicating needle is between gradations.

7. Manually adjusted low and high markers ("red-line" indicators) were
   available but not used on exhaust ventilation monitoring equipment.

K-Basins

1. Numerous deficiencies were noted during the observation of an operator
   performing a routine patrol of the KW-Basin.  Many of these deficiencies
   were in the conduct of operations area.  Most of the systems in the basin
   were shutdown, but no provision for this situation had been made with regard
   to entries in the patrol log.  This caused some confusion for the operator
   and resulted in his making several errors.  Examples of deficiencies
   include: the operator was not familiar with the proper action to take if an
   out-of-specification condition was found and was confused on how to record
   such a condition; the operator was not familiar with requirements for
   logkeeping and could not recall ever having been instructed in this regard;
   several errors in the log sheet were noted even though the sheet is
   currently undergoing its third revision this year; the log required the
   operator to sign or initial in approximately 114 places during a patrol that
   lasted about one and one-half hours; the operator was not alert to identify
   abnormal conditions existing in the facility.

2. During a tour of the KW-Basin Motor Control Room #1, it was noted that three
   electrical circuit breakers had been removed from an energized electrical
   panel.  In their place, heavy green colored tape had been placed over the
   breaker handle openings.  No lockout/tagout was in place.  This condition
   had existed for over a month, was known by and had been reported to facility
   management by the operators.  No protective actions other than the taping
   had been taken.  The operator making routine patrols no longer logged the
   condition as being abnormal.

3. A temperature gauge calibration procedure required the calibration
   instrument well temperature to be set to 150oF.  The instrument reading
   displayed temperature to the first decimal point.  Actual temperature
   steadied at 150.4oF.  The procedure did not indicate what temperature range
   was satisfactory.

4. The temperature gauge calibration procedure was difficult to follow step-by-
   step.  The instrument technician used the data sheet, rather than the
   procedure, to guide him through the calibration.  The data sheet was filled
   out incorrectly when one gauge failed the calibration.