II.  MAJOR TECHNICAL ACTIVITIES OF THE BOARD DURING 1994
  
  A. HEALTH AND SAFETY MANAGEMENT OF DEFENSE NUCLEAR FACILITIES
  
     A significant result of the last major reorganization of the
  Department of Energy in 1993 was that the roles and responsibilities of
  the offices involved in nuclear safety were not clearly delineated.  In
  May 1994, the Board imposed a reporting requirement on DOE (pursuant to 42
  U.S.C. 2286b(d)) requiring the Department to provide a  brief summary
  description of the basic safety management system that DOE currently has
  in place for satisfying its responsibilities under the Atomic Energy Act
  to protect or to minimize danger to life and property.     The Board
  requested DOE to describe how safety is considered throughout the life
  cycle of  defense nuclear facilities, including the major stages of
  design, construction, operation,  and decommissioning.  DOE was also
  requested to clearly define the nuclear safety responsibilities of the
  various line and internal oversight organizational elements.
  
     In its October 1994 response, DOE described the objectives, tasks,
  and safety considerations for each phase of the system life cycle, as well
  as the general transition, interface, and information flow requirements
  among the phases.  The response provides a systems-oriented framework for
  DOE to examine its safety management program critically.  Additionally,
  the Department revised its Manual of Functions, Assignments and
  Responsibilities.  The Board views these steps as positive measures toward
  strengthening the Department's safety management program, and is now
  assessing the effectiveness with which this manual has been implemented by
  headquarters and field organizations.
  
     In response to budgetary restrictions, the Secretary announced a
  plan in December 1994 to review the structure of the Department.  This
  effort, to be performed by both DOE employees and independent experts,
  should afford a valuable opportunity to address systematically the subject
  of health and safety responsibilities of individuals and organizations
  within the Department.  Because of the clear opportunity for the
  Department to improve its health and safety management, the Board intends
  to monitor this effort during 1995.
  
  B. SAFETY ASPECTS OF THE ASSEMBLY, DISASSEMBLY, AND TESTING OF
       NUCLEAR WEAPONS
  
     DOE is responsible for maintenance and support of the active nuclear
  weapons stockpile, retaining the capability to resume nuclear testing (in
  accordance with Presidential direction), dismantlement of nuclear weapons,
  and associated research and development.  The nature of DOE's weapons
  mission in these areas has changed from its former thrust toward design,
  production and testing to an emphasis on dismantlement, stockpile
  maintenance, decommissioning, and safe storage.  DOE has defined its
  adjustments to these changes in two program initiatives:  (1) Stockpile
  Management, which deals with the retention of capability to maintain the
  systems in the U.S. nuclear weapons stockpile; and (2) Stockpile
  Stewardship, which deals with retention and development of the
  technological tools necessary to maintain confidence in the safety,
  reliability, and performance of U.S. nuclear weapons and their associated
  components.  The thrust of these initiatives is to move toward a smaller,
  but fully capable nuclear weapons complex.
  
     DOE's efforts to adapt the nuclear weapons complex to reflect
  changes in the U.S. national security posture have resulted in new areas
  needing safety attention.  The Board has taken action on four fronts to
  help ensure that such changes do not degrade nuclear safety.  These four
  areas of primary focus in 1994 were:  (1) the adequacy of technical
  staffing, (2) the evaluation of facility and process readiness, (3) the
  conduct of ongoing operations, and (4) ensuring that the safety of
  operations is standards-based. 
     
     Adequacy of Technical Staffing:  The Board continues to note the
  close relationship between the recruitment, training, and retention of
  well-qualified personnel and nuclear safety.  This issue is an especially
  crucial one in a "downsizing" environment.  The continued need for
  technically competent personnel in the weapons complex was addressed by
  the Board in its 1993 Recommendation 93-6;  Recommendation 93-3  addressed
  this issue DOE-wide.  
  
     The Board issued Recommendation 93-6 to highlight the need to retain
  access to and capture the unique knowledge of individuals who have been
  engaged for many years in assembly, disassembly, and testing of nuclear
  weapons, so as to avoid future safety problems.  The Board noted that many
  individuals are being lost from the defense nuclear system, due to
  retirement incentives, layoffs, and other downsizing activities, and that
  these individuals possess information that is not presently documented. 
  Retention of this information is essential if DOE is to maintain the
  capability to safely manage and maintain the weapons stockpile, and
  conduct dismantlement activities.
  
     The Secretary accepted Recommendation 93-6 in February 1994, stating
  that the Department shared the Board's concern about ensuring capability
  to conduct nuclear weapons testing operations and dismantle nuclear
  weapons safely.  In May 1994, the Secretary notified the Board that 45
  additional days were needed to develop an integrated and effective
  approach.  In its response to the Secretary, the Board stressed that some
  aspects of the recommendation have a high degree of urgency, emphasizing
  that impending early retirement of weapons experts in DOE and the National
  Laboratories would exacerbate an already inadequate staffing situation. 
  The Board noted that technical competence in DOE's defense activities was
  already below a level necessary for continued safety, and urged an
  aggressive approach to supplement the Defense Programs organization with
  additional, technically competent personnel.
  
     In July 1994, the Department submitted an Implementation Plan
  generally acceptable to the Board.  A specific element of the plan
  committed to an immediate review of staffing of specific organizational
  elements of DOE's weapons complex and the need for additional, technically
  qualified personnel.  Unfortunately, the initial efforts to assess
  staffing were unsatisfactory.  In September 1994, the Board wrote to the
  Department, stating that the initial report did "not address either of the
  explicit requirements of the commitment (i.e., the status of current
  staffing and recommendations for additional staff)."   However,
  discussions between the Board and the Secretary led to a commitment by DOE
  in late 1994 to: (1) allow the Headquarters staff to be supplemented
  immediately with ten additional personnel for nuclear safety-related
  activities; (2) conduct a comprehensive technical staffing review to
  identify where technical resources were lacking; and (3) determine how to
  focus additional resources.
  
     In general, DOE's progress on meeting the commitments in its
  implementation plan for Recommendation 93-6 has been limited, due in part
  to the staffing inadequacies highlighted by the Board.  In its September
  letter, the Board informed DOE of a number of deficiencies.  As a result
  of the Board's letter, DOE assigned senior DOE managers to better
  coordinate implementation of  Recommendation 93-6.  Their efforts did
  result in some additional progress, but at year-end, implementation of
  Recommendation 93-6 was still substantially behind schedule.
  
     The potential safety impact of a delay in meeting the objectives of
  Recommendation 93-6 is significant.
  
     During 1994, the Board also made inquiries as to the availability of
  technically qualified former military personnel to perform duties within
  the weapons complex.  This topic was the subject of a meeting between
  members of the Board and the Deputy Secretary of Defense in July 1994.  At
  that meeting, the members also specifically addressed the importance of
  assigning a senior military officer to the position of DOE Deputy
  Assistant Secretary for Military Applications and Stockpile Support
  (DASMASS) for a period longer than the customary two-year tour.  That
  officer should be a technically competent manager with a background in
  nuclear weapons and/or nuclear facilities. They also addressed the need
  for the Department of Defense to continue its attention to the selection
  of highly qualified individuals of sufficient stature and commitment to
  critical  positions as an essential element in ensuring the continuing
  safety of the defense nuclear complex.     
  
     Evaluation of facility and process readiness:  The readiness of
  facilities in the weapons complex to operate safely was a topic of
  significant Board attention throughout 1994.  Particular emphasis was
  placed on conduct of appropriate readiness reviews.   For specific weapon
  assembly and disassembly operations, the Nuclear Explosive Safety Study
  (NESS) along with the Qualification Evaluation (QE) processes are utilized
  to independently assess readiness.   
  
     In December 1993, the Board called for an independent review of the
  NESS process.  Subsequently, a review of the NESS process was conducted by
  an independent team composed of nuclear safety professionals from the
  Department of Defense and the DOE National Weapon Laboratories. 
  Completion of this review in May 1994 led to the development of a NESS
  Corrective Action Plan, which addressed program deficiencies, a number of
  which were taken care of by DOE immediately by issuing interim guidance
  instructions.  The remaining corrective actions are being integrated with
  the implementation of an earlier Recommendation 93-1, and are scheduled
  for completion by June 1995.  
  
     Throughout 1994, the Board exercised oversight of the majority of
  NESSs  performed by DOE for operations at the Pantex Plant and at the
  Nevada Test Site.  Oversight reviews were focused on the adequacy of
  interim guidance issued by DOE, and on field compliance with the guidance
  and with the requirements of DOE Order 5610.11 (which addresses nuclear
  explosive safety).
  
     Guidance for readiness reviews of weapons operations was developed
  by DOE in response to Recommendation 92-6.  The guidance calls for a
  Qualification Evaluation (QE) to be performed after certification of
  readiness by contractor and DOE line management.  The QE, performed by a
  team of National Weapon Laboratory personnel, assesses the adequacy and
  correctness of the procedures for weapon assembly or disassembly, and
  verifies that safety considerations have been addressed.  The Board
  provided DOE with suggested improvements to DOE's guidance paper, and at
  year-end, DOE was in the process of responding to the Board's comments.
  
     The Board observed and reviewed implementation of the QE process at
  the Pantex Plant.  On-going efforts to implement the process resulted in
  the identification of improvements required by both the DOE Amarillo Area
  Office and the DOE Albuquerque Operations Office.  The lessons learned
  from reviews performed in 1994 are to be used by DOE to upgrade future
  QEs. 
  
     Recommendation 93-6 called for maintaining safety-related nuclear
  testing expertise to ensure that if testing is required in the future, it
  can be resumed safely.   In support of this effort, and in response to
  Recommendation 92-6, DOE developed a Test Readiness Assessment (TRA)
  program.  DOE uses full-scale exercises as a primary means to achieve test
  readiness.  The Board provided several observations on the conduct of
  testing exercises where the intent of Recommendation 93-6 was not being
  met, and DOE committed to strengthen the exercise program in the areas
  identified by the Board.
  
     Conduct of Ongoing Operations:  Detailed review of the ongoing
  operations at facilities in the weapons complex received high priority in
  1994.  These reviews included, for example, standards-based evaluations
  of: conduct of operations, radiological controls, operational safety,
  maintenance of safety-related systems, and quality assurance.  One such
  review performed at the Y-12 Plant in Oak Ridge disclosed systemic
  problems with criticality safety and conduct of operations; these were
  addressed by the Board in Recommendation 94-4.  These problems are
  discussed in detail in Section I.E.1.  At the Pantex Plant, the Board
  continued to monitor DOE's progress in implementing a satisfactory level
  of conduct of operations, pursuant to its corrective action plan issued in
  response to the Board's November 1993 reporting requirement.
  
     Standards-based Operations:  During 1994, DOE completed its analysis
  of the differences between the safety requirements applicable to nuclear
  explosives facilities and those which are applicable to other defense
  nuclear facilities, as called for in the Department's Implementation Plan
  for Recommendation 93-1.  This analysis, coupled with the analysis called
  for in a December 1993 Board letter regarding the Nuclear Explosive Safety
  Study (NESS), led DOE to conclude that the guidance and requirements
  contained in its 5610 series of orders (on Nuclear Explosive Safety)
  needed improvement.
  
     The Department developed a plan to improve the requirements
  applicable to nuclear explosive facilities, which were set forth in orders
  and the NESS program.  DOE also committed to developing an action plan for
  upgrading and expediting order compliance self-assessments at facilities
  that assemble, disassemble and test nuclear weapons.
  
     Progress in achieving these improvements in order compliance self-
  assessment has been inconsistent, with some facilities showing substantial
  improvements (e.g., Los Alamos National Laboratory) and others lagging
  behind (e.g., Lawrence Livermore National Laboratory and the Nevada Test
  Site).   On the other hand, the Board was encouraged by DOE's commitment
  to extend the applicability of selected safety orders and to enhance the
  set of DOE standards.
  
  C. SAFELY MANAGING SURPLUS NUCLEAR MATERIALS AND WASTES
  
     1.   Safe Disposition of Surplus Nuclear Materials
  
     Recommendation 94-1, issued in May 1994, called for an accelerated
  schedule for stabilizing and repackaging unstable special nuclear
  materials and spent fuel.  DOE's Plutonium Vulnerability Study, a detailed
  and wide-ranging evaluation of the safety of plutonium stored in DOE
  facilities, reached conclusions similar to those reached by the Board. 
  However, the Board has concluded that the risks posed by those materials
  are more serious than appears to be recognized by DOE, and that DOE's
  schedules for stabilizing and repackaging need to be accelerated in the
  interests of worker and public safety.  Recommendation 94-1 specifically
  called on DOE to:
  
     o      bring stored plutonium metal and oxide at all sites into
            conformance with the DOE plutonium storage standard within
            approximately eight years;
  
     o      process the plutonium and trans-plutonium solutions in the
            Savannah River Site's F-Canyon within 2-3 years into forms
            safer for interim storage;
  
     o      repackage plutonium metal in contact with plastic at all sites
            within 2-3 years;
  
     o      process possibly unstable plutonium residues at Rocky Flats
            within 2-3 years into forms suitable for interim storage;
  
     o      process deteriorating irradiated fuel at the Savannah River
            Site within 2-3 years into forms suitable for interim storage;
  
     o      place deteriorating irradiated fuel from the K-Basins at the
            Hanford Site in a stable configuration within 2-3 years;
  
     o      establish a research program to help choose among candidate
            processes for conversion to interim forms and longer-term
            disposition; and
  
     o      maintain facilities that may be needed for future handling and
            treatment of such materials.
  
     The Department's initial Implementation Plan, submitted in December
  1994, was not acceptable to the Board.  DOE agreed in general terms with
  the Board's objectives but declined to commit itself to the
  recommendation's timetable for taking specific actions.  Meanwhile, the
  Board's sense of urgency was reinforced by further developments after the
  recommendation was issued.  
  
     As postulated by the Board, high concentrations of hydrogen gas have
  been found in the headspace of drums containing plutonium residues at
  Rocky Flats.  Radiography of these drums during 1994 showed that the
  residues were contained in plastic bottles, rather than in sealed
  stainless steel cans, as called for by good practice.  The Board has
  concluded that substantially increased action is required to implement
  Recommendation 94-1.
  
     Recommendation 94-1 recommended that storage of all plutonium metal
  and oxide conform to the then-draft DOE plutonium storage standard.  DOE
  subsequently issued the standard (in December 1994) requiring that
  plutonium oxide be thermally stabilized before packaging for storage, and
  that containers used to store plutonium metal or oxide be sealed,
  structurally adequate, corrosion-resistant, and free of organic materials. 
  This will require repackaging thousands of items stored at Rocky Flats,
  the Los Alamos and Lawrence Livermore National Laboratories, the Hanford
  Site, and the Savannah River Site.
  
     DOE has identified several sites where it is known or suspected that
  plutonium metal is in contact with plastic, creating the potential for
  producing radiolytic hydrogen.  These sites include Rocky Flats
  (approximately 250 items), the Savannah River Site (12 containers), and
  the Mound Site (number of items not known).  Currently, thirteen of the
  plutonium items that were originally packaged in contact with plastic at
  Rocky Flats have been repackaged.
  
     DOE has proposed processing the plutonium solutions remaining in F-
  Canyon systems at the Savannah River Site to metallic form within two
  years.  It is planned that the trans-plutonium solutions will be vitrified 
  in F-Canyon within the next five years, but the Board is concerned that
  continued storage of this highly radioactive material in a liquid form
  poses potential risks to the public.  The Board is working with DOE to
  explore alternatives that would lead to this material being stabilized
  sooner.  In addition, DOE is developing plans to stabilize the remaining
  uranium, neptunium, and plutonium solutions being stored in H-Canyon and
  F-Canyon.  The Board will continue to monitor these plans to ensure that
  these materials are stabilized safely and in a timely manner.
  
     In January 1995, DOE formally withdrew the Implementation Plan for
  Recommendation 94-1, in response to the Board's dissatisfaction.  A
  revised Plan is scheduled to be delivered to the Board in February  1995. 
  The Board expects that DOE will make firm commitments for an aggressive
  schedule to accomplish the stabilization called for in Recommendation 94-
  1.
  
     2.   Accelerated Waste Characterization at the Hanford Site 
  
     The Board continues to urge DOE to accelerate the pace of the
  program for characterizing and processing the contents of high level
  nuclear waste tanks at the Hanford Site.  In its 1990 Recommendation 90-7,
  the Board stated that the schedule for characterizing tanks containing
  ferrocyanide compounds needed to be greatly accelerated.  Its
  Recommendation 93-5 expanded upon Recommendation 90-7, stating that DOE
  should complete all safety-related characterization of high-level waste
  tanks at the Hanford Site within three years, with the characterization of
  the high priority  tanks being completed in the first two years. 
  Recommendation 93-5 also called for the characterization program to be
  integrated into the systems engineering program for the Tank Waste
  Remediation System at the Hanford Site to ensure the data necessary to
  select treatment and immobilization methods will be available when needed. 
  The Secretary of Energy accepted these recommendations.   The
  Implementation Plan for Recommendation 93-5 was accepted by the Board in
  March 1994.
  
     Sampling and analysis of the contents of high-level waste tanks are
  far behind schedule.  The schedule problems involve both the
  characterization strategy and its subsequent execution.  DOE has not been
  able to develop a technically defensible strategy for efficiently
  characterizing the high-level waste tanks.  Mechanical problems and poor
  sample recovery have plagued the contractor's core sampling equipment. The
  contractor is operating to a schedule that will not complete safety-
  related characterization of watch list tanks until two years after the
  Implementation Plan commitment, and the remaining tanks one year later
  than committed.  DOE is analyzing the situation to see if the goals of
  Recommendation 93-5 can be achieved with substantially less sampling and
  analysis.  Thus far, no technically sound plan of action has emerged, and
  DOE has not convinced the Board that it can meet the goals of
  Recommendation 93-5.  
  
     3.   Storage of Spent Nuclear Fuel
  
     During 1994, the Board continued its 1993 activities in review of
  storage of spent nuclear fuel storage at the Idaho National Engineering
  Laboratory (INEL), the Savannah River Site, and the Hanford Site.
  
     In the past year, 189 fuel containers were successfully moved from
  an old, structurally unstable location to a newer and more structurally
  competent storage basin at the Idaho Chemical Processing Plant.  The Board
  considers these and other actions being taken to manage vulnerabilities at
  INEL to be a DOE safety improvement.
  
     The K-East Basin at the Hanford Site contains more than a thousand
  tons of deteriorating, irradiated nuclear fuel.  The fuel is substantially
  corroded and the basin is heavily contaminated.  These degraded conditions
  result in increased waste generation, higher personnel exposure, and
  greater difficulty in the handling, storage and disposal of the fuel.  The
  K-East Basin has leaked on several occasions, and is likely to leak again. 
  In addition, analysis shows that in a severe seismic event, the basin may
  not remain intact.  Contaminated water released from the basin could
  migrate to the nearby Columbia River.
  
     As part of its Recommendation 94-1, the Board called for the
  deteriorating fuel in the Hanford Site's K-East Basin and fuel storage
  basins at the Savannah River Site to be placed in a stable configuration
  for interim storage within two to three years.  DOE's current planning
  calls for packaging the K-East Basin fuel and the associated fission
  product sludge, and removing it from the basin by 1999.  Defense-related
  fuel in the Savannah River Site basins is scheduled for processing by
  2004, with the bulk of the most deteriorated fuel being processed by 1997. 
  DOE is currently re-evaluating its commitments under Recommendation 94-1,
  in an effort to improve these schedules.
  
     4.   Low Level Waste Management
  
     In September 1994, as part of its Recommendation 94-2, the Board
  recommended that DOE complete a complex-wide review of the low-level waste
  issue, with the objectives of establishing  the dimensions of the low-
  level waste problem and identifying necessary corrective actions to bring
  operations into compliance with applicable safety standards.  In
  preparation for the substantial increase in low-level waste projected from
  cleanup programs, the Board recommended that DOE's Implementation Plan
  include a program for forecasting future burial needs.   The Board urged
  that more immediate steps be taken to complete performance assessments for
  all active low-level waste burial sites, as required by DOE Order 5820.2A. 
  The Board also recommended that DOE issue instructions to ensure that
  performance assessments are based on total inventories of low-level waste
  (past, present, and future) emplaced or planned for a burial site and that
  performance objectives be achieved for the composite of all low-level
  waste disposal facilities on the site.
  
     The Secretary of Energy accepted Recommendation 94-2 in October 1994
  and committed to undertake a complex-wide baseline assessment of DOE's
  low-level radioactive waste disposal requirements and practices.  The
  Department also recognized the importance of assessing cumulative impacts
  to the public health and safety due to total waste inventories and all
  low-level waste disposal facilities on a site.  At year-end, DOE was in
  the process of developing its Implementation Plan.  


  D. SAFETY ASPECTS OF CONDUCT OF OPERATIONS
  
     1.   Conduct of Operations
  
     DOE's requirements regarding conduct of operations at its facilities
  are set forth in DOE Safety Order 5480.19, which establishes the
  expectation that operational formality at defense nuclear facilities be on
  a par with that used by the commercial nuclear industry.  In June 1994, as
  part of DOE's annual report for Recommendation 92-5, the Department
  provided a brief description of the operational status and plans for
  future use of facilities in the defense nuclear complex.
  
     The report did not present significant new initiatives regarding
  requirements for conduct of operations.  Recent reportable occurrences and
  observations made during site visits by the Board's staff members, and
  DOE's August 1994 report of its review of conduct of operations, indicate
  slow and uneven progress in implementing Departmental requirements.  The
  status of implementation of DOE 5480.19 as stated in the June 1994 report,
  is too optimistic since significant deficiencies exist in the
  implementation of this order throughout the complex, more than four years
  after its issuance. 
  
     An example of deficient conduct of operations practices is provided
  by recent observations at the Y-12 Plant in Oak Ridge.  Although DOE and
  the operating contractor at the Y-12 Plant at the Oak Ridge Site have made
  some improvements in conduct of operations over the past two years,
  several violations of Operational Safety Requirements (OSRs) and
  Compliance Schedule Agreements (CSAs) during 1994 indicated an
  unsatisfactory level of conduct of operations.
  
     In September 1994, during a routine site review, members of the
  Board's staff observed several violations of nuclear criticality safety
  limits in Y-12 storage vaults and brought these violations to the
  attention of contractor management and the DOE Facility Representative. 
  Neither the DOE nor contractor personnel present took the actions required
  by the applicable criticality safety procedure.  Proper actions were taken
  only after members of the Board's staff notified the DOE Y-12 Site Office
  Manager.  As a result of these violations, contractor management curtailed
  Y-12 activities and began a comprehensive site-wide review of compliance
  with all CSAs.  That review identified more than 1300 CSA noncompliances. 
  Contractor management subsequently shut down all operations at Y-12
  pending correction.  
  
     This apparent breakdown of administrative controls and other conduct
  of operations problems at Y-12 were key factors leading the Board to issue
  Recommendation 94-4, calling for DOE to fully evaluate compliance with
  OSRs and CSAs, determine root causes of identified violations, review the
  nuclear criticality safety program, and establish actions to resolve the
  nuclear criticality deficiencies at Y-12.   The Board also urged DOE to
  compare the level of conduct of operations at Y-12 to the level expected
  by DOE in implementing the Board's Recommendation 92-5.
  
     DOE accepted Recommendation 94-4 in mid-November, and is developing
  an implementation plan in parallel with improving criticality safety,
  conduct of operations, and other administrative safety programs before
  resuming Y-12 operations.   During 1995, the Board intends to monitor
  DOE's efforts to resume operations at Y-12.
  
     On the other hand, some notable examples exist where the right mix
  of management attention, resources, and staffing expertise has been
  brought together to implement an effective conduct of operations program. 
  Examples include the startup of the Replacement Tritium Facility and the
  restart of F-Canyon, both at the Savannah River Site; and the restart of
  Building 559 at Rocky Flats.  At these facilities, line managers were
  personally committed to the program and involved in finding and correcting
  problems, and communicated their strong support and expectations to
  subordinates.  Sufficient numbers of experienced operations personnel were
  assigned to the facilities, and DOE field organizations were staffed with
  knowledgeable managers and facility representatives who were committed to
  enforcing the correct standards.
  
     2.   Readiness of Facilities to Operate
  
     In response to Recommendation 92-6, DOE issued a new order, DOE
  Order 5480.31, in September 1993, establishing requirements for starting
  or resuming operations and the readiness review process.  An associated
  standard, DOE-STD-3006-93, which was issued in April 1994, provides
  detailed guidance for planning and conducting readiness reviews at defense
  nuclear facilities, other than those involved in nuclear explosives
  activities.  The issuance of these requirements and standards is a
  positive action toward assuring nuclear safety throughout the operating
  complex.
  
     The Board has monitored implementation of the new order across the
  complex.  Some examples of the results of the Board's oversight appear
  below.
  
  o    In early 1994, the Board reviewed preparations for increased storage
       of pits in Zone 4 at the Pantex Plant, finding, among other things,
       that DOE and contractor line management had not achieved an adequate
       state of readiness before conducting an Operational Readiness Review
       (ORR) for pit storage, according to the requirements of DOE Order
       5480.31.  The premature ORR revealed practices needing improvement. 
       Thus, contrary to the original intent, the ORR team functioned as an
       adjunct to line management, rather than as an independent check of
       readiness.
  
  o    This practice, which effectively nullifies the safety benefits of an
       independent check, was observed in a number of other cases.  The
       Board raised this issue in a letter to the Department in April 1994. 
       In August 1994, DOE responded by committing to provide further
       training to line management personnel on the readiness review
       process and to revising DOE Order 5480.31 to more clearly define
       actions in certifying readiness to operate.       
  
  o    At Rocky Flats, DOE completed an Environmental Assessment for
       limited use of Building 707 to stabilize plutonium-bearing residues,
       and found no significant environmental impact.  Although an ORR had
       been completed more than two and a half years earlier, DOE decided
       a reassessment was warranted.  In July 1994, DOE completed that
       additional ORR for limited operations in Building 707.  The Board
       reviewed the preparations for renewed calcining operations and based
       on its staff's report, concluded that the ORR was conducted
       satisfactorily, and so informed DOE in August 1994.  DOE authorized
       resumption of the limited operations in Building 707 in December
       1994.
  
  o    At the Idaho National Engineering Laboratory, the Board and its
       staff monitored preparations to restart the de-nitrator process at
       the Idaho Chemical Processing Plant.  In June 1994, DOE completed an
       ORR.  The Board found that preparations by line management and
       conduct of the ORR adequately demonstrated readiness to restart
       operations. 
  
  o    The Board also monitored the process of establishing readiness to
       resume operation at various facilities at the Savannah River Site,
       including the F-Canyon, FB-Line, and the In-Tank Precipitation
       facilities.  Preparations for restart of both F-Canyon and FB-Line
       in 1994 included ORRs conducted by DOE Headquarters, which
       identified several issues requiring resolution before restart.
  
  o    As previously stated,  the Oak Ridge Y-12 Plant management had shut
       down most nuclear operations in late 1994 because of numerous
       noncompliances with safety requirements.  During this hiatus, DOE
       chose to conduct a number of important nuclear operations at Y-12,
       including support for inspections by the International Atomic Energy
       Agency, receipt of highly enriched uranium from Kazakhstan (the
       SAPPHIRE project), and receipt of certain components of nuclear
       weapons disassembled at the Pantex Plant.  In each of these cases,
       the Y-12 contractor prepared a special activity package describing
       the additional controls and actions that would be taken to ensure
       safety of these high priority  activities during the shut-down
       period.  The Board evaluated the review and approval process and
       subsequently reviewed the proposed operations.  In each case, the
       Board saw no undue risk to health and safety of the public or
       workers. 
       
  o    In early 1994, the Board reviewed the readiness of the LANL TA-55
       Plutonium Facility to proceed with production of plutonium oxide
       pellets in support of NASA's Cassini Mission to Saturn.  LANL and
       DOE did not conduct full operational readiness reviews prior to
       restart.  They relied on what they believed to be adequate
       experience of the operators from previous campaigns for fabrication
       of similar pellets.  However, to review whether the higher
       throughput rate required for Cassini posed a significant risk, the
       Board held two public meetings in March 1994.  Subsequently, in
       reviewing compliance with procedures and safety limits, LANL
       management suspended production operations for two and a half months
       to make operational improvements.  Production operations began again
       in late July 1994.
  
  E. SAFETY ASPECTS OF MANAGING THE DEFENSE NUCLEAR FACILITY       
     SYSTEM LIFE CYCLE
  
     1.   Systems Engineering Implementation
  
     The Board has become increasingly aware that DOE does not treat
  interacting operations at individual sites or combinations of sites as a
  system whose components mutually affect each other.  This point is
  commonly overlooked in planning of facilities, operations, and programs,
  and more often that not leads to unworkable results.  A systems-based
  process attempts to optimize the solution of a complex problem by breaking
  the problem into component parts and then engineering component parts in
  the context of the whole.  For example, preparation of the high level
  waste in the tanks at the Hanford Site for geologic disposal will require
  characterization, pre-treatment, vitrification, and packaging. 
  Engineering the solutions for these complementary functions must be done
  in the context of the system objective; namely a stabilized waste form
  suitable for disposal.
  
     During 1994, the Board reviewed systems engineering activities at
  several facilities including: the control of safety bases for operations
  at the Pantex Plant;  improvements to be made in the OSR surveillance
  process at the TA-55 facility at LANL; and the remediation of high level
  waste at the Hanford and Savannah River Sites and at the Idaho National
  Engineering Laboratory (INEL).  Systems engineering activities related to
  the disposition of special nuclear material and spent nuclear fuel at the
  Hanford Site , INEL, the Savannah River Site, and Rocky Flats were also
  reviewed by the Board in the past year.  To date, reviews have shown that
  these various DOE activities have been largely unsatisfactory.  In
  general, the Board has noted that DOE has not consistently taken a
  formalized systems approach to solving safety, technical, and managerial
  problems.
  
     A complex-wide DOE standard that formalizes the method would help. 
  The need for better guidance on systems engineering was apparent during a
  number of the Board's reviews in 1994.  Several examples are provided
  below.
  
          On two occasions, in April and May,  the Board informed
       DOE of what it considered to be inadequacies in design basis
       information involving systems serving safety functions,
       configuration management, and flow-through of technical
       requirements to operational procedures at the Pantex Plant and
       at LANL.  Subsequently, DOE elected to curtail operations at
       the Pantex Plant and at LANL's TA-55 facility for extended
       periods.
  
          As part of the Tank Waste Remediation System (TWRS) at
       the Hanford Site, DOE announced its intention to build
       additional one-million gallon, double-shell tanks as major
       elements of the Multi-functional Waste Tank Facility (MWTF). 
       The Board's review of the process of design of these tanks,
       both in the managerial and technical areas, resulted in the
       issuance of Recommendation 92-4 calling for a systems
       engineering approach to the design, construction, operation,
       and eventual decommissioning of the MWTF.  DOE has made some
       progress toward use of systems engineering for project
       development within the TWRS.  However, at the end of 1994, it
       was still not being fully used by DOE.  It was not used to
       decide whether new tanks are really needed, how many there
       should be, and how large they should be.  
  
          The use of systems engineering by DOE's Office of Spent
       Nuclear Fuel (EM-37) has evolved from a series of DOE-
       sponsored workshops, site meetings and site activities during
       1994.  This has resulted in the development of functional
       requirements at a high enough level to ensure some consistency
       across the defense nuclear complex.  However, during a recent
       visit to the Savannah River Site, it was observed that both
       ongoing and planned contractor projects supporting the storage
       and processing of spent fuel are not linked to the Spent
       Nuclear Fuel Systems Engineering Program.  The situation
       resembles that with the TWRS described above.  There seem to
       be no near-term plans to integrate the Spent Nuclear Fuel
       Systems Engineering Program with current spent nuclear fuel
       projects in the field.
  
     Failure to use a systems approach in planning can lead to greatly
  increased cost, delays, inferior solutions to problems, and even inability
  to solve some problems.  The Board will continue to emphasize the need for
  a systems engineering approach in these and other projects in the complex.
  
     As part of its efforts to streamline project development, DOE is
  revising DOE Order 4700.1, dealing with systems management.  The Board has
  reviewed initial drafts of the revised order and has provided its comments
  to DOE regarding needed improvements to address the problems noted above. 
  All these activities are ongoing and have had or will have significant
  impact on operations or decommissioning of numerous DOE facilities.  
  
     2.   Seismic and Other External Hazards Mitigation
  
      During 1994, the Board's review of seismic hazards focused on the
  design adequacy of key facilities in DOE's nuclear materials storage and
  waste management.   Reviews continued of the design basis adequacy of the
  In-Tank Precipitation Facility (ITP), the H-Area Waste Tank Farms, and the
  Defense Waste Processing Facility (DWPF) at the Savannah River Site; the
  Tank Waste Remediation System at the Hanford Site; the spent fuel storage
  basins at the Idaho Chemical Processing Plant; and Building 371 at Rocky
  Flats.  The adequacy  of the Chemistry and Metallurgy Research Laboratory
  (TA-3) and the Plutonium Facility (TA-55) at Los Alamos National
  Laboratory were also reviewed, and a November 1994 letter was accordingly
  sent to DOE requesting a report concerning design practices at LANL. 
  
     Based on  its review of the seismic aspects of DOE's efforts to
  consolidate the large inventory of plutonium and highly enriched uranium
  at Rocky Flats into a single building,  the Board concluded that DOE's
  ongoing activities to better identify and respond to potential hazards
  from natural phenomena were not well integrated.  The activities were not
  logically structured or sufficiently encompassing in either detail or
  scope to assure protection of public health and safety.
  
     In September 1994, the Board  issued Recommendation 94-3, calling
  for a systems approach to the design basis for Building 371 at Rocky Flats
  and the safety concerns associated with the increased storage of special
  nuclear material in this facility.  The Secretary has accepted the Board's
  recommendation, and the Department is currently developing an
  Implementation Plan.
  
     Since the types and magnitudes of potential earthquakes act as
  important driving forces on facility design and modification decisions,
  the Board continues to monitor efforts to characterize earthquake ground
  motion at the Hanford Site, INEL, LANL, Rocky Flats, the Oak Ridge
  Reservation, and the Savannah River Site.  The Board has raised questions
  regarding the emphasis DOE places on probabilistic methods for
  characterizing earthquake ground motion, without concurrently reconciling
  that methodology to the analytical procedures used successfully in the
  commercial nuclear power program.  Probabilistic methods have been
  changing rapidly, with new and untested assumptions and extrapolations
  being introduced.  Validation of these models will require time and
  experience.  The Board is examining and has questioned the use of
  probabilistic methods in lieu of the deterministic approach used by the
  commercial nuclear industry.
  
     The Board intends to continue to work with DOE on these matters
  during 1995.
  
     3.    Criticality Safety
  
     In Recommendation 93-2, the Board recommended that DOE retain its
  program of criticality experiments to improve the criticality data base
  and to serve in training the community of criticality engineers.  The
  Department responded positively to this recommendation.  DOE chose the Los
  Alamos Critical Experiments Facility (LACEF) for this purpose and formed
  a Nuclear Criticality Steering Committee to provide guidance in responding
  to Recommendation 93-2.  DOE identified projected funding and experiments
  for execution through Fiscal Year 1995 and summarized the significant
  accomplishments in an annual report on the status of the program.  The
  Board will continue to review the adequacy of future funding for
  criticality experiments and criticality engineer training, as well as the
  operation of the LACEF in general.
  
     In late September 1994, after draining low-concentration plutonium
  solution from a storage tank, an operator in Building 771 at Rocky Flats
  drained solution from another tank, outside the scope of the procedure. 
  As a result, about five liters of highly concentrated plutonium solution
  were collected in a potentially unsafe geometry.  Although criticality did
  not occur, this action defeated the controls that had been put in place to
  prevent a nuclear criticality accident.  Following this event, the Rocky
  Flats plant contractor suspended tank draining operations as well as a
  number of other operations that involve the handling of special nuclear
  material.  In November 1994, the Board requested that DOE address the
  issues raised in Board Recommendation 94-4 as applicable to this
  criticality infraction and provide a report within 60 days.  At the end of
  the year, the suspension was still in effect, and DOE was preparing its
  response to the Board's request for a report.
  
     4.   Safety Analysis of Site Operations
  
     The Board continued to review the technical adequacy of Safety
  Analysis Reports (SAR's) of DOE facilities. During 1993, the Board's
  review of analyses of potential aircraft crashes at defense nuclear
  facilities indicated that the methodologies employed in these studies vary
  significantly from site to site.  It was seen that the differences
  resulted from lack of uniform guidance by DOE.  Within the past year, DOE
  has initiated the development of a consensus standard to address this
  deficiency.
   
     In October 1993, the Board requested that DOE prepare a report
  providing additional information on several technical issues concerning
  military overflights of the Pantex Plant and  the methodology used for
  evaluation of the impact of an aircraft crash into the Pantex Plant Zone
  4  storage magazines.  The Board reviewed DOE's report and questioned the
  validity  of the Pantex Plant's analysis in a letter to the Department in
  June 1994, and requested that a safety evaluation be conducted using
  methodology prescribed in DOE Order 5480.21, Unreviewed Safety Questions. 
  DOE addressed the issues raised by the Board and found errors in the
  calculations of the probability of an aircraft crash into Zone 4.   
  
     A cooperative activity by DOE, the City of Amarillo, the U.S. Air
  Force, and the Federal Aviation Administration (FAA) resulted in an
  agreement to reduce the number of aircraft overflights of the Pantex Plant
  significantly during the next five years. 
  
     The Board has reviewed safety analyses for several other DOE defense
  nuclear facilities, including separations facilities, and the high-level
  waste storage and processing facilities at the Savannah River Site (SRS). 
  Several of these facilities are scheduled to begin operations in 1995.
  
     The Board conducted several reviews of the safety of the F-Canyon
  and FB-Line.  These reviews resulted in the implementation of additional
  safety measures and the upgrade of existing safety analysis documentation. 
  Some of the specific measures include: (1) isolation of Tank 17.1, which
  contains highly radioactive americium and curium solutions, to reduce the
  risk of release to the environment; (2) upgrade of capabilities to monitor
  the activity of cooling water to reduce the risk of a release to the
  environment; (3) reclassification of the process vessel vent system to
  provide additional controls to prevent the accumulation of flammable gas;
  and (4) modification of the 3rd and 4th level ventilation systems at the
  FB-Line to prevent unmitigated releases during a fire.  The F-Canyon
  restarted second plutonium cycle operations in February 1995 and the FB-
  Line is scheduled to restart in April 1995.
  
     The Board reviewed the safety analysis for the In-Tank Precipitation
  (ITP) Facility and questioned the adequacy of several key assumptions
  related to the rates of benzene generation and the degree of mixing.  
  These assumptions had led to a DOE conclusion that a flammable vapor
  mixture could not form in the tank headspace under either normal or
  abnormal conditions.  In response to the Board's questions, DOE
  implemented a program to validate the assumptions made in the safety
  analysis.  This program includes the development of a computer simulation
  of the tank headspace to determine the degree of mixing during normal and
  abnormal conditions (e.g., loss of ventilation).  The results of this
  analysis will be validated by a test program prior to initial startup of
  the ITP, scheduled in July 1995.
  
     The Board has monitored the startup test program for the Defense
  Waste Processing Facility (DWPF) and has reviewed the safety of process
  operations.  The design and classification of safety systems that control
  and prevent the formation of flammable vapor mixtures in several process
  operations were questioned.  In response to the Board's questions and
  DOE's own independent oversight findings, DOE reassessed the design and
  classification of these safety systems.  The need for several significant
  upgrades has been identified (e.g., backup inert gas purging systems). 
  These will result in a significant reduction of the risk to the workers
  and public.  Board reviews also led to comprehensive reassessment of the
  facility,  integration of required research and development efforts, and
  significant improvements in conduct of operations, operator training,
  control system design, and mitigation of process hazards.  DWPF is
  scheduled to start up in December 1995.
  
     DOE has explored the concept of risk acceptance in its safety
  management programs.  This is a potential departure from the deterministic
  approach based on engineering disciplines traditionally used in safety
  assessments in the commercial nuclear industry as well as in the military
  weapons safety program.  The Board has held numerous discussions with DOE
  about the use of risk assessment and its acceptance in safety management,
  particularly where data for probability estimates are lacking.  The Board
  continues to encourage DOE to make maximum use of deterministic analysis
  coupled with defense-in-depth mitigation of accidents and hazards, while
  looking to risk determination as additional confirmatory information for
  use in the Department's safety management programs.