May 5, 1995

The Honorable Victor H. Reis
Assistant Secretary for Defense Programs
Department of Energy
Washington, D.C.  20585

Dear Dr. Reis:

On November 25, 1994, the Defense Nuclear Facilities Safety Board (Board)
requested a report identifying the formal process(es) the Los Alamos National
Laboratory (LANL) is following to identify and mitigate hazards in the design,
construction, and preparation for operation of new and upgraded defense
nuclear facilities.  In your initial reply of March 6, 1995, you stated that
the Chemistry and Metallurgy Research (CMR) building upgrades project will
serve as an example for defense nuclear projects at LANL.

The Board's staff has recently visited the CMR building, as well as the TA-55
Plutonium Facility, to review electrical, instrumentation and control systems,
and configuration management.  The staff has provided the Board with the two
enclosed reports.  Based on these reports, it is likely that a proper
identification of hazards for the apparent mission of CMR would lead to the
necessity of providing emergency/standby power.  LANL stated that while
emergency/standby power will be considered for the upgrades, it is possible
that neither emergency nor standby power will be implemented.  In addition, it
appears that configuration management activities need to be considerably
strengthened prior to significant additional physical work on the CMR
upgrades.  

The Board believes these observations merit Department of Energy line
management attention.  Hence, the enclosed staff trip reports are forwarded
for your information and use.  Mr. Steven Krahn of the Board's staff will be
available to provide any additional information you may require. 

                              Sincerely,

                              John T. Conway
                              Chairman

c:     Mr. Mark Whitaker

Enclosures

DEFENSE NUCLEAR FACILITIES SAFETY BOARD

February 22, 1995

MEMORANDUM FOR:       G. W. Cunningham, Technical Director

COPIES:               Board Members

FROM:                 Ajit K. Gwal

SUBJECT:              Los Alamos National Laboratory - Chemistry and Metallurgy
                      Research and Technical Area 55 - Trip Report (January 23-26,
                      1995)

1. Purpose:  This report documents a review of the electrical, instrumentation,
   and control systems at the Los Alamos National Laboratory (LANL) Chemistry
   and Metallurgy Research (CMR) building and the Technical Area 55 (TA-55)
   facility by Defense Nuclear Facilities Safety Board (DNFSB) technical staff,
   Ajit K. Gwal and R. Todd Davis on January 23-26, 1995.

2. Summary:  

   a.  CMR Building:

       1.  Maintenance:  A comprehensive program for corrective, preventive, and
           predictive maintenance does not exist for electrical equipment at the
           CMR building.  Facility electrical maintenance is performed
           approximately every three years by a site-wide LANL organization,
           regardless of equipment requirements in accordance with industry
           standards and vendor recommendations.

       2.  Emergency/Standby Power:  The facility ventilation system (that
           maintains directional air flow to prevent spread of contamination),
           fire alarm system, and most radiological monitors are not supplied with
           emergency or standby power.  Reliable power is an essential element of
           the power distribution system for defense nuclear facilities to ensure
           safe facility shutdown, limit the spread of contamination, and detect
           fire and radiological hazards.

       3.  Battery Ventilation:  Lead-acid battery ventilation in both the CMR
           building and the TA-55 facility is inadequate.  Ventilation is
           necessary to prevent hazardous buildup of hydrogen gas.  There is
           currently no plan to upgrade the battery ventilation systems.  Good
           industry practices with respect to battery room ventilation are the
           requirements of American National Standards Institute (ANSI) C2,
           National Electric Safety Code.

   b.  TA-55 Facility:

       1.  Oil-Insulated Transformer:  Four oil-insulated transformers, that are
           part of the power distribution system, are located inside the TA-55
           facility.  The transformer oil, that provides transformer cooling, is
           flammable and is a fire hazard if the transformer leaks or fails
           catastrophically.

       2.  Electrical Calculations:  Electrical calculations required by industry
           standards for voltage profile, short circuit studies, and protective
           device coordination were not available.  These calculations are
           necessary in the evaluation of the electrical distribution system's
           safety and reliability.

       3.  Emergency Power:  The facility currently has only one standby Diesel
           Generator (DG).  There is an ongoing staff review to determine if the
           facility requires emergency backup power and, therefore, requires an
           additional diesel generator.

3. Background:  The CMR building was constructed in the early 1950s and provides
   experimental facilities for plutonium and uranium chemistry and metallurgy
   research.  The TA-55 plutonium processing and handling facility, that was
   constructed in the mid 1970s,  provides capabilities for recycling,
   preparation, fabrication and research of plutonium and analytical chemistry.
   
4. Discussion:

   a.  The review identified the following potentially significant issues at the
       CMR building:

       1.  Maintenance:  Electrical maintenance at the CMR building is performed
           by a site-wide organization approximately every three years.  However,
           many electrical components (e.g., batteries, relays and breakers)
           require more frequent maintenance.  CMR personnel are preparing a
           Master Equipment List (MEL) in accordance with Department of Energy
           (DOE) Order 4330.4B, Maintenance Management Program, that will identify
           safety and non-safety related equipment.  As discussed in the CMR
           building Maintenance Implementation Plan, the MEL will eventually be
           used for maintenance planning and scheduling.

       2.  Emergency/Standby Power:   The facility ventilation system (that
           maintains directional air flow to prevent spread of contamination),
           fire alarm system, and most radiological monitors are not supplied with
           emergency or standby power and become inoperable during a loss of
           power.  DOE Order 6430.1A requires emergency or standby power for " .
           . . equipment components whose operating continuity is determined to be
           vital  . . .  for protection of health, life, property, and safeguards
           and security systems. . . [including] fire alarm, security alarm, and
           supervisory sensing devices designated essential by the cognizant DOE
           authority."  Based on the safety-related function of the systems
           identified above, the staff believes a reliable backup power source is
           appropriate for the CMR building.  Additional analysis is required to
           determine whether the backup power supply should be emergency or
           standby.  CMR personnel stated that installation of backup generators
           will be considered during the second phase of upgrades scheduled to
           begin in 1996.  

       3.  Battery Ventilation:  ANSI C2 National Electric Safety Code requires
           adequate ventilation and loss of ventilation alarms for rooms with
           lead-acid batteries to ensure hydrogen does not buildup and result in
           an explosion.  The battery systems at both the CMR building and the TA-
           55 facility do not meet the requirements of ANSI C2 (i.e., inadequate
           ventilation and no loss of ventilation alarms).

       4.  Electrical Upgrade:  Because the CMR building was constructed in the
           early 1950s and is reaching the end of its design life, significant
           upgrades are required to allow the building to continue its mission. 
           An interim safety analysis report was written in 1992 that identifies
           the facility weaknesses and formed the basis for a 10-year upgrade
           project.  The project is divided into three phases with the first
           through third phases scheduled to be complete in 1996, 2002, and 2003,
           respectively.  Most of the electrical upgrades, that  are budgeted for
           approximately 20 million dollars, are scheduled for accomplishment
           during the first phase of upgrades.  The electrical upgrades include
           replacement of three substations, correcting deficiencies, installing
           an Uninterruptible Power Supply (UPS) for the stack monitors and
           upgrading the emergency lighting, low voltage power distribution,
           grounding and lightning systems.

       5.  Facility Electrical Support:  Except for personnel associated with the
           current electrical upgrades, the CMR building does not have an
           electrical systems engineer as part of the dedicated staff. 
           Considering the size and type of facility, the staff believes facility
           staffing should include an electrical systems engineer.

       6.  Single Point Failure:  The LANL electrical distribution system can
           receive power from two separate power generation plants.  However, the
           high voltage transmission lines that provide power to the site cross
           each other at one point.  A failure of the transmission lines at this
           point could isolate the site from power for an extended period.

   b.  The review identified the following potentially significant issues at the
       TA-55 facility:

       1.  Oil-Insulated Transformer:  Four oil-insulated transformers located
           inside the plutonium handling facility are part of the power
           distribution system.  The transformer oil provides cooling for the
           transformer.  Because the oil is flammable,  it is a fire hazard if the
           transformer leaks or fails catastrophically.  DOE Order 6430.1A states
           that "only hazardous gases or liquids that are necessary for a process
           shall be used in plutonium processing and handling facilities."  In
           addition, the National Electrical Safety Code and National Fire
           Protection Association (NFPA) 70, National Electric Code, require
           indoor oil-insulated transformers be located in a transformer vault. 
           The code requirements for the transformer vault include fire walls and
           doors, ventilation, and oil containment and drainage.  The TA-55
           transformers do not meet the requirements for oil containment. 
           Additional justification and/or mitigation of the oil hazard may be
           appropriate to ensure safe operation of the TA-55 facility.  DNFSB
           staff believes that the replacement of oil-insulted transformer with a
           dry type transformer is a prudent approach to resolve this concern. 

       2.  Electrical Calculations:  Electrical calculations for voltage profile,
           short circuit studies and protective device coordination, as required
           by the ANSI/Institute of Electrical and Electronics Engineers (IEEE)
           standard 141, IEEE Recommended Practice for Electrical Power
           Distribution for Industrial Plants, and ANSI/IEEE standard 242, IEEE
           Recommended Practice for Protection and Coordination of Industrial and
           Commercial Power Systems, were not available.  Therefore, the staff
           could not verify the capability of electrical equipment to withstand
           available short circuit currents without creating unsafe conditions for
           site workers.

       3.  Emergency Power:  The TA-55 facility currently has only one Diesel
           Generator.  In addition, this generator does not start automatically
           after failure of the normal source of power.  TA-55 personnel stated
           that a review of DG design has been performed and that final
           determination of DG classification and functional requirements will be
           addressed in the Final Safety Analysis Report (scheduled to be
           submitted to DOE in July 1995).  There is an ongoing staff review to
           determine if the facility requires emergency backup power and,
           therefore, requires an additional diesel generator and design upgrades.

       4.  Utility Control System Upgrade:  The TA-55 utility control system,
           which monitors and partially controls the power distribution,
           ventilation, and radiological monitoring systems, is over 15 years old
           and fails frequently.  The facility is upgrading the system with
           programmable logic controllers that will provide reliable utility
           monitoring and control capabilities.  This project is scheduled to be
           completed in 1996.

5. Future Staff Actions:  The DNFSB staff plans to continue to follow the
   upgrade project for the CMR building including resolution of maintenance,
   backup power, and battery ventilation issues identified in this report.  In
   addition, the staff plans to follow-up on the TA-55 facility resolution of
   staff observations relative to the backup DG, oil-insulated transformers, the
   electrical distribution system calculations and the utility control system
   upgrade.

DEFENSE NUCLEAR FACILITIES SAFETY BOARD

February 9, 1995

MEMORANDUM FOR:         G.W. Cunningham Technical Director

COPIES:           Board Members

FROM:             Donald J. Wille

SUBJECT:          Los Alamos National Laboratory - Configuration Management at
                  Chemistry and Metallurgy Research Building and Technical Area 55 
                  (January 24-26, 1995)

1. Purpose:  This report documents a review of configuration management
   activities at the Los Alamos National Laboratory (LANL) Chemistry and
   Metallurgy Research (CMR) building and the Technical Area 55 (TA-55)
   Plutonium Facility (PF-4) by Defense Nuclear Facilities Safety Board (Board)
   technical staff, Donald J. Wille and Roger W. Zavadoski on 
   January 24-26, 1995.

2. Summary:   Configuration management at LANL is only a few years old and a
   significant learning process is still underway.  Facility managers define the
   practices and procedures for their own facilities.  At the CMR facility, the
   change control procedure applies only to the current Phase 1 electrical
   upgrade activities.  There is a need to considerably strengthen the
   configuration management program prior to Phase 2 upgrade activities.  At TA-
   55 twenty design change packages are in progress under the configuration
   management control procedure and only one package has been completed. 

   The design bases for the ventilation systems at CMR and TA-55 are not in
   compliance with the Department of Energy (DOE) Order 6430.1A, General Design
   Criteria in that, neither facility has a commitment to provide an ongoing
   comparison of the design against requirements. 

3. Background:

   a.  Configuration Management at CMR- The CMR facility Configuration Management
       Plan was issued in December 1994 and the policy issued in January 1995
       (contained in the Quality Management Plan).  The CMR change control
       procedure was issued in December 1994 based on the change control
       procedure developed for TA-55 and applied to the Phase 1 electrical system
       upgrades currently in progress.

   b.  Configuration Management at TA-55- TA-55 issued a Configuration Management
       Plan dated January 20, 1995, that defined a program consistent with the
       guidelines in the DOE standard, Guide for Operational Configuration
       Management Program, DOE-STD-1073-93.  This plan includes an operational
       program and an adjunct design basis reconstitution activity. 

   c.  Compliance with DOE Order 6430.1A- The draft Safety Analysis Report (SAR)
       for CMR issued in 1994 contained an Appendix 3 listing the comparison of
       the facility design with the requirements of DOE Order 6430.1A.  The final
       SAR is in preparation, and LANL indicated that it does not contain such a
       comparison.  

4. Discussion:
       
   a.  CMR - Configuration Management - The configuration management (CM) process
       at CMR is a very new activity and does not have a dedicated individual. 
       The CM function is provided by the Facility Manager, or designee, on a
       part-time basis.  The Facility Management group does have sensitivity to
       the ownership of the facility and knowledge of the daily ongoing
       activities within the building.  However, this is often on an informal
       basis, which could lead to surprises.  

   b.  CMR - Change Control - The recently issued change control procedure only
       applies to the current Phase 1 upgrades and does not apply to temporary
       changes (variances) or changes to procedures.  This results in a slow
       learning process and may not include necessary work items, such as
       maintenance, for some time.  Configuration management activities need to
       be considerably strengthened prior to Phase 2 upgrade activities.
   
   c.      TA-55 - CM Program - The recently issued configuration management
           program plan recognizes that not all elements of the final program can
           be implemented at the outset and compensating measures will be taken in
           the interim.  For example, tracking of proposed changes against
           drawings will be done using a retrievable index until a Master Document
           List and controlling software are developed.  

   d.      TA-55 - System Classification - Classification of the facility
           structures, systems, and components (SSC) will be in four SSC grades
           based on the TA-55 SAR upgrade project.  These are (1) Safety class
           (SC); (2) Safety-significant (SS); (3) Mission-critical (MC); and (4)
           Balance-of-plant (BOP).  Currently only four systems are included in
           the two safety grades.  They are (1) Confinement System - (SC)
           (includes portions of the ventilation systems); (2) Zone 1, 2, and 3
           Ventilation Systems - (SS) (sections not included above); (3) Critical
           Alarm System - (SS); and (4) Continuous Air Monitors - (SS).

       The ongoing SAR upgrade project analysis may result in additional systems
       being added to the safety grades.  It is important to note that many
       support systems that may be needed for proper functioning of safety grade
       systems are not included, such as Uninterruptible Power Supply (UPS) and
       the Diesel Generator.  This will require further review as part of the
       Safety and Hazards Analysis and Electrical Systems elements.

   e.      TA-55 - Design - System Design Descriptions (SDD) are being prepared to
           capture the system features and design requirements.  This procedure
           only requires SDDs to be prepared for the four safety grade systems,
           although a total of 12 SDDs are being prepared at the present time. 
           The as-built drawing program in progress is expected to have about 300
           drawings transferred to a Computer Aided Design (CAD) system. 
           Approximately 15,000 drawings exist for the original facility.

   f.      TA-55 - Change Control - A new procedure for Change Control for
           Systems, Structures, and Components was issued on June 17, 1994.  There
           are 20 Design Change Packages (DCPs) initiated under this procedure
           with 17 DCPs currently in development.  Of the remaining three DCPs,
           one is approved for construction, one is installed and approved for
           operation, and one DCP is completed and closed.  This procedure
           provides for a comprehensive review and documentation of proposed
           design changes and physical item changes.  The level of review and
           analysis for a DCP depends on the nature of the proposed change and
           always includes a safety screen review.  

   g.  Ventilation Systems Design at CMR and TA-55 - The ventilation systems at
       CMR and TA-55 are not in accordance with certain requirements of DOE Order
       6430.1A, General Design Criteria, for redundancy, emergency power supply,
       and mitigation of off-site dose following postulated accidents. 
       Compliance with the requirements of DOE Order 6430.1A will not be
       identified in the updated SARs.  It is noted that DOE Order 5480.23
       section 8.b.(3).(b) requires that a SAR address applicable statutes,
       rules, regulations, and DOE Orders, and provide sufficient detail to serve
       as a comprehensive reference, and explicitly demonstrate compliance with
       these applicable statutes, rules, and Orders.  

5. Future Staff Actions:  The Board's staff plans to review the following:

   a.  Review some completed DCPs for technical adequacy and compliance with
       procedures.

   b.  Review development of completed SDDs and the basis for design
       requirements.

   c.  Review the final SAR for CMR and the SAR Upgrade for TA-55 for compliance
       with DOE Order 5480.23 to address applicable statutes, rules, regulations,
       and DOE Orders; particularly, DOE Order 64301.A.