DEFENSE NUCLEAR FACILITIES SAFETY BOARD

December 9, 1994


MEMORANDUM FOR:       G. W. Cunningham, Technical Director

COPIES:               Board Members

FROM:                 M. B. Moury, Pantex Program Manager

SUBJECT:              Pantex Plant:  Staff Review of the Qualification Evaluation
                      Process.

1. Purpose:  This memorandum provides Defense Nuclear Facilities Safety Board
   (DNFSB) staff observations of four 1994 Qualification Evaluations (QE),
   including:

   a.  W79 Capping QE for Dismantlement (QED) [September 13-16, 1994 - Moury]
   b.  W70 Keel Erosion QED  [September 13-16, 1994 - Martin]
   c.  W48 QED, which included:
       (1)     W48 DMSO QED [September 27-30, 1994 - DeLoach, Owen, Drain (SPC)]
       (2)     W48 Contingency Procedures QED [October 25-26, 1994 - DeLoach]
       (3)     W48 Mechanical QED [November 15-16, 1994 - DeLoach, Andrews,
               Preston]
       (4)     W48 War Reserve (WR) QED [November 29 - Ongoing - Waugh, DeLoach] 
   d.  W78 QE for Surveillance (QES) [ September 13-15, 1994 - Waugh]

2. Background: The revised guidance for readiness reviews of
   assembly/disassembly operations  was published in Rev. 1, Change 8 to the
   Albuquerque Operations Office (DOE-AL) Dismantlement and Production Manual,
   Chapter 3.7 (D&P 3.7). Comments on the adequacy of the directive were
   provided by the Board to the Department of Energy (DOE) in response to a
   Recommendation 92-6 deliverable on December 9, 1994. 
   
   D&P 3.7, Section 6 states the QE is intended to be "a formal, systematic,
   performance-based examination of tooling, testers, equipment, procedures,
   personnel, and facility controls to ensure that nuclear weapon
   assembly/disassembly operations will be performed in a safe and predictable
   manner."  D&P 3.7 describes the QE process and defines the requirements for
   determining readiness to start-up, restart, or continue weapon
   assembly/disassembly operations at the Pantex Plant.  There are three
   variants of the QE: the Qualification Evaluation for Dismantlement (QED);
   the Qualification Evaluation for Surveillance (QES); and the Qualification
   Evaluation for Production (QEP).  The requirements for conducting the
   evaluations are similar.

3. Summary:   The DNFSB staff observed the W48 QEDs to assess the
   implementation of D&P 3.7.  In addition, the staff observed the W79 Capping
   QED, the W70 Keel Erosion QED and the W78 QES, that were conducted before
   the release of the new guidance in D&P 3.7.  

   The QEDs observed demonstrated an increased involvement by the National
   Laboratories, with their unique weapons expertise and experience, in
   reviewing nuclear weapon operations.   However, implementation of the
   requirements of D&P 3.7 was inadequate.  Specifically, the reviews were
   functioning more as technical assistance visits than an independent check
   of readiness.  The QE's observed by the staff lacked the rigor and
   formality demonstrated during other independent readiness reviews observed
   at other DOE sites. Additional concerns include: several QE team members
   lacked independence;  the QE team composition precluded adequate review of
   technician training and conduct of operations; detailed criteria were not
   systematically assessed; and findings appeared to be forced to the lowest
   classification, "enhancement", including procedure deficiencies and a
   violation of an explosive safety rule.  The staff also noted that Mason &
   Hanger's (M&H) implementation of the readiness to proceed process and the
   Amarillo Area Office (DOE-AAO) verification of M&H's readiness did not meet
   the requirements of D&P 3.7.

4. Discussion:   The following general comments are applicable to the QEs
   observed by the staff.

   a.  The QE process is not being implemented as an independent readiness
       evaluation as described in D&P 3.7 or other readiness-to-proceed
       evaluations as described in DOE Order 5480.31, Startup and Restart of
       Nuclear Facilities.  It compares more closely to a technical assistance
       visit than a readiness evaluation.  The QE daily meetings were congenial
       discussions in which M&H personnel freely challenged and influenced
       categorization of QE team members' findings.  This practice is not
       consistent with an independent check of  "readiness to startup, restart,
       or continue weapon assembly/disassembly operations" as defined in D&P
       3.7.

   b.  The QEs focused on the seven general areas of safe nuclear weapons
       operation enumerated in Section 9.2 of D&P 3.7.  However, the QEs did
       not appear to assess operations in a systematic manner using the
       detailed criteria provided in section 9.3 of D&P 3.7.  Observations were
       often subjective and there was no assurance that all defined criteria
       were adequately addressed by the team.  A staff review of the
       observation sheets revealed that few of the observations made by the QE
       Team members were based on D&P 3.7 criteria or requirements from DOE
       Orders or standards in use at Pantex.

   c.  The mix of participants on the QE team limited their ability to evaluate
       the demonstration of procedural safety and adequacy of individual steps. 
       Rigorous review of conduct of operations and technician training for the
       specific dismantlement program was lacking.  There were many operational
       deficiencies identified by the DNFSB staff during the QEs that were not
       detected by the QE team.  The deficiencies consisted primarily of
       procedure-adherence violations, use of unapproved pre-operational
       checklists, poor radiological controls, and recurring deficiencies with
       procedures and procedure sign-off sheets (Q-sheets). 

   d.  Several QE team members lacked independence as required by D&P 3.7 in a
       manner that had the potential to compromise their objectivity.  In the
       W48 QED, several QED members including a Core Team co-chair had
       previously approved changes to the Nuclear Explosive Operating Procedure
       (NEOP).  In the W79 Capping QED the Lawrence Livermore National
       Laboratory (LLNL) Core Team leader had been a supervisor for the capping
       process and the M&H Team Member was the cognizant assembly engineer for
       the activities being reviewed.  

   e.  QE team members were required to propose the necessary actions to
       correct their findings.  This practice is not required by D&P 3.7 and is
       inconsistent with the handling of findings during other readiness
       reviews in the DOE complex, where corrective actions are developed by
       line management.  

   f.  It appeared to DNFSB staff observers that categorization of QE team
       findings were being skewed to the lowest level, termed "enhancement,"
       that do not require any corrective action.  Examples included findings
       on NEOP changes that were required to permit procedure compliance by the
       technicians, and one violation of an explosive safety rule (placing an
       explosive component on a cart without brakes).  This may be due to D&P
       3.7 not containing guidance or criteria for determining how to
       categorize findings.

   g.  In some areas, the operations that were demonstrated to the QE team did
       not accurately represent planned operations on War Reserve (WR) units. 
       Examples include execution of informal process and procedure changes,
       use of additional technicians to conduct the dismantlement than planned
       for the WR, and not demonstrating critical steps in the dismantlement
       such as handling and protection of detonator cables due to trainer
       constraints.

   h.  The Qualification Evaluation for Surveillance (QES) observed was
       conducted with even less rigor and formality than the QEDs observed. 
       Specifically, QES team members were absent for large portions of the
       review and no review plan was developed as required by D&P 3.7.  All the
       concerns with the QEDs described above also applied to the QES.  The
       value of the QESs as they are currently conducted is questionable.  The
       differences in these evaluations appear to be due, in part, to different
       divisions in DOE-AL being responsible for conducting the reviews.

   i.  The W48 QED was hampered by lack of full implementation of the defined
       readiness to proceed  process as evidenced by the numerous deficiencies
       identified with the NEOPs.  The QED team identified over 120 specific
       procedure issues in addition to those identified by the DNFSB staff
       during the first three segments of the W48 QED.  Additional NEOP
       deficiencies continue to be identified during the ongoing W48 WR QED. 
       M&H STD-7301, Operational Readiness (OR) Procedure, provides line
       management "a formal, auditable methodology for determining operational
       readiness of activities."  Based on these numerous deficiencies, it is
       not apparent that all the reviews and actions required by STD-7301 were
       fully implemented and performed.  The specific provisions of  STD-7301
       were not provided in the readiness to proceed documentation and were not
       reviewed by DOE-AAO as required by D&P 3.7. 

5. Future Staff Actions:  The staff will continue to observe QE activities at
   Pantex and to evaluate the implementation of D&P 3.7.