Peter S. Winokur, Chainnan

Jessie H. Roberson, Vice Chairman

John E. Mansfield

Joseph F. Bader

Washington, DC 20004-2901

13,

Huizenga

_L.:a,........ £~"lI'" Advisor for Environmental M(maQeInellt

lJ3"t"'\o-r1"1n'\i31t'\t" ofEnergy

Independence Avenue,

Washington, DC 20585-0113

Huizenga:

The staffofthe Defense Nuclear Facilities Safety Board (Board) has conducted a series

ofreviews to evaluate the implementation ofIntegrated Safety Management at the activity level

at ofEnergy (DOE) sites. recently, in November 2011, the staffreviewed

activity-level processes procedures Savannah River Nuclear

Solutions (SRNS) at the Savannah River Site. The staff's review identified weaknesses in

hazard analysis and identification of controls, as well as in DOE oversight.

The Board's stafffound SRNS's processes procedures have on occasion led to

an incomplete set ofhazard controls necessary to ensure that activity-level is accomplished

safely. SRNS's hazard analysis process does not readily accommodate breaking down ofwork

tasks and subtasks that for the effective identification ofhazards and development of

controls.. As a result, the hazard analysis process does not consistently identify or specify a

complete set ofcontrols for task-specific hazards.

staff also reviewed oversight ofactivity-level work planning provided by the

DOE Savannah River Operations Office (DOE-SR). The review revealed that DOE-SR had not

been performing meaningful programmatic oversight ofwork planning and Ofnote,

neither DOE-SR nor SRNS had perfonned a thorough review ofwork planning and control using

the guidelines issued by DOE's Office ofEnvironmental Management in April 2010.

time ofthe staff's review, both DOE-SR and SRNS were engaged in revising the

procedures and improving the processes for activity-level work planning~ including DOE-SR

oversight in this area. The enclosed intended to DOE-SR and SRNS in this

important and ongoing effort to strengthen worker safety.

Sincerely,

Peter S. Winokur,

Chairman

Enclosure

c: Mr. Glenn S. Podonsky

Dr.. David C. Moody

Mari-Jo Campagnone
DEFENSE FACILITIES SAFETY BOARD

March 9,2012

FOR: T. J. Dwyer, Technical Director

COPIES: Board Members

SUBJECT:

z. McCabe, R. Verhaagen

Activity-Level Work Planning and Control, Savannah River

Nuclear Solutions

This report documents a review by the staff of the Defense Nuclear Facilities Safety

Board (Board) of the implementation of Integrated Safety Management (JSM) in the activitylevel work planning and control processes and procedures used by Savannah River Nuclear

Solutions (SRNS) at the Savannah River Site (SRS). The staff also evaluated the oversight of

planning and control by the Department of Energy (DOE) Savannah River Operations

Office (DOE-SR). The review was performed by members ofthe Board's staff, D. Gutowski,

z. McCabe, Owen, R. Raabe, and R. Verhaagen, during the week of November 14,2011.

The Board's SRS site representatives, D. Burnfield and Santillan, also participated in the

review.

Background. SRNS is the management and operating contractor at SRS. SRNS

develops and maintains the manuals and codes of practice used by SRNS and the high-level

waste contractor, Savannah River (SRR). The staffs review focused on SRNS's

procedures and processes for planning and controlling production and maintenance at the activity

level, including three key institutional procedures: Conduct ofMaintenance; 2S-1.1,

Procedure Administration; 80-122, TaskLevelHazardAnalysis. The Board's staff

evaluated the effectiveness of these procedures in directing work planners to identify and analyze

hazards, to identify controls, to controls in work packages and

procedures. The staff also evaluated the implementation of these procedures through interviews

personnel of operations E and L Areas.

the time of the review, SRNS was formulating revisions to its processes and

procedures for planning and controlling work. For example, the hazard analysis procedure was

being revised to state more clearly for using a team approach (versus serial

and review) to performing hazard analyses and identifying hazard controls. The number of

_..1L-L....... _ ...................&.'" processes used was being

seven to combining maintenance, and

production operations processes a single set of directives and eliminating the separate
recent developments ~",,'..a.U""IL'-'

procedures for work planning,

to .... _.a.t........a...........

a recently developed DRS Corporation work ......~r'\."o,;---"t" is "('1:1-:l,t''';'"t:lnt"t=l£1

.....r'\.nort"·Il"OC'l 1I'"Orl1l1l1l1160n to

"~1'"",I .... -t-'I_n..·.... f'\.__ of these nT...,.£""t::l,1"111""J::;)C' aid greatly in the

-nc:l1 r-·"I.,If"l~i-.:7 as more _..I.:lI. ...., __ current ~..l'-;VV'L:JLJ"',;!J

leave the workforce. addition to being complicated, SRNS's planning procedures

IrelaU{~ntJlv use vague terms-for "as .....a._ .."'~_,_ necessary"-and as a result do

not always specify requirements or to ..,_......... ...,.................. ..l..l'''-''-'"... ....,....,......A.

The Assisted Hazard Analysis (AHA) software application does not readily accommodate

work ta s task-level h~r;~n't'"r"1C'

As a result, the AHA application and process fail to consistently identify or specify controls for

task-specific hazards. These processes and procedures can lead to

inadequate hazard analyses a set of controls.

supporting these conclusions are organized below with respect to the core functions of ISM.

Scope staff often is not broken

tasks and subtasks as necessary for subsequent hazard identification and selection of

a associated a may not

identified. Additionally, instructions, AHAs, and radiological work permits (RWPs) for a

given job often identify different controls and are not well integrated. SRNS does not always

analyze controls by each of these to ensure not

conflict.

SRNS's work planning benefit greatly in area that draft

instructions be developed to assist with definition of the scope of work and subsequent hazard

analysis. These instructions in They

would help ensure that subtasks are defined in sufficient hazards associated with

each subtask can be evaluated, and the instructions, are integrated

and specified controls analyzed in aggregate. current reQIUII'emLen-ts

guidance for performing walkdowns are scant, and training does not compensate for this lack of

Strengthening the

improve performance in this area, and indeed is recommended in the work planning guidelines

issued by Office in 2010.

authorizes "model work orders'" for use in jobs ofsimilar

orders are pre-existing work packages intended for use with specified equipment in a specified

a similar scope is to a piece

-'i"'''.Li-J.i..A..AvJl..i..L. or a location, SRNS's process requires only that the model work order be

fouted for approval prior to use. This process does not a evaluation of the scope

of to ensure is for new

work and location; hence any new hazards introduced with this different work may not be

recognized. formal to use of the order the

applicability of ensure hazards are _....r,._ ..... _I .......

2
Analyze Hazards and Implement Controls-SRNS uses the software application

for higher-hazard and more complex work planning. The application allows planners to

associate hazards with either tasks or subtasks. a ofthe weaknesses in

defining the scope ofwork, the process does not consistently or specify controls at

the subtask leveL One limitation ofthe AHA application is the inability of planners to quantify

the identified hazards. This is an important analysis as controls can vary

depending on the magnitude ofthe hazard (e.g., noise, voltage, or pressure hazards).

Additionally, controls hazards identified in an may not be specified in the and/or

in the procedure. For example:

• AHA work in E Area did not specify controls associated with each identified

hazard. Many ofthe controls were marked "N/A-will be detennined during mockup

training" or "controls as specified in TWD [technical document]." It was

unclear what controls were identified during mockup training, and many instances

the TWD specified no controls for identified hazards.

• The control in an AHA for cask unloading in L Area was "containment and/or

contamination controls are included in the technical work document." The TWD

specified no containment or contamination controls.

The staffs review revealed weaknesses in application ofRWPs to control

radiological hazards. In particular, SRNS is not using RWP suspension limits adequately to

control hazards. RWPs for operations in both E and L Areas specified artificially high

suspension limits that were not based on expected radiological conditions. Rather, the

suspension limits were set high to provide latitude for performance ofthe work instead ofbeing

responsive to unanticipated hazardous conditions. DOE Standard 1098-2008, Radiological

Control, provides guidance for selecting suspension limits so that workers are alerted to

changing radiological conditions. In one case, an RWP specified different suspension limits

depending on the selected personal protective equipment, rather than the anticipated radiological

conditions. In another instance, a radiological parameter used as a suspension limit could not be

measured until after the work had been completed. These are all indications that the selection

and application ofRWP suspension limits need to be improved.

Perform Work within Controls-The Board's staff observed the performance of

operations in E and L Areas. In all cases, the pre-job briefs were interactive and thorough. The

workers were clearly experienced and competent, and the majority ofwork observed was well

performed. Supervisors were actively involved in observing the workers. The staff noted

instances in which supervisors intervened to ensure that appropriate controls were in place.

During the conduct of one operation, a pump was placed on top of a drum with its power cord

stretched horizontally in the air. The work team knew the pump to

discussed this possibility at the pre-job brief, but they did not know that the proximity of

electrical outlets and the length ofthe power cord would result in this introduced hazard.

A more thorough job walkdown could have prevented this situation and could have been

perfonned

Feedback and Improvement-SRNS routinely seeks to improve its activity-level work

3
planning processes and procedures, as by ongoing improvement .............". ......._"'....

observed by the staff. SRNS actively solicits worker feedback and acts on worker input.

However, not to

""'-'..I."I.'lo.I-"~~" a focused thorough assessment ofits procedures or processes. The EM guidelines

reView could have been

It be is an

and former chair, ofthe Energy Facility Contractors Group's project to develop a guideline

U-'-"~~~.I-..I."""..I...I." for work planning This effort to planning across the DOE

complex is COlnrrlenaatJle.

DOE-SR's not effective identifying and

correcting the weaknesses noted above. As ofthe time ofthe staffs review, DOE-SR had not

......_ .... A-....,.........JLlLj...........,...., meaningful oversight planning and control at the programmatic level,

relying solely on to oversight area

as part oftheir daily duties. DOE-SR had not performed a dedicated work planning assessment

using 2010 EM guidelines. Those DOE-SR assessments to staffthat

identified planning and control as a functional area lacked any substantive observations.

These assessments were not on planning and control

related to project management..

DOE-SR management had recently identified the need to increase oversight ofwork

pla~nrrmg and actions were in progress, not the least ofwhich was the

assignment a subject matter expert to focus on this area. EM is requiring all ofits sites to

assess planning control as one ofthe focus areas annual site ISM

declarations for 2011. These are all moves in the right direction that should clearly improve the

contractor's performance in this area..

4