Peter S. Winokur, Chainnan

Jessie H. Roberson, Vice Chainnan

John E. Mansfield

Joseph F. Bader

DEFENSE NUCLEAR FACILITIES

SAFETY BOARD

Washington, DC 20004-2901

June 27, 2012

Mr. David Huizenga

Senior Advisor for Environmental Management

U.S. Department of Energy

1000 Independence Avenue, SW

Washington, DC 20585-0113

Dear Mr. Huizenga:

The staff of the Defense Nuclear Facilities Safety Board (Board) recently reviewed the

maintenance program at the Waste Isolation Pilot Plant (WIPP) and identified several issues of

concern to the Board. The enclosed report documents deficiencies in the procedural quality and

compliance of the maintenance program, as well as other maintenance-related issues. Given the

uniqueness and importance of the WIPP mission, it is imperative that all structures, systems, and

components serving a safety function be reliably maintained and monitored.

The enclosed report is being forwarded to assist the Department of Energy's (DOE)

Carlsbad Field Office and WIPP contractor in strengthening the WIPP maintenance program.

The Board understands that efforts are underway to improve and assess implementation of the

contractor's corporate work planning and control standard. However, staff observations during

this review indicate that significant progress is still necessary. Therefore, pursuant to

42 U.S.C. § 2286b(d), the Board requests a report within 90 days of receipt of this letter

identifying actions taken or planned by DOE to resolve these safety issues.

Sincerely,

Peter S. Winokur, Ph.D.

Chairman

Enclosure

c: Mr. Jose R. Franco

Mrs. Mari-Jo Campagnone
DEFENSE NUCLEAR FACILITIES SAFETY BOARD

StaffIssue Report

April 3, 2012

MEMORANDUM FOR:

COPIES:

FROM:

SUBJECT:

T. J. Dwyer, Technical Director

Board Members

T. Hunt

Maintenance Program, Waste isolation Pilot Plant

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

Board (Board) of the maintenance program at the Waste Isolation Pilot Plant (WIPP). The

management and operating contractor at WIPP is DRS Washington TRD Solutions, LLC (WTS);

the Department of Energy's (DOE's) Carlsbad Field Office (CBFO) oversees this contract. Staff

members T. Hunt, T. Cutler, and D. Winters, together witll outside expert D. Boyd, performed

the on-site portion of the review during the week of March 5, 2012.

Background. High quality work documents and workers' strict compliance with those

documents are significant contributors to the safe implementatioIl of any nuclear maintenance

program. The Board's staff reviewed work planning and control processes in support of

operations and maintenance at WIPP in July 2010. Among other findings, the staff identified

work procedures that failed to contain necessary controls and could not be performed as written.

A letter from the Board dated October 22, 2010, noted that "safe conduct of operations and

maintenance is of particular importance at WIPP because ofits llnique position as the DOE's

only operating facility for disposal oftransuranic waste."

Subsequently, WTS developed two key maintenance program and process documents--

the WIPP Nuclear Maintenance Management Program and the Work Control Process procedure.

In a visit to WIPP in October 2011, the Board's staff observed a DRS Global Management &

Operations Services (URS) corporate assessment of these documents against the recently issued

URS Work Planning and Control Standard. It was identified during this assessment that

improvements had been made in the WTS directives governing work planning and control, but

that improvements had not yet been made in maintenance work control documents and field

implementation. Additionally, DOE's Office of Environmental Management (EM) issued an

Activity Oversight Report, dated October 2011, on the same assessment that identified many

deficiencies in WIPP's maintenance work control documents (WCDS)l o The Activity Oversight

1 WeDs are also known as technical procedures, work packages, or work instructions. All are referred to herein as

WeDs, with the exception of quotes from a reference document. Administrative documents may also be referred to

as procedures.
Report went on to say that a more thorough and rigorous review of additional WCDs was

warranted to determine the status of the program.

Observations of Contractor Processes and Activities. The Board's staffreviewed the

WIPP maintenance program and its conformity to the requirements and guidance in DOE Order

433.1B, Maintenance Management Program for DOE Nuclear Facilities; DOE Guide 433.1-1A,

Nuclear Facility Maintenance Management Program Guide for Use with DOE 0 433.1; and

facility- and company-specific documeIlts. In addition, the staff observed plan-of-the-day

meetings, pre-job reviews, post-job reviews, operational support activities, and maintenance

operations. The following sections describe deficiencies identified by the staff with respect to

the quality of and compliance with maintenance WCDs, post-maintenance testing, pre-job

reviews, annual system walkdowns, maintenance resources, placekeeping, and DOE oversight.

Quality ofWork Control Documents-Various assessments at WIPP during the past two

years have identified the need to upgrade maintenance WCDs so they can be performed as

written. The WTS maintenance organization identified opportunities to improve the format and

clarity of preventive maintenance (PM) WCDs and initiated efforts to evaluate and revise each

WCD by December 2010; however, this initiative was eventually suspended because of

competing priorities. Since incorporating the URS Work Planning and Control Standard and

developing the Work Control Process procedure, WTS has focused on upgrading waste handling

WCDs; thus, little progress has been made on upgrading the maintenance WCDs. WTS has

slowly begun to focus more on reviewing and potentially rewriting the more than 650 PM WCDs

(only two of which had been approved at the time ofthe staffs visit) to be consistent with the

new Work Control Process document. (The two revised PM WCDs showed no improvementbased on number of staff comments-when compared to five other maintenance WCDs that had

not been upgraded.)

Based on a review of seven WCDs, the staff concluded that the preventive and corrective

maintenance WCDs need to be enhanced to be more clear and concise and to reflect actual

conditions and practices in the field. The staff informally forwarded a detailed list of comments

on the seven WCDs to WTS/CBFO for their consideration. Selected WCD deficiencies noted by

the staff during tabletop reviews and observations of maintenance activities are listed below.

(Most of the conditions identified are inconsistent with the WCD requirements and expectations

delineated in the Work Control Process procedure; the WIPP Writer's Guide; the Maintenance

PM/MWO [Model Work Order] Controlled Document Processing procedure; and/or DOE

Standard 1029, Writer's Guide for Technical Procedures.)

• The use of formatting (e.g., warnings, cautions, and notes) and terminology was

inconsistent

• The WCDs were not always technically accurate (e.g., warnings erroneously

indicated that radiological hazards existed) or administratively accurate (e.g., action

steps not beginning with a singular, present-tense action 'verb)

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• Some WCDs lacked the clarity necessary to be followed without confusion (e.g., not

specifying the person responsible for sign-offs)

• The detail and language of some steps did not support error-free performance of work

(e.g., equipment/tooling tolerances and ranges not included where necessary)

• WCDs did not consistently reflect human factors considerations (e.g., WCD callouts

not matching equipment labels)

Guidance for the Development ofWork Control Documents-The WIPP Procedure

Writer's Guide states that a technical procedure is required for maintenance and testing of

equipment and articulates expectations for procedure development. The scope of the Work

Control Process procedure includes the development of preventive, predictive, and corrective

maintenance WCDs. WIPP's Maintenance PM/MWO Controlled Document Processing

procedure provides a protocol for processing PM procedures. All three of these documents

provide guidance on the development of maintenance work documents but are not always

consistent. For example, each describes a different format for the required sections of a WCD.

This inconsistency could create confusion among procedure writers and workers as to the

necessary format and content of maintenance work documents. Reconciling these three work

document guides would increase the likelihood of WCDs being developed consistently and

meeting workers' expectations.

Compliance with Work Control Documents-Three of the seven WCDs the staff

reviewed in the field were suspended either during the pre-job briefing (task preview) or during

execution of the first performance step. These suspensions, due to the inability to perform steps

as written, were initiated after the Board's staff or DOE facility representative brought the issues

to the attention of the field work manager. During the performance of three other maintenance

activities, steps in the WCD having no direct safety impact could not be executed as written, so

workers-instead of suspending the job-used skill-of-the-craft to augment the WeD and

accomplish the work. Although the staff observed a few cases in which maintenance technicians

worked around steps, there was also evidence that WTS management was actively counseling the

workers on compliance with WCDs and the need to stop work if the WeDs could not be

executed as written. The following are examples of wh.ere maintenance personnel did not stop

work when WeD issues arose:

• A technician worked around the step to connect two serial cables together by instead

connecting one serial cable directly to a control box because the procedure could not

be performed as written. The technician stated that a serial cable was sometimes left

in the control box so the connection could be made.

• The step to check a trip coil and mechanical linkage could not be performed as

written, so the electricians used skill-of-the-craft to first remove a plate covering the

components. It would have been advisable to suspend work until the task had been

analyzed and the WCD revised to specify removing the cover plate, if appropriate.

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• Operators moved/rolled a large circuit breaker about 25 feet without WCD

authorization. Providing a WCD action step to move the breaker before performing

the subsequent step would help avert a potential interference.

• Maintenance personnel executed a lockout by placing a breaker in the "OFF" position

instead ofthe procedurally required "OPEN" position. This inconsistency in

nomenclature requires maintenance technicians to deduce that "OPEN" and "OFF"

are synonymous.

Placekeeping-As noted in the DOE Standard 1029, a best practice to help workers track

their progress in a WCD and reduce the likelihood of omitting or duplicating action steps is the

use of placekeeping. WIPP process documents, including the Conduct ofOperations Manual,

are silent on the operators employing the placekeeping protocol (although some WCDs note that

placekeeping is optional and provide brackets at the beginning of steps for that purpose). The

majority of operators that the staff observed implementing WCDs did mark each step as being

completed before proceeding to the next step, and in one case, this prevented a WCD violation.

Proceduralizing expectations for placekeeping and making it a firm requirement during the

performance of complex or high-hazard procedures would enhance control over maintenance

activities.

Post Maintenance Testing-WTS has not established a rigorous and well-documented

process for post maintenance testing (PMT). WTS has no document clearly defining the PMT

process and the required PMT for each type of equipment in the PM program. As a result, the

test requirements and acceptance criteria for PMT activities are sUbjective-i.e., at the discretion

of the individual writing the work package-and are more likely to be developed and applied

inconsistently. DOE Guide 433.1-1A notes that "maintenance [personnel] should include

predefined [emphasis added] PMTs injob instructions." WTS management indicated that they

plan to develop a PMT procedure similar to an effective procedure that is used at another DOE

site.

Annual System Walkdowns-The annual walkdowns are a critical activity performed to

ascertain the operability, availability, reliability, and overall health of site systems. The resultant

report also serves as documentation of the cognizant manager's (CM) assessment of the

cognizant engineer's (CE) and alternate CE's requalification and system knowledge. The

expectation, as expressed by WTS management and outlined in the Annual System

Health/Walkdown/Requalification procedure, is that the CM, CE, alternate CE, and CBFO

representative participate in the system walkdown. The staff's review of numerous records

indicated that this expectation is not consistently being met by the CM, alternate CE, and CBFO

representative. Limited resources were cited to explain why CMs and alternate CEs do not

always participate in walkdowns. Three CMs support about 100 systems, and there are several

CE position vacancies and eight CEs in qualification (a 2-3 year process). In addition, no

alternate CE is assigned to 9 of 14 vital safety systems and about 60 systems overall. These

strained resources may result in a lack of attentioll to systern maintenance that is necessary to

ensure that all safety systems will meet facility needs.

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Pre-Job Reviews-Pre-job reviews (or briefings) are important to support the safe and

compliant accomplishment of work. As described in the WIPP procedure for pre- and post-job

reviews, the type of pre-job review to be conducted depends on the frequency, complexity, and

risk associated with the work. The pre-job review may be a task preview, tailored pre-job

briefing, standard pre-job briefing, electrical pre-job briefing, or walkdown/dry run/mockup

training. This approach to pre-job reviews is overly complex, and the use of multiple similar

terms for different levels of review is confusing. The staff observed several task previews/prejob briefings and, although these are two different activities performed prior to commencement

of work, they appeared to be interchangeable in practice. Discussions with two field work

managers revealed that there was some confusion as to when each applied. Although not stated

in the pre-job review procedure, it is appropriate for the individual who conducts the review to

be the first-level supervisor who will actually be overseeing the work in the field (usually the

field work manager or work group manager at WIPP). Additionally, WIPP procedures require

documenting the printed name, 'badge number, and initials of all briefing attendees, but this was

not done in three instances.

Maintenance Resources-WTS faces obstacles to maintaining an experienced and skilled

workforce. Attrition, a reduction in force, and retirement pose substantial concerns for a

workforce in which the average age is about 50 years. WTS currently has several openings for

electrical and instrumentation and control personnel; these positions are difficult to fill because

of competing industries (e.g., oil, gas, potash) in southeastern New Mexico. One of the impacts

of a shortage of maintenance personnel is an increase in backlogged work. The backlog of

preventive and corrective maintenance work has increased in the past few months as a result of

workforce restructuring, a revised work control process, and increased rigor in complying with

WCDs. WTS will need to manage its personnel resources prudently to reduce the effects on

safety-related equipment and systems.

The WIPP physical plant is now showing considerable signs of aging, and resources are

not being applied to address these issues in a timely manner. Noncriticallnaintenance itemssome of which are potentially (and eventually) safety-related-are being deferred. For example,

work on stripping deteriorated paint and rust scale from the steel surface of the salt hoist frame

(tower) and repainting it to inhibit further corrosion has been deferred for several years beyond

when it would ordinarily be performed. In addition, much of the equipment has single-point

failure modes, and procurement of replacement parts will require significant lead time, on the

order of months.

DOE Oversight-The individual responsible for overseeing the WIPP maintenance

program for CBFO recently departed, and the vacancy has not yet been filled. Current plans are

to have an electrical safety individual qualify as the replacement maintenance oversight person.

This is an I8-month process after the qualification card has been developed. Also, at the time of

the staffs visit, a field office oversight person was not assigned to all vital safety systems (e.g.,

underground ventilation) to track and verify acceptable performance in meeting established

safety requirements. Cognizant individuals were subsequently assigned to those vital safety

systems, and the paperwork to reflect the coverage is in process. The workforce staffing analysis

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indicates that three full-time equivalent personnel are needed to fulfill safety system oversight

responsibilities, but only two are presently functioning in that capacity.

Conclusions. During this review, the Board's staffidentified flaws in several elements

of the WTS maintenance program at WIPP. Chief among these was the quality and usability of

maintenance WCDs. WTS management estimated that the upgrading of maintenance WCDs to

meet local requirements lags behind the upgrading of waste handling WCDs by about 18 months.

Management also realizes that a culture change is necessary with respect to workers recognizing

deficient WCDs and stopping work accordingly. Even though the staff observed a few cases in

which technicians worked around steps in WCDs that they could not comply with as written, the

staff also saw evidence that WTS management is actively counseling maintenance workers on

WCD compliance and the need to stop work if WeDs cannot be executed as written. Continued

diligence to resolve these issues and the others documented in this report should make the

maintenance program at WIPP safer and more efficient.

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