DEFENSE NUCLEAR FACILITIES SAFETY BOARD

January 12, 2024

TO: Katherine R. Herrera, Acting Technical Director

FROM: L. Lin, Z.C. McCabe, and E.P. Richardson, Resident Inspectors

SUBJECT: Savannah River Site Activity Report for Week Ending January 12, 2024

Event Investigations: DOE-SR has initiated their effectiveness review of the changes to the site 

process and procedure improvements in regard to event investigations. Last year, SRNS in 

collaboration with BSRA and SRMC drafted a complete revision to the site procedure governing 

event investigations and provided training to all investigators. DOE-SR plans to have their 

effectiveness review completed in February.

Savannah River Tritium Enterprise (SRTE): SRTE personnel conducted an emergency 

preparedness drill at the Tritium Extraction Facility (TEF). The drill scenario consisted of an 

operator inadvertently pulling a thermocouple vacuum gauge out of a vessel containing tritium 

and pulling a glove from the glovebox, resulting in a hydrogen deflagration and release of tritium 

from the TEF stack and an injury. Although there were still issues with the conduct of the drill 

and the demonstrated response, the RIs noted several areas of improvements with the execution 

and subsequent feedback discussed amongst the drill team and SRTE personnel as compared to 

last year’s drills (see 8/25/23 report). Most notably, the SRTE personnel and drill team present 

at the controller debrief were appropriately complimentary and critical of the drill performance 

and identified actions to improve future performance. Among the noted shortcomings was the 

less than adequate timeliness and lack of prioritization of classifying the emergency by the 

emergency response organization. In addition, the scenario did not provide information 

regarding the tritium air monitor in the exhaust duct for the room the event occurred in, which 

would have provided the drill players additional information regarding the duration and quantity 

of the release. Players and controllers also noted breakdowns in communications. For example, 

no one from operations was left at the incident scene when the incident scene coordinator went to 

the incident command post and instead had to rely on other personnel to provide updates.

C-Area: The RIs attended an issue investigation on a lockout that was improperly installed. 

One lock was utilized for multiple single point lockouts (SPLT) when there should have been 

four locks. In addition, two of the four lockout tags were missing signatures and/or dates. This

lockout was needed to de-energize a panel to support modification work at C-Reactor. A pre-job 

briefing was performed, but it did not cover how this lockout was to be hung. For some breaker

SPLTs, the equipment is not substantial enough to hang multiple locks and an alternate 

protective measure can be employed instead. In this case, the breaker was substantial enough to 

hang multiple locks on it. The workers performed the safe energy check and then proceeded to 

install the lockout with the foreman and general foreman observing. Later that day, the facility 

point of contact noted the potential issue with the lockout and notified the shift operations 

manager. The construction superintendent paused the work and set up barricades around the 

area. During the issue investigation, personnel noted that they misinterpreted the requirements 

of the site manual that a lock and tag is required for each SPLT. The personnel involved in the 

work were not familiar with this type of lockout. Previously, they had signed onto lockouts that 

had required and had already been reviewed and verified by other personnel. Facility personnel 

are developing corrective actions.