DEFENSE NUCLEAR FACILITIES SAFETY BOARD

March 22, 2024

TO: Timothy J. Dwyer, Technical Director

FROM: Frank Harshman and Clinton Jones, Resident Inspectors

SUBJECT: Oak Ridge Activity Report for Week Ending March 22, 2024

Nuclear Criticality Safety (NCS): The resident inspector (RI) attended an event investigation 

and critique on the sampling of potential fissile material without NCS controls. An industrial 

hygiene (IH) technician, accompanied by chemical operators, obtained a sample to test for 

asbestos as part of clean out of a legacy carbon burner system in the Building 9212 headhouse. 

They took the sample due to a possible asbestos exposure that occurred in a previous event but 

did not recognize that the sample potentially contained fissile material (see 03/15/24 report). 

CNS determined in the event investigation that no formal process exists to evaluate if the 

samples being requested have the potential to contain fissile material. In addition, the current IH 

sample process permits the technicians to check in with the production supervisor instead of the 

shift manager (SM) which removed a possible barrier to prevent this event. CNS developed 

corrective actions to correct these lapses in process including evaluating the overall sampling 

processes. In the RI’s opinion, the critique was sufficiently critical of the event investigation and 

resulted in additional corrective actions to those identified in the event investigation. 

Building 9212: The RI, NPO NCS program manager, NPO facility representative, and CNS 

NCS engineers conducted a walkdown in a process wing in the building. The RI identified ties 

used to attach NCS signs to hand rails had degraded and were no longer performing their 

intended function. The RI provided that information to the CNS NCS personnel who made note 

of it for correction. The RI discussed NCS signage and the implemented NCS controls 

throughout the walkdown and found the answers sufficient. 

Building 9204-2E: Production personnel were removing a material from a unit during the 

disassembly process when an IH technician monitoring the activity detected elevated levels of 

the material being removed in the area. The production personnel backed off from the area and 

notified the SM. The procedure addressed the potential for a spill and included instructions for 

cleaning it up, but the production personnel did not have the personal protective equipment or the 

training to clean the spill. The SM notified the spill response team who responded to clean the 

area. The operation resumed two days later without addressing the issue of the production 

personnel not being qualified to perform spill cleanup, which is an anticipated condition in the 

procedure. Upon resumption of the disassembly process, more material leaked out of the unit. 

The production personnel again notified the SM and a boundary was established around the area. 

IH technicians confirmed the area outside of the spill did not have elevated levels of the material. 

The SM called the spill response team who cleaned the area. Upon cleanup of the area, the 

production personnel were permitted to continue the disassembly. Within 30 minutes of the 

work restarting, another leak of the material occurred, resulting in another backoff and 

subsequent cleanup by the spill response team. In the RI’s opinion, if a procedure covers a 

hazardous process with an anticipated condition, the personnel who are involved in the pre-job 

briefing to perform the work steps should be capable of completing the procedure as written. 

CNS should not rely on an external spill response team to complete work. The procedure should 

have been suspended pending having the production personnel obtain the proper qualifications 

and equipment to perform the tasks.