NIST Response to NCNR Event

James Olthoff, Associate Director for Laboratory Programs

June 2022
NIST Immediate Actions

ü Convened a NIST-Level Incident Response Team 

to provide institutional support for NCNR 

Public Affairs, Safety, Acquisitions, Chief 

Counsel, Director’s Office Chief of Staff

ü Ensured communications with stakeholders 

ü Provided resources necessary to recover from 

the event and resume safe operations

ü Obtained review and recommendations from 

external subject matter experts 
External Review

Alexander Adams, Jr.

Chief, U.S. Nuclear Regulatory Commission 

Research & Test Reactors Licensing Branch 

(retired)

Dr. Julia Phillips

Vice President & CTO, Sandia National 

Laboratory (retired), Executive Emeritus 

National Science Board

Dr. Thom Mason

Director, Los Alamos National 

Laboratory, President and CEO of Triad 

National Security, LLC (Triad)

Dr. Eric Kaler

President, Case Western 

Reserve University

Subject Matter Experts individually evaluated: conditions that allowed the Feb 3 2021 event to occur; NCNR’s 

response to the immediate event; NIST’s management of the event; efficacy and completeness of the proposed 

corrective actions. Each SME provided an independent review and recommendations to NIST Leadership.
Key Findings and Recommendations

1. The NCNR is an important national resource, it is imperative to restart safely. 

2. The root cause analysis was thorough and comprehensive.

3. NIST Leadership should provide resources needed for corrective actions, in full.

1. Ensure adequate staffing, by recruiting and retaining qualified staff 

2. Improve reactor operator training, including emergency response training

3. Support long-term efforts to improve safety culture and continuous improvement, 

including external benchmarking to ensure best practices

4. NIST Leadership should be engaged, provide ongoing support for NCNR operations. 

1. Elevate risk management of NCNR to the NIST-level and recognize regulatory risk

2. Ensure adequate resources to support nuclear safety at the NCNR 

3. Ensure adequate internal and external oversight by the SEC and SAC

4. Align and integrate NCNR into NIST safety management programs 

5. NIST should institutionalize lessons learned from this event, incorporate into NIST story.

NIST concurs with findings and recommendations of Subject Matter Experts and is working to implement both 

short-term corrective actions and long-term operational changes to address these.
NCNR Status Update

06.14.2022 Photo credit: Brian Renegar
NCNR – A National User Facility

30 beam instruments/experiments | ~40% of U.S. scientific productivity in neutrons

demand >> supply (2-3X)

>3000 research participants/year

~50 companies/year
• Fission products detected in confinement building upon normal 

reactor startup causing reactor to automatically shut down 

• No health/safety impacts to staff, public, or environment

• The event posed no risk to personnel nor the community

Direct cause – a fuel element was unlatched at startup, did not 

receive sufficient cooling, and overheated.

Unplanned Shutdown - February 3, 2021 
NRC Special Inspection Report Issued

NRC public meeting and report released on March 16th

7 apparent violations

Enforcement: Alternative Dispute Resolution → AIP is the goal

Outcome: Final confirmatory order to be issued to NIST
Status

Filter elements

March 11, 2022 - President signs FY2022 

omnibus spending bill. Official White House 

Photo by Adam Schultz

Progress

Root causes determined and corrective actions 

identified in several incident reviews

Funds for corrective actions secured in FY22

Significant progress made in corrective actions 

Primary coolant system cleanup continues 

Fuel inspection complete

Alternate startup core concept analysis 

underway

Two scientific community briefings since last 

VCAT meeting
Status

What’s Next?

NIST – complete restoring the reactor to 

operational readiness

NIST – complete all corrective actions required 

for reactor restart

NRC – issue confirmatory order (CO) to NIST

NIST – begin implementation of enforcement 

actions from CO

NRC – issue decision on NIST’s restart request

NIST – schedule user experiments

Filter elements

March 11, 2022 - President signs FY2022 

omnibus spending bill. Official White House 

Photo by Adam Schultz
Restart

Restart = Technical Readiness & NRC Authorizes Restart

Technical Readiness

Assumptions:

• Primary coolant filtering goes perfectly

• Plan to use alternate startup core successful

Low power testing: August

Neutron production: September

NRC

Verify implementation of enforcement actions

Approve license amendment 

Complete required regulatory inspections

Authorize restart

Technical and regulatory process timing uncertainties remain
Uncertainties potentially affecting 2022 restart

Note: COVID continues to be a risk that could lead to delays in several of the items above

Risk item Probability Potential impact

Cleanup of primary does not go as planned Medium High

Fuel elements cannot be reused* Medium High

Concept for startup core concept cannot be implemented Low High

Protracted license amendment disposition for startup core Medium High

Procedure revisions required for startup delayed Low Low

Additional corrective actions from external review impacts restart Medium Medium

Protracted license amendment disposition for visual checks Low Medium

NRC does not authorize restart

• Not satisfied with corrective actions

• Not satisfied with progress towards corrective actions

Medium High

*This risk item has been removed from the risk register now that we are pursuing an alternative to fuel reuse: the current plan 

is to use a startup core composed of fresh fuel elements and 7th-cycle elements that were *not* in the core on February 3, 

2021.
Strengthening Operations Safety at the NCNR

The fuel damage event on February 3, 2021, was unprecedented in research 

reactor history.

NIST is committed to ensuring that a fuel damage incident like that of February 3, 

2021, never happens again.

NIST’s corrective actions and program improvements are broad and 

comprehensive and minimize the probability that an event with the potential to 

impact public health and safety occurs.

9
Root Cause Analysis

Instruments, Equipment, & Tools

Deficiencies in the fidelity of latch determination equipment and tools

Procedures

Inadequacies in latch checking procedures

Procedural compliance not enforced

Qualifications & Training

Inadequacy of training and qualification program

Management Systems

Insufficient change management system

Inadequate oversight of refueling operations

Culture of complacency in reactor operations group

ROOT CAUSES

10
Traits of a Healthy Nuclear Safety Culture

INPO 12-012: Traits of a Healthy Nuclear Safety Culture

Individual Commitment

Personal Accountability

Questioning Attitude

Safety Communication

Management Commitment

Leadership Accountability

Decision-Making

Respectful Work 

Environment

Management Systems

Continuous Learning

Problem Identification and 

Resolution

Environment for Raising 

Concerns

Work Processes
Instruments, Equipment, & Tools

Deficiencies in the fidelity of latch determination equipment and tools

Procedures

Inadequacies in latch checking procedures

Procedural compliance not enforced

Qualifications & Training

Inadequacy of training and qualification program

Management Systems

Insufficient change management system

Inadequate oversight of refueling operations

Culture of complacency in reactor operations group

ROOT CAUSES

Leadership Values and Actions

Problem Identification and Resolution 

Work Processes

Continuous Learning

Safety Communications

Questioning Attitude

Environment for Raising Concerns

Root causes directly related to 

broader safety culture issues

12

Root Cause Analysis & Safety Culture
Safety Culture

13

Our nuclear safety culture is a work-in-progress

We are committed to continuous improvement
Benchmarking

What does “good” 

safety culture look like? 

Safety culture and 

operations informed by 

best practices at other 

organizations

Nuclear Safety Culture Improvement Program

Goal: Build and maintain strong nuclear safety culture and system

Education

Opportunities to learn 

about ways to ensure 

safety are sought out 

and implemented

Monitoring and 

Assessment

Effectiveness of the 

NSCIP is monitored 

regularly

Communications

A healthy safety culture is 

directly supported by 

frequent communications 

focused on safety.

Continuous 

Improvement

Safety culture and 

operations are 

continually improved 

and informed in 

multiple ways

14
Benchmarking

What does “good” 

safety culture look like? 

Safety culture and 

operations informed by 

best practices at other 

organizations

Nuclear Safety Culture Improvement Program

Goal: Build and maintain strong nuclear safety culture and system

Education

Opportunities to learn 

about ways to ensure 

safety are sought out 

and implemented

Monitoring and 

Assessment

Effectiveness of the 

NSCIP is monitored 

regularly

Communications

A healthy safety culture 

is directly supported by 

frequent 

communications 

focused on safety.

Continuous 

Improvement

Safety culture and 

operations are 

continually improved 

and informed in 

multiple ways

15

A few of the developments relevant to safety culture improvement include:

 Initial NSCIP program plan draft complete

 Baseline nuclear safety culture assessment completed 

by OSHE. Implementation of response underway. 

 Benchmarking underway (DOW, ANSTO, INL, HFIR, 

AFRRI to date)

 Implemented new NCNR safety recognition program

 Strengthened safety communications (e.g. culture, 

incidents, lessons-learned)

 Leadership safety training: Building Employee 

Engagement for a Strong Safety Culture
External Review – NCNR Actions

Issue Action

Staffing and Resources • Resources and creative actions (OHRM) to recruit, hire, and retain reactor operators, including 5th

shift.

• Ensure resources for reactor operations and maintenance commensurate with needs of an 

organization with a continuously improving culture of safe operations

Safety Culture • NSCIP: establish a culture of continuous improvement, change management

• Shift from experiential knowledge to detailed written procedures: procedure revisions and adoption 

of industry standard procedure use and adherence principles

Emergency Response 

Training

• Wider range of potential scenarios for drills, including scenarios that extend beyond radiation issues

Alignment and integration 

between NCNR and 

NIST/OSHE

• Strengthen and clarify roles, responsibilities, authorities, and resource availability via scenario 

planning between NCNR and NIST/OSHE to ensure corporate-level support from NIST along with 

flexibility for specific needs of the NCNR: OSHE safety support embedded in NCNR

Enhance reactor safety 

oversight bodies, SEC and 

SAC, and engage with 

external organizations with 

expertise

• Outreach to (and benchmark programs at) other organizations with expertise managing process risk 

such as chemical processing industry, power plants, Institute of Nuclear Power Operations (INPO)

• Enhance role of SEC, including scope of reviews and audits, broaden membership for more external 

perspectives and expertise

• Enhance role of SAC