Department of Energy Best Practices Workshop

H-Completion Criticality Safety ImprovementPhil Breidenbach, Manager

Environment, Safety and Healthand

Mike Borders, ManagerF Disposition Project

Washington Savannah River Company

September 12-13, 2006

ISM at the Savannah River Site

Nuclear Safety

Washington Savannah River Company (WSRC) is committed to excellence in all aspects of safety, especially nuclear safety.

Savannah River Site

H Area

2

The Situation in H-Completion

• Too many errors­ Concerns primarily in the area of criticality safety

HCP Criticality Safety

0

5

10

15

1999 2000 2001 2002 2003 2004 2005

Year

Nu

mb

er

Reportable Events Non-reportable Errors

ProductionRate

Production rate doesn’t matter, success is event free performance. 3

Significant 2005 Events

• Charge of dissolver before a criticality safety calculation was complete­ Caused by inadequate communication and an

inadequate procedure

• Potential transfer to an evaporator of solution exceeding allowable grams of Uranium­ Caused by procedure noncompliance and an

unnecessarily complex procedure

4

Improvement Actions

­ Immediate actions• Two-day stand down started June 9• Added senior engineer with criticality expertise• Increased involvement of the Criticality Safety Committee

­ Longer-term actions• Top-to-bottom review of the H-Completion Project (HCP) criticality safety program• Review of all operating procedures for fissile material• Conducted level of knowledge testing for HCP personnel relative to criticality safety• Reevaluate cross qualification initiatives to ensure adequate knowledge and

proficiency• Strengthened the assessment process associated with criticality safety• Authorized funding for implementation of engineered controls to replace some

administrative controls• Initiated integrated root cause analysis of recent events

• After the dissolver event

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Improvement Actions (Contd.)

• After the evaporator event­ Suspended fissile operations July 1­ Management Control Plan approved July 13, which described the

causes of the problems and the actions that would be complete prior to resuming fissile operations

Some problems can’t be fixed on the run. 6

Common Causes

• Inadequate disciplined operations­ Procedure compliance­ Specificity of communication

• Inadequate procedures­ Excessive and unnecessary

procedural complexity­ Inadequate defense in depth in

procedures

• Inadequate leadership­ Accountability

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Improvement Strategy

• Operational pause to focus on causes and corrective actions

• Prioritized system-by-system review• Operator / First Line Manager (FLM) / System Engineer

teams formed for every system­ System engineers put on shift to work with operators

• Managed as a project from the War Room

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Improvement Actions

• People­ Disciplined operations leadership

sessions – focus on expectations and accountability

­ Shift proficiency demonstration­ Senior supervisory watch (SSW)

• Procedures­ Criticality control review­ Procedure review

• Plant­ System walkdowns­ Distributed Control System (DCS)

review

9

Improvement Examples

Reduced complexityImproved use of DCSIncreased defense in depthImproved DCA

People won’t consistently achieve excellence without excellent defenses. 10

Removing Complexity

• Fissile Material Tank Transfer­ Before

• Poor procedure format increasing likelihood of calculation error

­ After• Simple table that increases chance of success

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Removing Complexity—Before

Calculate the mass balance in Tank 11.21. RECORD Tank 8.3, 8.3/11.1 (if EU was blended), 8.3/15.2 (if 15.2 was blended), or

8.3/12.1 (if PuCs was blended) and Tank 11.4 Liquid Level data.Tank 8.3, or 8.3/11.1, or 8.3/12.1, or 8.3/15.2 lbs transferred to Tank 11.2 from NOP 221-H-4212, Step 5.1.5 or NOP 221-H-225, Step 5.3.4, or NOP 221-H-4218, Step 5.3.4 or NOP 221-H-227, Step 5.3.4. (B)Tank 11.4 initial lbs from NOP 221-H-4212, Step 5.1.2 or NOP 221-H-225, Step 3.1.7, or NOP 221-H-4218, Step 3.1.7, or NOP 221-H-227, Step 3.1.6. (C)Final 11.4 weight factor (HN-16B)Final 11.4 lbs (D)

2. CALCULATE the Tank 11.4 increase.Tank 11.4 Increase = Final 11.4 lbs (D) – Initial 11.4 lbs (C)= ( lbs)-( lbs)= lbs (E)

3. CALCULATE the mass balance around Tank 11.2.

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Removing Complexity—After

13

Improved Use of DCS

Receipt of Low Activity Waste in Evaporator Feed Tank 8.7

Complexity Indicator Before After

Total pages 21 10

Total procedure steps 100 60

Total criticality safety steps 33 13

Total criticality safety calculations 11 1

Total attachments for data collection 8 1

14Complexity is an enemy – complex administrative controls fail.

Increased Defense in Depth—Global Changes

• Before­ Inconsistent use of Independent Verification and Second Person

Verification­ FLM engagement not required at key points in evolutions

• After­ Independent Verification (IV) in Critical data collection ­ Second Person Verification (SPV) of calculations­ FLM verification at key transition points

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Improved DCA

• Move from Administrative Controls to Engineered Controls­ Created DCS alarms to augment operator rounds / administrative

actions­ Credited existing alarms versus administrative operator actions

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Results

• 17 systems reviewed and released for operations• 465 procedures reviewed

­ 207 procedures containing criticality safety steps revised­ 20 procedures eliminated­ Procedural complexity reduced­ Defense in depth increased

• 200 training sessions conducted for 120 individuals• Double Contingency Analysis (DCA) improvements

­ Credited existing engineered controls versus administrative controls­ Created DCS alarms to augment administrative controls­ Tightened implementation of DCA controls in procedures

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WSRC Independent Review, 11/05“Disciplined operations in H-Canyon had made a notable improvement since the last ISME.”

WGI Independent Review, 1/06“Significant improvement was noted in Conduct of Operations within the H-Completion project since the July 2005 review…”

DOE OA Review, 2/06“H-Canyon managers and operators are committed to rigorous and formal conduct of operations. At the H-Canyon , facility management has effectively communicated its expectations for meeting conduct of operations requirements. The improvements are evident.”

Results (Contd.)

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Results (Contd.)

Criticality Safety Events Caused By Poor Disciplined Operations

0

1

2

3

12

/04

1/0

5

2/0

5

3/0

5

4/0

5

5/0

5

6/0

5

7/0

5

8/0

5

9/0

5

10

/05

11

/05

12

/05

1/0

6

2/0

6

3/0

6

4/0

6

5/0

6

6/0

6

Month/year

Num

ber

3C2 3C3

7 Months Time 12 Months Time

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Long-term Improvements

Continue the shift from administrative controls to engineered controls

Restructure the DCA for event free execution Continue the focus on self assessment

Event

ErrorPrecursors

Vision, Beliefs, &

Values

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

FlawedDefenses

InitiatingAction

Vision, Beliefs, &

Values

Event

ErrorPrecursors

ErrorPrecursors

Vision, Beliefs, &

Values

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

Mission

Goals

Policies

Processes

Programs

FlawedDefensesFlawed

Defenses

InitiatingAction

InitiatingAction

Vision, Beliefs, &

Values

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Learning Points

• Production rate doesn’t matter – success is event free performance

• Some things can’t be fixed while operating• People can’t consistently achieve excellence without

excellent defenses­ You have to choose controls wisely­ Complexity is an enemy

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Questions

• Phil Breidenbach ­ philip.breidenbach@srs.gov­ (803)952-9897

• Michael Borders ­ michael.borders@srs.gov­ (803)952-4395

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