Criticality Safety Lessons Learned: It CAN Happen Here

1. Criticality Safety Lessons Learned: It CAN Happen Here! Dr. Jerry N. McKamy NNSA, NA-117

2. 2 Review of Lessons Learned Backwards Looking (LA-13638) Chronology of Process Criticality Accidents General Observations Lessons Learned Forward Looking: A Case History Video: �It CAN Happen Here!� Generalized Leading Indicators Suggestions for Monitoring Criticality Safety

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4. 4 Observations from Criticality Accidents 22 Process Accidents; 21 Solution; 1 Metal No Accidents Involving Storage No Accidents Involving Transportation No Accidents Resulted in Significant Off-Site Radiation Exposures Non-Routine Operations Increase Risk No Accidents Due to Faulty Criticality Calculations

5. 5 Operational Lessons Learned from Criticality Accidents Rely on Favorable Geometry Solution Vessels Develop & Follow Formal Procedures � CONOPS Potential for Types and Severity of Abnormal Conditions Must be Well Understood NCS Must be Integrated with MC&A � Especially Holdup and Solution Assay Operations Involving Both Organic and Aqueous Solutions Require Extra Diligence Engineered Controls Important to NCS Must Have High Reliability and Failure Should Be Apparent Criticality Accident Alarms Reduce Exposures

6. 6 Managerial Lessons Learned from Criticality Accidents Supervisors Must Ensure Operators are Trained and Perform Work as Intended Equipment Must Be Designed For Ease of Use Policies Must Encourage Self-Reporting and Self-Learning, Not Blaming and Punishing Senior Management Must Understand the Hazard Regulators Must Ensure that Contractors are Trained, Processes and Programs are In Place, and Work is Performed as Intended

7. 7 Forward Looking: A Case History at Rocky Flats Background � Building 771 in 1993-94 Rushing to Restart Aqueous Solution Processing Facility to Shut Facility Down Permanently Presence of Large Quantities of High Concentration Solution in Favorable Geometry Tanks and Large Holdup in Piping, Ductwork, and Equipment Management Focus on Schedule/Award Fees and Ensuring Compliance with Environmental Laws Perception that Criticality Was Incredible Due to Cessation of Production Mission Fully Compliant Safety Programs Immature CONOPS

8. 8 Leading Indicators in Bldg. 771 Multiple, Frequent, Low Consequence CONOPS Failures Decision to Transfer Solutions from Favorable Geometry to Unfavorable Geometry Inadequate Safety Oversight � NCS Staff Support to Operations; No Effective NCS Oversight Group Operations Management Authorized New Work to Old, Outdated Criticality Safety Limits Operations Management Responded to Abnormal Conditions Involving Fissile Solutions Without Contacting NCS Staff

9. 9 Warnings Issued On Three Occasions Between March 1993 and February 1994 NCS Management Wrote Senior Plant Management Concerned About Increasing Criticality Safety Risks and Recommended Slowdown of Work to Allow CONOPS to Mature �Without proper attention given to training operators and strengthening barriers in the field (not only on paper) a criticality accident is almost certain to occur. Reliance cannot be placed on a �paper infrastructure� which always precedes actual implementation of a new safety culture.�

10. 10 Generalized Leading Indicators Fissile Solutions or Significant Holdup Present Reliance on Administrative Controls Tolerance of Low-Consequence Recurrent Abnormal Events Operations Management Distracted (Incentive Fees, Environmental Compliance, Rad Con, etc.) Operations Management Believes Risk of Criticality Accident Low and/or Abdicates Safety to Support Organization Absence of Criticality Safety Oversight Function Empowered by, and Reporting to, Senior Management

11. 11 Suggestions for Monitoring Criticality Safety Justification and Management Approval to Shift from Engineered Controls to Administrative Controls Require Management to Justify Basis for Initial Selection of Administrative Controls Over Engineered Controls Pay Special Attention to Abnormal Events that Indicate Management is Distracted or Focused Away from NCS Develop a Performance Metric to Monitor and Reduce Repeat Criticality Safety Infractions/Deficiencies Line Management Must Maintain Awareness of the NCS Program and Its Implementation on the Floor Establish a Nuclear Criticality Safety Committee Reporting to Senior Management and Empowered to Direct Safety Improvements Across Programs & Facilities