Criticality Safety Lessons Learned: It CAN Happen Here!

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Criticality Safety Lessons Learned It CAN Happen
Here!

• Dr. Jerry N. McKamy
• NNSA, NA-117

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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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Chronology of Criticality Accidents
 
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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

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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 MCA 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

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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

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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

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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

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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.

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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
  

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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