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3 NNFD – 3525 Uptake Event Unexpected operational conditions during shearing of 5 th package CAM alarm occurred during shearing operations – CAM was in general vicinity, but not intended to monitor this activity Alarm response was less than adequate –RCT investigated and reset alarm personnel believed there was no airborne risk anomalous operation or radon suspected –Second CAM went into alarm –Material was placed in safe configuration –Two employees remained in the general area conflicting priorities between alarm response and security –First CAM went into alarm again Dose assessment determined that seven personnel received inhalation uptake of HEU –Total committed effective dose below 5 % of the regulatory limit for all personnel
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ORNL is managed by UT-Battelle for the US Department of Energy
Enforcement Lessons LearnedUnexpected Airborne ReleasePresented to EFCOG Regulatory & Enforcement Technical Subgroup
Debbie JenkinsORNL Enforcement Coordinator
October 21, 2015
2 NNFD – 3525 Uptake Event
Summary of Event• In August 2014, Personnel were
resizing and repackaging highly enriched uranium (HEU) material into an approved shipping container
• Work was performed on the 2nd floor mezzanine in a Lexan enclosure
• Activity was not expected to generate airborne radioactivity and no ventilation was provided
• June – August 2014 received and repackaged 4 batches
3 NNFD – 3525 Uptake Event
Unexpected operational conditions during shearing of 5th package• CAM alarm occurred during shearing operations – CAM was in
general vicinity, but not intended to monitor this activity
• Alarm response was less than adequate– RCT investigated and reset alarm
• personnel believed there was no airborne risk • anomalous operation or radon suspected
– Second CAM went into alarm– Material was placed in safe configuration– Two employees remained in the general area
• conflicting priorities between alarm responseand security
– First CAM went into alarm again
• Dose assessment determined that seven personnel received inhalation uptake of HEU
– Total committed effective dose below 5 % of the regulatory limit for all personnel
4 NNFD – 3525 Uptake Event
Comprehensive investigation initiated to identify causes• Direct cause – Unexpected airborne contamination exited shear
enclosure and went unrecognized until monitors alarmed
• Root Cause – Incorrect assumption regarding airborne contamination potential resulted in inadequate planning of work and inadequate contamination control
• Contributing Causes– Legacy items with little know about specifications– No destructive size reduction previously conducted– SMEs not involved in work planned – missed opportunity– Staff did not immediately exit are upon first alarm– Surface contamination encountered during previous work evolutions did not
trigger questions– Personnel authorized to re-enter work area without fully understanding
hazards
5 NNFD – 3525 Uptake Event
Broad corrective actions focusing on safety culture improvements included the following• Radiological Protection
– Intensive four-day proficiency training completed for all Rad staff
– Procedures were revised to add more clarity on alarm response actions and expectations
– Radiological Engineer staffing levels and involvement in work planning increased
– RWP development process strengthened
– Qualification process for RCTs and supervisors revised to focus on facility-specific competencies
– RCT continuing training redesigned to emphasize the need for more realistic and challenging hands-on practice drills
• Line Organization– Procedures updated and clarified
• Work control
• Pre-job briefing
• Alarm and abnormal response
• Work Acceptance
• Prioritization of safety vs. security issues
– Staff re-trained to new expectations– Drill program enhanced to include
facility specific drills
6 NNFD – 3525 Uptake Event
In January 2015, Notice of Intent (NOI) to Investigate was received from OE
• Call from OE to provide CA clarification• Would be recommending CO to OE
• NOI received• Management and Site Office approval of
CO request already in place• CO request drafted and ready for final review
• Unallowable cost letter issued
• Signed CO agreement - $ 112, 500
• Notified unofficially that CO would be granted
• Called OE to notify that a CO would be submitted within a week
• OE agreed to hold off on document request and scheduling of investigation
• CO request transmitted to OE
• Call from OE requesting CA clarification• OE Enforcement Specialist communicated
that he would be recommending the CO to his management
May 20
Jan 16
Jan 29
Feb 12
Jan 20
Jan 23
Friday
Tuesday
Friday
Thursday
• Draft CO agreement received for review
Apr 13
7 NNFD – 3525 Uptake Event
Developed 5-page Consent Order Request
• Acknowledgment of significance of event
• Mitigating Responses– Compensatory measures– Investigation/corrective action summary
• Laboratory-Wide Safety Culture Improvement Initiatives– Safe Conduct of Research– Front line supervisor training– Safety mentoring
• Radiation Protection Program Improvements– Organizational changes– Trending and analysis– Radiation Monitoring– Training and drills– Lessons learned
8 NNFD – 3525 Uptake Event
Rationale for why a CO was warranted• Demonstrated and consistent history of noncompliance
reporting (NS, WSH, Security)
• Demonstrated history of strong radiological program performance and commitment to continuous improvement
• Prompt and thorough reporting of circumstances surrounding the release
• Comprehensive and aggressive investigation of event• Timely development of corrective actions addressing
not only issues specific to the event, but also underlying cultural issues
• Transparent communication and interaction with ORNL Site Office regarding the event and path forward
