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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
5
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
7
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
8
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
11
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.
12
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
15
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
16
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
17
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.)
18
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
19
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
20
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
21
Questions
• Phil Breidenbach [email protected] (803)952-9897
• Michael Borders [email protected] (803)952-4395
22