[DNFSB
LETTERHEAD]
August 5, 2005
The Honorable Samuel W. Bodman
Secretary of Energy
1000 Independence Avenue, SW
Washington, DC 20585-1000
Dear Secretary Bodman:
The Defense Nuclear Facilities
Safety Board (Board) has reviewed the Department of Energy’s (DOE) revised
Implementation Plan for Recommendation 2004-1, Oversight of
Complex,
High-Hazard Nuclear Operations, dated June 10, 2005. The Board notes with satisfaction the
additional detail in the revised plan with respect to the Central Technical Authorities
and the Office of Nuclear Safety Research. The plan should result in significant improvement
in DOE’s oversight of its high-hazard nuclear operations and reduce the
likelihood of a nuclear accident.
The Board accepts this plan, on
the condition that the Project Execution Plan to
Improve Oversight of Nuclear Operations (PEP) is modified to address the following issues. Several commitments in the Implementation Plan
are identified in the text of Resolution Approaches for various Safety Issue
Resolution areas, but are not captured in the numbered commitments of the Implementation
Plan or in the tasks listed in the PEP. Other commitments require evaluating activities
and processes, culminating in the submission of reports identifying
deficiencies, recommendations, or proposed corrective actions; however, neither
the Implementation Plan nor the PEP includes tasks or commitments to resolve
the deficiencies and implement corrective actions. Additionally, several supporting tasks in the
PEP do not achieve the desired results set forth in their associated
commitments. A consolidated list of
these items is provided in the enclosure to this letter. The Board requests that these commitments and
supporting tasks be incorporated into the PEP, and that the responsible PEP
Project Manager brief the Board on the revised PEP as soon as practicable.
The Board also wishes to direct
senior management attention to the Board’s letter of February 14, 2005, which
discussed the need for DOE to institute technical qualification requirements
for the Central Technical Authorities as a necessary means of sustaining the organizational
change described in the Implementation Plan. The Board is adamant regarding the need for
technically qualified individuals of the highest caliber to serve as the
Central Technical Authorities. The Board
strongly encourages the Secretary of Energy to take the necessary steps to
implement stringent technical qualification requirements for future appointments
to these important safety positions.
In its Implementation Plan, DOE
commits to Integrated Safety Management (ISM) “as the foundation of its safety
management system and process”. The
Board wishes to stress that any changes to the ISM system brought about as a
result of the Implementation Plan must not diminish any of the existing ISM
requirements or guidance.
As currently structured, the PEP
is an extension of the Implementation Plan. However, the Board believes that the change
control policy requirements detailed in Section 6.1 of the Implementation Plan
should apply to any deletion of tasks from the PEP. The Board will carefully monitor DOE’s
progress toward achieving the objectives of this Implementation Plan―improving
DOE’s oversight of high-hazard nuclear operations and establishing a highly reliable
organization. In particular, key
measures of success will include the following:
Sincerely,
A.
J. Eggenberger
Chairman
c: Dr. Bruce M. Carnes
Mr.
Mark B. Whitaker, Jr.
Enclosure
Enclosure
Recommended
Additions to the
Project Execution Plan to Improve Oversight of
Nuclear Operations
5.1.1 Instituting Central Technical
Authorities
Commitments 2 and 3 specify
letter reports to the Secretary of Energy declaring that certain requirements
have been met and “providing the basis for this declaration”. The criteria for the bases are discussed in
the list immediately preceding the commitments but are not well defined. Individual tasks should be added to the Project
Execution Plan to Improve Oversight of Nuclear Operations (PEP) that will help achieve and
define these bases.
The following item from the text
of the Resolution Approach (page 5) should
be captured as a task in the PEP: Define
the roles, responsibilities, and authorities of the Central Technical Authorities
(CTA) in the Safety Research Program (see also the discussion of Section 5.1.3 below).
The following items from the
text of the Resolution Approach (page 7) should also be captured as tasks in
the PEP:
5.1.2 Providing Effective
Federal Oversight
Commitment 5
addresses the Department of Energy
(DOE) Safety Oversight Manual.
The text preceding the
commitments outlines three categories of Criteria and Review Approach Documents
(CRADs) to be developed for this manual. However, commitments and schedules for
developing these groups of CRADs are not included in either the Implementation Plan
or the PEP. Appropriate tasks should be
added to the PEP to require the development of specified categories of CRADs,
with definite development priorities and delivery dates being listed. Additionally, issuing the manual with its CRADs
in July 2006 may not support the timely oversight reviews identified in
Commitment 16 of the Implementation Plan. The Board understands that these CRADs are
being developed by a very limited number of personnel, and suggests that DOE
invest additional personnel and resources to accelerate this effort.
The Implementation Plan (page
14) states, “Finalization of the DOE [Safety] Oversight Manual will not delay
issuance and use of the oversight CRADs”. No task supports this commitment. Therefore, a new task should be added to the
PEP to ensure that completed CRADs are published as they are completed.
Additionally, the Implementation
Plan (page 14) states, “Existing lines of inquiry and other available review
tools for each functional/topical area will be collected from the field following
completed reviews. These checklists and
lines of inquiry will be validated and provided as guidance....” No
task supports this commitment. Therefore, a new task should be added to the
PEP to ensure that this feedback loop for CRAD development is developed.
The following items from the
text of the Resolution Approach (page 12) should also be captured as tasks in
the PEP:
5.1.3 Instituting a Nuclear
Safety Research Function
Commitments 7 and 8 specify
letter reports to the Secretary declaring that certain requirements have been
met and “providing the basis for this declaration”. The criteria for the bases are discussed in
the list immediately preceding the commitments but are not well defined. Individual tasks should be added to the PEP
that will help achieve and define these bases, including the following:
Establish and formalize office
processes for identifying, prioritizing, selecting, and executing
safety-related research and development.
Describe the interfaces between
the nuclear safety research program and other organizations (e.g., Program
Secretarial Offices, including the Office of Science; sites; CTAs).
The Implementation Plan (page
16) states that the objectives of the nuclear safety research program will
include “advancing the information needed to develop technical directives”. This objective is not adequately discussed in
either the Implementation Plan or the PEP. An appropriate grouping of tasks should be
added to the PEP regarding the development of effective interfaces with regard
to DOE Order 251.1, to ensure that appropriate changes are made to directives
affected by research findings. A related
task concerns the commitment (page 17) to “identify changes in DOE directives
and standards, when appropriate, based on nuclear safety”. This commitment should be included in this
grouping.
The following item from the text
of the Resolution Approach (page 18) should also be captured as an appropriate
grouping of tasks in the PEP: Disseminate
nuclear safety research findings.
5.1.4 Establishing Clear Roles,
Responsibilities, and Authorities
Commitment 9, Deliverable B,
concerns a report to the Secretary that requires the evaluation of review
activities; however, the commitment does not include a task or commitment to
resolve any identified deficiencies or implement any necessary corrective
actions. Timely correction/disposition
of identified deficiencies by senior management using adequate resources is an
attribute of high-reliability organizations. Appropriate tasks should be added to the PEP
to (1) resolve any identified deficiencies; (2) implement corrective actions or
recommendations, with the appropriate senior management involvement and
resources to achieve successful closure; and (3) follow up and verify
effectiveness of the corrective actions.
5.1.5 Ensuring Technical
Capability and Capacity to Fulfill Safety Responsibilities
There are no supporting tasks in
the PEP associated with the latter portion of Commitment 11, “a plan for
implementing this concept and a mechanism for maintaining the list”. Appropriate tasks should be added.
In the Resolution Approach (page
24), the Implementation Plan states
that when DOE identifies experienced and technically capable personnel, “these
persons will assist the Department in improving overall technical capability”. This statement is not supported by a commitment
in the Implementation Plan or a task in the PEP. The PEP should include a grouping of tasks to
define the role of these personnel and then implement that role, followed by verification
of the effectiveness of the tasks.
Similarly, DOE commits to the
evolution of Nuclear Executive Leadership Training (page 25) “into an
institutionalized leadership and development program”. Although the PEP tasks supporting Commitment
12 indicate that DOE will “complete training and assess effectiveness” (line
162), there are no tasks designed to institutionalize and sustain the training.
A grouping of tasks to support these
goals should be added to the PEP.
The deliverable associated with
Commitment 12 does not meet the requirements of the commitment. The requirement is to provide structured
training for safety professionals, senior managers, and decision makers. The deliverable discussed addresses only
Nuclear Executive Leadership Training. Appropriate groupings of tasks should be added
to the PEP to develop the entire suite of structured training for all of these
important classes of personnel.
Under Commitment 14, DOE will
appoint an emeritus-level panel, which will then make recommendations. However, neither the Implementation Plan nor
the PEP provides for implementation of any of these recommendations. An appropriate grouping of tasks should be added
to the PEP to resolve and close out recommendations from the emeritus-level
panel.
The PEP tasks supporting
Commitment 14 are focused on oversight
personnel. However, the commitment
should address all personnel with federal safety assurance responsibilities. Tasks should be added to the PEP to support
this broader range of personnel.
The following items from the
text of the Resolution Approach (page 26) should also be captured as tasks in
the PEP:
Provide new and reassigned
personnel the training and mentoring necessary to fulfill their safety
responsibilities.
Assign appropriate technical
qualification standards to the identified federal safety assurance personnel
and individual objectives for completing qualifications.
Identified individuals will
complete technical qualifications to identified standards.
5.1.6 Verification of
Federal Safety Assurance Capability
The PEP tasks supporting
Commitment 16 do not require interim oversight reviews.
Should there be issues requiring
resolution, January 2008 may be too long to wait to implement the necessary
changes. Tasks for interim sampling
should be added to the PEP.
The following item from the text
of the Resolution Approach (page 28) should also be captured as an appropriate
grouping of tasks in the PEP: A review plan with CRADs will be developed to
guide the review. Follow-on verification
activities will be performed as necessary to determine when objectives have
been successfully institutionalized and whether additional improvement
opportunities exist.
5.2.1 Department-wide
Action Plan for Columbia and Davis-Besse Events
In its acceptance letter of July
21, 2004, DOE emphasized that the Columbia accident and Davis-Besse incident
would provide valuable lessons learned as key inputs in developing the Implementation
Plan for Recommendation 2004-1. DOE may
have only partially achieved this objective. Some lessons derived from these events were
developed too late to influence the commitments in the Implementation Plan and
are being handled in a separate corrective action plan. These two efforts need to be closely
coordinated. Pertinent lessons from this
separate effort should be incorporated into the PEP in such a fashion as to
assist in the resolution of the appropriate commitments in the Implementation
Plan.
5.2.2 Comprehensive
Operating Experience Program
Commitment 17 involves
developing an action plan related to the Columbia and Davis-Besse events. Commitments 18 and 19 involve developing and
implementing a DOE Operating Experience Program. However, in the interval before complete
implementation of the Operating Experience Program (projected by July 2007),
other major external events that represent valuable lessons applicable to DOE
may occur. Appropriate tasks should be
added to the PEP to ensure that lessons from such events (e.g., the fire at
British Petroleum’s Texas City refinery and the pipe break in the Thermal Oxide
Reprocessing Plant at Sellafield) are identified, analyzed, disseminated, and
acted upon throughout the complex.
5.2.3 Verification of
Implementation of Operating Experience
Commitment 20 specifies a report
to the Secretary verifying the effectiveness of the implementation of Operating
Experience Program; however, the commitment does not include a task or
commitment to resolve any identified deficiencies or implement any necessary
corrective actions. Appropriate tasks
should be added to the PEP to (1) resolve any identified deficiencies; (2)
implement corrective actions or recommendations with the appropriate senior
management involvement and resources to achieve successful closure; and (3)
follow up and verify the effectiveness of the corrective actions.
5.3.1 Enhancing ISM
Implementation at DOE Headquarters and Field Offices
The purpose of Commitment 21, Deliverable B, is not clear. Appropriate supporting tasks should be added
to the PEP to define and track the actions expected as an outcome of the decision
specified in the commitment.
The following items from the
text of the Resolution Approach (page 37) should also be captured as tasks in
the PEP:
5.3.2 Work Planning and
Work Control Processes at the Activity Level
Commitment 24 specifies a series
of oversight reports by DOE Headquarters line oversight on work planning and
work control; however, the commitment does not include a task or commitment to
resolve any identified deficiencies or implement any necessary corrective actions.
Appropriate tasks should be added to the
PEP to (1) resolve any identified deficiencies; (2) implement corrective
actions or recommendations, with the appropriate senior management involvement
and resources to achieve successful closure; and (3) follow up and verify the effectiveness
of the corrective actions.
5.3.3 Integration and Use
of Feedback Mechanisms to Produce Improvement
The PEP task (line 285)
associated with Commitment 25 does not match the deliverable and appears to be
mislabeled.
In the PEP tasks supporting
Commitment 26, the requirement to provide midcourse direction appears to be met
with respect to ESE, but not with respect to NNSA. Tasks should be added to the PEP to ensure
that all of DOE meets this commitment.
5.3.4 ISM Verification
The Implementation Plan states,
“Full ISM verifications are envisioned to occur at least every 5
years. More frequent full verifications may be
appropriate where significant system or performance weaknesses are identified”.
An appropriate grouping of tasks should
be included in the PEP to support this important commitment.
Commitment 27 specifies reports
on comprehensive ISM reviews at two major sites; however, the commitment does
not include a task or commitment to resolve any identified deficiencies or
implement any corrective actions. Appropriate tasks should be added to the PEP to
(1) resolve any identified
deficiencies; (2) implement corrective actions or recommendations, with the
appropriate senior management involvement and resources to achieve successful closure;
and (3) follow up and verify the effectiveness of the corrective actions.
6.2 Reporting
Given the importance of the PEP
to the successful execution of the Implementation Plan and the fact that DOE
may be exercising its discretion to add PEP tasks or adjust PEP delivery dates,
an updated PEP should be provided to the Board concurrent with DOE’s periodic briefings.
This commitment should also be added to
the PEP.