DEFENSE NUCLEAR FACILITIES SAFETY BOARD
October 6, 1994
MEMORANDUM: | G.W. Cunningham, Technical Director | |
COPIES: | Board Members | |
FROM: | Matthew B. Moury, Pantex Program Manager | |
SUBJECT: | Pantex Site - DNFSB Staff Trip Report - W55 Case Cutting Incident |
The Board staff reviewed the El prepared for the case cutting evaluation. The review revealed several deficiencies including incomplete instructions, incorrect sequencing of steps that would have resulted in missing steps for repetitive work, and the failure to include critical instructions in the procedure such as the method for cleaning (decontaminating) the case.
There are few, if any, requirements in DOE Orders supporting or requiring an Integrated Work Control Program for defense nuclear facilities. However, facilities such as the Rocky Flats Environmental Technology Site and the Savannah River Plant have found that such a program is a necessary tool in providing a safe, high-quality operating environment. Further, such a program is indispensable in the fulfillment of several of the criteria of DOE Order 5700.6C Quality Assurance. Specifically, Criterion 1 Program, Criterion 4 Documents and Records, and Criterion 5 Work Processes.
In response to the generation of airborne radioactivity during the subject occurrence, the Radiation Safety Department intends to require the use of filter respirators for personnel inside the contamination area. However, personnel immediately outside the contamination area would not be required to use respirators. These two areas are only separated by a rope barrier and no studies have been performed to determine air flow patterns in the bay. Article 531.1 of the RCM states "Use of respiratory protection shall be reduced to the minimum practical by implementing engineering controls and work practices to contain radioactivity at the source." Pantex has not performed a formal engineering evaluation to determine what measures are available to eliminate the need for respiratory protection during this evolution.
Analysis of bioassay samples of exposed personnel had not been completed at the time of the review. Although these were emergent, non-routine samples, no urgency was placed on the contractor used by Pantex to expedite analysis. In fact, at the time of the review, about six weeks after the occurrence, the Radiological Control Manager had not confirmed that the contract with the analysis contractor included a clause to expedite emergent samples.