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[ Briefing Slides ]
1
1 UNITED STATES OF AMERICA
2 NUCLEAR REGULATORY COMMISSION
3 OFFICE OF THE SECRETARY
4 ***
5 BRIEFING ON LESSONS LEARNED FROM THE NUCLEAR
6 CRITICALITY ACCIDENT AT TOKAI-MURA AND
7 THE IMPLICATIONS ON THE NRC'S PROGRAM
8 ***
9 PUBLIC MEETING
10
11 Nuclear Regulatory Commission
12 One White Flint North
13 Commissioner's Conference Room
14 11555 Rockville Pike
15 Rockville, Maryland
16 Monday, May 8, 2000
17 The Commission met in open session, pursuant to
18 notice, at 10:02 a.m., the Honorable RICHARD A. MESERVE,
19 Chairman of the Commission, presiding.
20 COMMISSIONERS PRESENT:
21 RICHARD A. MESERVE, Chairman of the Commission
22 GRETA J. DICUS, Member of the Commission
23 NILS J. DIAZ, Member of the Commission
24 EDWARD McGAFFIGAN, JR., Member of the Commission
25 JEFFREY S. MERRIFIELD, Member of the Commission
2
1 P R O C E E D I N G S
2 [10:02 a.m.]
3 CHAIRMAN MESERVE: Good morning.
4 The Commission is meeting this morning to hear
5 from the staff on lessons learned from the criticality
6 accident at Tokai-Mura and the possible implications of that
7 accident for the NRC's program. This briefing is supported
8 by Commission paper SECY 00-0085, which was made available
9 to the public on April 24th.
10 I think, as of all us would agree, that as the
11 accident in Japan is revealed, an event anywhere in the
12 world can have implications throughout the world, and I
13 don't mean just the physical consequences just because of
14 the fact that an accident anywhere causes us to need to
15 reevaluate our own programs and activities, make sure that
16 we're comfortable with where we are.
17 The staff has undertaken such an analysis and what
18 lessons are to be learned from the accident for our own
19 programs.
20 We will have the benefit on our second panel of an
21 evaluation that was conducted under the auspices of the
22 Nuclear Energy Institute, and then we will have a third
23 panel that will consist of representatives from the
24 Department of Energy who had participated in evaluation of
25 the accident in Japan and also, of course, participated in
3
1 evaluation of the implications of the accident for DOE
2 facilities.
3 We very much look forward to this morning's
4 briefing, and let me see if my colleagues have any opening
5 comments.
6 COMMISSIONER MERRIFIELD: I just want to say, you
7 know, as we start on in this, at least from my point,
8 ultimately, obviously, it's with some sympathy to the
9 families of the two gentlemen who were deceased as a result
10 of this accident.
11 Certainly, for my part, I want to put that in the
12 record.
13 Obviously, this has also been a trying time for
14 our sister agency -- sister agencies in Japan that have been
15 attempting to struggle with this, and certainly, having been
16 in difficulties of our own in years past and having received
17 their support, would want to recognize the fact that we --
18 we do recognize that they are going through a trying time
19 and would have my sympathy in that regard.
20 CHAIRMAN MESERVE: Commissioner Merrifield has
21 made a very fair point.
22 I have just returned from a visit to Japan, and it
23 is -- I'll just report that there's obviously a very
24 aggressive effort underway in Japan to understand the
25 accident, understand its implications, which has very
4
1 significant implications for the structuring of their own
2 regulatory program.
3 As much as we have tried to learn from this
4 accident, it's clear to me that the Japanese have made very
5 aggressive efforts to do the same and are taking a variety
6 of actions to respond to the situation.
7 Dr. Travers, you may proceed.
8 MR. TRAVERS: Thank you, and good morning.
9 As you indicated, Mr. Chairman, the staff is here
10 to provide you with a summary of the events that surrounded
11 the September 30, 1999, criticality accident that occurred
12 at the JCO facility located in Tokai-Mura, Japan.
13 Additionally, as requested by the President and
14 the National Security Council, the NRC has completed its
15 review of the lessons learned from this accident, reviewed
16 the criticality safety activities at the major U.S. fuel
17 cycle facilities, and in fact, has verified that existing
18 NRC oversight program, we believe, is adequate to ensure
19 criticality safety at those facilities.
20 Giving the briefing today is Bill Troskoski. Bill
21 is a Senior Fuel Facility Inspector in the Office of Nuclear
22 Materials Safety and Safeguards and has been coordinating
23 the NRC activities performed over the last seven months in
24 response to the accident.
25 Bill is the author of the review and lessons
5
1 learned Commission paper that was provided to the Commission
2 in April.
3 Also here with me today are Janice Dunn Lee, who
4 is the Director of the Office of International Programs;
5 Bill Kane, who is the Director of NMSS; Frank Congel, who is
6 the Director of the Incident Response Operations; and Mike
7 Weber, who is the Director of the Division of Fuel Cycle
8 Safety and Safeguards in NMSS, and I'm going to turn the
9 briefing over to Bill Troskoski.
10 MR. TROSKOSKI: Thank you.
11 May I have slide one, please?
12 Good morning.
13 I am pleased to brief the Commission on the
14 staff's review of the Tokai-Mura criticality accident, the
15 lessons that we have learned as a result of that accident,
16 and the implications for NRC's fuel cycle facility.
17 Slide two.
18 This briefing will cover the purpose of NRC's
19 review of the accident, the basic background of the process
20 involved, the root causes identified by the Japanese
21 regulators, and the consequences, both on-site and off-
22 site.
23 I would then like to highlight the staff's actions
24 taken in response to the accident, followed by a general
25 review of the deficiencies identified by the Japanese
6
1 regulatory authorities, and review the implications for NRC-
2 licensed facilities.
3 Following this, I will discuss several emergency
4 response issues identified by the Japanese and compare these
5 issues against the NRC program.
6 Finally, I would like to provide the staff's
7 conclusions for your consideration.
8 I should state at the outset that the NRC staff
9 recognizes that our fuel cycle oversight program can be
10 improved.
11 Indeed, NRC has been revising Part 70 and last
12 year initiated a process to review our program for fuel
13 facilities, in concert with the stakeholders.
14 Nevertheless, we are pleased by the positive
15 conclusions of our assessment.
16 The next slide, please.
17 The President requested the Department of Energy
18 and the NRC to conduct a review of U.S. nuclear facilities
19 to assure that a similar accident would be unlikely here.
20 Even without such a request, we had planned to
21 review the lessons learned from the Tokai accident as part
22 of our continuing efforts to enhance the effectiveness of
23 our oversight program.
24 To accomplish this task, we reviewed the current
25 safety operations at U.S.-licensed and -certified
7
1 facilities, we considered the implications for NRC's
2 oversight program, and drafted a report addressing the
3 lessons learned and implications.
4 Slide four, please.
5 By way of background, the accident occurred on
6 September 30, 1999, at the JCO Company site in Tokai-Mura.
7 This is a densely-populated area located about 70 miles
8 northeast of Tokyo.
9 The accident occurred in the conversion building,
10 shown here at the end of the arrow. The site plan
11 illustrates the general scale of the facility, and please
12 note the zero to 200-meter scale bar shown on the bottom
13 righthand side of the slide.
14 The nearest residential building is located about
15 150 meters to the southwest of the conversion building. To
16 the north of that residential building is a lumber yard
17 where several workers were located during the first several
18 hours of the accident.
19 About 160 members of the public were subsequently
20 evacuated from within 350 meters of the plant, and 310,000
21 people were subsequently sheltered within 10 kilometers of
22 the facility.
23 Slide five.
24 The top portion of this slide is a diagram of the
25 process and written operating procedures as approved by the
8
1 Japanese regulatory authorities.
2 The bottom portion shows the actual procedure that
3 was used during the accident. The accident occurred in the
4 precipitation tank, which is shown about in the middle of
5 the process.
6 It is important to know that there was no hardware
7 failure involved.
8 Official reports document that this was apparently
9 not the first time that JCO employees had deviated from the
10 written procedures without proper authorization in order to
11 increase productivity.
12 Some other important factors directly related to
13 the accident are that this was the first time the process
14 was run in the last two to three years; of the three
15 operators involved in the accident, two had no previous
16 experience with the 18.8-percent enriched process, and the
17 third operator had only about one or two months' previous
18 experience.
19 The operators deviated from JCO's revised
20 procedures, which were not reviewed by either their safety
21 department or the regulator, due in part to production
22 pressures.
23 Slide six, please.
24 Based on the Japanese investigations, the direct
25 cause of the accident was due to the conduct of the
9
1 operations.
2 Had the facility been operated in accordance with
3 the approved procedures, this accident would not have
4 happened.
5 Based upon the staff's review of the Nuclear
6 Safety Commission's reports, the root causes were inadequate
7 regulatory oversight, lack of an appropriate safety culture,
8 and inadequate worker training.
9 Slide seven, please.
10 Sadly, as a result of the accident, two of the
11 three workers died from radiation exposure. The third
12 worker has been released from the hospital but is still
13 under medical observation.
14 The doses presented on this slide are estimates,
15 and refinements to the estimates are certainly possible as
16 evaluations continue.
17 I would like to emphasize two points about this
18 graph.
19 First, note that the doses to the three operators
20 greatly exceeded the doses to the other people involved.
21 Second, note that there were more members of the
22 public exposed than workers.
23 This is very unusual, because criticality
24 accidents are not generally expected to cause off-site
25 exposure. However, in this case, proximity of members of
10
1 the public to the conversion building yielded a different
2 result.
3 The next slide, please.
4 As the Commission is aware, we activated the NRC
5 Emergency Operations Center during the accident. After we
6 conducted a preliminary evaluation of the available
7 information both during HP LaserJet Series IIHPLASEII.PRSs
8 diffusion plants to focus the inspectors' attention on what
9 we believed were the potential problem areas.
10 As a result of the additional inspections, no
11 significant safety issues were identified at those
12 facilities.
13 We also issued an information notice to the fuel
14 cycle licensees to alert them to what we believed were the
15 potential problems based on initial reports from the
16 government of Japan, the International Atomic Energy Agency
17 visit, and the Department of Energy visit.
18 Since the accident, the staff has continued to
19 review and evaluate lessons learned to determine
20 implications for commercial nuclear fuel cycle facilities
21 and our regulatory program.
22 The sources of information included the various
23 reports and briefings provided by the Japanese regulatory
24 authorities, including the Nuclear Safety Commission and the
25 Science and Technology Agency, other agencies such as the
11
1 IAEA, DOE, and the Japanese Atomic Energy Research
2 Institute, as well as open news sources.
3 Next slide, please.
4 Based on the information developed from the above
5 sources, the staff looked at each program component that was
6 identified as deficient and performed a comparison between
7 the factors that contributed to the accident at Tokai and
8 U.S.-licensed facilities.
9 The safety evaluation performed by JCO and
10 approved by the regulator assumed that the criticality was
11 not possible.
12 Also, JCO was not required to install a
13 criticality accident alarm system or develop an emergency
14 plan or provide operator training regarding criticality
15 safety.
16 U.S. licensees are required to perform evaluations
17 that assume that a criticality is possible. They are
18 required to install a criticality alarm system and develop
19 an emergency plan.
20 Further, licenses also have individual operator
21 training requirements.
22 The NRC's oversight program reviews the
23 development and implementation of these program components.
24 Slide 10, please.
25 Operations at the JCO conversion facility were not
12
1 inspected since 1992.
2 Operations at U.S. facilities receive periodic
3 announced and unannounced inspections throughout the year.
4 Procedures are required at both the JCO facility
5 and U.S. facilities.
6 The NRC oversight program addresses procedure
7 development, review, and approval, including criticality
8 safety reviews, as appropriate, and procedure
9 implementation.
10 At the JCO facility, inadequate management control
11 is exercised over the startup of the 18.8-percent enriched
12 uranium process.
13 No steps were taken to ensure that the appropriate
14 safety limits and controls were flowed down to the operators
15 through procedures, postings, and training.
16 At U.S. facilities, the operating license defines
17 the authorized activities and the management control systems
18 to assure that the appropriate safety limits are developed
19 and implemented.
20 The Japanese regulatory authorities also noted
21 that there was not an appropriate safety culture at the JCO
22 facility.
23 Management did not believe that a criticality was
24 possible, and they did not exercise proper control over site
25 activities.
13
1 At U.S. facilities, the NRC inspection process
2 provides feedback regarding a licensee's performance.
3 Inspection findings, event, and other reports are
4 periodically evaluated and trended as part of our licensee
5 performance reviews that are performed periodically for each
6 facility.
7 As a result of the review that we performed, we
8 identified no gaps in the NRC's regulatory oversight
9 process.
10 Slide 11, please.
11 In addition to identifying the specific
12 deficiencies that contributed to the accident, the Japanese
13 Nuclear Safety Commission's report also addressed several
14 performance issues related to emergency response that
15 surfaced during the accident.
16 They noted that the initial emergency response was
17 complicated by a lack of a criticality accident alarm
18 system, the local population did not receive a timely
19 notification to evacuate the immediate area, there were
20 interface problems between various government organizations,
21 and JCO's communications and emergency response system were
22 not adequate to support what they felt needed to be done.
23 Slide 12, please.
24 The staff also considered whether each of these
25 issues is address by NRC requirements.
14
1 As a result of our review, we believe that our
2 regulatory requirements and the NRC's licensing and
3 inspection process provides an appropriate level of
4 emergency preparedness for U.S. fuel cycle facilities.
5 Our facilities are required to have functional
6 criticality accident alarm systems, and we do inspect that
7 as part of our core inspection program.
8 Emergency plans are required for the larger
9 facilities.
10 We do have a reg guide that defines what the
11 content of the plans should be. The emergency plans are
12 reviewed and approved by the licensing function, and they
13 must address issues such as prompt notification of off-site
14 response organizations and they must address the
15 coordination of emergency actions.
16 From those approved emergency plans, licensees are
17 required to develop site-specific implementing procedures.
18 They are also required to conduct periodic drills with the
19 local emergency response organizations and invite the state
20 and local governments to participate if they so choose. At
21 the end of the drills, they hold critiques to identify
22 lessons learned.
23 The NRC core inspection program reviews emergency
24 planning.
25 Slide 13.
15
1 In conclusion, we believe that the Japanese
2 government has conducted a thorough investigation of the
3 criticality accident at Tokai-Mura.
4 We believe that the accident root causes are
5 similar to causes of previously criticality accidents that
6 have occurred throughout the world.
7 The current safety program carried out at
8 commercial U.S. fuel facilities makes a similar accident
9 unlikely, and finally, emergency response plans provide
10 defense-in-depth at U.S. facilities.
11 That would conclude the staff's formal
12 presentation at this time.
13 MR. TRAVERS: If I may just make one point of
14 emphasis, Bill mentioned that the U.S. program, in contrast
15 to the Japanese program, includes periodic inspections at
16 fuel facilities.
17 In fact, at the facilities that have our license
18 for high-enriched uranium, we have resident inspectors, and
19 at the gaseous diffusion plants, as well.
20 So, we not only have a periodic inspection
21 capability and program that covers all fuel cycle
22 facilities, but in those instances where high-enriched
23 uranium is licensed for use, we have a resident inspector
24 program.
25 That concludes our presentation.
16
1 CHAIRMAN MESERVE: Thank you very much for a
2 helpful presentation.
3 Commissioner Diaz.
4 COMMISSIONER DIAZ: Good morning.
5 I believe that the staff should be congratulated
6 on focusing its studies on what is really important from our
7 perspective, which is the analysis of not the event in
8 itself, which we had no control over, but the results of the
9 events and how can we use it to ensure adequate protection
10 of public health and safety in this country, and I have gone
11 through it carefully, and I am satisfied that every effort
12 has been made to compare situations and make sure that we
13 have addressed those issues.
14 I think that it appears that we have done a very
15 good job, and I'd like to thank the staff for it.
16 I have two questions.
17 The first one is on the actual review that was
18 done for our facilities, and is there any additional action
19 that the staff believes is needed to ensure adequate
20 protection of public health and safety at U.S. facilities at
21 this time?
22 MR. TROSKOSKI: No additional action is needed.
23 Again, we are revising Part 70, and we are also looking to
24 revamp our program to make it more risk-informed and
25 performance-based, and that will certainly enhance it, and
17
1 we recognize that we can do a better job with our oversight
2 program in that regard.
3 As far as there being any immediate safety issue
4 that we needed to take action on or that we need to take
5 action on in the immediate future, no.
6 We believe that there is an adequate margin of
7 safety at each of the facilities today.
8 COMMISSIONER DIAZ: All right. Thank you.
9 The second area is always one of my pet peeves,
10 and it deals with information to the public, and I realize
11 that there are many things that were not under our control
12 in here, of course, it was in the control of somebody else.
13 However, I still believe that, like the Chairman
14 stated, we need to be able to respond to these situations
15 when they happen, and I will make a comment and then I'll
16 ask the question.
17 It is obvious -- and of course, Los Alamos has
18 done a very good analysis, but we have known for a long
19 period of time that accidents at fuel facilities or at
20 research reactors have very limited capabilities to cause
21 public health and safety damage, that the damage is normally
22 -- or the risks are constrained to the area of the facility
23 that -- like in this case shown and like Commissioner
24 Merrifield already pointed out, there was an unfortunate,
25 you know, death of two workers, one is already injured.
18
1 There was some, you know, radiation levels
2 registered for people close to the facility, already alluded
3 to it.
4 However, I always get concerned that one of our
5 missions is to bound these things in terms of what the
6 public health and safety perceptions are, and I was
7 wondering whether, not the first day when we have no
8 information, not the second day, but if we, in our public
9 information, public affairs efforts, did we try to establish
10 that criticality accidents at fuel facilities are bounded by
11 the limitations of the small amount of fuel, the small
12 amount of fission products, all of those things that make
13 criticality accidents things that we worried about but that
14 have never caused a significant public health and safety
15 issue. Did we address this issue? And I don't know who is
16 going to answer that question.
17 MR. TROSKOSKI: The press release that we issued
18 did not address that, sir.
19 It was something we were just focusing on the
20 event at the time but we weren't trying to say, hey, our
21 facilities are enveloped by the analysis, we don't expect
22 there to be off-site consequences, if there are we've got an
23 emergency plan there.
24 We were more just focused on a much more narrow
25 focus on the event at hand because of the high news profile
19
1 that it received.
2 COMMISSIONER DIAZ: As a lesson learned from this,
3 should we be prepared, if there is -- you know, which there
4 could be, because they are not impossible, they are --
5 accidents do happen -- to address the level of risk
6 associated with accidents?
7 I think this is a major issue that faces the NRC.
8 We need to be able to bound the risk for the people that we
9 serve, and we need to be able to address it, and I repeat,
10 for criticality accidents at fuel facilities, the public
11 health and safety impacts will always be small, and I will
12 say will, not could. There are limits to what it could do.
13 MR. KANE: I think your point is well taken,
14 Commissioner.
15 I know one of the things that we were dealing with
16 early on was we wanted to also make sure we completely
17 understood what had happened so that tempered, I think, some
18 of our earlier discussions.
19 COMMISSIONER DIAZ: Thank you, Mr. Chairman.
20 CHAIRMAN MESERVE: Commissioner Merrifield.
21 COMMISSIONER MERRIFIELD: Thank you, Mr. Chairman.
22 Upon reviewing these materials, it would appear to
23 me that, obviously, competitive pressures did play a role in
24 some of the consequences, inadequate staff resources.
25 Obviously, there may be some other cross-cutting factors,
20
1 human factors and safety culture, leading to the accident.
2 Are the inspection programs and the regulatory
3 programs that we have here at the NRC, combined with some of
4 the industry self-assessments -- are they adequate to detect
5 circumstances where there may be deteriorating trends on
6 cross-cutting factors? Could you talk to that a little bit?
7 MR. TROSKOSKI: I believe they are.
8 We go out and we look in a number of areas,
9 everything from operations to crit safety to chem safety to
10 health physics, etcetera.
11 We periodically evaluate the problem reports at
12 these facilities to look for trends.
13 We bring it all together as part of the licensee
14 performance review process that we do, but aside from that,
15 if we find any potential significant indicator, it's
16 certainly run up the management pole, management chain, very
17 quickly, so that we can take action, especially when you're
18 talking about use of procedures, plant modifications, losing
19 control over the conduct of operations in the facility.
20 That's something that we look at in detail, both
21 the regions and headquarters, from a number of different
22 perspectives and disciplines.
23 So, I think we've got -- we would be able to find
24 that out in a timely manner.
25 MR. KANE: We are sensitive to those issues.
21
1 Again, what we measure is safety performance, and we believe
2 that, by doing it that way and having our periodic
3 assessments with the regions of safety performance, that we
4 are able to detect if that turns out to be the cause -- the
5 root cause of change in safety performance, we would be able
6 to pick that up through our inspection program, we believe.
7 COMMISSIONER MERRIFIELD: I want to take the
8 opportunity to compliment the staff for their hard work on
9 this issue.
10 As the Nation's leading regulator of nuclear power
11 plants and fuel cycle facilities, we were obviously
12 inundated from inquiries from the press about this incident,
13 and obviously, as has been mentioned, we tried to respond to
14 those inquiries in a measured and well-informed manner.
15 Are there any lessons that we have to learn for
16 ourselves about this incident and how we can appropriately
17 act in terms of providing public information about incidents
18 that happen at facilities external to the United States?
19 MR. CONGEL: Yes, Commissioner. I'd like to
20 briefly describe a program that we are in the process of
21 developing right now and that will be brought up before the
22 Commission shortly.
23 As a result of Tokai-Mura, as you just mentioned,
24 there was a communication and information requirement placed
25 on us that was different from some of the planning that we
22
1 already had in place.
2 It was also enhanced with the experience that we
3 had during the Y2K rollover; namely, to have the Federal
4 Government coordinated in such a way that we were speaking
5 in a consistent as well as a proceduralized way.
6 The effort that we are in preparation of is called
7 the One Voice initiative, and it is a direct result of what
8 happened at Tokai-Mura.
9 Very briefly, the existing Federal radiological
10 emergency response plan calls for a designation of a lead
11 Federal agency, and for foreign events of this sort, EPA is
12 the lead.
13 Of course, EPA, like all of us, has its principle
14 focus on protection of U.S. citizens, and Commissioner Diaz
15 pointed out, this particular event, although very
16 catastrophic for the workers and potentially affecting the
17 local population, did not have any direct potential impact
18 on the U.S.
19 So, EPA's role was low-key.
20 On the other hand, the request for information
21 about facilities similar to those in the United States that
22 would be overseen by us or run by Department of Energy was
23 intense, and we mustered a response that was outside of the
24 scope and planning of the FRERP, and what we are in the
25 process of preparing that you will shortly see is a
23
1 coordinated effort using the FRERP as a base and the Federal
2 Radiological Protection Coordinating Committee, which is
3 made up of 17 agencies that have responsibilities in this
4 area, so that in anticipation of such an event, we will have
5 a procedure in place that will address this.
6 It clearly requires a different coordination than
7 one that would require protecting American citizens.
8 That's probably the principle lesson learned, I
9 would say, from our response basis.
10 COMMISSIONER MERRIFIELD: I think part of our role
11 as an agency in this regard is to make sure that we are
12 providing accurate and timely information to the American
13 public, so they are appropriately informed about these
14 incidents and are able to put them in an educated context.
15 COMMISSIONER DIAZ: The things that, you know, I
16 tried to address, and Commissioner Merrifield has focused on
17 it again, is, for example, for two days, at least, maybe
18 three days, you could see it in the TV, you know, CNN was
19 calling this, you know, the new Chernobyl, you know, and you
20 know, creating alarm, and I think we need to be ready to
21 bound these things, to say, you know, this doesn't have the
22 amount of fission products, it cannot -- you know, even if
23 the entire mass gets airborne, it's just really not in that
24 category, and I think our capability of, you know, quickly
25 bounding the -- not exactly, because we don't know about it,
24
1 but providing some bounding to the potential for public
2 health and safety is a very good function that we must be
3 able to carry out.
4 Thank you, sir.
5 COMMISSIONER MERRIFIELD: I think the American
6 people deserve to have accurately and timely information
7 about these accidents, and I agree with the Commissioner.
8 One last point I would want to make, and then I'll
9 bow out for this panel -- I had an opportunity last week, as
10 some other Commissioners may have, to meet with a delegation
11 of individuals from the Japanese bar association.
12 They were here to learn more about the way in
13 which the United States regulates nuclear materials, and
14 they were making some recommendations to the Japanese diet
15 about how the Japanese regulatory system may be enhanced,
16 and I mentioned to them, as this Commission has, both
17 publicly and privately, previously, that we believe that
18 having the NRC as an independent regulator, without other
19 external or internal government involvement, enhances our
20 role and our ability to regulate nuclear power plants and
21 nuclear fuel cycle facilities.
22 I think that is something that Japanese diet is
23 strongly considering at this point in terms of some of the
24 recommendations for modifying their system, and certainly,
25 for my part, I'd want to put in the public record a repeat
25
1 of our earlier statements that we believe independence in a
2 regulator of the nuclear industry makes a lot of sense.
3 Thank you, Mr. Chairman.
4 CHAIRMAN MESERVE: Commissioner McGaffigan.
5 COMMISSIONER McGAFFIGAN: I have about three lines
6 of questioning I want to pursue, and one of them has been
7 provoked by the earlier comments.
8 I was Acting Chairman the day of this event, and
9 we did, as Frank talked about, activate our center on a -- I
10 don't know the right term -- contingency basis.
11 We knew it didn't affect people in this country,
12 wouldn't affect people in this country, but there was a
13 typical fog of war.
14 We did not have good information. We were getting
15 it from CNN and from various other folks, and so, it was
16 difficult to know when it was going to be over, how many
17 local residents had been exposed at levels about the, you
18 know, 100-milligram, 1-millisievert public dose limit, and
19 all of that.
20 One of the people who did the best job in the
21 first couple of days, I think I recall, bounding the
22 accident was actually Tom Cochran of NRDC.
23 I think he was one of the talking voices on one of
24 these shows, and he was quite complimentary towards the U.S.
25 regulatory system and towards bounding the issue for the
26
1 public.
2 I think we could do a better job, but it was very
3 difficult during those opening hours to have a real sense as
4 to what was going on.
5 The other thing I'll say about lessons learned --
6 and this is probably a little -- in my role as Acting
7 Chairman -- Frank talked about EPA being low-key.
8 I think the person who normally does this stuff at
9 EPA was actually on leave that day, and it was very hard
10 getting a rise out of anybody at EPA.
11 State was involved.
12 DOE was involved. DOE was so involved that the
13 first thing we knew that DOE was doing something was when
14 Secretary Richardson made announcements with Mr. Adamov from
15 Moscow, and so, he sort of asserted DOE leadership.
16 The President made a statement, which we didn't
17 know about until after the fact, we had to get it from OSTP.
18 So, there was a lot -- this One Voice initiative,
19 I think, is quite important.
20 I think there -- we have to have a connection with
21 the White House during any event, domestic or international,
22 and we need to make sure that somebody, even if it's on an
23 ad hoc decision, somebody is put in charge of the
24 interagency groups, because I think part of the lack of good
25 communication that day was, you know, if secretaries of
27
1 energy and ministers of atomic energy of Russia have to be
2 making statements about it, it must be really, really
3 severe, and so, there were lots of mess-ups that day from
4 our perspective that we can improve on.
5 But in terms of bounding it, I think it takes 24
6 hours to bound one of these things. I really do. I think -
7 - because you just don't have enough information.
8 So, that was more of a statement than a question.
9 The thing that struck us all that day, I will tell
10 the public, was how could Japan have gotten to be so
11 different?
12 We were shocked, because I think, in the first few
13 hours, we heard that STA had not touched this facility since
14 1992, and we all just were amazed at how different that was,
15 and I think it's a regulatory failure.
16 I think the Japanese government has decided it was
17 a regulatory failure on their part, was at least part of the
18 problem.
19 Does anybody have a sense how one can get -- maybe
20 Janice -- how the Japanese regulatory system could get so
21 out of kilter not just with the U.S. but with European, with
22 other regulatory systems?
23 MS. DUNN-LEE: Well, I don't have a very good
24 answer for you there.
25 Japan, of course, is a mature nuclear country. We
28
1 consider them very like-minded, and we have regulatory
2 cooperation and dialogue with them on a very regular basis,
3 and I think it's a good question. I really -- I don't have
4 an answer for that, how it got out of kilter. It isn't
5 identical.
6 COMMISSIONER McGAFFIGAN: The charts on 9 and 10
7 really -- you know, they're meant to say we don't have a
8 problem, but they're really an indictment of the old
9 Japanese system, old Japanese regulatory system.
10 I mean I'll tell you what I think part of the
11 problem is.
12 I've followed Japan for a quarter-century, working
13 first at Rand and then in the executive branch and in the
14 Congress, and I honestly think -- and I think they're fixing
15 it -- STA shouldn't have been in the regulatory business.
16 It's a small entity within a large research
17 ministry. It's about to be combined and become a super-
18 research ministry, and as I understand it, they're going to
19 take most of the regulatory function out of STA and put it
20 in MITI, but they're still leaving some self-regulatory
21 within that large research institution that I fear will get
22 lost, especially given this track record.
23 So, if there are Japanese members of the public
24 listening, I would strongly suggest you think about, as
25 Commissioner Merrifield already has alluded to, having an
29
1 independent regulator regulating all of this stuff and
2 regulating to world standards.
3 One of the comments in Nucleonics Week recently, a
4 May 4th Nucleonics Week, was why hadn't Japan used, on the
5 industry, more peer review, and the argument was, at least
6 in this article, because open criticism involved in peer
7 reviews does not mesh easily with the Japanese culture, and
8 I think that that's again something -- I know it doesn't
9 mesh easily with Japanese culture, but I would strongly
10 suggest that they try to find a way to build in that sort of
11 thing.
12 The NEI document that -- I'm going to use the
13 bound version that was on our chair -- and it's good to be
14 criticized from this direction -- suggests that we may have
15 more than adequate regulatory oversight in this country in
16 several areas.
17 On page 11 of their paper, they suggest that the
18 single uranium conversion plant receives more than adequate
19 regulatory oversight. They suggest the DDPs, you know, have
20 continued intensity of regulation that may be
21 disproportionate to risk.
22 That's on page 11, and then on page 13, they again
23 suggest that we work to lower the regulatory burden on these
24 sites.
25 There is, however, a clear opportunity for
30
1 industry and NRC, working together, to enhance the
2 regulatory paradigm.
3 Specifically with regard to the conversion
4 facility and the gaseous diffusion plants, do you believe
5 that we are over-regulating at the moment, that there is
6 excess regulation?
7 MR. TROSKOSKI: No, sir.
8 You take a look at the bulk hazardous chemicals at
9 the conversion facility, you fail any one of the large tanks
10 that they have out there, and you look at the impact it will
11 have to the members of the public, that will have an off-
12 site impact.
13 Unlike a criticality, it will extend miles beyond
14 the boundary.
15 They have the greatest concentration of bulk
16 hazards, second only to the GDPs, and the greatest hazards
17 at both of these sites are chemical hazards, and these
18 chemical hazards are not something that will cause an
19 increase in cancer 20 years down the line, they have the
20 capability of killing people immediately.
21 So, I think we've got, currently, about the right
22 look at these facilities.
23 So, I would respectfully disagree with our
24 colleagues.
25 COMMISSIONER McGAFFIGAN: I do want to note -- and
31
1 Bill Kane is going to answer -- it's nice to be criticized,
2 in a day like today, for over-regulating rather than under-
3 regulating.
4 I'm glad we're in this boat and Japan is in the
5 other boat.
6 COMMISSIONER MERRIFIELD: It's a good thing to be
7 an independent regulator.
8 COMMISSIONER McGAFFIGAN: Right. It is.
9 MR. KANE: I think it's a fair question, and Bill
10 touched on some of the things that we have got in the works,
11 so to speak, right now.
12 I mean I would tick off Part 70 --
13 COMMISSIONER McGAFFIGAN: I think the new Part 70
14 --
15 MR. KANE: -- which is intended to be more risk-
16 informed; independent safety assessments, which are part of
17 that, which have to be developed and form the basis for
18 determining, you know, whether further changes are needed.
19 Our revised oversight program that we're working
20 on is fully intended to make sure that we're spending just
21 what we need in the right places, and finally, I would say
22 that we're in the process now of reexamining our core
23 program to determine across our core program where the
24 resources should be, and this is -- and this is going to
25 have a -- this is going to be a risk-informed re-look at the
32
1 core program.
2 So, while, at one level, I think Bill's answer is
3 correct, I think, at another level, we always need to
4 examine our programs to make changes, and I believe that we
5 have, with those three initiatives ongoing, I am sure that
6 you're going to see further changes.
7 COMMISSIONER McGAFFIGAN: My last comment is a
8 compliment to the staff.
9 Today's Inside NRC mentions the inspections by
10 Region II and Region III at Westinghouse's plant in South
11 Carolina and the hematite facility that's going to be closed
12 in Missouri, and I remember a similar report that I read on
13 the NFS Irwin inspection a few months ago.
14 I think it's inspections of those sort that are
15 why we have a successful regulatory system. They identify
16 issues early and make sure that the licensees stay attuned
17 to them, and so, I compliment the staff for their work, and
18 I'd point to, again, the Japanese public, look at those
19 inspection reports and see how our staff does it.
20 MR. TRAVERS: If I could just make one quick
21 comment, I happen to agree with that; I think inspections
22 are important, and they're particularly important when you
23 think of the changing nature, the dynamic nature of the
24 business.
25 Very often what we find when we go in on an
33
1 inspection is a fairly changed environment, you know,
2 depending on the business at hand at any given point in
3 time. So, it really has, from that perspective --
4 COMMISSIONER McGAFFIGAN: This is a business
5 that's under stress, because as I think Commissioner
6 Merrifield pointed out, hematite is going to close, there is
7 consolidation occurring in the industry, and we need to be
8 attuned to the pressures that come from that.
9 Thank you.
10 CHAIRMAN MESERVE: I have just a couple of small
11 questions.
12 Your slide 12 -- you had pointed out about your
13 emergency response -- our emergency response drills, and you
14 indicated that they are periodic, and I'd be curious to know
15 how often do we have them.
16 MR. TROSKOSKI: Biennial. Licensee drills are
17 biennial, once every two years.
18 CHAIRMAN MESERVE: You indicated that state and
19 local governments are invited to participate but didn't go
20 on to say whether they do participate, and I wondered how
21 active the state and local governments have been in that
22 process.
23 MR. TROSKOSKI: I cannot tell you which states and
24 local governments participate or don't, although I believe
25 most of them do to some extent, but I couldn't give you the
34
1 numbers offhand, sir.
2 MR. CONGEL: I can answer part of it. The smaller
3 licensees -- there is a high variability, and we can get
4 back to the Commission just what the extent of participation
5 there is, and the bigger sites, particularly the GDPs, there
6 is full government participation, just like it is around our
7 power plant sites.
8 CHAIRMAN MESERVE: It seems to me that, if there
9 are sites where there are high risks, we ought to maybe be a
10 little stronger than invite, strongly encourage, and if
11 there's Commission involvement to be necessary to help that
12 along, we'll be happy to do it.
13 One of the other aspects of this accident that I'd
14 be interested -- and this is information, largely. One of
15 the things that surrounded the Tokai-Mura accident was that
16 they were -- while they customarily were dealing with
17 material fairly low-enrichment, they were -- had material of
18 18-percent enrichment, and they were not following normal
19 procedures, but it does raise a question, it seems to me, in
20 my mind, about the extent to which we have a process that's
21 like 50.59 that allows our licensees to make changes without
22 prior NRC review, and you might say something about what
23 kind of engagement we would have if, all of a sudden, the
24 licensee were to be dealing with materials of different
25 enrichment than they had analyzed before.
35
1 MR. WEBER: Licensees are specifically authorized
2 to possess and process certain enrichment material.
3 So, unless their license already authorizes them
4 to process a higher enrichment, they wouldn't be allowed to
5 possess that kind of material except, in some cases, small
6 quantities.
7 With respect to a 50.59 process, the existing
8 regulations in Part 70 allow licensees to make certain
9 changes to their material control and accounting plans,
10 physical protection plans, and emergency response plans,
11 provided that they meet certain thresholds, without getting
12 prior NRC approval, and one of the things the Commission
13 will soon have before it is an opportunity to review what
14 the staff recommends as a final change control requirement
15 in the new Part 70 revisions.
16 Some licensees already have the flexibility to
17 make those kind of changes under their existing licenses,
18 but the new proposed requirement would allow that -- as
19 consistent with the proposed rule -- would allow licensees
20 in general to have that kind of flexibility.
21 We think that's a really important regulation, as
22 reflected in the proposed rule, because it allows the
23 flexibility, yet maintains the safety of operations.
24 So, it's something that has to be implemented
25 quite carefully and in a controlled way.
36
1 CHAIRMAN MESERVE: I'd like to thank the staff
2 very much. This has been quite a helpful and informative
3 presentation.
4 Our next panel will consist of various individuals
5 who had participated in the preparation of the document that
6 was prepared under the auspices of the Nuclear Energy
7 Institute entitled "Assessment of Nuclear Criticality Safety
8 and Emergency Preparedness at U.S. Nuclear Fuel Plants."
9 Those individuals consist of Mr. John Brons, who's
10 from the institute, and two consultants, Mr. Robert Bernero,
11 who is very familiar to many of us, and Mr. James Clark.
12 MR. BRONS: I'm Jack Brons, and to my left is Jim
13 Clark, on my right Bob Bernero, as you know, who is somebody
14 is very familiar to all of you.
15 You're familiar with Bob's experience. Jim has
16 about 40 years' experience in the fuel processing industry
17 and the waste management industry. My experience, similar
18 duration, is primarily in reactors and with some relevant
19 and significant experience in the conduct of assessments.
20 There is one note I'd like to make about the team
21 as we begin this.
22 It was our objective when we put the team together
23 to have individuals involved who have extensive knowledge of
24 the fuel processing industry.
25 That brings with it some potential for conflict of
37
1 interest, and I would like you to know that Mr. Bernero has
2 informed us before we began these reviews a continuing
3 interest of some substance with the USEC, the gaseous
4 diffusion plants, and the Mr. Clark has a continuing
5 interest and involvement with NFS Irwin.
6 We accommodated those interests as we proceeded
7 with the reviews.
8 Neither gentleman took any sort of a lead role
9 when we were involved in that particular plant that was
10 relevant to them, and so, in terms of discovery of issues
11 and items, until the other two of us had come across
12 something, they did not participate.
13 I think it's important to disclose that at the
14 beginning, however, we were aware of those potential
15 conflicts.
16 The review process that we did was put together on
17 the basis of an industry initiative taken promptly after the
18 accident in Japan.
19 We assembled the team, and then the first
20 assignment for the team -- slide two, please -- was to
21 identify for ourselves the factors contributing to the
22 Tokai-Mura event, and I will not discuss each of the items
23 listed on this slide. It is intended perhaps primarily as
24 an index. I'll refer to some of these areas later on.
25 But to tell you what we did with them, once we
38
1 determined these contributing factors, the team then
2 identified a substantial listing of questions which we
3 needed to address that got us at each of these points.
4 We provided that package of questions to the
5 facilities together with an outline of how we would conduct
6 our review.
7 They, in turn, then provided us with a reading
8 package intended to address these questions that we had
9 prepared in response to these contributing factors, we
10 already read the NRC inspection reports for the two years
11 preceding the event for each facility that was available in
12 the Public Document Room.
13 When we arrived at the facility, our first part of
14 the review was a very extensive question-and-answer session,
15 then, with management, where we went over this set of
16 questions that is conditioned on this contributing factors,
17 while we tried to probe the degree to which the facility had
18 a wholesome response to the questions we asked.
19 We then conducted a tour of the facility, visiting
20 all the parts that we considered necessary to review
21 criticality, safety, and emergency planning.
22 We conducted interviews of operators, supervisors,
23 middle managers, and at the end of the first part of our
24 review, weighing the results of the management presentation,
25 the answers to the questions that we received in the
39
1 interviews, and the observations that we had made during the
2 facility tour, we then identified to the facility several
3 areas that we would individually take on and do an in-depth
4 review in order to determine the correctness of our
5 observations or areas where we needed further information.
6 Then, when we were finished, we provided the
7 facility with a debrief of our observations.
8 Next slide, please.
9 It was very clear to us that the fuel processing
10 industry in the United States are clear beneficiaries of the
11 regulatory and standards processes in the United States.
12 The regulations and the standards are observed, and we
13 believe that they provide for fundamental safety.
14 We did not observe any conditions that we
15 considered to be of safety urgency during the course of our
16 review. We had had discussions with senior staff before we
17 conducted this review. We committed to them that, if we had
18 anything that was of safety urgency, that we would bring it
19 immediately to the attention of the facility and then
20 facility would then report to you consistent with the
21 regulations, but none of those conditions were observed.
22 The team concluded that the facilities are
23 operating safely.
24 Next slide, please.
25 Our review was based not upon pure regulatory
40
1 threshold, however.
2 We used as a basement for discernment in the
3 development of our observations and findings at each
4 facilities a standard of best industry practice.
5 Now, because this team and our review is
6 relatively unique, admittedly, as we did the first few
7 facilities, that standard was based upon the team's
8 experience.
9 Later in the review and as benchmarked in this
10 report which we've presented to you, the standard is, as I
11 mentioned, not based on a threshold of regulatory or
12 standards compliance but, rather, observed actual superior
13 performance in the industry.
14 If we have described a best practice in this
15 report, it is not a figment of our imagination or a wish
16 list; it is actually being done.
17 Now, we have grouped -- I have grouped the factors
18 here for presentation efficiency, and so, I will discuss the
19 observations that we had on items one and two of that list
20 of nine contributing factors, and they generally revolve
21 around the safety culture for operations.
22 It was clear in Japan that there were some
23 commercial pressures that led to the behaviors that led to
24 the accident.
25 We found here that safety of operations is clearly
41
1 the dominant focus.
2 All facilities provide some information to their
3 workforce about their commercial situation. We found
4 information in the dining room or the cafeteria or some out
5 on the shop floor.
6 Our observation and the results of our interviews
7 indicate that that business data is treated as simply that,
8 business data, it's information, and we did not find any
9 evidence that it was dominating operations.
10 It was very clear that the workers had a clear
11 understanding that they had the authority and the obligation
12 to stop the processes in place if they were uncertain or had
13 a safety consideration.
14 We found, because part of our questions looked at
15 the flow-down of procedures for consistency with license
16 conditions, that we found that the procedures are consistent
17 with the license conditions for each individual facility,
18 and we found that the facilities are striving for procedural
19 adherence.
20 They are not all achieving procedural adherence.
21 We found in some instances that the expectations
22 of management for use of the procedures is sometimes poorly
23 communicated and certainly, in many instances, variously
24 understood by the workforce.
25 Now, that said, we did not observe conditions
42
1 where people were not following procedures.
2 What we found instead were situations where the
3 expectation of management might easily be interpreted as the
4 procedure should be open and available as you perform it
5 step by step.
6 The nature of the operations do not permit that.
7 The workforce generally performs repetitive
8 efforts, and we have described that in the report, and they
9 generally are certainly intent on following the procedures,
10 but there is a gap between expectations as expressed by
11 management and the actual practice in the facilities.
12 We have noted in our report what we've found in
13 the way of best practice, and in this area what we would
14 describe as best practice is that there was a very
15 thoughtful policy on the part of management describing how
16 procedures should be used.
17 Mechanisms were in place to facilitate the use of
18 procedures in that manner. It was well communicated to the
19 workforce, supported, enforced, and the understanding of the
20 workforce was congruent with the expectations of management,
21 and that does exist at some facilities out there.
22 Next slide.
23 The nuclear criticality safety program we found to
24 be one marked by uniform adoption of the double-contingency
25 principle.
43
1 It is an underlying feature of criticality safety
2 that involves the use of double contingency.
3 We found a preference for the use of engineered
4 controls throughout the industry; that is, practices which
5 are aimed at eliminating administrative controls,
6 administrative controls being those that are primarily
7 dependent upon human behavior and engineered controls being
8 those which are built into the process.
9 We found some use of triple-contingency practices
10 out there; that is, where the facility had identified and
11 put in place an additional level of contingency, and the
12 team has noted that that is both a plus and a minus.
13 In some instances, the application of another
14 layer of contingency confronts the operators with additional
15 sets of data that can promote confusion.
16 So, the -- while the concept of building in
17 additional layers of safety is an important and valuable
18 one, it must be done in a very thoughtful and rational way
19 or it can cause confusion.
20 There is also a widespread use and expectation
21 that nuclear criticality safety postings will be deployed in
22 the plant, and we did find, to some extent, that there is a
23 variable effectiveness to those postings, and in particular,
24 if they come out of the print shop and they are not
25 necessarily printed in the right size or they're not posted
44
1 in the right location, then they can't be as effective as
2 they might be.
3 In that regard, in the area of best practice, we
4 found a number of things, and relative to the postings,
5 where the operations department has a significant control
6 over how those criticality postings are deployed, and the
7 way they're printed and placed in the plant seems to enhance
8 their effectiveness considerably.
9 Other best practices that we observed were cross-
10 train surveillance.
11 This is referring to the fact that, at some
12 facilities, radiological technicians have been trained to
13 observe for criticality safety issues or engineers are used
14 to do surveillances for criticality safety issues, and we
15 found that to be a significant plus, and other facilities
16 have very rigorous programs that systematically challenge
17 administrative controls that remain in place.
18 Next slide, please.
19 Now, I want to stress, as I leave the nuclear
20 criticality safety area, that it was not this team's
21 objective to review the applications and calculations behind
22 standards and codes used to define criticality measurements.
23 Rather, our focus was on the management of
24 criticality safety, and so, in this view-graph, I'm
25 discussing or outlining the issues that we discussed or
45
1 found relative to areas of management, training, and
2 oversight, items four, five, and six on the index of
3 contributing factors.
4 We found that the use of event experience from
5 Tokai-Mura was not as aggressive as we would have hoped. We
6 found everyone familiar with the Tokai-Mura event, but in
7 our view, it was an occasion to very forcefully use it to
8 reinforce standards in place, and generally, the event was
9 used as simply communication of an occurrence and
10 information to the workers, rather than a very vigorous,
11 gee, this happened, we want to use it as forcefully as we
12 can.
13 We also found some weakness in the understanding
14 of criticality and the factors used to control criticality.
15 We found across the board understanding that
16 criticality is a significant event, we found across the
17 board understanding that criticality can occur here, but
18 when you get down to defining exactly what a criticality is,
19 many workers were weak in that regard, and that led to a
20 subsequent weakness in understanding the controls that are
21 used relative to criticality; that is, geometry, moderator
22 control, and so on.
23 They were unable to relate those terms, a term
24 like moderator or spacing, to the physical occurrence of
25 criticality.
46
1 Relative to the qualification process, we found,
2 really, two types of qualification processes out there, one
3 which I will call a very formal qualification card, lots of
4 documentation behind the qualification of a worker, and the
5 other being more of an apprentice/journeyman relationship in
6 qualifying and training people.
7 The team did not observe any significant
8 differences in the results of either of those two processes,
9 but we have suggested to the industry that, where the
10 apprentice/journeyman-type approach be used, that there
11 should be some management oversight processes to review the
12 quality of that work or that effort.
13 We found supervisory involvement to be very, very
14 good throughout the board. We found active engagement of
15 supervisory personnel and middle management engineering
16 personnel in the plant observing the processes whenever we
17 were there.
18 In terms of operating procedure control, all of
19 the facilities have a process for controlling changes and
20 allowing the workers to know whether or not changes are --
21 have been instituted to procedures that they are using.
22 We find in some instances, however, that the --
23 where the number of changes is frequent, many of them for
24 administrative reasons or something of that nature, that the
25 processes for raising awareness of changes that are
47
1 substantive is weakened.
2 We looked at configuration and restart control,
3 and we found it was good, and the staff noted to you, our
4 regulations require certain reviews before starting
5 processes.
6 The requirements for restarting processes or
7 infrequent process are less well-defined in the regulation.
8 Nevertheless, we found that they are widely used in the
9 industry, and the team suggests that that practice, which is
10 not required in most cases by regulation but which is done
11 at all facilities, is a very substantial point that would
12 minimize the likelihood of an event similar to Tokai-Mura's.
13 In the audits and surveillance areas, we found
14 that all are being conducted in accordance with their
15 licenses. The results are -- leave room for improvement.
16 I would summarize what we found by saying that
17 routinely-required audits are producing routine results.
18 The audits which are done for special purposes are producing
19 more worthwhile results.
20 In terms of corrective actions, we found that the
21 programs -- many of them are diffuse, and it was of some
22 concern to us that the -- there seems to be a built-in
23 deference to NRC results or findings.
24 If a relatively routine item is identified by an
25 NRC inspector, it may well assume a level of importance that
48
1 exceeds a more important issue identified by facility
2 management, and we identified that to the facilities.
3 In terms of best practices, we found that there
4 were some facilities that had very infrequent operating
5 procedure changes, that they were tightly controlled, that
6 the workforce understands what criticality means and all of
7 the terms involved with control of criticality, and that the
8 qualification processes and use use selected highly-trained
9 individuals and that there are oversight programs supporting
10 management objectives and that those oversight programs
11 engage more than just the functional staff; that is, they
12 take advantage of other people in the plant for oversight.
13 Next slide, please.
14 In the area of instrumentation and dosimetry, as
15 you heard earlier from the staff, there are very specific
16 regulations and requirements, and in our review, we
17 determined that all aspects that we received were fully
18 acceptable.
19 As a result of determining that fairly quickly, we
20 did not perform a sufficient in-depth review in that area to
21 identify what we would call best practices, and so, none are
22 listed in terms of instrumentation dosimetry; it's certainly
23 a very acceptable program that's out there.
24 In terms of emergency preparedness, we found plans
25 and very good facilities in place at each one of the 10
49
1 locations.
2 The scope of exercises and drills is appropriate
3 to the risks.
4 We found that, while all of them considered the
5 prospect of criticality as one of the events -- that is, all
6 of them except for the conversion facility, which does not
7 have a risk of criticality -- considered criticality but few
8 had provided full consideration to the notion of an extended
9 criticality; that is, what would they actively do if a
10 criticality went on for some 19 hours, as it did at Tokai-
11 Mura, how would you stop it, and lastly, there was some
12 weakness that we discovered in terms of understanding how to
13 deal with highly-irradiated staff that might be involved in
14 an accident.
15 In terms of best practice, we found an excellent
16 emphasis on events with the highest probability and the
17 worst case situation was thoroughly considered.
18 In the area of regulatory oversight, as the staff
19 noted, there was clearly an element of inadequate regulatory
20 oversight at Tokai-Mura.
21 We reviewed the inspection reports, we reviewed
22 how they were treated at the facilities, and in our view,
23 the regulatory oversight is sufficient or more than
24 sufficient. We felt that the oversight at the highly-
25 enriched uranium facilities and the low-enriched facilities
50
1 is about right. We felt that the oversight at the gaseous
2 diffusion plants and the conversion facilities may be more
3 than is needed.
4 Next slide, please.
5 Overall, this was a very unique opportunity, and
6 we've come up with this category which we call results
7 integrated, which goes a little bit beyond our charter. We
8 limited ourselves very much to the focus on the contributing
9 factors point.
10 Nevertheless, we had three people with a
11 reasonable amount of experience who had completely open
12 access, and we were focused on safety, and we visited all of
13 the facilities one after another.
14 So, that gave us a view which is not commonly
15 achieved.
16 We are also very mindful, as your questions
17 earlier have indicated, that the competition and
18 consolidation in the industry makes this a time of
19 transition which is one where there is a need for great
20 vigilance.
21 We found that the facilities have not, for a
22 variety of reasons, proprietary and in some cases
23 constraints provided simply because of the merger and
24 acquisition activity that's going on, do not talk to each
25 other as much as might be desirable, and there's been some
51
1 concern about sharing proprietary information or shielding
2 proprietary information, but we think, in this time of
3 competition and consolidation, that most of the items that
4 we have identified as best practices in this report have
5 nothing to do with the proprietary nature of the processes,
6 and we do believe that there is an opportunity for the
7 industry to do more benchmarking, which should improve both
8 the efficiency and, along with it, the safety of all these
9 facilities.
10 When we took some consideration of the facilities
11 themselves and the basic processes, it led us to some
12 consideration of the concept of risk and the regulatory
13 process, as well.
14 We noted that both management and the NRC, in some
15 areas, seemed to be treating the facilities with programs
16 similar to those used at reactors. So, we would note and
17 were fairly forceful in our report to say these are not
18 reactor.
19 As you've noted in your discussion earlier,
20 relative to criticality, the risk is almost exclusively on-
21 site. The off-site risk is low, and it is primarily
22 chemical and process risk and is certainly -- these
23 facilities are different enough in their operations that the
24 one size fits all approach to regulation does not seem to
25 fit.
52
1 Next slide, please.
2 Again, coming back to our conclusions, the team
3 noted at the start of this that the consensus was that the
4 regulatory process was sufficiently vigorous and different
5 in the United States that the risk of an accident was
6 relatively lower and that the facilities in the United
7 States could be expected to be operating safely.
8 Based upon our review, we are able to affirm that
9 view.
10 Nevertheless, we found some opportunities where we
11 think that there are places where safety or operations can
12 be improved, but we do note that the assumption that is used
13 in the United States -- that is, that criticality can happen
14 here -- is a very sound basis for safety planning and should
15 remain.
16 That concludes our report.
17 CHAIRMAN MESERVE: I'd like to thank you all for a
18 very helpful report.
19 On the one hand, it's reassuring, but on the other
20 hand, you have raised some issues that present some issues
21 for us as we think about these facilities in the future, and
22 obviously, you've raised some issues that ought to be of
23 interest to the organizations that you evaluated in the
24 course of your review.
25 There's one area where I had -- I want to explore
53
1 a little bit further with you -- that I had -- I may not
2 have quite understood your comments.
3 You indicated that there was a gap in the
4 expectations of management with regard to procedures and
5 procedural compliance and what was really going on. You
6 couple the existence of what you observed with your comments
7 about worker understanding of criticality issues and
8 consequences of purpose of various of the controls, and that
9 combination is not suggestive of a very good situation, and
10 I may have misunderstood the nature of the gap that you
11 perceived, but could you comment further on that?
12 MR. BRONS: Certainly, and then I'll invite Bob
13 and Jim to comment.
14 Many of the facilities are using -- if you talk to
15 the senior management, you will hear the term that we
16 operate by verbatim compliance with the procedures.
17 Now, that implied to this team -- verbatim
18 compliance implies a perform steps exactly as written mind-
19 set and operation and generally requires open reference to
20 step by step as you are performing the procedure.
21 When we talked to the operators themselves -- and
22 this is uniform, at all the facilities -- we found a very
23 rapid willingness to say we follow procedures.
24 There's a clear intent to follow procedures on the
25 part of management and the workers.
54
1 So, then, the gap I referred to is what does this
2 statement of management mean? How do they expect it to be
3 carried out? And as we interviewed various managers, we got
4 different impressions of what they mean by verbatim
5 compliance.
6 As you talked to the workers, you found that they
7 variously interpreted those statements as well.
8 As I mentioned, what you see in these where you're
9 doing repetitive procedures in most cases is that the
10 workers are trained in the procedures and they perform them
11 without immediate reference to the procedure at any given
12 time.
13 When you go and look at the items that have been
14 collected by the facility or that are visible in NRC
15 inspection reports, you find a number of instances of
16 procedural -- non-compliance with procedures.
17 Well, if you have an expectation that it's
18 verbatim compliance and the workforce says that they intend
19 to comply and they are not, it indicates that there is an
20 understanding on the part of the workforce that their charge
21 is to comply with the intent of the procedure.
22 Now, that's different than verbatim compliance.
23 So, it's that gap in communication that I talk
24 about and an understanding of how is this procedure to be
25 used and how does a worker perceive it should be used.
55
1 CHAIRMAN MESERVE: I guess I'm not following why
2 you don't see a safety concern that arises from that gap in
3 a situation in which, as your report indicates, there is
4 maybe incomplete knowledge by the workers of the
5 consequences of departing from procedures.
6 MR. BERNERO: I would like to offer something on
7 that.
8 In the case of criticality safety and worker
9 understanding, for example, we encountered workers who
10 recognized that there was an importance to these criticality
11 safety controls, even when they were very unhappy with them,
12 you know, like restrictions about you can only move one
13 container at a time.
14 The thing we're pointing out in worker
15 understanding is their understanding of the nature of a
16 criticality or the controlling factors moderator mass and so
17 forth depended too much, in our view, on recognizing the
18 importance because they were told it was important, and it
19 would be very helpful, we think, that the workers understand
20 further why these controls are important.
21 Now, there is, indeed, an underlying safety
22 question.
23 You know, you obviously want a well-trained worker
24 to adhere to strict controls for criticality safety and to
25 understand why he or she is doing it, and therein lies a
56
1 potential for a weakening of safety control, but our concern
2 with procedure adherence is a much more general things,
3 where very few facilities laid out a coherent structure --
4 this procedure will be in hand, when you do the thing, you
5 do it and you check off or in some way follow it step by
6 step. This other procedure, you will memorize and you will
7 do it, you know, it will be there on file, you will have
8 training updates periodically, and then, other procedures,
9 you follow an intent or you have more flexibility.
10 That's a more prevalent problem where we have the
11 management saying tight adherence or verbatim compliance and
12 then the actual practice was more fuzzy.
13 MR. BRONS: I would take it a step further.
14 The answer to your question is there can be a
15 safety concern in the issue that we raise.
16 I would tell you that our observation was, where
17 the steps in the procedure or the requirements involved
18 criticality safety postings, we don't think there was any
19 ambiguity at all, and indeed, those are posted generally,
20 some places not as effectively as others but there for the
21 worker to see it.
22 There's almost a step out of the procedure, for
23 instance, it becomes this posting.
24 So, there's less concern from the standpoint that
25 this lack of -- the gap that I describe in procedural --
57
1 between expectations and actual performance will affect a
2 criticality safety issue, but they certainly do have issues
3 of procedural non-compliance, because in cleaning a
4 component or something like that, there is a procedure.
5 The worker follows what he believes to be the
6 intent of it, ends up with a spill of powder or what have
7 you. Well, that is an issue, and it comes from this gap
8 that I talk about.
9 So, there's an area to work on, but I think it's -
10 - relative to criticality safety, it was not a concern of
11 ours.
12 CHAIRMAN MESERVE: I have just one other question.
13 Your report is an excellent one in identifying
14 areas of where there might be some improvements that could
15 be made, identifying best practice, and I'd be curious if
16 you have any sense of the response of the beneficiaries of
17 your study to those recommendations.
18 Some of them don't necessarily involve us but are
19 ones that I think you would urge the industry to consider,
20 and I'd be curious as to whether you have any insight to the
21 reaction to the report.
22 MR. BRONS: Yes. Thank you for asking that,
23 because one of the things I forgot to do was acknowledge the
24 fact that we have representatives of all the facilities
25 here, and the response has been excellent.
58
1 This initiative was established without a basis
2 that -- we weren't setting up a new organization, so they
3 did not have an obligation to respond to us. Nevertheless,
4 we have heard from all of them.
5 They've been appreciative of the comments that we
6 provided.
7 We understand that they have also provided the
8 details of the findings at each facility to the NRC
9 inspectors that visit, so that the individual details have
10 been provided to your staff, and that that has been fed back
11 to the headquarters staff here.
12 But relative to the facilities themselves, I'm
13 aware of some outreach to INPO, for example, to help some
14 facilities on some items, that that's occurred.
15 I am aware of some communications between
16 facilities, where they're trying to share practice, and we
17 have had industry discussions about establishing some sort
18 of benchmarking activity and moving ahead with that.
19 Those plans have not been solidified, but there
20 has been a high level of interest, and we understand that
21 they're taken our recommendations very clearly.
22 CHAIRMAN MESERVE: Seems to me that would be a
23 very valuable activity.
24 MR. BRONS: Yes, sir.
25 CHAIRMAN MESERVE: Commissioner McGaffigan.
59
1 COMMISSIONER McGAFFIGAN: I want to join the
2 Chairman in commending you for the report. I think it's
3 excellent work on your part, and I'm glad everybody in the
4 industry voluntarily worked with you.
5 Your first slide had a list of nine factors
6 contributing to the event, the last of which was inadequate
7 regulatory oversight, but as I read that chart, the first
8 eight almost derive from nine.
9 I mean if you have an inadequate regulatory
10 oversight, then you're likely to have permitted deviations,
11 tacit approval of procedural deviation, insufficient
12 training, insufficient administrative controls.
13 A lot of that falls from not having a regulator,
14 and as we know, this facility had not been touched by the
15 regulator since 1992 prior to this event.
16 Do you all have any sense -- I mean I asked the
17 first panel -- it was not your charter here -- how Japan got
18 so different from not only us but from European practice?
19 MR. BRONS: Certainly on my part, it is pure
20 speculation.
21 I personally believe that the root cause is the
22 decision that was made at the time the facility was
23 originally licensed that the assumption would be made that
24 criticality was proscribed by virtue of having procedures in
25 place, and that allowed everybody to say, well, if that's
60
1 the case, then we don't need to regulate.
2 I believe that that's the reason, but I don't know
3 that.
4 MR. CLARK: I second that. I was stunned that the
5 Japanese could get into this fix, and I came to the
6 conclusion that their belief that it couldn't happen was
7 what led it to happen.
8 MR. BERNERO: I would just like to add that we all
9 had that same reaction, but then we turned away from further
10 pursuit of it, as our report says.
11 We tried to focus on these nine contributing
12 factors as the basis for a comprehensive scrutiny of the
13 U.S. facilities and not to try to fully evaluate the
14 Japanese event.
15 COMMISSIONER McGAFFIGAN: Your report -- as I
16 asked the first panel -- and as I said, I'm happy to be
17 being criticized from being an over-regulating regulatory
18 body when we're dealing with events of this sort, but your
19 report does suggest that, with regard to the uranium
20 conversion plant and the gaseous diffusion plants, we may be
21 over-regulating at the moment.
22 Do you want to elaborate more on that, and is the
23 new Part 70, in and of itself, with the ISA and all that,
24 going to fix it, or is there more that needs to be done?
25 You also heard the staff's reaction.
61
1 MR. BERNERO: Recognizing what was said about the
2 potential conflict of interest with the gaseous diffusion
3 plants, let me turn to the conversion plant and just note a
4 couple of historical factors that influenced this.
5 In the old days, when the environmental impact
6 statements were done on fuel cycle facilities, the off-site
7 chemical risk was not a factor, because it was not NRC's
8 jurisdiction.
9 Then, with the Sequoyah Fuels accident, there was
10 a legal analysis that said, if it's part of your process,
11 you have to consider it, and so, there ensued a great deal
12 of chemical risk regulation.
13 The gaseous -- the conversion plant has the
14 peculiarity, if you have ever visited it -- I know some of
15 you have -- the radiological risk is basically the ore yard
16 and doesn't get spread, and that hasn't been a matter of
17 contention, but the chemical risk of UF-6 is quite small
18 compared to the chemical risk of hydrofluoric acid which is
19 in outdoor tanks that are massive and so forth, and in fact,
20 the state participation in any emergency exercise is that
21 which would be associated with chemical plant risk, and so,
22 the NRC finds itself, in regulating a Part 40 licensee, to
23 have -- as part of its license application, have an
24 appropriate emergency preparation, and you're regulating
25 chemical risk, and you have a very tenuous connection to the
62
1 dominant chemical risk, and so, it does raise a very serious
2 question about the degree of regulation that is appropriate,
3 and of course, that facility gets tourists and inspectors in
4 rather large number, which is -- it's a practical matter of
5 over-regulation.
6 Calvert Cliffs went through that when they were
7 first licensed, and any reactor near Washington would get
8 lots of tourists, and with the gaseous diffusion plant in
9 Paduca, across the river, I'm sure whoever visits says,
10 well, I'll kill two birds with one stone.
11 Well, one of those birds -- it gets a lot of those
12 tourists.
13 COMMISSIONER McGAFFIGAN: We also have an MOU with
14 OSHA, and we have some responsibilities for looking at the
15 chemical side, don't we? I mean you're suggesting that --
16 or is there some other regulator who will deal with the
17 chemical risks there?
18 MR. BERNERO: The MOU with OSHA -- which, by the
19 way, was developed years ago, when I was here. The MOU with
20 OSHA is with regard to worker safety, and the dominant risk
21 -- and I think the staff even said it in the earlier
22 briefing -- is the chemical risk off-site, and if you look
23 at the emergency plans and the seismic analyses, that plant
24 has done seismic analyses, and it's chemical risk, and
25 that's not OSHA.
63
1 COMMISSIONER MERRIFIELD: If I can jump in, I used
2 to deal with some of these issues when I was on the Senate
3 environment committee.
4 Part of it, you know, looking at the glass as
5 being half full or half empty and saying, well, in
6 comparison to the other chemical side of the house, the NRC
7 regulation is too much.
8 The question of some may be not that we have too
9 much but that others have too little, and I would want to
10 put that out for the record.
11 COMMISSIONER McGAFFIGAN: I would tend to agree.
12 Jack, you wanted to say something in addition.
13 MR. BRONS: Well, I really think that Bob has
14 adequately described the risk side of it.
15 Just to cover both of those facilities, I really
16 think the issue at the conversion plant is the one that's
17 related more to the tourism.
18 They just get a lot of visits because they're
19 close to the gaseous diffusion plant, and frankly, that ends
20 up in a pretty substantial number of billable hours, which
21 is surprising.
22 COMMISSIONER McGAFFIGAN: You're talking about
23 tourism by NRC staff.
24 MR. BRONS: Yes, sir.
25 The gaseous diffusion plant -- I think our take on
64
1 that would be that the issue is confused by a whole host of
2 legacy issues related to the presence or prior DOE issues
3 there, and our -- part of our contention there was
4 basically, if you look at the inspection reports for the
5 gaseous diffusion plants -- as I mentioned, we looked at two
6 years of reports for each of these facilities.
7 Frankly, we ultimately, in all honesty, only
8 reviewed one year's worth of the gaseous diffusion plants,
9 because the volume was so great, just huge by comparison,
10 and when you consider the level of enrichment that's
11 licensed there and the nature of the operation and the
12 nature of the risks, it just didn't seem to stack up.
13 COMMISSIONER McGAFFIGAN: The problem is -- and
14 again, today's Inside NRC has a separate article about a
15 stand-down at one of the gaseous diffusion plant, the
16 Portsmouth decontamination facility, because of 22 largely
17 self-found safety violations, and they closed it down, and
18 they are going to start up this week, according to the
19 article.
20 The spokesman for USEC says that these were
21 criticality issues of low significance. It's very difficult
22 to make a criticality event occur, she said. It just goes
23 to show how rigid these NRC requirements are. NRC also
24 stated the safety requirements -- or significance is low.
25 So, maybe we're finding stuff that is of low
65
1 safety significance, but it still seems like, when we send
2 in an inspection team, we find a lot of stuff there, and so,
3 we need to figure out at some point whether the stuff we're
4 finding is significant and it's significant enough that they
5 actually closed the facility down for a few days to try to
6 get all of -- you know, make a complete audit of the things
7 that were wrong before they started up again.
8 MR. BRONS: Well, there are some threshold
9 questions related to the characterization of criticality
10 safety issues that need to be looked at.
11 So, the primary suggestion we made -- and it was
12 on my first slide -- is that these facilities are the
13 beneficiaries of a sound regulatory process.
14 COMMISSIONER McGAFFIGAN: I agree.
15 MR. BRONS: I don't want this discussion to
16 detract from that.
17 COMMISSIONER McGAFFIGAN: I tried at the outset -
18 - although I ended up making -- putting too much emphasis
19 here -- I think that the fundamental conclusion of your
20 report is sound, and I think we all appreciate the detail
21 that it's gone into, and that fundamental finding at the
22 outset is a wonderful finding.
23 Thank you.
24 CHAIRMAN MESERVE: Commissioner Merrifield.
25 COMMISSIONER MERRIFIELD: When I visited the
66
1 Paduca facility, I did not go to the conversion plant.
2 COMMISSIONER McGAFFIGAN: You're not a tourist.
3 COMMISSIONER MERRIFIELD: I will go there
4 separately and alone, and I would say, further, that of all
5 the places that I have visited as NRC Commissioner, never
6 once have I felt like a tourist.
7 Let me first turn to -- I don't know what page it
8 is on your slides, because ours aren't numbered, but it's
9 the results relative to safety culture for operations, and
10 it's not mentioned in your slides, nor was it mentioned by
11 our staff -- you know, we obviously -- we talk a lot about a
12 safety conscious work environment and having a situation in
13 which the workers at the plants, whether it's a fuel cycle
14 facility or at a generating station, have a willingness to
15 raise concerns.
16 One of the issues that isn't here relates to our
17 allegation process.
18 Now, this has been a bone of contention on both
19 sides.
20 There are some who feel that we're not as vigorous
21 as we should be in following up on allegations, and there
22 are some in industry who perhaps feel we are too aggressive
23 in following up on allegations, but the process is what it
24 is, and it does provide an opportunity for workers who have
25 disagreement with the way in which the management is
67
1 operating the plant to raise that to the NRC and allow our
2 investigation and enforcement folks to take a look into it.
3 I'm not fully cognizant of the situation in Japan.
4 I don't think they have a system which is quite like ours,
5 but as a general question, do you think that the existence
6 of that allegation process is also a contributing factor to
7 differentiating the safety at our plants from perhaps those
8 in Japan?
9 MR. BRONS: We did not look into or obtain, to the
10 best of my knowledge, any information about allegations at
11 any of the facilities.
12 What we did do, though, was ask the workers
13 themselves, and the middle managers and the engineers that
14 we talked to, about how comfortable they were in some of
15 these things that we were told that they were expected to
16 do.
17 For example, all facilities said our people are
18 free to stop the process whenever they want. Well, one of
19 our questions to the workers was do you feel like you'd be
20 supported if you did that, and I was astonished at the
21 wholesome answers that I got. They were very good. They
22 felt that they would be strongly supported in making a
23 decision to shut down the process.
24 So, that was a factor in my mind that led me to
25 conclude that we have a very healthy safety environment, but
68
1 we didn't get into allegations at all.
2 MR. CLARK: We didn't specifically talk about
3 allegations, but in the discussions, the interviews,
4 discussions were relatively random. There were some picks
5 by management based upon what time of day or something.
6 They were very frank. They were generally
7 private. There was no indication that people were holding
8 back anything. They knew, I believe, that we were there to
9 help the facility.
10 They knew that we would hold confidential our
11 discussions, by name, that we were having with them, and to
12 a person, they were -- seemed to be very comfortable with
13 what they were telling us and the safety of the facility.
14 Technically, they had a broad spectrum of
15 capability, but you had a sense that they felt safe, that
16 they felt that they could communicate, especially with their
17 supervisors, about any concerns that they might have.
18 MR. BRONS: We did have one facility where a
19 number of workers -- all three of us experienced in
20 interviews -- raised an issue of concern about one part of
21 the process, and all said that they had raised that to the
22 management, we found, in pulling the string, that, in fact,
23 management had a list of concerns that they had heard from
24 workers, and it happened to be the item that was brought up
25 to us was the top item on the list. Management had it there
69
1 to address. There we counseled management you ought to feed
2 back a little better to your people about this list, but it
3 clearly was being heard, and they felt free to bring it up.
4 COMMISSIONER MERRIFIELD: I think that's very
5 positive. Hopefully, upon our own investigation and
6 discussions with those workers, our inspectors would
7 hopefully get the same kind of answers about a willingness
8 to raise safety concerns.
9 I'd like to turn to the next results page relative
10 to emergency preparedness.
11 The third bullet you have talks about the
12 consideration of extending criticality and highly-irradiated
13 personnel.
14 My reading on the incident at Tokai-Mura -- one of
15 the issues there was the fact that the two -- or the three
16 individuals who were injured, two of whom, as we mentioned,
17 have subsequently died -- there was some confusion about
18 what facilities to take them to in order to receive
19 appropriate medical treatment, and in fact, at least one of
20 the individuals had to be shuttled from one facility to
21 another in a relatively quick succession.
22 Do we have -- do you think that there is
23 sufficient understanding of how to treat personnel who have
24 these injuries, and does that follow through -- or do you
25 have any understanding of whether that follows through to
70
1 the facilities that would receive those personnel, and are
2 there some things that we need to do to follow up on that to
3 make sure that, if there are individuals who receive, in the
4 unfortunate and hopefully highly unlikely situation that
5 they would receive doses, that we have identified and the
6 licensees have identified facilities to receive those and we
7 have the right plans in place?
8 MR. BRONS: As I mentioned, this is an area where
9 we felt that there was some weakness, and I'd like to break
10 your question down into two parts.
11 None of these facilities is located very close to
12 some place that would ultimately manage these people, and
13 so, one of our questions about the treating of highly
14 irradiated personnel was focused on will the interim
15 facility -- because all of them have arrangement with a
16 local hospital, and they generally have trained that
17 hospital in treating people who are contaminated, but as you
18 well understand the issues for persons highly irradiated,
19 where vomit may be radioactive, the fillings in their teeth
20 may be radioactive, there's a dose to the care workers, that
21 may not have been explained to the local receiving hospital.
22 So, one aspect, we were trying to promote the
23 increased training of the local hospital to deal with that
24 issue.
25 Relative to the second issue, in almost all cases,
71
1 it would require helicopter evaluation to the ultimate
2 facility, and although there were some exceptions, it was
3 our belief that the facilities knew where the people would
4 go ultimately -- that is, what was the teaching or major
5 medical center that was able to care, and our concern was
6 have you really nailed down the transportation arrangements,
7 so we don't have to rely on what we think they know how to
8 do it, and that was our concern.
9 Now, beyond that, we did not get at all into the
10 qualifications of the ultimate facility to handle radiated
11 people. It's beyond our capability.
12 COMMISSIONER MERRIFIELD: Mr. Chairman, I think
13 this is an area that we may have identified an action item
14 on which we need to work with our Federal and state
15 counterparts to make sure we've got this well in hand in
16 the, as I said, highly unlikely event that this might occur
17 here.
18 Thank you.
19 CHAIRMAN MESERVE: Commissioner Diaz.
20 COMMISSIONER DIAZ: Yes. Thank you, Mr. Chairman.
21 Again, I thank you for your good report and your
22 observations.
23 Let me just look at your -- I think it's page six.
24 It's your contributing factor four, five, six slide, and at
25 the very bottom, it says corrective action programs diffuse
72
1 differential to NRC.
2 A quick statement. I've always stated and I
3 continue to believe and, I think, will continue to believe
4 that, you know, safety is in the hands of the people that do
5 the work, and our interaction is very important in
6 delineating what their actions are, but they do it, and I'm
7 a little concerned with the corrective actions programs
8 diffuse and differential to NRC.
9 Will you explain what you mean by that?
10 MR. BRONS: Yes.
11 The meaning behind corrective action is diffuse is
12 that many of the facilities have a number of internal
13 oversight programs.
14 Many of them take the results of those individual
15 internal programs and have their own tracking list.
16 So, there might be an oversight program that's
17 generated by the operations department, and it's got its own
18 list of corrective actions and tracking and follow-through
19 and so on, and then there may be another one from the
20 nuclear safety organization that has its own list of
21 corrective actions and so on, and yet another from the
22 regulatory affairs department, if there was one. I'm just
23 creating a hypothetical case here.
24 So, when we talk about diffuse, we're talking
25 about those deficiencies being managed in separate programs,
73
1 so that it's very difficult for management to identify
2 trends or make cross-comparisons to importance of issues or
3 even prioritize the work for their force.
4 Now, many of the other facilities have put that
5 into a common system, and that was really what we would
6 describe at a best practice facility, is they have a common
7 corrective action program.
8 So, that's the term diffuse.
9 The deferential to NRC is exactly the idea I
10 expressed earlier, and that is that we found, in some
11 instances, where there was a separate corrective action
12 program for NRC-identified items, and if you asked
13 management about the corrective action program that they
14 were tracking and trending and following, that's the one
15 they referred to, and the ones that had items identified by
16 their own staff seemed to be of lesser name recognition and
17 importance.
18 COMMISSIONER DIAZ: I think that is an issue that
19 I thank you for bringing it to our attention, and I am going
20 to look forward to our staff to address it sometime.
21 Now, that's the hard part of my questions.
22 The next one is just having some fun, and I have
23 to have some fun.
24 I'm going to go back to this slide in which you
25 talk about the extended criticality, number seven, and you
74
1 know, I've been listening intently to you talking about how
2 the operators, you know, train and it's important to have
3 the criticality training, how all these things are, and I
4 just want to get some of the nomenclatures and the issues
5 back into my own frame of reference.
6 You know, what we call criticality and we will
7 continue to call criticality always starts as a super-
8 criticality issue first and then it becomes critical and
9 then is achieve some low state.
10 The issue is not whether it's critical or not,
11 because you could be critical at almost zero power. The
12 issue is what is the power level at which it continues to
13 operator, and normally, that's sub-critical, but it could be
14 sub-critical at a very high power level, will radiate, will
15 continue to create fission products, will do all of these
16 things.
17 So, I think it's important that, when we look at
18 criticality safety, people understand there is a difference
19 between the word I would call criticality and the word power
20 level at which it operates.
21 You could be, you know -- and I'm sure you all
22 have done it -- you could be critical at a very, very tiny
23 power level, you know, micro-watts, and you can actually
24 look at it, and it is not a big deal.
25 Now, you can be sub-critical in a power plant or
75
1 at a facility, a 3,000-megawatt thermal, and that really
2 will burn you to a crisp.
3 So, I think it is -- you know, it is this
4 differentiation that becomes important. It is the ability
5 to bring the power level to a known hazardous level that is
6 important.
7 People keep, you know, getting in the issue of
8 criticality. You look at Tokai-Mura, you know, you will
9 look at it from criticality followed by a small criticality
10 pulse which comes from the delay in neutrons coming down,
11 and then you can see small variations, and it trends down,
12 and the reason it trends down is because there is not enough
13 to maintain the criticality.
14 To conclude my statement, at one time I said that
15 criticality is like humility. Once you believe you've
16 achieved it, you've just lost it.
17 MR. BRONS: Commissioner, your fun taken well, and
18 believe me, the team well understands the term criticality.
19 I think we might be better had we described it in the case
20 of this accident as an extended super-criticality.
21 COMMISSIONER DIAZ: No, no. It's an extended sub-
22 criticality.
23 MR. BRONS: But the point I'd like to get to is
24 that what we were looking for is control, and considerations
25 for the control of the event, where the hazard by the
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1 radiation emitted was greater than is tolerable and what
2 methods do you have in place to reduce that hazard to a
3 controlled and tolerable level, and that's what we're
4 pursuing.
5 COMMISSIONER DIAZ: All right. Thank you, sir.
6 MR. BERNERO: I would just like to add -- or even
7 to detect that it is at a power level that is potential
8 lethal.
9 COMMISSIONER DIAZ: Very important. Thank you,
10 sir.
11 CHAIRMAN MESERVE: On behalf of the Commission, I
12 would like again to express my appreciation to this panel
13 for their work and for their presentation this morning.
14 Our final panel consists of two individuals who
15 participated in the DOE's work on this same subject, and
16 they are Tom McLaughlin, who is the Group Leader for Nuclear
17 Criticality Safety at Los Alamos, and Jerry McKamy, who is a
18 Nuclear Criticality Safety Specialist, Office of Engineering
19 Assistance at DOE.
20 Why don't you proceed?
21 MR. LAUGHLIN: If I could please have the first
22 view-graph, first slide -- and as I look over at your hand-
23 outs, yours aren't in color. You can see the ones on the
24 monitor.
25 Perhaps on the next view-graph it will make more
77
1 of a difference, but let me just say that your staff does
2 have the e-mail file which is -- has the attachment that can
3 be printed out in color, if it makes significant help in the
4 future.
5 Just a brief comment on this particular view-
6 graph.
7 The report that's behind this particular cover is
8 close to being printed. It's been close to being printed
9 now for quite a while, and I can only say that it's
10 unfortunate that it's not out yet, but it is coming, and
11 it's hopefully coming within the next three weeks.
12 It was ready to be published back in August.
13 We had been working with our Russian colleagues
14 for the prior several years to get at documented
15 descriptions of their past accidents that had never been
16 documented and described and shared with the rest of the
17 world, and it was at a quadrennial criticality get-together,
18 international get-together that the French were hosting in
19 mid-September at which the Russians made a very large
20 presentation of the information that, indeed, is coming out
21 in this revised document, not knowing that, one week later,
22 the Japanese would have an accident.
23 There were many Japanese at this international
24 get-together, and so, indeed, I was over in England the next
25 week trying to piggy-back different and sundry trips and
78
1 activities, and I was at the Los Alamos equivalent at the
2 time of the accident, and I will comment on something that
3 relates to what Commissioner McGaffigan said a minute ago,
4 namely that, yes, indeed, Tom Cochran put out some good
5 information that surprised me, too.
6 I have known Tom over the years, and tragically
7 enough, we get our information from CNN, because whether
8 it's Japan or any other country, if we don't quickly release
9 accurate information, the media will improvise.
10 There was no need for the media to have improvised
11 if the Japanese had shut down their reaction, but they did
12 not do that as quickly as they could have. That's another
13 story.
14 On the next view-graph, we just look at briefly
15 the historical portrayal of the accidents as they have
16 occurred. There have been 22.
17 We'll say more about the statistics on them, but I
18 think the interesting feature is that we, the United States,
19 and Russia both had a significant learning curve, and we
20 learned.
21 In other words, we both had like one accident a
22 year for 10 years.
23 Yes, they might have had nearly twice as many as
24 us, but perhaps statistics on a factor of two really don't
25 tell us a whole bunch.
79
1 But during the mid-'50s to mid-'60s, we both had
2 like one accident a year for 10 years. I have had many long
3 conversations with my Russian colleagues, and it's
4 interesting, the very, very similar situations that we both
5 encountered in our countries.
6 The one accident in England is at the British
7 Nuclear Fuels site. That was 1970.
8 Then, of course, the Russians did have a more
9 recent accident than we have had in 1997, insignificant
10 consequences to that accident, but still, it did occur, and
11 very little publicity, too, you might notice, because it was
12 not much earlier than the Japanese accident, very little
13 publicity, and then, of course, the Japanese accident.
14 So, in this report and what I am going to share a
15 few words on a little bit later are, indeed, data and
16 information that are gleaned from our awareness of 22
17 accidents, not just one accident, not just the Japanese
18 accident, and it's interesting and probably not to be
19 unexpected that the Japanese accident didn't tell us
20 anything startling new.
21 Yes, it's always a unique event. Any accident
22 will be. There are always some characteristics that are a
23 little bit different than the other ones. But indeed, many
24 of them have very similar out-falls, very similar
25 consequences, and so, indeed, most of the comments that I
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1 will be making have to do with the pulling together of
2 information from all 22 accidents.
3 COMMISSIONER DIAZ: Mr. Chairman, the accident in
4 Argentina -- you don't consider it in here?
5 MR. LAUGHLIN: There are two categories of
6 criticality accidents. I don't believe that that's in the
7 packet that is going to come up on the view-graph, but yes,
8 Commissioner Diaz, as you're well aware, in this report,
9 there are two parts.
10 In fact, there are three parts, but the first two
11 parts have to do with the two varieties of criticality
12 accidents.
13 The first variety is those that occur in process
14 facilities such as the JCO facility. A second variety are
15 those that occur in the research reactor and critical
16 experiment arena, where you intend to get critical, where
17 that is your goal, and therefore, we do differentiate the
18 regulation of those.
19 One is reactor safety in this country; one is
20 criticality safety.
21 That's not necessarily the case in Russia. They
22 don't differentiate the regulation of them that way.
23 COMMISSIONER DIAZ: Thank you.
24 MR. LAUGHLIN: Yes, sir. So, indeed, Argentina is
25 described in here.
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1 COMMISSIONER DIAZ: Okay.
2 MR. LAUGHLIN: In the full report.
3 The next view-graph, please.
4 Here, indeed, we just comment on a few of the
5 statistics of the accidents, 22 total. I'll also bring in
6 the point that, indeed, almost all of them have been with
7 solutions.
8 There was one metal, the 1978 accident in Russia
9 was with metal, and while that's extremely unlikely just
10 because it's much more difficult to control solutions than
11 it is to control metals, I think we have benefitted
12 significantly from the fact that there has been one metal.
13 One, it has helped us to reach people who
14 previously might have had the mind-set, it just can't
15 happen. There have been, unfortunately, nine fatalities.
16 It was seven prior to the Japanese accident.
17 And then this next bullet on exposures, public
18 exposures -- this was also mentioned by various of the
19 commissioners at some level, namely that these are not going
20 to ever be held threatening to the public if we have the
21 public where they're supposed to be, outside the fence if
22 you will.
23 These are a worker health and safety issue.
24 We all know -- and I don't want to belittle --
25 that, indeed, the public can be scared, the public can have
82
1 ill health because of concerns, but not from the direct
2 radiation exposure, and where it says manageable levels only
3 in one accident, that is, indeed, the most recent accident
4 in Japan, and that was, in my mind, preventable in the sense
5 that they could have shut the reaction down much sooner than
6 they did, but that's the politics of what goes on, not the
7 technical issues.
8 The environmental contamination, as we have all
9 understood, was negligible. Tragically enough it wasn't
10 zero, and therefore, the local farmers could not sell their
11 produce, and there were lawsuits, and that's understandable.
12 None of the criticality accidents will be
13 damaging. Commissioner Diaz made this very clear, that the
14 consequences of a criticality accident are always going to
15 be benign from that point of view, and I will comment that,
16 indeed, comments were made about providing reasonable bounds
17 for these accidents.
18 We have that information. We understand these
19 accidents enough to appreciate what those reasonable bounds
20 are.
21 There have been a series of experiments that I'm
22 sure, Commissioner Diaz, but perhaps others, you are aware
23 of in the past in this country, the cube experiments in
24 France, the crack in Silene experiments.
25 They provided us those fission rates and those
83
1 first spike yields, etcetera, that we can then use to
2 extrapolate to our own facilities to understand what
3 reasonable bounds might be.
4 Let's go on to the next.
5 I have broken down the accidents and distilled the
6 lessons learned from all of these 22 into three view-graphs;
7 one is general, and the next two get more into operator
8 issues and then supervisory and managerial and regulatory
9 issues, but on this very first view-graph, I do want to
10 stress that, indeed, there haven't been any accidents
11 associated with single failures.
12 In other words, it wasn't that we had all of our
13 eggs in one basket and the basket broke. It has been a
14 combination that was very difficult, obviously, to have had
15 the ability to foresee ahead of time, and that has led to
16 the accident.
17 The second comment has already been made by, I
18 believe, one of the people prior to me, that, indeed, no
19 accidents primarily attributable to hardware failure.
20 Hardware failure might have been associated as a contributor
21 at a lower level but not even a major contributor to any of
22 the accidents, and it's been the human element, people
23 misunderstanding, the people miscommunicating, the people
24 doing things that maybe they thought they weren't going to
25 hurt themselves but were knowingly out of bounds that has
84
1 led to the accidents.
2 It's the human element that has been associated
3 with that.
4 On the next view-graph, we will take a look at the
5 operator-related issues, and while I have phrased these a
6 little bit differently, more in question form, to the
7 operator, I think you get the message, namely the operators
8 truly understanding what might be very obvious to us.
9 In other words, I work routinely with people who
10 write procedures, I work with process supervisors, I work
11 with the operators back at Los Alamos, and it's very common
12 that the operator would interpret a word differently than
13 the supervisor, might say it's clear what I meant, it's very
14 obvious.
15 When you look at the thesaurus of the English
16 language, there are typically 30 or 40 words that might be
17 associated with any one word, and so, we have to make sure
18 that not only do we write it to what we think is clear but
19 then we get feedback and we get confirmation that the
20 operators understand the words exactly as we meant them.
21 Do we work only according to written procedures?
22 Several of the past accidents have been associated with
23 people getting information, for example, over the telephone
24 from the analytical laboratory on concentrations and
25 misunderstanding words or passing information from one
85
1 operator to the next about please come help me out, I have
2 to go here, here's where I'm at, you take over, etcetera,
3 and not having a clear hand-off, and indeed, do the
4 operators know the consequences?
5 Clearly, all three of these were associated with
6 Tokai-Mura, again not to be unexpected. These are commons
7 ones I've distilled.
8 In your handouts, I gave you a much longer listing
9 of all of the various and sundry causes and lessons learned,
10 and I say in your handouts, not in the ones that are the
11 direct replica of what's on the screen here but in the
12 information that I passed as more background briefing
13 material that will be in the report in greater detail, but
14 these are a distillation of some of those larger numbers of
15 lessons learned and causes, statements.
16 So, indeed, it's important that the operators
17 understand the consequences, and I think we've all heard --
18 and it's encouraging -- that, indeed, people don't hesitate
19 to pull the emergency stop on the train, if you will. They
20 understand and follow the stop-work policy.
21 So, if we can have the next one, then, we will go
22 into regulatory issues, we'll go into supervisory and
23 management issues, and here I guess I might -- and maybe
24 it's just semantics, but I think I would word it differently
25 or I would discuss it differently if I was saying, if we had
86
1 the right regulations in place maybe in Japan or if they
2 were doing it like we were doing it, would this accident
3 have been prevented?
4 Well, perhaps, but I would say, at least at Los
5 Alamos, if a regulator comes in and more than one time in a
6 hundred can find something that's truly significant out of
7 bounds, then yours truly should be fired.
8 If things aren't being done safely that I have
9 control over, then, indeed, if I am not the first line of
10 defense and the most important line of defense, nobody is,
11 but that's perhaps more a philosophical issue -- again,
12 supervisory, management, regulatory issues.
13 This is -- the first bullet is the major learning
14 curve from the '50s and '60s.
15 We were working with large process vessels to get
16 a job done in both countries, and a very -- at least
17 perceived to be an extremely important job then, of course,
18 and we relied largely on concentration control and people
19 not getting out of bounds on that concentration control and
20 solutions, and indeed, that's not as foolproof as working
21 with limited-diameter vessels, etcetera, and so, indeed, we
22 did have a series of accidents there.
23 We have learned that lesson, and to a large
24 extent, we have written that out of the way we do business.
25 It will never be perfect.
87
1 You don't process low-level waste in two-liter
2 bottles. You'll never do that economically, and so, at some
3 point, you must rely on concentration control, but to a
4 large extent, we've solved that one.
5 Make it easy to do the job right. This was a
6 classic with the Japanese accident. It was difficult to get
7 the job done efficiently, effectively, economically
8 according to the procedure.
9 If you followed the procedure, it was going to
10 take you a lot longer, it was going to take you a lot more
11 consternation.
12 It might have been physically a lot more difficult
13 just to get it done, and indeed, if you're the person who's
14 in charge or if you're the regulator, when was the last time
15 that you got out on the floor and observed it, or at least,
16 if you don't get to the floor very frequently because you're
17 the regulator, can only show up once every so many months or
18 so many years, do you at least ask the supervisor when was
19 the last time you saw the job done properly, of course, and
20 again, do you know that the operators understand the
21 consequences, do they understand the concept of criticality?
22 That was obviously not known in Japan.
23 I believe that's the last view-graph. If there's
24 another one, I'm going to be surprised.
25 I certainly welcome questions.
88
1 CHAIRMAN MESERVE: I'd like to than you for a very
2 helpful presentation.
3 Why don't we turn to my colleagues and see if they
4 have questions.
5 Commissioner Merrifield?
6 COMMISSIONER MERRIFIELD: I don't have any
7 questions. I would say I also appreciate, I think, a very
8 good presentation and certainly look forward to the report
9 when it finally comes out.
10 I have one comment I want to make, and it's not
11 related directly to the presentation you all made, but we
12 have as an agency and we have as a country a very good
13 relationship with the Japanese.
14 We have a bilateral arrangement with our Japanese
15 counterparts; it is one that we've had for some time; it is
16 one that we have that is very close; and it's one that we
17 value.
18 We've had a lot of pointed questions today and
19 we've had concerns that have been raised.
20 For those not familiar with this process, this is
21 our tendency of doing things.
22 I wouldn't want our Japanese counterparts to take
23 it in the wrong way. Certainly, it's not intended as a
24 lecture upon the Japanese nor simply to make them feel as
25 if, you know, we're the United States NRC and we know
89
1 better.
2 I think there's a spirit of really trying to get
3 to the bottom of this, trying to understand if there are
4 ways in which we can improve our own process, and for my
5 part, I believe that there is an open willingness to work
6 with the Japanese to the extent that we can, to the extent
7 that they're open to this, to helping them improve their
8 process.
9 Ultimately our goal -- and we know we share that
10 with our Japanese counterparts -- is to improve health and
11 safety, and anything we can do to help them in that regard,
12 I think we ought to try to do so.
13 Thank you, Mr. Chairman.
14 CHAIRMAN MESERVE: Commissioner Diaz.
15 COMMISSIONER DIAZ: It's a pleasure to see you,
16 and I'm going to deviate from my normal processes and tell
17 you that I agree with your presentation, with all your
18 points, and I want to thank you for it.
19 CHAIRMAN MESERVE: Commissioner McGaffigan.
20 COMMISSIONER McGAFFIGAN: I'm not sure I'm going
21 to agree with all the points, but let me start.
22 You twice during your presentation criticized the
23 Japanese for not shutting down the reaction as quickly as
24 they should have.
25 Could you elaborate more on what your view is that
90
1 they should have been able to do during that extended
2 period?
3 MR. LAUGHLIN: My pleasure. And let me also
4 support Commissioner Merrifield's comment.
5 We, indeed, have worked closely with our Japanese
6 colleagues in incorporating the write-up of their accident
7 into this report.
8 As I mentioned, it was ready to go to press last
9 August, and then, last September, we had the accident before
10 we could get it to press, and so, we stopped the press, and
11 we have, indeed, incorporated the most recent information in
12 there.
13 I also will say that we had a delegation from
14 Japan -- and I'm sure they visited you folks -- I want to
15 say in January.
16 It was a delegation of eight or 10 folks, and a
17 couple of them -- I say this not to imply anything good,
18 bad, but a couple of them had military uniforms on and they
19 were from the defense side of the house, I believe, but it
20 was a mixed committee, and I addressed them also just
21 exactly on this issue, because they pointed out that I had
22 made the comments, and they said, well, what would you do,
23 and I looked at the gentleman with the military uniform on,
24 and I said clearly you shut the reaction down by draining
25 the tank, now surely you could figure a way to do that, and
91
1 he smiled and said I understand.
2 This is not high-tech physics.
3 COMMISSIONER McGAFFIGAN: No, I understand, and it
4 may say something about the Japanese preparedness. My
5 recollection that day is that there were e-mails coming out
6 Japan looking for boron injection machines. They were
7 flailing around for a while trying to figure out what to do,
8 and it may be that -- but I know boron injection machines is
9 one of the things that they were looking for that day, and I
10 think DOE was looking to see if they could help. You
11 probably were in the middle of it.
12 MR. LAUGHLIN: But you didn't need that. All you
13 needed to do was drain the bank, and all I can say is, if it
14 were to happen tomorrow at Los Alamos, I may not get
15 involved in draining the tank either, because it will be at
16 a decision higher than me, and it was at a decision much
17 higher than the local folks, plus I think it was their
18 mentality to say, well, we have informed our federal
19 government, now it's up to them to tell us what to do, and
20 so, it was a political decision.
21 COMMISSIONER McGAFFIGAN: You heard the NEI task
22 force. You heard our staff pat themselves on the back with
23 those two view-graphs that showed how different our
24 regulatory system was from the Japanese regulatory system.
25 You heard NEI say that the beneficiary in this country of
92
1 regulatory controls and standards organizations, and you
2 sort of down-played that.
3 That may not be surprising coming from DOE where
4 you self-regulate, but how do you replicate within the DOE
5 system and how do you maintain over an extended period of
6 time, in the absence of regulatory controls from the outside
7 -- you have ES&H; and they're represented here, but you don't
8 have routine inspections, you don't have resident
9 inspectors, you deal with highly-enriched materials. How
10 does that work over time?
11 MR. LAUGHLIN: One can say that these accidents
12 are very infrequent, of course, and all I can say is maybe
13 one shouldn't get too proud about 42 years without an
14 accident. They can happen.
15 We had one back in '58 that led to a loss of life,
16 and there have only been two losses of lives in this type of
17 accident in this country. So, we're not, clearly, proud of
18 that, but let me just speak with another hat on.
19 This says Los Alamos National Laboratory. I
20 happen to be the chairman of a national consensus standard
21 writing committee, ANS-8.
22 ANS-8 is responsible for the care, feeding,
23 promulgation, retirement, etcetera, of all criticality-
24 related standards in this country.
25 The Nuclear Regulatory Commission and the
93
1 Department of Energy both subscribe to every single one of
2 those ANS-8 standards. There are about 16.
3 Again, I am the chairman of that committee. I
4 have been for about 10 years now.
5 I believe that they are the basis for our track
6 record in this country, and worldwide. There are a very few
7 -- there are three right now -- international standards in
8 criticality safety, but even those three, which have more
9 recently become international standards, are patterned
10 directly on the U.S. national standards, because that was
11 the template. They have come first.
12 And so, the United States has been very advanced-
13 looked, very advanced-working and -planning in the
14 regulatory climate, and I think it's a recognition that
15 these, indeed, if they are followed, can provide for safe,
16 efficient operations, where I think that your staff, NEI
17 tend to maybe depart somewhat, and we have the same
18 departures within the Department of Energy, so it's not that
19 you're any different than we are in that regard.
20 It's the detailed implementation. We can all
21 subscribe to the basic standards. The words in there are
22 very general, they're rather high-level, but they do provide
23 good common sense guidance.
24 So, we live to the same guidance you do at Los
25 Alamos versus Nuclear Fuel Services versus Babcock & Wilcox
94
1 or whomever, and we try our very best to implement that in
2 the spirit of which the words were written, but we live to
3 the exact same regulations, and I will repeat -- and this
4 may be something that we can agree to disagree on -- if we
5 are not implementing those standards as intended and doing
6 it well, then a regulator coming in infrequently is very
7 unlikely to keep me away from the accident, very unlikely.
8 If I rely on regulators coming in, I don't care at what
9 frequency, or even an in-house regulator, I am derelict.
10 COMMISSIONER McGAFFIGAN: I agree that you have
11 the first responsibility. I think that's true for all of
12 our licensees.
13 I think, at least for some licensees, having an
14 occasional inspection and having to present for approval
15 significant changes for license amendments and that sort of
16 thing and having extra eyes look at it is a useful part of
17 the process, but that's --
18 MR. LAUGHLIN: And we do that, too, at Los Alamos.
19 COMMISSIONER McGAFFIGAN: Okay.
20 COMMISSIONER DIAZ: May I just get in here?
21 I think, you know, the existence of the regulatory
22 framework is indispensable, whether it is the NRC or DOE or
23 Los Alamos.
24 I have done many criticality experiments at Los
25 Alamos, with probably the most difficult substance of them
95
1 all, uranium hexaflouride in vapor form, between 93 and 97
2 percent enriched, and I can attest to the fact that I was,
3 you know, having to subscribe to very strict procedures of
4 how to do it and how we will not go critical until we wanted
5 to, which is the issue of control that the gentleman brought
6 up.
7 When we wanted to go critical, we, of course, did
8 not go critical, we went super-critical, because that's the
9 only way we could know we're going to be around criticality,
10 but multiple times, you know, the procedures were there, the
11 controls, you know, calling double-jeopardy, and they were
12 present, and that was something that I think, you know, we
13 do very well within, you know, our country, it is the
14 prevention of criticality.
15 We learn and we do it very well, with very strict
16 procedures.
17 CHAIRMAN MESERVE: I'd like to ask you a question
18 that isn't really directed so much at your slides as at
19 other activities that arose out of the accident at the
20 Department of Energy.
21 Is it my understanding that you had done an
22 evaluation of all of your facilities?
23 I'm curious whether there any weaknesses that were
24 observed at the DOE facilities in this area that have
25 implications for our sites?
96
1 Are there any insights that came from your review
2 of your array of facilities, of course, which we do not
3 regulate, that we ought to know about and bear in mind?
4 MR. McKAMY: We are currently finishing up our
5 report, which is a summary of the five site reviews that we
6 did. I'm going to touch on that a little bit. And right
7 now we're in the process of going over all of the site self-
8 assessments. So, those results are coming in. So, we
9 haven't yet looked at them all.
10 Probably, as you've seen from the five site
11 reports that we have released -- you touched on some things
12 like operator understanding of the controls and the basis
13 for the controls.
14 There's nothing new in our reports that you
15 haven't already touched on. They basically cover some of
16 the same ground.
17 CHAIRMAN MESERVE: If there are no further
18 questions, I'd like to thank this panel and the ones that
19 preceded it for --
20 MR. LAUGHLIN: I apologize. I believe my
21 colleague here has something that he would like to make as a
22 presentation, and I think that, because I asked for
23 questions after my part, that I gave a misimpression there.
24 MR. McKAMY: I was just going to walk you all
25 through the department's improvement initiatives that you
97
1 just mentioned real quickly, if you have time.
2 CHAIRMAN MESERVE: How long would it take? Can
3 you keep it to five minutes or so?
4 MR. McKAMY: I'll keep it to five minutes, yes.
5 Really, what I intended to do was just walk you
6 through the elements of the improvement initiative and not
7 go into a lot of the detailed results.
8 The three things that I'd like to discuss here
9 real briefly are the improvements that we initiated as a
10 result of the department's implementation plan that was a
11 response to the Defense Nuclear Facility Safety Board
12 Recommendation 97-2, and the two features that are important
13 -- they're all important, but two that are key are the
14 initiatives to formally train and qualify the criticality
15 safety analysts around the contractor doing this kind of
16 analysis.
17 We have a formal qualification plan that we are in
18 the process of implementing for the contractor criticality
19 safety analysts, and we also have a formal training
20 qualification program now in place for the DOE field office
21 personnel whose job it is to oversee those contractors, and
22 those are two initiatives that we began in 1997.
23 Another element that's important is that we are
24 going to require attendance by the Federal staff and a large
25 percentage of the contractor criticality safety staff an
98
1 advanced criticality safety course that we developed at Los
2 Alamos, and the purpose of that is to give criticality
3 safety practitioners, the practitioners in the field and
4 also the regulators, if you will, hands-on knowledge of
5 critical experiments.
6 Most haven't had such experience in the past, and
7 so, they can go to Los Alamos, actually perform some
8 critical experiments in a controlled way, get some hands-on
9 knowledge and feel for how things go critical, those very
10 procedures that you talked about, and also, that dovetails
11 real nicely in the syllabus with actually performing
12 criticality safety evaluations of a facility at TA-55.
13 So, they get to look at experiments and then do a
14 real-life application.
15 So, we're going to provide that experience.
16 So, those are two elements we had as a result of
17 the department's response to 97-2.
18 The second thing I'd like to mention briefly is we
19 held a department-wide workshop on criticality safety self-
20 improvement, and the thrust of that workshop was to improve
21 contractor and DOE self-assessments.
22 We provided detailed lines of inquiry to senior
23 department managers and senior contractor managers to ANSI
24 ANS-8.19. It's one of the standards Tom told you about.
25 It's a mandatory standard in the DOE orders, and it's the
99
1 administrative practices standards for criticality safety.
2 The expectation was to encourage the contractors
3 to go out and improve their self-assessment methodologies to
4 cover in detail each one of the elements in the criteria in
5 a systematic way that are contained in the ANSI 8.19.
6 We also gave out guidance for assessment of the
7 field office criticality safety programs that were derived
8 from DOE policy 450.5 -- that's the oversight of line
9 management, safety oversight policy -- so that the field
10 programs could assess their ability to do oversight and
11 criticality safety, and that happened in August of 1999.
12 The final element we also promulgated was
13 criticality safety performance measures for use by
14 contractors and local DOE and monitoring improvements in
15 criticality safety, so that you measure how well you're
16 doing in crit safety.
17 And finally, the last element was, on November
18 3rd, the Deputy Secretary issued an initiative that had five
19 new elements in it, and that's some of the ones you
20 mentioned.
21 One of the elements was a high-level screening
22 review of five key facilities. Again, those five reports
23 are out.
24 We're currently reviewing the summary results from
25 those reviews, and those should be released this month, and
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1 those five facilities were DOE Y12 plant, the Los Alamos PF-
2 4 area and TA-55, Hanford, HB Line, and Outside Canyons, and
3 we also looked at Hanford PFP, and we looked at Rocky Flats
4 Building 371, and those areas were primarily selected
5 because they were the ones involved with fissile solution
6 processing, and those typically have the higher risks of
7 criticality accidents. So, that's one initiative.
8 Another initiative was to direct all of the sites
9 to do detailed self-assessments according to the criteria we
10 issued at the workshop, meaning walk through every one of
11 the ANSI 8.19 criteria using the lines of inquiry that we
12 promulgated there and to develop the corrective action plans
13 for any weaknesses that they have and then provide those to
14 headquarters for review.
15 Also, the sites were all directed to develop
16 performance metrics for criticality safety and provide those
17 to headquarters.
18 The fourth task was to do a headquarters review of
19 those corrective actions and those self-assessments and then
20 to write a final report to the Secretary later this year,
21 and then the final task was to look at relocation of TA-55,
22 which is the critical experiments facility, where our
23 advanced training course goes on, as well as other missions
24 to support national security and nuclear safety.
25 So, those are the department's criticality safety
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1 improvement initiatives, or at least major elements.
2 CHAIRMAN MESERVE: Thank you very much.
3 I'd like to suggest that, as you have various of
4 the products that you've described completed, whether you
5 could make sure that you send them to our staff so we can
6 gain the benefit of all the work that you've done.
7 MR. McKAMY: You bet.
8 CHAIRMAN MESERVE: With that, I'd like to thank
9 this panel and --
10 COMMISSIONER McGAFFIGAN: Mr. Chairman, I could
11 ask one question? His presentation provoked a thought.
12 This really goes to Mr. Laughlin.
13 The DNFSB 97-2 report he's just reminded me of was
14 quite critical, especially of the loss of knowledge about
15 criticality issues within the department. How did you get
16 in that state? I mean there is a regulator. It's maybe not
17 the NRC, but there is a regulator who is pointing out what
18 was a significant weakness.
19 MR. LAUGHLIN: There are perhaps a multitude of
20 reasons.
21 COMMISSIONER McGAFFIGAN: You have to give the 30-
22 second version.
23 MR. LAUGHLIN: More managerial, perhaps, that
24 anything else.
25 You are seeing turnover of the corporate logo at
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1 many sites on a year or two-year basis. There is a desire
2 to get a contract award fee and then leave, in my mind.
3 We are seeing many things that are associated with
4 lack of stability in who is in charge of that entity, and
5 therefore, they are saying, well, we'll hire the criticality
6 staff, we'll hire the people to do the job, but if you don't
7 know the skeletons in the closet, you're at a significant
8 disadvantage.
9 You need people who are interested in staying
10 there for the long haul, and we have lost that, to a large
11 degree, within the department, and it's very undesirable,
12 but it's a fact.
13 COMMISSIONER McGAFFIGAN: Thank you.
14 CHAIRMAN MESERVE: Let me just say on that point
15 that I participated in a
16 National Academy of Sciences study in 1986 where we pointed
17 out to the department that they were losing their
18 criticality expertise and that they ought to do something
19 about it, and they haven't.
20 Okay.
21 I'd like to thank you very much.
22 I also would like to echo some comments that
23 Commissioner Merrifield made that we do have very important
24 relations with the Japanese. They are relations that are
25 ones that are of great benefit to our agency, and there were
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1 lots of rather blunt and direct comments that were made
2 today. That was not intended to be critical, it was not
3 intending to be piling on, it was really to make sure that
4 we have a candid appraisal of the situation, and we all
5 benefit from that.
6 With that, we're adjourned.
7 [Whereupon, at 12:26 p.m., the briefing was
8 concluded.]
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