Emergency Preparedness and Response at the Pantex Plant, 75665-75673 [2015-30562]
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Dated: December 1, 2015.
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SUMMARY:
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Henry Williams,
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[FR Doc. 2015–30590 Filed 12–2–15; 8:45 am]
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recommendation to the Secretary of
Energy concerning the need to address
specific deficiencies with, and
strengthen regulatory compliance of, the
emergency preparedness and response
capability at the National Nuclear
Security Administration’s Pantex Plant
that require timely resolution.
DATES: Comments, data, views, or
arguments concerning the
recommendation are due on or before
January 4, 2016.
ADDRESSES: Send comments concerning
this notice to: Defense Nuclear Facilities
Safety Board, 625 Indiana Avenue NW.,
Suite 700, Washington, DC 20004–2001.
FOR FURTHER INFORMATION CONTACT:
Mark Welch at the address above or
telephone number (202) 694–7000. To
review the figures referred to in
Recommendation 2015–1, please visit
www.dnfsb.gov.
Dated: November 27, 2015.
Joyce L. Connery,
Chairman.
DEFENSE NUCLEAR FACILITIES
SAFETY BOARD
Recommendation 2015–1 to the
Secretary of Energy
Sunshine Act Meetings
Emergency Preparedness and Response
at the Pantex Plant, Pursuant to 42
U.S.C. 2286a(b)(5) Atomic Energy Act of
1954, as Amended
Dated: November 23, 2015
The Defense Nuclear Facilities Safety
Board (Board) recommends that
deficiencies identified with the
implementation of existing
requirements in Department of Energy
(DOE) Order 151.1C, Comprehensive
Emergency Management System, be
corrected at the Pantex Plant to ensure
adequate protection of workers and the
public. During a series of interactions,1
we identified three areas of concern
regarding the site’s emergency
preparedness and response capability.
Pantex Plant personnel took action in
response to some of the concerns
identified, but significant concerns still
exist. We conclude that each area of
concern by itself has the potential to
threaten the adequate protection of the
public health and safety in the event of
an operational emergency. Those areas
of concern are (1) inadequate drill and
exercise programs, (2) no demonstrated
capability to provide timely, accurate
information to the public regarding offsite radiological consequences, and (3)
inadequate technical planning bases and
decision-making tools. We believe that
DOE and the National Nuclear Security
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CONTACT PERSON FOR MORE INFORMATION:
Mark Welch, General Manager, Defense
Nuclear Facilities Safety Board, 625
Indiana Avenue NW., Suite 700,
Washington, DC 20004–2901, (800) 788–
4016. This is a toll-free number.
CHANGES IN MEETING:
Dated: November 30, 2015.
Joyce L. Connery,
Chairman.
[FR Doc. 2015–30624 Filed 12–1–15; 11:15 am]
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DEFENSE NUCLEAR FACILITIES
SAFETY BOARD
[Recommendation 2015–1]
Emergency Preparedness and
Response at the Pantex Plant
Defense Nuclear Facilities
Safety Board.
ACTION: Notice, recommendation.
AGENCY:
Pursuant to 42 U.S.C.
2286a(b)(5), the Defense Nuclear
Facilities Safety Board has made a
SUMMARY:
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1 Interactions included the Board’s March 2013
public meeting and hearing in Amarillo, TX, two
Board technical staff reviews in October 2012 and
December 2014, and exercise observations in
January and August 2014 and February 2015.
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Administration (NNSA) must address
these concerns in order to ensure the
adequate protection of the public and
the workers at the Pantex Plant.
The Board communicated its concerns
with emergency preparedness and
response across the DOE complex in its
Recommendation 2014–1, Emergency
Preparedness and Response. The issues
identified in this report are specific to
the Pantex Plant and concern the NNSA
Production Office (NPO) and
contractor’s 2 inadequate
implementation of existing DOE
requirements.
Background: Emergency Preparedness
and Response Capability. Personnel at
the Pantex Plant conduct work vital to
our national defense. Due to the nature
of the operations and the spectrum of
materials in use at the site, the range of
possible accidents varies widely.
Working with high explosives,
hazardous chemicals, and radioactive
materials results in the potential for
operational emergencies ranging from
industrial process-related accidents to
significant material releases due to
energetic events. The site is also subject
to a range of natural phenomena
hazards; tornados, high winds, lightning
strikes, rain-induced flooding, and
earthquakes are all possible in the
region. Of particular concern to us are
those accident scenarios that may cause
radioactive material to be dispersed and
deposited off site. Given the short
distance from some facilities to the site
perimeter and the average wind speeds
at the site, these materials may affect
public lands in the emergency planning
zone within a short period of time.
Board Finding: Drill and Exercise
Programs. Based on our observations,
we conclude that the Pantex Plant
contractor has not demonstrated
adequate capabilities through its drill
and exercise programs. The Pantex Plant
contractor’s execution of emergency
drills and exercises is insufficient to
provide opportunities for all personnel
to develop and demonstrate proficiency
at emergency response. No site-wide
exercises conducted since 2011 have
simulated any significant radiological
consequences. No site-wide exercise
was conducted in 2013 (although a
hurriedly executed, unchallenging
small-scale scenario in January 2014
purportedly fulfilled the 2013 site-wide
exercise requirement). The Board also
observed that both NPO and contractor
capabilities to assess site performance in
drills and exercises are inadequate, and
2 Consolidated Nuclear Security, LLC, became the
management and operating contractor in July 2014.
The previous contractor was Babcock & Wilcox
Technical Services Pantex.
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believes this limits the effectiveness of
the existing programs. A robust drill and
exercise program would be varied
enough to address all response elements
across the spectrum of hazards and
facilities over time.
Board Finding: Timely, Accurate
Information to the Public Regarding OffSite Radiological Consequences. Our
review found no demonstrated
capability to provide timely, accurate
information to the public regarding offsite radiological consequences. State
radiological monitoring response teams
are located in Austin, TX, and must
travel nearly 500 miles before they are
available to monitor affected areas.3 The
Pantex Plant emergency response
organization develops and provides
models of radioactive material releases
to state and county officials, but no
verification of these models with realworld measurements is performed until
state radiological monitoring response
teams arrive.4 Pantex Plant contractor
assets may be released at the plant’s
discretion in accordance with existing
memoranda of understanding and
agreement between the site and the
counties/state. However, we found no
instance in the last five years where the
contractor exercised off-site monitoring.
Finally, we note that while existing DOE
requirements establish a thirty minute
threshold for off-site notification, the
proximity of some Pantex Plant facilities
to the plant boundary is such that
material could contaminate off-site
locations in a shorter time period.
Board Finding: Technical Planning
Basis and Decision-Making Tools. The
Board reviewed the technical planning
bases and decision-making tools for the
Pantex Plant’s emergency management
program and found that they are
inadequate to demonstrate protection
from time-sensitive events and do not
consider all hazards at the site.
Decision-making tools 5 lack significant
3 The DOE Radiological Assistance Program
(RAP) is a national emergency response asset that
provides around-the-clock first-response capability
to assess radiological emergencies, and has a team
stationed in Amarillo, TX. This team may not be
consistently available due to competing priorities
and may not have sufficient local resources to
support a response outside the Pantex Plant. DOE
has not incorporated the RAP into the Pantex
Plant’s existing exercise program, leaving to
question the capability of the RAP resources to
provide off-site support. Additionally, there is
potential that the RAP team could be deployed
elsewhere at the time of an incident, precluding the
use of that resource.
4 The dispatch of state radiological monitoring
response assets may also be delayed due to the
issues identified with the Pantex Plan decisionmaking tools.
5 Decision-making tools currently available exist
to aide operators and first responders with a quick
determination of the likely magnitude of accident
consequences, communicate protective actions to
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details and include built-in delays that
hinder effective execution. While the
existing decision-making tools, such as
emergency action levels (EALs), may
minimize the risk of false alarms, their
design precludes providing timely,
accurate, and conservative
recommendations to the public.
Conclusion. The mission of the
Pantex Plant is vital to our nation’s
defense, and the consequences of a
significant accident would be difficult
to overcome. A robust, comprehensive,
tested, and sustainable emergency
preparedness and response capability is
vital to ensure the adequate protection
of the public health and safety during
operational emergencies. Specifically,
deficiencies must be addressed in the
drill and exercise programs, in
demonstrating the capability to provide
timely, accurate information to the
public regarding off-site radiological
consequences, and in the technical
planning bases and decision-making
tools.
Recommendations. To address the
deficiencies summarized above, the
Board recommends that DOE and NNSA
take the following actions at the Pantex
Plant:
1. Ensure the Pantex Plant drill and
exercise programs comprehensively
demonstrate proficiency in responding
to emergencies for all hazards, all
facilities, and all responders, consistent
with the technical planning bases and
any updates to them, over a five-year
period in accordance with DOE Order
151.1C (or subsequent revisions). As
part of this demonstration of
proficiency:
a. Develop and institute a basis for
conducting the drill program in support
of emergency operations.
b. Strengthen the exercise program to
provide an adequate number of
challenging scenarios per year,
including at least one full-scale, sitewide exercise, in order to maintain
qualifications and ensure proficiency of
the emergency response organization
and first responders.
c. Conduct a comprehensive
assessment of the drill and exercise
programs bases, schedule, and
execution against a risk-ranked set of:
i. All hazards;
ii. All facilities; and
iii. All response elements.
d. Evaluate and improve the
effectiveness of the NPO and contractor
processes used to critique drills and
exercises.
2. Develop and implement processes
and demonstrate the capabilities to:
workers, and ensure protective action
recommendations are delivered to public decisionmakers in a timely manner.
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Office (NPO) and the contractor 1 to
address supplemental questions and
clarify statements made during the
hearing. In 2014, members of the
Board’s staff observed two site-wide
emergency response exercises. In
December 2014, the Board’s staff team
conducted another program review to
examine specific aspects of the Pantex
Plant emergency management program.
The Board’s staff team observed the
execution of certain emergency
management program elements during a
site-wide emergency response exercise
conducted in February 2015. In
addition, the Board’s Site
Representative at Pantex, who is
stationed there on a full-time basis,
made observations regarding the
emergency preparedness and response
capability of the Pantex Plant as part of
his routine oversight of the Pantex Plant
facilities and operations.
During each of these activities, the
Board’s staff team provided on-site
feedback to NPO and the contractor, and
culminated this exchange with a formal
teleconference close-out brief on March
17, 2015. Pantex Plant personnel took
action in response to some of the
concerns identified during the activities
noted above, but significant concerns
still exist. The following section
expands on observations provided to the
Pantex Plant during the March 2015
teleconference and provides the
technical basis for further Board action.
Observations. The Board’s staff team’s
observations are organized into three
main sections: the drill and exercise
programs, notification and support to
off-site agencies, and technical planning
bases and decision-making tools.2
lllllllllllllllllllll
Drill and Exercise Programs—Based
Joyce L. Connery,
on its observations, the Board’s staff
Chairman.
team concludes that the Pantex Plant
Recommendation 2015–1 to the
contractor has not demonstrated
Secretary of Energy
adequate capabilities through its drill
Emergency Preparedness and Response and exercise programs. The Board’s staff
team found that the Pantex Plant
at the Pantex Plant
emergency drill and exercise programs
Findings, Supporting Data, and
do not provide sufficient opportunities
Analysis
for personnel to develop and
demonstrate proficiency at emergency
Introduction. During the past three
response with respect to all response
years, members of the Defense Nuclear
elements across the spectrum of hazards
Facilities Safety Board’s (Board) staff
and facilities. The drill program does
conducted several activities to gain and
not act as part of a comprehensive
maintain awareness of the state of
training and qualification program, but
emergency preparedness and response
at the Pantex Plant. In October 2012, the
1 Consolidated Nuclear Security, LLC, became the
staff team conducted a wide-scope
program review supporting preparations management and operating contractor in July 2014.
The previous contractor was Babcock & Wilcox
for the Board’s March 2013 public
Technical Services Pantex.
meeting and hearing in Amarillo, TX.
2 The focus of the Board’s staff reviews was not
comprehensive in all elements of the emergency
After the public meeting and hearing,
management program. Additional problems may
members of the Board’s staff interacted
exist in other elements of the program, such as
with the National Nuclear Security
federal oversight and the quality of the site’s
Administration (NNSA) Production
agreements with off-site stakeholders.
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a. Ensure the timeliness and accuracy
of notifications to state and local
authorities is commensurate with the
initiation of off-site release of
radioactive material at the Pantex Plant.
b. Provide consistent radiological
monitoring support if an accident
releases radiological material off-site,
until state resources arrive and can
assume responsibility for off-site
monitoring.
3. Evaluate, incorporate, and validate
(correctness, completeness, and
effectiveness), the following changes to
the Pantex Plant decision-making tools
and notification processes:
a. Evaluate the emergency action level
(EAL) process for those accident
scenarios identifiable solely via
instrumented systems to reduce delays
in determining and implementing
protective actions.
b. For those accident scenarios that
are not identifiable solely via
instrumented systems, evaluate the
range of emergency conditions and
potential indicators, and identify where
new monitoring systems can be added
or existing administrative controls can
be modified to improve timeliness of
response.
c. For all scenarios, evaluate if some
protective actions should be initiated
based solely on initial indicators (i.e., a
precautionary evacuation) while
confirmatory indicators are sought.
d. Upon completion of these
evaluations, incorporate new guidance
and training for any changes made to
the EAL decision-making tools and
notification processes into the drill and
exercise program.
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during the last few years has mainly
supported preparation for the site’s
annual exercises.
Department of Energy (DOE) Order
151.1C Comprehensive Emergency
Management Program [1] outlines
several requirements for drill and
exercise programs. Specifically, Section
4.b (Exercises) states:
• A formal exercise program must be
established to validate all elements of
the emergency management program
over a five-year period.
• Each exercise must have specific
objectives and must be fully
documented (e.g., by scenario packages
that include objectives, scope, timelines,
injects, controller instructions, and
evaluation criteria).
• Exercises must be evaluated.
• A critique process, which includes
gathering and documenting observations
of the participants, must be established.
• Corrective action items identified as
a result of the critique process must be
incorporated into the emergency
management program.
Additionally, specified facility-level
requirements include:
• Each DOE/NNSA facility subject to
this chapter must exercise its emergency
response capability annually and
include at least facility-level evaluation
and critique.
• DOE evaluations of annual facility
exercises (e.g., by Cognizant Field
Element, Program Secretarial Officer, or
Headquarters Office of Security and
Safety Performance Assurance) must be
performed periodically so that each
facility has an external DOE evaluation
at least every three years.
• Site-level emergency response
organization elements and resources
must participate in a minimum of one
exercise annually. This site exercise
must be designed to test and
demonstrate the site’s integrated
emergency response capability. For
multiple facility sites, the basis for the
exercise must be rotated among
facilities.
Scope of Exercise Scenarios: Based on
observing implementation across DOE’s
sites, the Board’s staff team summarized
these requirements as the need to
exercise all facilities, all hazards, and
all response elements. The following
sections describe the Board’s staff
team’s observations of the Pantex Plant’s
implementation of drill and exercise
requirements.
For the five-year period (2011–2015)
reviewed by the Board’s staff team, the
following scenarios represent the
totality of Pantex Plant’s site-wide
exercises:
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• 2011: Explosion in a nuclear
explosive facility with no contamination
outside the facility.
• 2012: Seismic event leading to
building damage (no radiological or
hazardous material release).
• 2014a: Liquid nitrogen release from
a truck accident (make-up for no
exercise in 2013).
• 2014b: Severe event (tornado) tabletop.
• 2015a: Severe event (seismic) with
a transportation accident, wildfire, and
mass casualty (no radiological or
hazardous material release).
• 2015b: Security event with
hazardous material release.
The Board’s staff team reviewed
documentation that showed some
facilities at the Pantex Plant did not
hold an evaluated activity to
demonstrate response capability,
regardless of whether the activity was a
site-wide exercise, limited scope
exercise, or other form of evaluation.3
The plant’s analysis of the hazards for
emergency preparedness and response
is organized into a single emergency
planning hazards analysis (EPHA),
effectively identifying the plant as one
facility when in reality there are
numerous facilities with diverse
hazards. This organizational structure
contributes to the limited number of
evaluated exercises at the Pantex Plant.
Pantex is currently undertaking an effort
to reevaluate the organization of the
EPHA (i.e., dividing the single EPHA
into multiple EPHAs). The Board’s staff
team received conceptual information
about this effort and will continue to
review any proposed changes to the
organization of the Pantex EPHA, since
such a change may provide a formal
basis for additional facility exercises.
The Pantex Plant has a range of
hazards that may challenge emergency
responders and decision-makers.
Natural phenomena such as tornados,
fires, lightning strikes, and rain-induced
flooding exist alongside operational
3 The Pantex Plant is a collection of buildings of
various designs that house a variety of activities and
operations that occur at the plant. There are bays
and cells, which come in several variations and can
be standalone or collocated, in which assembly and
disassembly of nuclear explosive assemblies is
conducted. There are buildings in which nonnuclear operations, such as explosive operations,
are conducted. There is a variety of storage areas
including storage of nuclear materials, nuclear
explosive assemblies, explosives, and other
hazardous materials. There are also various
transportation activities within operational areas
and across the site. For the purposes of exercises,
various areas or types of operations could be
grouped as representing different types of facilities.
In the context of the layout of facilities at the Pantex
Plant, the Board’s staff team believes that it would
be appropriate to conduct some type of exercise or
other form of evaluation for each representative
type of activity and operation.
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activities involving hazardous and
radiological materials. The Board’s staff
team observed, directly and by
document review, the range of exercise
scenarios being conducted and found
them to be too limited compared to the
range of hazards at the plant. Often
these scenarios were simplistic and not
sufficiently challenging to truly
demonstrate response capability for the
hazard being exercised. DOE Guide
151.1–3, Programmatic Elements,
Section 3.0 ‘‘Exercises’’ [2] provides a
method of scheduling exercises to
ensure coverage of all hazards at a site
over a five-year period. However, it is
the opinion of the Board’s staff team
that hazards with a higher frequency of
occurrence, significance of
consequences, or complexity of
emergency response may need to be
exercised more frequently than other
hazards. Exercise scenarios from the
past three years included a nitrogen
spill, a primarily table-top tornado
event, and a simulated earthquake with
no radiological material impact.
The potential for more significant
consequences and complicated
responses exists at the Pantex Plant’s
facilities. For example, a high explosive
violent reaction has the potential to
release radioactive material both on site,
outside of the nuclear explosive facility
(i.e., a bay), as well as off site. Fires in
areas containing radioactive material
have the potential to drive more
significant radiological response actions
by plant personnel. It is the opinion of
the Board’s staff team that the Pantex
Plant should more frequently exercise
challenging radiological responses.
The Pantex Plant has not consistently
exercised all response elements between
2011 and 2015, which is insufficient to
meet DOE requirements. There does not
appear to be a deliberate approach to
demonstrating integrated emergency
response capability. For example, the
August 2014 exercise [3] relied on to
meet the annually required site-wide
demonstration of proficiency,
postulated a tornado affecting the site.
This was the plant’s first significant
effort at exercising a severe event, but
was also credited as the annual sitewide exercise. The Board’s staff team
observed that few field participants
demonstrated their response
capabilities. While this was a valuable
training and planning activity for a
severe event, this exercise was the sole
site-wide event for that time period. The
Board’s staff team believes that it is
appropriate to exercise a more complete
array of site response elements, not just
fire and rescue responders,
demonstrating their proficiency. The
2013 exercise (conducted in January
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2014) and the February 2015 exercise
also did not involve significant field
participation other than fire and rescue
services. Within the last five years,
Pantex has not completed a full
participation exercise (i.e., all on-site
employees participating through
protective actions and response); sitewide exercises have only included
participation from a small subset of the
plant population.
Training and Qualification of
Emergency Responders: The limited
number and scope of exercises
conducted each year also affects the
training, qualification, and proficiency
of emergency responders. The Pantex
Plant’s emergency response organization
is made up of three shifts of responders
on a rotating watch bill. It is unclear to
the Board’s staff team how the site can
demonstrate proficiency and support
training and qualification across all
responders when an insufficient number
of facility and site-wide exercises are
being scheduled to support a three-shift
emergency response organization. The
Pantex Plant training, drill, and exercise
program plan authorizes participation in
a limited-scope evaluated activity (e.g.,
functional exercises or limited scope
performance demonstrations) to
maintain qualification within the
emergency response organization [4].
Pantex Plant exercise after action
reports document repeated emergency
response organization shortcomings
during site-wide exercises,4 and
demonstrate that these limited-scope
opportunities are not sufficiently
rigorous to qualify and maintain
proficiency of personnel at emergency
operations.
Exercise Assessment: The Board’s
staff team believes that the Pantex
Plant’s development and assessment of
exercise objectives contributes to the
continuing limited effectiveness of the
emergency exercise program. The staff
team assessed the exercise objectives
and does not consider them to be
effective tools for identifying problems
that can be analyzed and corrected.
First, the objectives reviewed by the
staff team were not always adequate to
evaluate the effectiveness of actions
taken by responders. For example,
objectives do not always differentiate
between taking an action and taking the
right action in a timely fashion. The
February 2015 exercise evaluation guide
for the Plant Shift Superintendents
(PSS) [5] included four criteria to
evaluate the PSS’s objective of
4 The Board’s staff team observed the past three
site-wide exercises and also noted poor
performance by the emergency response
organization.
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implementing protective actions (see
Figure 1); the criteria do not address
whether protective actions are
implemented in time to be effective and
whether the corrective protective
actions are correct for the event.
Another example of an objective from
the February 2015 exercise that the staff
team believes was not adequate
involved processing information (see
Figure 2). This objective evaluates the
collection of information by the PSS,
but does not evaluate communication of
this information to responders. The PSS
received information about trapped
victims involved in an on-site
transportation accident event involving
a passenger vehicle and a material
transporter, but did not verify that the
Incident Commander took the correct
response. In fact, the Incident
Commander was not notified that the
on-site transportation accident had
occurred, and no action was taken for
almost an hour, at which point the Fire
Department responded. During the
controller/evaluator after action
critique, the objective was evaluated as
‘‘Met’’ based on the fact that the PSS
received the information; although the
controller/evaluator did note in the
After Action Report that ‘‘No
communication with the Incident
Commander was observed’’ [6]. This
objective did not require the controller/
evaluator to adequately consider the
quality of the action taken upon receipt
of the information.
Second, if all objectives are weighted
equally, the importance of certain
actions over others cannot be
distinguished. The Pantex Plant is
undertaking an effort to change the
grading scheme for emergency exercises
to focus only on objective-by-objective
performance and not incorporate any
objective and criterion weighting or
overall grade scheme. In the objective
shown in Figure 1, selecting the correct
protective action is a single criterion,5
which could be missed. Yet if all other
criteria are completed, the objective may
still be met. The overall objective—to
implement time-urgent protective
actions—seems to be more valuable to
an effective response than objectives
that simply measure adherence to
administrative procedures. It is the
opinion of the Board’s staff team that,
without some indication of an
objective’s overall importance, the plant
is likely to have difficulty interpreting
the exercise results and will be
5 Note that the criterion actually asks, ‘‘What
protective action(s) was implemented.’’ This
discussion addresses the intent of that criterion (i.e.,
the Board’s staff team believes that the intent of the
criterion was to determine ‘‘Was the correct
protective action implemented?’’).
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challenged to prioritize and apply
resources to those response elements
that require additional attention and to
address corrective actions.
Last, the Pantex Plant could meet all
of its exercise objectives but still
fundamentally fail to protect the
workers and public. The February 2015
exercise is an example. During the
participant hot wash and controller/
evaluator after-action critique, most
objectives were determined to be ‘‘Met.’’
Yet, on-site first responders were
potentially exposed to an off-site
chemical hazard. This was not
considered an objective and, therefore,
did not influence the positive
perception of the exercise results by the
participants, controllers, and evaluators.
Developing meaningful objectives
requires a balance between criteria that
are reasonably observable versus the
need to confirm a subjective quality
(e.g., effectiveness). The ability to
measure the quality of action taken,
sometimes by independent oversight, is
a necessary part of objective
evaluations.
The Board’s staff team believes that
deficiencies in assessing performance in
exercises also contribute to the
continuing limited effectiveness of the
emergency management program.
Exercise participants conduct hot
washes at the end of each exercise. The
hot washes are intended to be a vehicle
for participants to self-critique their
response performance, including both
positive and negative aspects, and to
identify potential areas for
improvement. The hot washes that the
Board’s staff team observed at the
Pantex Plant tended to focus on faults
with the exercise scenario rather than
issues with emergency response
performance. The participants raised
issues such as the perception that a
scenario was unrealistic or that
controllers did not have adequate
simulations for what the participants
would observe in real-life. Many
participant observations focused on
deficiencies in administrative
equipment and tools, such as printer or
fax machine problems. While the
readiness of these resources is important
to an adequate response, the purpose of
the exercise program is to demonstrate
proficiency. Many participant
observations also focused on the
positive results of their actions, but
failed to identify whether the actions
taken would have been effective during
the given emergency scenario. As a best
practice, mature organizations tend to
have an experienced functional team
leader (e.g., the Emergency Operations
Center (EOC) Emergency Director) lead
the hot wash, rather than rely on the
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75669
exercise controller/evaluator for this
role. Most response elements at the
Pantex Plant do not incorporate this
practice.
For each exercise, controllers and
evaluators conducted after action
critiques to collect data and
observations about the performance of
exercise response participants, as well
as concerns with exercise control. While
these were preliminary data gathering
activities, the Board’s staff team noted
the same lack of critical assessment
among the exercise evaluators.
Evaluators did not explicitly compare
the actions taken by participants to the
expected or most desirable responses as
they related to the fundamental purpose
of emergency response. For example,
while data on when a particular
communication was faxed may have
been collected, the quality and
usefulness of the communication to
inform its addressee were not evaluated.
Discussions focused on specific
functional area performance, as assessed
against binary objectives such as a
checklist, but did not address the
effectiveness of interfaces between
functional areas.
For example, during the February
2015 exercise, the EOC received
information concerning an off-site
release of a hazardous chemical from a
train accident. The consequence
assessment team performed modeling to
inform decision-makers of the effect on
plant personnel, including first
responders. Fire Department personnel
who responded to the on-site
transportation accident were within the
projected plume while performing
rescue operations. Neither the PSS nor
the EOC informed the Fire Department
personnel of the potential exposure
(e.g., type of material, quantity, timing,
or recommended personal protective
equipment). This information was
eventually provided to the incident
command late in the scenario. Exercise
objectives were evaluated as ‘‘Met’’ for
these individual functional areas during
the evaluator after action critique. The
effectiveness of organizational interfaces
can be masked by such stove-piped
evaluations.
Emergency Management Drill and
Exercise Program Oversight: The
Board’s staff team considers it a
significant deficiency that NPO and
contractor oversight did not identify the
issues discussed in this section. Other
than the emergency management
program manager, the Board’s staff team
observed limited evidence of interaction
with NPO functional area subject matter
experts in the evaluation of exercise
reports. NPO review of exercise
assessments appears weak in that
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exercises with observed deficiencies do
not result in reports with commensurate
findings. Where issues are identified,
the contractor’s causal analyses are
often weak or superficial, leading to
development of ineffective corrective
actions and recurrence of the same
issues in subsequent exercises. The
concern with ineffective corrective
actions is also evident when DOE’s
independent oversight organizations
observe exercises and provide reports to
the plant. DOE’s Office of Emergency
Management Oversight (formerly HS–63
and also OA–30) provided reports
highlighting concerns with the Pantex
Plant’s emergency management
program; these reports also identify
recurring issues that the contractor has
not effectively addressed [7, 8, 9, 10].
Timely, Accurate Information to the
Public Regarding Off-site Radiological
Consequences—The Board’s staff team
found no demonstrated capability to
provide timely, accurate information to
the public regarding off-site radiological
consequences. Accident scenarios
postulated at the Pantex Plant may
result in the release of radioactive
material or other hazardous materials
from facilities. The released material
may then be carried across the site
boundary and contaminate public roads
and land. The proximity of some
facilities at the plant to the site
boundary is such that in certain
scenarios, material could contaminate
off-site locations within a short period
of time.
Notification to off-site organizations
provides two important functions: first,
it warns members of the public to take
protective action in response to an
accident; second, it initiates off-site
response assets that can control access
and conduct radiological monitoring.
The notification processes used at the
Pantex Plant may not provide enough
time for protective action
recommendations to be issued and
executed before radioactive material is
dispersed off-site. Any delay in
notification adds to the time necessary
for state response assets to deploy.
Notification may be delayed due to the
emergency action level (EAL) decisionmaking processes. Additionally, state
radiological monitoring assets may be
delayed in reaching the vicinity of
Amarillo due to geographic constraints.6
6 The DOE Radiological Assistance Program
(RAP) is a national emergency response asset that
provides around-the-clock first-response capability
to assess radiological emergencies, and has a team
stationed in Amarillo, TX. This team may not be
consistently available due to competing priorities
and may not have sufficient local resources to
support a response outside the Pantex Plant. DOE
has not incorporated the RAP into the Pantex
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The response teams, located in Austin,
TX, must travel nearly 500 miles before
they are available to monitor the
affected area. Notification delays would
also impede instituting access control to
public use areas around the site. While
the Pantex Plant emergency response
organization develops and provides
models of radioactive material releases
to state and county officials, actual
monitoring to verify material deposition
off site may not be proactively
performed by the site’s radiological
response assets; these assets may be
released at the plant’s discretion in
accordance with existing memoranda of
understanding between the site and the
counties/state. Pantex Plant radiological
support personnel do not exercise this
monitoring function during drills and
exercises, and do not have processes in
place to describe how off-site field
monitoring would be executed.
There are limited requirements in
DOE Order 151.1C that specify how the
site will plan for these events and
handle off-site radiological monitoring.
The Board’s staff team notes that the
Pantex Plant has made agreements, via
memoranda of understanding, with state
and local authorities to create
communication channels for much of
this information. However, these
existing mechanisms do not provide the
proactive support from the plant to the
local community that is necessary to
ensure any release of contamination is
accurately tracked in a timely manner to
ensure the protection of the public.
Given that the Pantex Plant is close to
public roads and land, and has the
potential to release radiological material
off site within minutes of an initiating
event, stronger requirements in the
Order are needed to ensure the plant
performs effective off-site monitoring
until the necessary State of Texas
resources arrive.
Technical Planning Bases and
Decision-making Tools—The Board’s
staff team found that the technical
planning bases and decision-making
tools for the Pantex Plant’s emergency
management program are inadequate to
demonstrate protection from timesensitive events and do not consider all
hazards at the site. For the set of hazards
analyzed, the technical planning tools
developed to respond to emergencies
are inadequate to ensure timely
notification of the need for protective
actions to the workers and
Plant’s existing exercise program, leaving to
question the capability of the RAP resources to
provide off-site support. Additionally, there is
potential that the RAP team could be deployed
elsewhere at the time of an incident, precluding the
use of that resource.
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recommended protective actions to the
public.
To meet DOE Order 151.1C
emergency planning element
requirements, a site must conduct an
all-hazard analysis. From this survey,
certain accident sequences are selected
for additional consideration in the
EPHA. The EPHA provides the basis for
developing the site’s EALs. EALs, which
are also required by DOE Order 151.1C,
are used during an emergency event to
determine the categorization and level
of classification of the emergency event.
When using an EAL, emergency
response decision-makers attempt to
answer two questions. First, is the event
an operational emergency? Second, if
so, what is the potential area of impact
and the degree of emergency response?
The safety basis development process
uses a similar hazard analysis process.
When developing a safety basis, some
infrequent accidents may be screened
out of further analysis if they have a low
probability of occurrence. However, for
the purposes of EPHAs, low-probability,
high-consequence events should be
further analyzed to determine the
magnitude of potential consequences
and the expected level of response.
Guidance is provided in DOE’s
Emergency Management Guide 151.1–
1a, Emergency Management
Fundamentals and the Operational
Emergency Base Program. ‘‘The DOE
approach requires some planning even
for events whose severity exceeds the
design basis for safety controls; the
facility/site or activity must be prepared
to take actions to limit or prevent
adverse health and safety impacts to
workers and the public’’ [11]. While
these analyses of low-probability events
may be less quantitative, they still need
to be performed to ensure DOE and its
contractors are cognizant of potential
consequences and conduct an
appropriate level of planning.
For events that Pantex Plant
emergency management personnel have
analyzed, the site uses EALs as a tool to
determine if an operational emergency
is occurring and the classification of the
event, to notify site workers of the need
for protective actions, and to notify the
public of recommended protective
actions. As currently developed, these
EALs include a confirmatory step that
may delay decision-makers providing
these notifications and
recommendations for protective actions
for several minutes, possibly up to 30
minutes. The ability to provide
notifications and recommendations for
protective actions to workers and the
public in a timely manner significantly
increases the safety of these groups
during operational emergencies. DOE
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Order 151.1C specifies a 15-minute
window to notify DOE Headquarters
and the public of events in progress [1].
Pantex Plant emergency management
personnel chose to use a decision tree
model in their EALs, visually guiding an
operator through decisions being made
in response to an event on site. The
example in Figure 3 below, taken from
the Pantex EALs [12], shows the flowpath through decision making to action.
An operator—in the case of the Pantex
Plant, the PSS—enters the EAL with
relevant information concerning an
emergency event. This leads the PSS to
a conservative emergency categorization
and classification. These classifications
(Alert, Site Area Emergency, and
General Emergency) ensure appropriate
responses are taken given the
anticipated magnitude of the accident
consequences. In most radiological
EALs at the Pantex Plant, the PSS
receives initial information of
emergency conditions from an
instrumented signal. For example,
coincident fire and radiation monitor
alarms would indicate the presence of a
possible fire with radioactive material
release.
The Pantex Plant EALs also include
confirmatory indicators as an explicit
step in the decision-making process
before classification can be performed.
These are typically in the form of
personnel providing eyewitness
confirmatory statements about the
nature of an event. From the EAL front
matter [12], page 8:
The PSS or Emergency Manager must rely on
information resulting from communication
with whoever is in command at the
emergency scene, emergency responders, and
plant personnel to supply confirmatory
information necessary to make emergency
classification decisions.
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From page 11:
Using the appropriate EAL, the PSS or
Emergency Manager follows the decision tree
and attempts to identify initial and
confirmatory indicators of an actual
emergency event while simultaneously
continuing to gather information on the
situation from Incident Command,
emergency responders, and plant personnel.
[If these resources are not already there, they
are dispatched.] During this time, initial
protective actions may be implemented
[emphasis added] to protect plant personnel.
If EAL confirmatory indicators are present
and detected, the PSS or Emergency Manager
follows the decision-tree to the classification
area. This section may require retrieval of
information on the quantity and type of
material involved in the incident from the
Move Right System or use of inserted tables.
Once determined, the PSS or Emergency
Manager classifies the emergency based on
the EAL information.
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These classification decisions allow
the PSS to determine what, if any,
protective actions are necessary for
personnel on site and recommended
protective actions for the public off site.
Waiting for confirmation from first
responders, if not provided by some
other source, may cause a delay in the
PSS issuing notifications and
recommendations for protective actions
to the workforce and the public. For
example, in the following EAL, if no
confirmatory information is provided,
someone must be dispatched to confirm
if an explosion truly occurred [12].
Similarly, note the reliance on
personnel observations and inferences
to assist the decision maker through
appropriate classification of a fire in a
nuclear explosive or special nuclear
material facility [12].
In the following example, radiological
support personnel must be dispatched,
if not immediately available at the
scene, to confirm the validity of a
tritium release alarm before the
appropriate emergency classification
and protective actions are determined
[12].
In the following example, it is not
clear what a ‘‘Convincing Report’’ or
combination of fire indicators is without
further training or guidance on
expectations for those who may report
such events [12].
The specific examples provided,
which are not intended to be all
encompassing, demonstrate that the
Pantex Plant emergency management
strategy is reliant on confirmatory
indicators and does not always provide
sufficient guidance on how to
accomplish the required confirmation.
Immediate (or precautionary) protective
actions, which protect the site workers
in the short-term, would be delayed
while additional assessment is
performed. Such additional assessment
would also delay notifying the off-site
public of protective action
recommendations. The Board’s staff
team believes changes to these
procedures, or incorporation of
additional instrumentation of adequate
reliability, would provide the level of
protection necessary to ensure a timesensitive response to radiological
accidents while minimizing false
alarms.
Conclusions. The Board’s staff team
considers the concerns described above
to be significant and concludes that the
Pantex Plant’s emergency management
program will require Board action to
influence DOE to address these
deficiencies. The plant has made
changes to specific programmatic
elements; however, significant
improvements have not yet been
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75671
realized. Focused effort at addressing
the concerns will substantially ensure
protection of the workers and public at
the Pantex Plant. Some specific actions
to address these concerns include:
• Ensure the Pantex Plant drill and
exercise programs comprehensively
demonstrate proficiency in responding
to emergencies for all hazards, all
facilities, and all responders, consistent
with the technical planning bases and
any updates to them, over a five-year
period in accordance with DOE Order
151.1C (or subsequent revisions). As
part of this demonstration of
proficiency:
Æ Develop and institute a basis for
conducting the drill program in support
of emergency operations.
Æ Strengthen the exercise program to
provide an adequate number of
challenging scenarios per year,
including at least one full-scale sitewide exercise, in order to maintain
qualifications and ensure proficiency of
the emergency response organization
and first responders.
Æ Conduct a comprehensive
assessment of the drill and exercise
programs bases, schedule, and
execution against a risk-ranked set of:
D All hazards;
D All facilities; and
D All response elements.
Æ Evaluate and improve the
effectiveness of the NPO and contractor
processes used to critique drills and
exercises.
• Develop and implement processes
and demonstrate the capabilities to:
Æ Ensure the timeliness and accuracy
of notifications to state and local
authorities is commensurate with the
initiation of off-site release of
radioactive material at the Pantex Plant.
Æ Provide consistent radiological
monitoring support if an accident
releases radiological material off-site,
until state resources arrive and can
assume responsibility for off-site
monitoring.
• Evaluate, incorporate, and validate
(correctness, completeness, and
effectiveness), the following changes to
the Pantex Plant decision-making tools
and notification processes:
Æ Evaluate the emergency action level
(EAL) process for those accident
scenarios identifiable solely via
instrumented systems to reduce delays
in determining and implementing
protective actions.
Æ For those accident scenarios that
are not identifiable solely via
instrumented systems, evaluate the
range of emergency conditions and
potential indicators, and identify where
new monitoring systems can be added
or existing administrative controls can
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be modified to improve timeliness of
response.
Æ For all scenarios, evaluate if some
protective actions should be initiated
based solely on initial indicators (i.e., a
precautionary evacuation) while
confirmatory indicators are sought.
Æ Upon completion of these
evaluations, incorporate new guidance
and training for any changes made to
the EAL decision-making tools and
notification processes into the drill and
exercise program.
The Board’s staff team believes these
problems will not be adequately
addressed by Board’s Recommendation
2014–1, Emergency Preparedness and
Response [13]. Recommendation 2014–
1 identifies specific concerns with DOE
as a regulator, including a failure to
maintain an adequate requirement set,
which led to inconsistent
implementation across DOE, as well as
a lack of rigor in federal and contractor
oversight that let problems persist.
While some of DOE’s actions to address
Recommendation 2014–1 may provide a
framework for the Pantex Plant to
improve its emergency preparedness
and response, the staff team believes the
concerns noted above exist due to
inadequate implementation of the
current requirements. As a result, the
staff team believes that timely resolution
of these concerns requires separate
Board action.
Risk Assessment for Recommendation
2015–1
Emergency Preparedness and Response
at the Pantex Plant
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The recommendation addresses
vulnerabilities in the Pantex Plant’s
implementation of Department of
Energy (DOE) requirements for
emergency preparedness and response.
In accordance with the Defense Nuclear
Facilities Safety Board’s (Board)
enabling statue and Policy Statement 5
(PS–5), Policy Statement on Assessing
Risk [14], this risk assessment was
conducted to support the Board’s
Recommendation 2015–1, Emergency
Preparedness and Response at the
Pantex Plant. As stated in PS–5,
The Board’s assessment of risk may involve
quantitative information showing that the
order of magnitude of the risk is inconsistent
with adequate protection of the health and
safety of the workers and the public . . . the
Board will explicitly document its
assessment of risk when drafting
recommendations to the Secretary of Energy
in those cases where sufficient data exists to
perform a quantitative risk assessment.
DOE’s hazards assessments address
initiating events, preventive and
mitigative controls, and consequences.
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Initiating events in these assessments
include operational and natural
phenomena events. Preventive and
mitigative controls are design basis
controls identified in safety analysis
documents. Consequences cover a wide
spectrum, ranging from insignificant to
catastrophic effects.
The emergency management program
exists at the Pantex Plant because the
risk associated with its facilities is
acknowledged by DOE and is required
by law. Emergency response provides
the ‘‘last line of defense in the event of
. . . [an] accident’’ [15]. Therefore, the
emergency management program needs
to function effectively to protect the
workers and the public.
This recommendation is focused on
improving the effectiveness of the
Pantex Plant’s emergency management
program. A quantitative risk assessment
on the effectiveness of this program
requires data on probability and
consequences. Detailed data on the
probability of failure in emergency
management program elements are not
available for the Pantex Plant, nor do
effective comparisons exist. Therefore, it
is not possible to do a quantitative
assessment of the risk of these elements
to provide adequate protection of the
workers and the public.1
The Board believes that more robust
implementation of existing
requirements would reduce the risk
associated with the spectrum of
accidents postulated at the plant,
regardless of the cause, including
process upsets, the effects of natural
phenomena, and man-made initiating
events, as well as provide additional
margin to respond to those events
considered beyond the design basis.
Cited References
[1] Department of Energy, Comprehensive
Emergency Management System, DOE
Order 151.1C, November 2, 2005.
[2] Department of Energy, Programmatic
1 Members of the Board’s staff conducted research
on other sources of risk information related to
emergency management programs and noted the
U.S. Nuclear Regulatory Commission (NRC)
evaluates commercial nuclear production and
utilization facilities against a set of sixteen
‘‘standards,’’ similar to DOE’s concept of fifteen
program elements found in DOE Order 151.1C,
Comprehensive Emergency Management System. Of
the sixteen NRC standards, four are considered
‘‘risk significant’’ and are weighted differently in
the application of the NRC’s reactor oversight
process, a regulatory scheme applied to certain
licensees to characterize the severity of findings [16,
17]. Under this scheme, findings identified within
these standards are considered more significant.
Three of the four standards, ‘‘Classification,’’
‘‘Notification,’’ and ‘‘Protective Action
Recommendations,’’ parallel the nature of the
concerns with elements of the Pantex Plant’s
emergency management program stated by the
Board in this recommendation.
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Elements: Emergency Management
Guide, DOE Guide 151.1–3, July 11,
2007.
[3] Pantex Plant Safeguards, Security, and
Emergency Services, Full Participation
Exercise 2014–1 (FPE 14–1) Exercise
Plan (Twister-14), August 6, 2014.
[4] Pantex Plant Safeguards, Security, and
Emergency Services, Emergency
Management Training, Drill, and
Exercise Program Plan, Issue 011, EM–
PLN–0023, (undated).
[5] Pantex Plant Safeguards, Security, and
Emergency Services, Full Scale Exercise
2015–1 (FSE 15–1) Exercise Evaluation
Guides (Shaker-15), February 4, 2015.
[6] Pantex Plant, February 4, 2015 Shaker-15
Exercise After Action Report, (undated).
[7] Department of Energy, Office of
Independent Oversight and Performance
Assurance, Volume II, Inspection of
Emergency Management at the Pantex
Plant, November 2002.
[8] Department of Energy, Office of Security
and Safety Performance Assurance:
Office of Independent Oversight and
Performance Assurance, Inspection of
Emergency Management at the Pantex
Site Office and the Pantex Plant, August
2005.
[9] Department of Energy, Office of Health,
Safety and Security: Office of
Independent Oversight: Office of
Emergency Management Oversight,
Independent Oversight Inspection of
Emergency Management at the Pantex
Site Office and the Pantex Plant, June
2008.
[10] Department of Energy, Office of Health,
Safety and Security: Office of
Independent Oversight, Independent
Oversight Review of Emergency
Management at the Pantex Site Office
and Pantex Plant, November 2010.
[11] Department of Energy, Emergency
Management Fundamentals and the
Operational Emergency Base Program:
Emergency Management Guide, DOE
Guide 151.1–1a, July 11, 2007.
[12] Babcock & Wilcox Technical Services
Pantex, Emergency Action Levels, MNL–
190884, Issue No. 007, (undated).
[13] Defense Nuclear Facilities Safety Board,
Emergency Preparedness and Response,
Recommendation 2014–1, September 3,
2014.
[14] Defense Nuclear Facilities Safety Board,
PS–5 Policy Statement on Assessing
Risk, August 15, 2013.
[15] Department of Energy, Office of
Emergency Management Mission,
accessed at: https://nnsa.energy.gov/
ourmission/emergencyresponse,
accessed April 24, 2015.
[16] U.S. Nuclear Regulatory Commission,
Emergency Plans, Title 10, Code of
Federal Regulations, Subsection 50.47.
[17] U.S. Nuclear Regulatory Commission,
Emergency Planning and Preparedness
for Production and Utilization Facilities,
Title 10, Code of Federal Regulations,
Part 50, Appendix E.
General References
Babcock & Wilcox Technical Services Pantex,
NNSA Emergency Readiness Assurance
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Plans—FY 2012 Submission: Completed
Activities For FY 2012 and Projected
Activities For FY 2013, Pantex ERAP,
(undated).
Defense Nuclear Facilities Safety Board,
Public Meeting and Hearing for Safety
Culture, Emergency Preparedness, and
Nuclear Explosive Operations at Pantex,
Amarillo, TX, March 14, 2013.
Defense Nuclear Facilities Safety Board,
Status of Emergency Management at
Defense Nuclear Facilities of the
Department of Energy, Technical Report21, March 1999.
Erhart, S.C., Pantex Emergency Management
Exercise (EMEX 13–1) January 2014,
memorandum to J. Maisonet, December
19, 2013.
Erhart, S. C., Public Hearing and Meeting
Regarding Safety Culture, Emergency
Preparedness, and Nuclear Explosive
Operations at Pantex, communication to
Peter S. Winokur, June 12, 2013.
Pantex Plant Safeguards, Security, and
Emergency Services, Operational
Emergency Manual, Issue No. 003, MNL–
352187, (undated).
Pantex Plant Safeguards, Security, and
Emergency Services, Pantex Plant
Comprehensive Emergency Management
Plan, Issue No. 007, EM–PLN–0019,
(undated).
Pantex Plant Safeguards, Security, and
Emergency Services, Pantex Plant
Emergency Planning Hazards
Assessment, Issue No. 009, MNL–
190881, (undated).
[FR Doc. 2015–30562 Filed 12–2–15; 8:45 am]
BILLING CODE 3670–01–P
DEPARTMENT OF ENERGY
Federal Energy Regulatory
Commission
Lhorne on DSK5TPTVN1PROD with NOTICES
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Dated: November 25, 2015.
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[FR Doc. 2015–30566 Filed 12–2–15; 8:45 am]
BILLING CODE 6717–01–P
E:\FR\FM\03DEN1.SGM
03DEN1
]]>Agencies
[Federal Register Volume 80, Number 232 (Thursday, December 3, 2015)]
[Notices]
[Pages 75665-75673]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-30562]
-----------------------------------------------------------------------
DEFENSE NUCLEAR FACILITIES SAFETY BOARD
[Recommendation 2015-1]
Emergency Preparedness and Response at the Pantex Plant
AGENCY: Defense Nuclear Facilities Safety Board.
ACTION: Notice, recommendation.
-----------------------------------------------------------------------
SUMMARY: Pursuant to 42 U.S.C. 2286a(b)(5), the Defense Nuclear
Facilities Safety Board has made a recommendation to the Secretary of
Energy concerning the need to address specific deficiencies with, and
strengthen regulatory compliance of, the emergency preparedness and
response capability at the National Nuclear Security Administration's
Pantex Plant that require timely resolution.
DATES: Comments, data, views, or arguments concerning the
recommendation are due on or before January 4, 2016.
ADDRESSES: Send comments concerning this notice to: Defense Nuclear
Facilities Safety Board, 625 Indiana Avenue NW., Suite 700, Washington,
DC 20004-2001.
FOR FURTHER INFORMATION CONTACT: Mark Welch at the address above or
telephone number (202) 694-7000. To review the figures referred to in
Recommendation 2015-1, please visit www.dnfsb.gov.
Dated: November 27, 2015.
Joyce L. Connery,
Chairman.
Recommendation 2015-1 to the Secretary of Energy
Emergency Preparedness and Response at the Pantex Plant, Pursuant to 42
U.S.C. 2286a(b)(5) Atomic Energy Act of 1954, as Amended
Dated: November 23, 2015
The Defense Nuclear Facilities Safety Board (Board) recommends that
deficiencies identified with the implementation of existing
requirements in Department of Energy (DOE) Order 151.1C, Comprehensive
Emergency Management System, be corrected at the Pantex Plant to ensure
adequate protection of workers and the public. During a series of
interactions,\1\ we identified three areas of concern regarding the
site's emergency preparedness and response capability. Pantex Plant
personnel took action in response to some of the concerns identified,
but significant concerns still exist. We conclude that each area of
concern by itself has the potential to threaten the adequate protection
of the public health and safety in the event of an operational
emergency. Those areas of concern are (1) inadequate drill and exercise
programs, (2) no demonstrated capability to provide timely, accurate
information to the public regarding off-site radiological consequences,
and (3) inadequate technical planning bases and decision-making tools.
We believe that DOE and the National Nuclear Security
[[Page 75666]]
Administration (NNSA) must address these concerns in order to ensure
the adequate protection of the public and the workers at the Pantex
Plant.
---------------------------------------------------------------------------
\1\ Interactions included the Board's March 2013 public meeting
and hearing in Amarillo, TX, two Board technical staff reviews in
October 2012 and December 2014, and exercise observations in January
and August 2014 and February 2015.
---------------------------------------------------------------------------
The Board communicated its concerns with emergency preparedness and
response across the DOE complex in its Recommendation 2014-1, Emergency
Preparedness and Response. The issues identified in this report are
specific to the Pantex Plant and concern the NNSA Production Office
(NPO) and contractor's \2\ inadequate implementation of existing DOE
requirements.
---------------------------------------------------------------------------
\2\ Consolidated Nuclear Security, LLC, became the management
and operating contractor in July 2014. The previous contractor was
Babcock & Wilcox Technical Services Pantex.
---------------------------------------------------------------------------
Background: Emergency Preparedness and Response Capability.
Personnel at the Pantex Plant conduct work vital to our national
defense. Due to the nature of the operations and the spectrum of
materials in use at the site, the range of possible accidents varies
widely. Working with high explosives, hazardous chemicals, and
radioactive materials results in the potential for operational
emergencies ranging from industrial process-related accidents to
significant material releases due to energetic events. The site is also
subject to a range of natural phenomena hazards; tornados, high winds,
lightning strikes, rain-induced flooding, and earthquakes are all
possible in the region. Of particular concern to us are those accident
scenarios that may cause radioactive material to be dispersed and
deposited off site. Given the short distance from some facilities to
the site perimeter and the average wind speeds at the site, these
materials may affect public lands in the emergency planning zone within
a short period of time.
Board Finding: Drill and Exercise Programs. Based on our
observations, we conclude that the Pantex Plant contractor has not
demonstrated adequate capabilities through its drill and exercise
programs. The Pantex Plant contractor's execution of emergency drills
and exercises is insufficient to provide opportunities for all
personnel to develop and demonstrate proficiency at emergency response.
No site-wide exercises conducted since 2011 have simulated any
significant radiological consequences. No site-wide exercise was
conducted in 2013 (although a hurriedly executed, unchallenging small-
scale scenario in January 2014 purportedly fulfilled the 2013 site-wide
exercise requirement). The Board also observed that both NPO and
contractor capabilities to assess site performance in drills and
exercises are inadequate, and believes this limits the effectiveness of
the existing programs. A robust drill and exercise program would be
varied enough to address all response elements across the spectrum of
hazards and facilities over time.
Board Finding: Timely, Accurate Information to the Public Regarding
Off-Site Radiological Consequences. Our review found no demonstrated
capability to provide timely, accurate information to the public
regarding off-site radiological consequences. State radiological
monitoring response teams are located in Austin, TX, and must travel
nearly 500 miles before they are available to monitor affected
areas.\3\ The Pantex Plant emergency response organization develops and
provides models of radioactive material releases to state and county
officials, but no verification of these models with real-world
measurements is performed until state radiological monitoring response
teams arrive.\4\ Pantex Plant contractor assets may be released at the
plant's discretion in accordance with existing memoranda of
understanding and agreement between the site and the counties/state.
However, we found no instance in the last five years where the
contractor exercised off-site monitoring. Finally, we note that while
existing DOE requirements establish a thirty minute threshold for off-
site notification, the proximity of some Pantex Plant facilities to the
plant boundary is such that material could contaminate off-site
locations in a shorter time period.
---------------------------------------------------------------------------
\3\ The DOE Radiological Assistance Program (RAP) is a national
emergency response asset that provides around-the-clock first-
response capability to assess radiological emergencies, and has a
team stationed in Amarillo, TX. This team may not be consistently
available due to competing priorities and may not have sufficient
local resources to support a response outside the Pantex Plant. DOE
has not incorporated the RAP into the Pantex Plant's existing
exercise program, leaving to question the capability of the RAP
resources to provide off-site support. Additionally, there is
potential that the RAP team could be deployed elsewhere at the time
of an incident, precluding the use of that resource.
\4\ The dispatch of state radiological monitoring response
assets may also be delayed due to the issues identified with the
Pantex Plan decision-making tools.
---------------------------------------------------------------------------
Board Finding: Technical Planning Basis and Decision-Making Tools.
The Board reviewed the technical planning bases and decision-making
tools for the Pantex Plant's emergency management program and found
that they are inadequate to demonstrate protection from time-sensitive
events and do not consider all hazards at the site. Decision-making
tools \5\ lack significant details and include built-in delays that
hinder effective execution. While the existing decision-making tools,
such as emergency action levels (EALs), may minimize the risk of false
alarms, their design precludes providing timely, accurate, and
conservative recommendations to the public.
---------------------------------------------------------------------------
\5\ Decision-making tools currently available exist to aide
operators and first responders with a quick determination of the
likely magnitude of accident consequences, communicate protective
actions to workers, and ensure protective action recommendations are
delivered to public decision-makers in a timely manner.
---------------------------------------------------------------------------
Conclusion. The mission of the Pantex Plant is vital to our
nation's defense, and the consequences of a significant accident would
be difficult to overcome. A robust, comprehensive, tested, and
sustainable emergency preparedness and response capability is vital to
ensure the adequate protection of the public health and safety during
operational emergencies. Specifically, deficiencies must be addressed
in the drill and exercise programs, in demonstrating the capability to
provide timely, accurate information to the public regarding off-site
radiological consequences, and in the technical planning bases and
decision-making tools.
Recommendations. To address the deficiencies summarized above, the
Board recommends that DOE and NNSA take the following actions at the
Pantex Plant:
1. Ensure the Pantex Plant drill and exercise programs
comprehensively demonstrate proficiency in responding to emergencies
for all hazards, all facilities, and all responders, consistent with
the technical planning bases and any updates to them, over a five-year
period in accordance with DOE Order 151.1C (or subsequent revisions).
As part of this demonstration of proficiency:
a. Develop and institute a basis for conducting the drill program
in support of emergency operations.
b. Strengthen the exercise program to provide an adequate number of
challenging scenarios per year, including at least one full-scale,
site-wide exercise, in order to maintain qualifications and ensure
proficiency of the emergency response organization and first
responders.
c. Conduct a comprehensive assessment of the drill and exercise
programs bases, schedule, and execution against a risk-ranked set of:
i. All hazards;
ii. All facilities; and
iii. All response elements.
d. Evaluate and improve the effectiveness of the NPO and contractor
processes used to critique drills and exercises.
2. Develop and implement processes and demonstrate the capabilities
to:
[[Page 75667]]
a. Ensure the timeliness and accuracy of notifications to state and
local authorities is commensurate with the initiation of off-site
release of radioactive material at the Pantex Plant.
b. Provide consistent radiological monitoring support if an
accident releases radiological material off-site, until state resources
arrive and can assume responsibility for off-site monitoring.
3. Evaluate, incorporate, and validate (correctness, completeness,
and effectiveness), the following changes to the Pantex Plant decision-
making tools and notification processes:
a. Evaluate the emergency action level (EAL) process for those
accident scenarios identifiable solely via instrumented systems to
reduce delays in determining and implementing protective actions.
b. For those accident scenarios that are not identifiable solely
via instrumented systems, evaluate the range of emergency conditions
and potential indicators, and identify where new monitoring systems can
be added or existing administrative controls can be modified to improve
timeliness of response.
c. For all scenarios, evaluate if some protective actions should be
initiated based solely on initial indicators (i.e., a precautionary
evacuation) while confirmatory indicators are sought.
d. Upon completion of these evaluations, incorporate new guidance
and training for any changes made to the EAL decision-making tools and
notification processes into the drill and exercise program.
-----------------------------------------------------------------------
Joyce L. Connery,
Chairman.
Recommendation 2015-1 to the Secretary of Energy
Emergency Preparedness and Response at the Pantex Plant
Findings, Supporting Data, and Analysis
Introduction. During the past three years, members of the Defense
Nuclear Facilities Safety Board's (Board) staff conducted several
activities to gain and maintain awareness of the state of emergency
preparedness and response at the Pantex Plant. In October 2012, the
staff team conducted a wide-scope program review supporting
preparations for the Board's March 2013 public meeting and hearing in
Amarillo, TX. After the public meeting and hearing, members of the
Board's staff interacted with the National Nuclear Security
Administration (NNSA) Production Office (NPO) and the contractor \1\ to
address supplemental questions and clarify statements made during the
hearing. In 2014, members of the Board's staff observed two site-wide
emergency response exercises. In December 2014, the Board's staff team
conducted another program review to examine specific aspects of the
Pantex Plant emergency management program. The Board's staff team
observed the execution of certain emergency management program elements
during a site-wide emergency response exercise conducted in February
2015. In addition, the Board's Site Representative at Pantex, who is
stationed there on a full-time basis, made observations regarding the
emergency preparedness and response capability of the Pantex Plant as
part of his routine oversight of the Pantex Plant facilities and
operations.
---------------------------------------------------------------------------
\1\ Consolidated Nuclear Security, LLC, became the management
and operating contractor in July 2014. The previous contractor was
Babcock & Wilcox Technical Services Pantex.
---------------------------------------------------------------------------
During each of these activities, the Board's staff team provided
on-site feedback to NPO and the contractor, and culminated this
exchange with a formal teleconference close-out brief on March 17,
2015. Pantex Plant personnel took action in response to some of the
concerns identified during the activities noted above, but significant
concerns still exist. The following section expands on observations
provided to the Pantex Plant during the March 2015 teleconference and
provides the technical basis for further Board action.
Observations. The Board's staff team's observations are organized
into three main sections: the drill and exercise programs, notification
and support to off-site agencies, and technical planning bases and
decision-making tools.\2\
---------------------------------------------------------------------------
\2\ The focus of the Board's staff reviews was not comprehensive
in all elements of the emergency management program. Additional
problems may exist in other elements of the program, such as federal
oversight and the quality of the site's agreements with off-site
stakeholders.
---------------------------------------------------------------------------
Drill and Exercise Programs--Based on its observations, the Board's
staff team concludes that the Pantex Plant contractor has not
demonstrated adequate capabilities through its drill and exercise
programs. The Board's staff team found that the Pantex Plant emergency
drill and exercise programs do not provide sufficient opportunities for
personnel to develop and demonstrate proficiency at emergency response
with respect to all response elements across the spectrum of hazards
and facilities. The drill program does not act as part of a
comprehensive training and qualification program, but during the last
few years has mainly supported preparation for the site's annual
exercises.
Department of Energy (DOE) Order 151.1C Comprehensive Emergency
Management Program [1] outlines several requirements for drill and
exercise programs. Specifically, Section 4.b (Exercises) states:
A formal exercise program must be established to validate
all elements of the emergency management program over a five-year
period.
Each exercise must have specific objectives and must be
fully documented (e.g., by scenario packages that include objectives,
scope, timelines, injects, controller instructions, and evaluation
criteria).
Exercises must be evaluated.
A critique process, which includes gathering and
documenting observations of the participants, must be established.
Corrective action items identified as a result of the
critique process must be incorporated into the emergency management
program.
Additionally, specified facility-level requirements include:
Each DOE/NNSA facility subject to this chapter must
exercise its emergency response capability annually and include at
least facility-level evaluation and critique.
DOE evaluations of annual facility exercises (e.g., by
Cognizant Field Element, Program Secretarial Officer, or Headquarters
Office of Security and Safety Performance Assurance) must be performed
periodically so that each facility has an external DOE evaluation at
least every three years.
Site-level emergency response organization elements and
resources must participate in a minimum of one exercise annually. This
site exercise must be designed to test and demonstrate the site's
integrated emergency response capability. For multiple facility sites,
the basis for the exercise must be rotated among facilities.
Scope of Exercise Scenarios: Based on observing implementation
across DOE's sites, the Board's staff team summarized these
requirements as the need to exercise all facilities, all hazards, and
all response elements. The following sections describe the Board's
staff team's observations of the Pantex Plant's implementation of drill
and exercise requirements.
For the five-year period (2011-2015) reviewed by the Board's staff
team, the following scenarios represent the totality of Pantex Plant's
site-wide exercises:
[[Page 75668]]
2011: Explosion in a nuclear explosive facility with no
contamination outside the facility.
2012: Seismic event leading to building damage (no
radiological or hazardous material release).
2014a: Liquid nitrogen release from a truck accident
(make-up for no exercise in 2013).
2014b: Severe event (tornado) table-top.
2015a: Severe event (seismic) with a transportation
accident, wildfire, and mass casualty (no radiological or hazardous
material release).
2015b: Security event with hazardous material release.
The Board's staff team reviewed documentation that showed some
facilities at the Pantex Plant did not hold an evaluated activity to
demonstrate response capability, regardless of whether the activity was
a site-wide exercise, limited scope exercise, or other form of
evaluation.\3\ The plant's analysis of the hazards for emergency
preparedness and response is organized into a single emergency planning
hazards analysis (EPHA), effectively identifying the plant as one
facility when in reality there are numerous facilities with diverse
hazards. This organizational structure contributes to the limited
number of evaluated exercises at the Pantex Plant. Pantex is currently
undertaking an effort to reevaluate the organization of the EPHA (i.e.,
dividing the single EPHA into multiple EPHAs). The Board's staff team
received conceptual information about this effort and will continue to
review any proposed changes to the organization of the Pantex EPHA,
since such a change may provide a formal basis for additional facility
exercises.
---------------------------------------------------------------------------
\3\ The Pantex Plant is a collection of buildings of various
designs that house a variety of activities and operations that occur
at the plant. There are bays and cells, which come in several
variations and can be standalone or collocated, in which assembly
and disassembly of nuclear explosive assemblies is conducted. There
are buildings in which non-nuclear operations, such as explosive
operations, are conducted. There is a variety of storage areas
including storage of nuclear materials, nuclear explosive
assemblies, explosives, and other hazardous materials. There are
also various transportation activities within operational areas and
across the site. For the purposes of exercises, various areas or
types of operations could be grouped as representing different types
of facilities. In the context of the layout of facilities at the
Pantex Plant, the Board's staff team believes that it would be
appropriate to conduct some type of exercise or other form of
evaluation for each representative type of activity and operation.
---------------------------------------------------------------------------
The Pantex Plant has a range of hazards that may challenge
emergency responders and decision-makers. Natural phenomena such as
tornados, fires, lightning strikes, and rain-induced flooding exist
alongside operational activities involving hazardous and radiological
materials. The Board's staff team observed, directly and by document
review, the range of exercise scenarios being conducted and found them
to be too limited compared to the range of hazards at the plant. Often
these scenarios were simplistic and not sufficiently challenging to
truly demonstrate response capability for the hazard being exercised.
DOE Guide 151.1-3, Programmatic Elements, Section 3.0 ``Exercises'' [2]
provides a method of scheduling exercises to ensure coverage of all
hazards at a site over a five-year period. However, it is the opinion
of the Board's staff team that hazards with a higher frequency of
occurrence, significance of consequences, or complexity of emergency
response may need to be exercised more frequently than other hazards.
Exercise scenarios from the past three years included a nitrogen spill,
a primarily table-top tornado event, and a simulated earthquake with no
radiological material impact.
The potential for more significant consequences and complicated
responses exists at the Pantex Plant's facilities. For example, a high
explosive violent reaction has the potential to release radioactive
material both on site, outside of the nuclear explosive facility (i.e.,
a bay), as well as off site. Fires in areas containing radioactive
material have the potential to drive more significant radiological
response actions by plant personnel. It is the opinion of the Board's
staff team that the Pantex Plant should more frequently exercise
challenging radiological responses.
The Pantex Plant has not consistently exercised all response
elements between 2011 and 2015, which is insufficient to meet DOE
requirements. There does not appear to be a deliberate approach to
demonstrating integrated emergency response capability. For example,
the August 2014 exercise [3] relied on to meet the annually required
site-wide demonstration of proficiency, postulated a tornado affecting
the site. This was the plant's first significant effort at exercising a
severe event, but was also credited as the annual site-wide exercise.
The Board's staff team observed that few field participants
demonstrated their response capabilities. While this was a valuable
training and planning activity for a severe event, this exercise was
the sole site-wide event for that time period. The Board's staff team
believes that it is appropriate to exercise a more complete array of
site response elements, not just fire and rescue responders,
demonstrating their proficiency. The 2013 exercise (conducted in
January 2014) and the February 2015 exercise also did not involve
significant field participation other than fire and rescue services.
Within the last five years, Pantex has not completed a full
participation exercise (i.e., all on-site employees participating
through protective actions and response); site-wide exercises have only
included participation from a small subset of the plant population.
Training and Qualification of Emergency Responders: The limited
number and scope of exercises conducted each year also affects the
training, qualification, and proficiency of emergency responders. The
Pantex Plant's emergency response organization is made up of three
shifts of responders on a rotating watch bill. It is unclear to the
Board's staff team how the site can demonstrate proficiency and support
training and qualification across all responders when an insufficient
number of facility and site-wide exercises are being scheduled to
support a three-shift emergency response organization. The Pantex Plant
training, drill, and exercise program plan authorizes participation in
a limited-scope evaluated activity (e.g., functional exercises or
limited scope performance demonstrations) to maintain qualification
within the emergency response organization [4]. Pantex Plant exercise
after action reports document repeated emergency response organization
shortcomings during site-wide exercises,\4\ and demonstrate that these
limited-scope opportunities are not sufficiently rigorous to qualify
and maintain proficiency of personnel at emergency operations.
---------------------------------------------------------------------------
\4\ The Board's staff team observed the past three site-wide
exercises and also noted poor performance by the emergency response
organization.
---------------------------------------------------------------------------
Exercise Assessment: The Board's staff team believes that the
Pantex Plant's development and assessment of exercise objectives
contributes to the continuing limited effectiveness of the emergency
exercise program. The staff team assessed the exercise objectives and
does not consider them to be effective tools for identifying problems
that can be analyzed and corrected.
First, the objectives reviewed by the staff team were not always
adequate to evaluate the effectiveness of actions taken by responders.
For example, objectives do not always differentiate between taking an
action and taking the right action in a timely fashion. The February
2015 exercise evaluation guide for the Plant Shift Superintendents
(PSS) [5] included four criteria to evaluate the PSS's objective of
[[Page 75669]]
implementing protective actions (see Figure 1); the criteria do not
address whether protective actions are implemented in time to be
effective and whether the corrective protective actions are correct for
the event.
Another example of an objective from the February 2015 exercise
that the staff team believes was not adequate involved processing
information (see Figure 2). This objective evaluates the collection of
information by the PSS, but does not evaluate communication of this
information to responders. The PSS received information about trapped
victims involved in an on-site transportation accident event involving
a passenger vehicle and a material transporter, but did not verify that
the Incident Commander took the correct response. In fact, the Incident
Commander was not notified that the on-site transportation accident had
occurred, and no action was taken for almost an hour, at which point
the Fire Department responded. During the controller/evaluator after
action critique, the objective was evaluated as ``Met'' based on the
fact that the PSS received the information; although the controller/
evaluator did note in the After Action Report that ``No communication
with the Incident Commander was observed'' [6]. This objective did not
require the controller/evaluator to adequately consider the quality of
the action taken upon receipt of the information.
Second, if all objectives are weighted equally, the importance of
certain actions over others cannot be distinguished. The Pantex Plant
is undertaking an effort to change the grading scheme for emergency
exercises to focus only on objective-by-objective performance and not
incorporate any objective and criterion weighting or overall grade
scheme. In the objective shown in Figure 1, selecting the correct
protective action is a single criterion,\5\ which could be missed. Yet
if all other criteria are completed, the objective may still be met.
The overall objective--to implement time-urgent protective actions--
seems to be more valuable to an effective response than objectives that
simply measure adherence to administrative procedures. It is the
opinion of the Board's staff team that, without some indication of an
objective's overall importance, the plant is likely to have difficulty
interpreting the exercise results and will be challenged to prioritize
and apply resources to those response elements that require additional
attention and to address corrective actions.
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\5\ Note that the criterion actually asks, ``What protective
action(s) was implemented.'' This discussion addresses the intent of
that criterion (i.e., the Board's staff team believes that the
intent of the criterion was to determine ``Was the correct
protective action implemented?'').
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Last, the Pantex Plant could meet all of its exercise objectives
but still fundamentally fail to protect the workers and public. The
February 2015 exercise is an example. During the participant hot wash
and controller/evaluator after-action critique, most objectives were
determined to be ``Met.'' Yet, on-site first responders were
potentially exposed to an off-site chemical hazard. This was not
considered an objective and, therefore, did not influence the positive
perception of the exercise results by the participants, controllers,
and evaluators. Developing meaningful objectives requires a balance
between criteria that are reasonably observable versus the need to
confirm a subjective quality (e.g., effectiveness). The ability to
measure the quality of action taken, sometimes by independent
oversight, is a necessary part of objective evaluations.
The Board's staff team believes that deficiencies in assessing
performance in exercises also contribute to the continuing limited
effectiveness of the emergency management program. Exercise
participants conduct hot washes at the end of each exercise. The hot
washes are intended to be a vehicle for participants to self-critique
their response performance, including both positive and negative
aspects, and to identify potential areas for improvement. The hot
washes that the Board's staff team observed at the Pantex Plant tended
to focus on faults with the exercise scenario rather than issues with
emergency response performance. The participants raised issues such as
the perception that a scenario was unrealistic or that controllers did
not have adequate simulations for what the participants would observe
in real-life. Many participant observations focused on deficiencies in
administrative equipment and tools, such as printer or fax machine
problems. While the readiness of these resources is important to an
adequate response, the purpose of the exercise program is to
demonstrate proficiency. Many participant observations also focused on
the positive results of their actions, but failed to identify whether
the actions taken would have been effective during the given emergency
scenario. As a best practice, mature organizations tend to have an
experienced functional team leader (e.g., the Emergency Operations
Center (EOC) Emergency Director) lead the hot wash, rather than rely on
the exercise controller/evaluator for this role. Most response elements
at the Pantex Plant do not incorporate this practice.
For each exercise, controllers and evaluators conducted after
action critiques to collect data and observations about the performance
of exercise response participants, as well as concerns with exercise
control. While these were preliminary data gathering activities, the
Board's staff team noted the same lack of critical assessment among the
exercise evaluators. Evaluators did not explicitly compare the actions
taken by participants to the expected or most desirable responses as
they related to the fundamental purpose of emergency response. For
example, while data on when a particular communication was faxed may
have been collected, the quality and usefulness of the communication to
inform its addressee were not evaluated. Discussions focused on
specific functional area performance, as assessed against binary
objectives such as a checklist, but did not address the effectiveness
of interfaces between functional areas.
For example, during the February 2015 exercise, the EOC received
information concerning an off-site release of a hazardous chemical from
a train accident. The consequence assessment team performed modeling to
inform decision-makers of the effect on plant personnel, including
first responders. Fire Department personnel who responded to the on-
site transportation accident were within the projected plume while
performing rescue operations. Neither the PSS nor the EOC informed the
Fire Department personnel of the potential exposure (e.g., type of
material, quantity, timing, or recommended personal protective
equipment). This information was eventually provided to the incident
command late in the scenario. Exercise objectives were evaluated as
``Met'' for these individual functional areas during the evaluator
after action critique. The effectiveness of organizational interfaces
can be masked by such stove-piped evaluations.
Emergency Management Drill and Exercise Program Oversight: The
Board's staff team considers it a significant deficiency that NPO and
contractor oversight did not identify the issues discussed in this
section. Other than the emergency management program manager, the
Board's staff team observed limited evidence of interaction with NPO
functional area subject matter experts in the evaluation of exercise
reports. NPO review of exercise assessments appears weak in that
[[Page 75670]]
exercises with observed deficiencies do not result in reports with
commensurate findings. Where issues are identified, the contractor's
causal analyses are often weak or superficial, leading to development
of ineffective corrective actions and recurrence of the same issues in
subsequent exercises. The concern with ineffective corrective actions
is also evident when DOE's independent oversight organizations observe
exercises and provide reports to the plant. DOE's Office of Emergency
Management Oversight (formerly HS-63 and also OA-30) provided reports
highlighting concerns with the Pantex Plant's emergency management
program; these reports also identify recurring issues that the
contractor has not effectively addressed [7, 8, 9, 10].
Timely, Accurate Information to the Public Regarding Off-site
Radiological Consequences--The Board's staff team found no demonstrated
capability to provide timely, accurate information to the public
regarding off-site radiological consequences. Accident scenarios
postulated at the Pantex Plant may result in the release of radioactive
material or other hazardous materials from facilities. The released
material may then be carried across the site boundary and contaminate
public roads and land. The proximity of some facilities at the plant to
the site boundary is such that in certain scenarios, material could
contaminate off-site locations within a short period of time.
Notification to off-site organizations provides two important
functions: first, it warns members of the public to take protective
action in response to an accident; second, it initiates off-site
response assets that can control access and conduct radiological
monitoring. The notification processes used at the Pantex Plant may not
provide enough time for protective action recommendations to be issued
and executed before radioactive material is dispersed off-site. Any
delay in notification adds to the time necessary for state response
assets to deploy. Notification may be delayed due to the emergency
action level (EAL) decision-making processes. Additionally, state
radiological monitoring assets may be delayed in reaching the vicinity
of Amarillo due to geographic constraints.\6\ The response teams,
located in Austin, TX, must travel nearly 500 miles before they are
available to monitor the affected area. Notification delays would also
impede instituting access control to public use areas around the site.
While the Pantex Plant emergency response organization develops and
provides models of radioactive material releases to state and county
officials, actual monitoring to verify material deposition off site may
not be proactively performed by the site's radiological response
assets; these assets may be released at the plant's discretion in
accordance with existing memoranda of understanding between the site
and the counties/state. Pantex Plant radiological support personnel do
not exercise this monitoring function during drills and exercises, and
do not have processes in place to describe how off-site field
monitoring would be executed.
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\6\ The DOE Radiological Assistance Program (RAP) is a national
emergency response asset that provides around-the-clock first-
response capability to assess radiological emergencies, and has a
team stationed in Amarillo, TX. This team may not be consistently
available due to competing priorities and may not have sufficient
local resources to support a response outside the Pantex Plant. DOE
has not incorporated the RAP into the Pantex Plant's existing
exercise program, leaving to question the capability of the RAP
resources to provide off-site support. Additionally, there is
potential that the RAP team could be deployed elsewhere at the time
of an incident, precluding the use of that resource.
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There are limited requirements in DOE Order 151.1C that specify how
the site will plan for these events and handle off-site radiological
monitoring. The Board's staff team notes that the Pantex Plant has made
agreements, via memoranda of understanding, with state and local
authorities to create communication channels for much of this
information. However, these existing mechanisms do not provide the
proactive support from the plant to the local community that is
necessary to ensure any release of contamination is accurately tracked
in a timely manner to ensure the protection of the public. Given that
the Pantex Plant is close to public roads and land, and has the
potential to release radiological material off site within minutes of
an initiating event, stronger requirements in the Order are needed to
ensure the plant performs effective off-site monitoring until the
necessary State of Texas resources arrive.
Technical Planning Bases and Decision-making Tools--The Board's
staff team found that the technical planning bases and decision-making
tools for the Pantex Plant's emergency management program are
inadequate to demonstrate protection from time-sensitive events and do
not consider all hazards at the site. For the set of hazards analyzed,
the technical planning tools developed to respond to emergencies are
inadequate to ensure timely notification of the need for protective
actions to the workers and recommended protective actions to the
public.
To meet DOE Order 151.1C emergency planning element requirements, a
site must conduct an all-hazard analysis. From this survey, certain
accident sequences are selected for additional consideration in the
EPHA. The EPHA provides the basis for developing the site's EALs. EALs,
which are also required by DOE Order 151.1C, are used during an
emergency event to determine the categorization and level of
classification of the emergency event. When using an EAL, emergency
response decision-makers attempt to answer two questions. First, is the
event an operational emergency? Second, if so, what is the potential
area of impact and the degree of emergency response? The safety basis
development process uses a similar hazard analysis process. When
developing a safety basis, some infrequent accidents may be screened
out of further analysis if they have a low probability of occurrence.
However, for the purposes of EPHAs, low-probability, high-consequence
events should be further analyzed to determine the magnitude of
potential consequences and the expected level of response. Guidance is
provided in DOE's Emergency Management Guide 151.1-1a, Emergency
Management Fundamentals and the Operational Emergency Base Program.
``The DOE approach requires some planning even for events whose
severity exceeds the design basis for safety controls; the facility/
site or activity must be prepared to take actions to limit or prevent
adverse health and safety impacts to workers and the public'' [11].
While these analyses of low-probability events may be less
quantitative, they still need to be performed to ensure DOE and its
contractors are cognizant of potential consequences and conduct an
appropriate level of planning.
For events that Pantex Plant emergency management personnel have
analyzed, the site uses EALs as a tool to determine if an operational
emergency is occurring and the classification of the event, to notify
site workers of the need for protective actions, and to notify the
public of recommended protective actions. As currently developed, these
EALs include a confirmatory step that may delay decision-makers
providing these notifications and recommendations for protective
actions for several minutes, possibly up to 30 minutes. The ability to
provide notifications and recommendations for protective actions to
workers and the public in a timely manner significantly increases the
safety of these groups during operational emergencies. DOE
[[Page 75671]]
Order 151.1C specifies a 15-minute window to notify DOE Headquarters
and the public of events in progress [1].
Pantex Plant emergency management personnel chose to use a decision
tree model in their EALs, visually guiding an operator through
decisions being made in response to an event on site. The example in
Figure 3 below, taken from the Pantex EALs [12], shows the flow-path
through decision making to action.
An operator--in the case of the Pantex Plant, the PSS--enters the
EAL with relevant information concerning an emergency event. This leads
the PSS to a conservative emergency categorization and classification.
These classifications (Alert, Site Area Emergency, and General
Emergency) ensure appropriate responses are taken given the anticipated
magnitude of the accident consequences. In most radiological EALs at
the Pantex Plant, the PSS receives initial information of emergency
conditions from an instrumented signal. For example, coincident fire
and radiation monitor alarms would indicate the presence of a possible
fire with radioactive material release.
The Pantex Plant EALs also include confirmatory indicators as an
explicit step in the decision-making process before classification can
be performed. These are typically in the form of personnel providing
eyewitness confirmatory statements about the nature of an event. From
the EAL front matter [12], page 8:
The PSS or Emergency Manager must rely on information resulting from
communication with whoever is in command at the emergency scene,
emergency responders, and plant personnel to supply confirmatory
information necessary to make emergency classification decisions.
From page 11:
Using the appropriate EAL, the PSS or Emergency Manager follows the
decision tree and attempts to identify initial and confirmatory
indicators of an actual emergency event while simultaneously
continuing to gather information on the situation from Incident
Command, emergency responders, and plant personnel. [If these
resources are not already there, they are dispatched.] During this
time, initial protective actions may be implemented [emphasis added]
to protect plant personnel.
If EAL confirmatory indicators are present and detected, the PSS or
Emergency Manager follows the decision-tree to the classification
area. This section may require retrieval of information on the
quantity and type of material involved in the incident from the Move
Right System or use of inserted tables. Once determined, the PSS or
Emergency Manager classifies the emergency based on the EAL
information.
These classification decisions allow the PSS to determine what, if
any, protective actions are necessary for personnel on site and
recommended protective actions for the public off site. Waiting for
confirmation from first responders, if not provided by some other
source, may cause a delay in the PSS issuing notifications and
recommendations for protective actions to the workforce and the public.
For example, in the following EAL, if no confirmatory information is
provided, someone must be dispatched to confirm if an explosion truly
occurred [12].
Similarly, note the reliance on personnel observations and
inferences to assist the decision maker through appropriate
classification of a fire in a nuclear explosive or special nuclear
material facility [12].
In the following example, radiological support personnel must be
dispatched, if not immediately available at the scene, to confirm the
validity of a tritium release alarm before the appropriate emergency
classification and protective actions are determined [12].
In the following example, it is not clear what a ``Convincing
Report'' or combination of fire indicators is without further training
or guidance on expectations for those who may report such events [12].
The specific examples provided, which are not intended to be all
encompassing, demonstrate that the Pantex Plant emergency management
strategy is reliant on confirmatory indicators and does not always
provide sufficient guidance on how to accomplish the required
confirmation. Immediate (or precautionary) protective actions, which
protect the site workers in the short-term, would be delayed while
additional assessment is performed. Such additional assessment would
also delay notifying the off-site public of protective action
recommendations. The Board's staff team believes changes to these
procedures, or incorporation of additional instrumentation of adequate
reliability, would provide the level of protection necessary to ensure
a time-sensitive response to radiological accidents while minimizing
false alarms.
Conclusions. The Board's staff team considers the concerns
described above to be significant and concludes that the Pantex Plant's
emergency management program will require Board action to influence DOE
to address these deficiencies. The plant has made changes to specific
programmatic elements; however, significant improvements have not yet
been realized. Focused effort at addressing the concerns will
substantially ensure protection of the workers and public at the Pantex
Plant. Some specific actions to address these concerns include:
Ensure the Pantex Plant drill and exercise programs
comprehensively demonstrate proficiency in responding to emergencies
for all hazards, all facilities, and all responders, consistent with
the technical planning bases and any updates to them, over a five-year
period in accordance with DOE Order 151.1C (or subsequent revisions).
As part of this demonstration of proficiency:
[cir] Develop and institute a basis for conducting the drill
program in support of emergency operations.
[cir] Strengthen the exercise program to provide an adequate number
of challenging scenarios per year, including at least one full-scale
site-wide exercise, in order to maintain qualifications and ensure
proficiency of the emergency response organization and first
responders.
[cir] Conduct a comprehensive assessment of the drill and exercise
programs bases, schedule, and execution against a risk-ranked set of:
[ssquf] All hazards;
[ssquf] All facilities; and
[ssquf] All response elements.
[cir] Evaluate and improve the effectiveness of the NPO and
contractor processes used to critique drills and exercises.
Develop and implement processes and demonstrate the
capabilities to:
[cir] Ensure the timeliness and accuracy of notifications to state
and local authorities is commensurate with the initiation of off-site
release of radioactive material at the Pantex Plant.
[cir] Provide consistent radiological monitoring support if an
accident releases radiological material off-site, until state resources
arrive and can assume responsibility for off-site monitoring.
Evaluate, incorporate, and validate (correctness,
completeness, and effectiveness), the following changes to the Pantex
Plant decision-making tools and notification processes:
[cir] Evaluate the emergency action level (EAL) process for those
accident scenarios identifiable solely via instrumented systems to
reduce delays in determining and implementing protective actions.
[cir] For those accident scenarios that are not identifiable solely
via instrumented systems, evaluate the range of emergency conditions
and potential indicators, and identify where new monitoring systems can
be added or existing administrative controls can
[[Page 75672]]
be modified to improve timeliness of response.
[cir] For all scenarios, evaluate if some protective actions should
be initiated based solely on initial indicators (i.e., a precautionary
evacuation) while confirmatory indicators are sought.
[cir] Upon completion of these evaluations, incorporate new
guidance and training for any changes made to the EAL decision-making
tools and notification processes into the drill and exercise program.
The Board's staff team believes these problems will not be
adequately addressed by Board's Recommendation 2014-1, Emergency
Preparedness and Response [13]. Recommendation 2014-1 identifies
specific concerns with DOE as a regulator, including a failure to
maintain an adequate requirement set, which led to inconsistent
implementation across DOE, as well as a lack of rigor in federal and
contractor oversight that let problems persist. While some of DOE's
actions to address Recommendation 2014-1 may provide a framework for
the Pantex Plant to improve its emergency preparedness and response,
the staff team believes the concerns noted above exist due to
inadequate implementation of the current requirements. As a result, the
staff team believes that timely resolution of these concerns requires
separate Board action.
Risk Assessment for Recommendation 2015-1
Emergency Preparedness and Response at the Pantex Plant
The recommendation addresses vulnerabilities in the Pantex Plant's
implementation of Department of Energy (DOE) requirements for emergency
preparedness and response. In accordance with the Defense Nuclear
Facilities Safety Board's (Board) enabling statue and Policy Statement
5 (PS-5), Policy Statement on Assessing Risk [14], this risk assessment
was conducted to support the Board's Recommendation 2015-1, Emergency
Preparedness and Response at the Pantex Plant. As stated in PS-5,
The Board's assessment of risk may involve quantitative
information showing that the order of magnitude of the risk is
inconsistent with adequate protection of the health and safety of
the workers and the public . . . the Board will explicitly document
its assessment of risk when drafting recommendations to the
Secretary of Energy in those cases where sufficient data exists to
perform a quantitative risk assessment.
DOE's hazards assessments address initiating events, preventive and
mitigative controls, and consequences. Initiating events in these
assessments include operational and natural phenomena events.
Preventive and mitigative controls are design basis controls identified
in safety analysis documents. Consequences cover a wide spectrum,
ranging from insignificant to catastrophic effects.
The emergency management program exists at the Pantex Plant because
the risk associated with its facilities is acknowledged by DOE and is
required by law. Emergency response provides the ``last line of defense
in the event of . . . [an] accident'' [15]. Therefore, the emergency
management program needs to function effectively to protect the workers
and the public.
This recommendation is focused on improving the effectiveness of
the Pantex Plant's emergency management program. A quantitative risk
assessment on the effectiveness of this program requires data on
probability and consequences. Detailed data on the probability of
failure in emergency management program elements are not available for
the Pantex Plant, nor do effective comparisons exist. Therefore, it is
not possible to do a quantitative assessment of the risk of these
elements to provide adequate protection of the workers and the
public.\1\
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\1\ Members of the Board's staff conducted research on other
sources of risk information related to emergency management programs
and noted the U.S. Nuclear Regulatory Commission (NRC) evaluates
commercial nuclear production and utilization facilities against a
set of sixteen ``standards,'' similar to DOE's concept of fifteen
program elements found in DOE Order 151.1C, Comprehensive Emergency
Management System. Of the sixteen NRC standards, four are considered
``risk significant'' and are weighted differently in the application
of the NRC's reactor oversight process, a regulatory scheme applied
to certain licensees to characterize the severity of findings [16,
17]. Under this scheme, findings identified within these standards
are considered more significant. Three of the four standards,
``Classification,'' ``Notification,'' and ``Protective Action
Recommendations,'' parallel the nature of the concerns with elements
of the Pantex Plant's emergency management program stated by the
Board in this recommendation.
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The Board believes that more robust implementation of existing
requirements would reduce the risk associated with the spectrum of
accidents postulated at the plant, regardless of the cause, including
process upsets, the effects of natural phenomena, and man-made
initiating events, as well as provide additional margin to respond to
those events considered beyond the design basis.
Cited References
[1] Department of Energy, Comprehensive Emergency Management System,
DOE Order 151.1C, November 2, 2005.
[2] Department of Energy, Programmatic Elements: Emergency
Management Guide, DOE Guide 151.1-3, July 11, 2007.
[3] Pantex Plant Safeguards, Security, and Emergency Services, Full
Participation Exercise 2014-1 (FPE 14-1) Exercise Plan (Twister-14),
August 6, 2014.
[4] Pantex Plant Safeguards, Security, and Emergency Services,
Emergency Management Training, Drill, and Exercise Program Plan,
Issue 011, EM-PLN-0023, (undated).
[5] Pantex Plant Safeguards, Security, and Emergency Services, Full
Scale Exercise 2015-1 (FSE 15-1) Exercise Evaluation Guides (Shaker-
15), February 4, 2015.
[6] Pantex Plant, February 4, 2015 Shaker-15 Exercise After Action
Report, (undated).
[7] Department of Energy, Office of Independent Oversight and
Performance Assurance, Volume II, Inspection of Emergency Management
at the Pantex Plant, November 2002.
[8] Department of Energy, Office of Security and Safety Performance
Assurance: Office of Independent Oversight and Performance
Assurance, Inspection of Emergency Management at the Pantex Site
Office and the Pantex Plant, August 2005.
[9] Department of Energy, Office of Health, Safety and Security:
Office of Independent Oversight: Office of Emergency Management
Oversight, Independent Oversight Inspection of Emergency Management
at the Pantex Site Office and the Pantex Plant, June 2008.
[10] Department of Energy, Office of Health, Safety and Security:
Office of Independent Oversight, Independent Oversight Review of
Emergency Management at the Pantex Site Office and Pantex Plant,
November 2010.
[11] Department of Energy, Emergency Management Fundamentals and the
Operational Emergency Base Program: Emergency Management Guide, DOE
Guide 151.1-1a, July 11, 2007.
[12] Babcock & Wilcox Technical Services Pantex, Emergency Action
Levels, MNL-190884, Issue No. 007, (undated).
[13] Defense Nuclear Facilities Safety Board, Emergency Preparedness
and Response, Recommendation 2014-1, September 3, 2014.
[14] Defense Nuclear Facilities Safety Board, PS-5 Policy Statement
on Assessing Risk, August 15, 2013.
[15] Department of Energy, Office of Emergency Management Mission,
accessed at: https://nnsa.energy.gov/ourmission/emergencyresponse,
accessed April 24, 2015.
[16] U.S. Nuclear Regulatory Commission, Emergency Plans, Title 10,
Code of Federal Regulations, Subsection 50.47.
[17] U.S. Nuclear Regulatory Commission, Emergency Planning and
Preparedness for Production and Utilization Facilities, Title 10,
Code of Federal Regulations, Part 50, Appendix E.
General References
Babcock & Wilcox Technical Services Pantex, NNSA Emergency Readiness
Assurance
[[Page 75673]]
Plans--FY 2012 Submission: Completed Activities For FY 2012 and
Projected Activities For FY 2013, Pantex ERAP, (undated).
Defense Nuclear Facilities Safety Board, Public Meeting and Hearing
for Safety Culture, Emergency Preparedness, and Nuclear Explosive
Operations at Pantex, Amarillo, TX, March 14, 2013.
Defense Nuclear Facilities Safety Board, Status of Emergency
Management at Defense Nuclear Facilities of the Department of
Energy, Technical Report-21, March 1999.
Erhart, S.C., Pantex Emergency Management Exercise (EMEX 13-1)
January 2014, memorandum to J. Maisonet, December 19, 2013.
Erhart, S. C., Public Hearing and Meeting Regarding Safety Culture,
Emergency Preparedness, and Nuclear Explosive Operations at Pantex,
communication to Peter S. Winokur, June 12, 2013.
Pantex Plant Safeguards, Security, and Emergency Services,
Operational Emergency Manual, Issue No. 003, MNL-352187, (undated).
Pantex Plant Safeguards, Security, and Emergency Services, Pantex
Plant Comprehensive Emergency Management Plan, Issue No. 007, EM-
PLN-0019, (undated).
Pantex Plant Safeguards, Security, and Emergency Services, Pantex
Plant Emergency Planning Hazards Assessment, Issue No. 009, MNL-
190881, (undated).
[FR Doc. 2015-30562 Filed 12-2-15; 8:45 am]
BILLING CODE 3670-01-P
