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United States Government Department of Energy

West Valley Demonstration Project

memorandumDATE: June 19, 2014

SUBJECT: Deferred Maintenance Extent of Condition Review

TO: David G. Huizenga, Acting Assistant Secretary for Environmental ManagementDOE-HQ, EM-i, FORS

Ralph E. Holland, Acting DirectorDOE-EMCBC, Office of the Director

Reference: Memorandum (363320) D. Huizenga to Distribution, “EM-wide Extent ofCondition Review on Deferred Maintenance,” dated April 16, 2014

Attached per the referenced memorandum is the Extent of Condition Review on DeferredMaintenance for the West Valley Demonstration Project (WVDP) report. The review wasconducted as an audit under NQA-1 requirements to ensure sufficient rigor was applied to thereview. The audit identified numerous observations, corrective actions, opportunities forimprovement, and noteworthy practices. Overall, the audit found that the WVDP is properlymaintaining safety systems in working order. However, important actions to preventpotential degradation of conditions and improve the site conduct of operations wereidentified.

Should you have any questions, please contact me at 716-942-4368 or Christopher Eckert ofmy staff at 716-942-4783.

Bryan C. Bower, DirectorWest Valley Demonstration Project

Attachment: Extent of Condition Review on Deferred Maintenance for the West ValleyDemonstration Project report

cc: J. A. Hutton, DOE-HQ, EM-40, FORS, w/att.P. J. Bembia, NYSERDA, AC-NYS, w/att.

CJE:363623-220

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U.S. Department of Energy andCH2M HILL B&W West Valley, LLC

Extent of Condition Review on DeferredMaintenance for the

West Valley Demonstration Project

June 16, 2014

This Page Intentionally Left Blank

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ExtentofConditionReviewonDeferredMaintenancefortheWestValleyDemonstrationProject

REVIEWSUMMARYRecenteventsintheDepartmentofEnergy(DOE)complexhavecausedtheDOEOfficeofEnvironmentalManagement(EM)toinitiatean“EM‐wideExtentofConditionReviewonDeferredMaintenance.”Theemphasisofthereviewcentersaround“whetherthesitehasappliedsufficientresourcestosystemandequipmentmaintenance,maintaininguptodateconfigurationcontrol,andmakingnecessaryupgradestosupportsysteminfrastructure.”TheDOEWestValleyDemonstrationProject(DOE‐WVDP)requestedthatCH2MHill,B&WWestValley,LLC(CHBWV),thecurrentDOEprimecontractorfortheremediationworkattheWVDPsite,performthereviewasan“audit”underNQA‐1toensuresufficientrigorwasemployedinconductingtheassessment.ThisreportdocumentstheresultsoftherequestedreviewfortheWVDP.TheWVDPisanuclearremediationandcleanupsitewithnoongoingproductionmission.Mostofthesite’sfacilitiesarescheduledfordeactivationanddemolition(D&D)overthenextseveralyears.ThescopeofthereviewinvolvespredominantlythefiveHazardCategory3nuclearfacilitiesatWVDP.Theseinclude:

TheMainPlantProcessBuilding(MPPB),thelargestfacilityatWVDP,constructedinthe‘60sforthepurposeofreprocessingspentfuel.Plantoperationswereterminatedin1972.Therearenooperationalproductionorprocessingsystems,andthebuildingisinthefinalstagesofpreparationfordemolition.

TheVitrificationFacility(VF),constructedinthe‘90sforthepurposeofvitrifyingtheHighLevelWaste(HLW)remainingafterfuelreprocessing.Operationsceasedintheearly2000s,andthefacilityisinthefinalstagesofpreparationfordemolition.

TheRemoteHandledWasteFacility(RHWF),constructedintheearly2000sforthepurposesofprocessingremotehandledequipmentremovedfromtheMPPBtheVitrificationFacility.ItisanoperationalfacilityandwillremainsountilTransuranic(TRU)wastecanberemovedfromWVDP.

TheLagStorageArea(LSA),constructedinthe‘80s,itssolepurposeisthestorageofwasteawaitingdisposal.ItwillremainanoperatingfacilityforthepurposedofstoringTRUwasteuntiltheTRUwastecanberemovedfromWVDP.

TheHighLevelWasteTankFarm,fourundergroundtanksformerlyusedforthestorageofHighLevelWaste(HLW)awaitingvitrification.Thetankshavebeenemptiedofthebulkoftheircontents,haveaheelremaining,andarebeingevaluatedtodeterminetheacceptablemeansofpermanentclosure.

TheWVDPhasnoactiveorpassivesystemsorequipmentthataredesignatedassafetyclassorsafetysignificantinthesiteDocumentedSafetyAnalysis(DSA).However,therearesystemsandequipmentthatareimportanttomaintainingsafeoperations.TheWVDPreviewfocusedondefense‐in‐depthequipmentattheWVDPandincluded,butwasnotlimitedtoradiation‐monitoringsystems,ventilationsystems,effluentmonitoringsystems,fireprotectionsystems,andpassiveconfinementbarrierintegrity.

As the vitrification campaign ended and the site transitioned into the D&D phase, the site adopted aphilosophy where maintenance programs were run with limited vigor, and equipment which wasnot considered important to safety was attended to as necessary based on failures (i.e., “run tofailure”). Due to the inefficiencies encountered under the “run to failure” approach, approximatelythree years ago the site management instituted a shift in this philosophy. The following actionshave been completed in the last three years:

• A computerized maintenance management system, referred to as CHAMPS, was procuredand populated with all equipment and components to update the site PreventiveMaintenance (PM) and Corrective Maintenance (CM) process from an antiquated system.This has provided a more reliable notification of PM cycles, as well as a better means oftracking.

• The development of a Maintenance Implementation Plan (MIP) and a Master Equipment List(MEL) that clearly delineate the systems and equipment that are deemed important for safeand efficient operations. The completion of preventive maintenance for MEL listedstructures, systems, and components (SSCs) are tracked as part of the Performance,Objectives, Measures and Commitments (POM&Cs).

• CHBWV formed an Executive Safety Review Board (ESRB), comprised of the contractor’ssenior executive staff, meets regularly and is chartered to provide thorough andcomprehensive review of all site safety programs. The Maintenance Program and the overallreliability of MEL-listed SSCs is one of 16 site safety programs routinely evaluated to assessoverall compliance and health of the program.

As a result of these initiatives, the site is in a much better position regarding the performance ofpreventative and corrective maintenance on all equipment that is important to maintaining safe andeffective operations. Generally, the audit team found that, even though there is a relatively smallworkforce at the WVDP, due to the high level of experience, required maintenance activities(e.g., PM5) were being reliably accomplished on equipment and systems important to safety. Also,in spite of aging equipment that may not be replaced or upgraded since this is a D&D site, safetysystem reliability and availability has remained high, even as D&D progresses.

The audit conducted determined that:

• For the period August 2013 through April 2014 (for available CHAMPS data), 1328 PMs forsystems and equipment either credited in the DSA, vital to safety or environmentalcompliance, or designated mission critical were due. Of these, there were 0% late and 1.5%(20) were waived or deferred. Typical reasons for waived or deferred PMs include lowusage of the equipment, equipment being replaced or new equipment being installed.

• CM, while not being tracked as formally as the PM program, is being adequately performedand has not been allowed to create any situations impacting safety of operations. The auditfound that there are currently only 20 open CM actions, the longest of which has been openfor 13 months. Of these, only one was related to any of the safety systems and equipmentbeing evaluated in this review. It was open for about 2 weeks, and was closed before thecompletion of the report.

• There are no systems or equipment that are safety related that are out of service orotherwise not performing their intended purpose.

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Though a conclusion of the audit team was that the PM/CM program at WVDP is performing toexpectations, the audit team identified corrective actions (CA5) and Opportunities for Improvement(OFI5) that the site will address in the interest of continuous improvement.

While a significant improvement in maintenance programs has been instituted, the fact remainsthat the MPPB and its attendant infrastructure systems that support its availability for safe andefficient performance of the deactivation work are long past their design life, and some systems andequipment are in danger of failure. Most notable among these are the MPPB ventilation system, thesite electrical distribution system, and the MPPB facility structure itself (e.g., leaking roofs).

Faced with the choice of spending millions of dollars to upgrade these systems, management hasmade the decision to invest in maintaining the existing equipment to the extent practical, investinginstead in performing the work needed to prepare the building for demolition, and developing aplan to phase out reliance on these aging systems. For example, the current ventilation system willbe phased out of operation over the next 2 years as a temporary skid-based ventilation will bepermitted and installed to replace the current system. Also, the site is discussing a means toupgrade the reliability of the installed power supply and distribution system with the local utility;however, it will be likely 4 years before this can be fully accomplished. Currently demolition of theMain Plant is scheduled to commence in 2018.

Site management has strived to implement the concept of balanced priorities to maintain facilitiesand equipment in a safe and efficiently operating configuration while minimizing expenditures forupgrades to systems and equipment that have a very limited life remaining. This balance ischallenging, especially considering the recent history of annual funding reductions experienced atthe site, which have seen site budgets dwindle from a peak of over $100M/year in the late 1990’sand early 2000’s to $60M/year currently. In spite of this challenge, the site has been successful andshould continue to be successful in maintaining a safe and efficient operation for the mission to beaccomplished.

Overall, the audit found the WVDP site to be properly maintaining safety systems in workingcondition. However, important actions to prevent potential degradation of conditions and improvethe site conduct of operations were identified. The audit team identified several important areasrequiring improvement and corrective actions. Additionally, the audit team identified OFI(i.e., aspects not critical to deferred maintenance, but changes that could improve site efficiency andeffectiveness), along with recognition of Noteworthy Practices. All are documented in the ensuingreport.

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Table of Contents

Acronyms and Abbreviations 1

Introduction 3

Background 3

Scope and Format of the Review 4

Results and Conclusions 10

Observations and Corrective Actions 12

Opportunities for Improvement 13

Noteworthy Practices 14

Appendix 1. CHBWV-led Audit Team Report A-i

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ACRONYMS AND ABBREVIATIONS

ARP — Alarm Response ProcedureCHBWV - The WVDP management team composed of CH2M Hill, Babcock & Wilcox (B&W), andEnvironmental Chemical Corporation (ECC)CA — Corrective ActionCAM — Continuous Air MonitorCAS — Contractor Assurance SystemCHAMPS — Computer software program used for tracking preventative maintenance (not an trueacronym)CM - Corrective MaintenanceCMMS — Computerized Maintenance Management SystemCPC — Chemical Process CellCSDM — Cognizant System Design ManagerD&D — Deactivation and DemolitionDDMS - Design Document Management SystemDOE - US Department of EnergyDOE-WVDP — US Department of Energy- West Valley Demonstration ProjectDSA — Documented Safety AnalysisEDR — Equipment Decontamination RoomERO — Emergency Response OrganizationESRB — Executive Safety Review BoardFM — Facility ManagerFP — Fire ProtectionGCR — General Purpose Cell Crane RoomHEPA — High-efficiency particulate airHLW — High Level WasteHPI — Human Performance ImprovementlAP — Integrated Assessment ProgramLAG — A temporary storage area (not a true acronym)LCO — Limiting Conditions of OperationLO/TO — Lock Out, Tag Out (also shown as LOTO)LOl — Lines of InquiryLWC - Liquid Waste CellMEL — Master Equipment ListMIP — Maintenance Implementation PlanMPO — Main Plant OperationsMPPB — Main Plant Process BuildingMWR - Minor Work RequestMWV — Management Workplace VisitsNESHAP — National Emissions Standards for Hazardous Air Pollutants

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OFI — Opportunities for ImprovementOITS — Open Items Tracking SystemORPS — DOE Occurrence Reporting and Processing SystemPM — Preventative MaintenancePOD - Plan of the DayPOM&Cs — Performance, Objectives, Measures and CommitmentsPPE — Personnel Protective EquipmentP50 — Plant Systems OperationsP50 Hub — Plant Systems Operations HubPSR — Process Safety RequirementPVS — Permanent Ventilation SystemPVU — Portable Ventilation UnitRHWF — Remote Handled Waste FacilityRVU — Replacement Ventilation UnitSERF — Safety Equipment Release FormsSO — Standing OrderSOP — Standard Operating ProceduresSME — Subject Matter ExpertSSCs — Systems, Structures and ComponentsTM — Temporary ModificationTRU - TransuranicTSR — Technical Safety RequirementsUPS — Uninterruptible Power SystemUR - Utility RoomVF — Vitrification FacilityWIP — Work Instruction PackageWIPP — Waste Isolation Pilot ProjectWVDP — West Valley Demonstration Project

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INTRODUCTION

Recent problems at the Department of Energy (DOE) Waste Isolation Pilot Project (WIPP) in NewMexico, involving the release of radioactive contamination, triggered an investigation thatestablished several causal factors in operation and performance, leading up to the off-normal WIPPevent. One of the more significant factors was the degradation of the safety equipment maintenanceprogram execution, allowing impaired function and subpar modifications to safety systems.

Based on this major element of the WIPP contamination event, the DOE EnvironmentalManagement (EM) Acting Assistant Secretary initiated an EM-wide “Extent of Condition Review onDeferred Maintenance.” DOE EM also provided a list of mandatory factors to be considered in thisExtent of Condition review. The requirement to perform this review for operations and activitiesover the past two-year period was flowed down to the WVDP.

Due to the importance of this review, WVDP chose to perform this review as an “audit” underNQA-1, thereby ensuring sufficient rigor in the assessment. CHBWV Audit Team Leader(Barbara Hill), with a CH2M Hill company subject matter expert (Herb Berman) and a selected teamof key CHBWV site personnel, along with personnel from DOE-WVDP, kicked off the Extent ofCondition review on May 5, 2014. The complete report from the CHBWV-led audit team is attachedto this Extent of Condition review as Appendix 1. The names of personnel participating in thisExtent of Condition review, along with their brief resumes, are provided therein.

BACKGROUND -

The US Department of Energy (DOE) manages the West Valley Demonstration Project (WVDP), a200-acre site approximately 35 miles south of Buffalo, New York. The original site operator(Nuclear Fuel Services), in conjunction with New York State authorization, processed commercialnuclear fuel, and some AEC (now DOE) fuel from 1966 to 1972. Uranium and plutonium wererecovered from this spent fuel, and the processing created about 600,000 gallons of high-levelradioactive waste.

In 1980 Congress passed the WVDP Act, directing DOE to clean up the site via vitrification andcontainerization of the high-level waste, disposal of remaining waste, and finally decontaminationand decommissioning (D&D) of all process equipment and related facilities at the site. The currentDOE prime contractor for this remediation work at the WVDP site is a team composed of CH2M Hill,Babcock & Wilcox (B&W), and Environmental Chemical Corporation (ECC), known collectively asCHBWV.

Today, the WVDP is a nuclear remediation and cleanup site with no ongoing production mission.Most of the site’s facilities are scheduled for deactivation and demolition (D&D) over the nextseveral years. However, facility and personnel safety in the performance of D&D activities is reliantupon maintaining systems and equipment to perform their intended functions. This reviewpresents a summary of observations, corrective actions, and opportunities for improvement withrespect to equipment maintenance, maintaining up to date configuration control, and makingnecessary upgrades to support system infrastructure.

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SCOPE AND FORMAT OF THE REVIEW

The scope of the review involves predominantly the five Hazard Category 3 nuclear facilities atWVDP. These include:

• The Main Plant Process Building (MPPB), the largest facility at WVDP, constructed in the ‘60sfor the purpose of reprocessing spent fuel. Plant operations were terminated in 1972. Thereare no active production or processing systems operational, and the building is in the finalstages of preparation for demolition.

• The Vitrification Facility, constructed in the ‘90s for the purpose of vitrifying the HLWremaining after fuel reprocessing. Operations ceased in the early 2000s, and the facility is inthe final stages of preparation for demolition.

• The Remote Handled Waste Facility (RHWF), constructed in the early 2000s for thepurposes of processing remote handled equipment removed from the Main Plant theVitrification Facility. It is an operational facility and will remain so until TRU waste can beremoved from WVDP.

• The Lag Storage Area (LSA), constructed in the ‘80s, its sole purpose is the storage of wasteawaiting disposal. It will remain an operating facility for the purposed of storing TRU wasteuntil the TRU waste can be removed from WVDP.

• The High Level Waste Tank Farm, 4 underground tanks formerly used for the storage ofHLW awaiting vitrification. The tanks have been emptied of the bulk of their contents, havea heel remaining, and are being evaluated to determine the acceptable means of permanentclosure.

The WVDP has no active or passive systems or equipment that are designated as safety class orsafety significant in the site DSA. However, there are systems and equipment that are important tomaintaining safe operations. The WVDP review focused on defense-in-depth equipment at theWVDP and included, but was not limited to radiation-monitoring systems, ventilation systems,effluent monitoring systems, fire protection systems, and passive confinement barrier integrity.

The audit team developed Lines of Inquiry (LOl) that they felt could be used to cover the completelist of mandatory factors DOE-HQ provided as the review criteria. This resulted in the definition of23 LOIs, encompassing all of the safety systems and equipment at the site and a comprehensivesampling of the policies, procedures and controls used at WVDP to conduct site operations. TheseLOI are listed in Table 1.

All DOE mandatory factors were crosswalked to the WVDP LOI to ensure completeness. For a fewelements, a clear crosswalk did not exist. For example, DOE criteria number 25 (“Number ofsignificant unplanned production level changes”) has little applicability at WVDP. Table 2 presentsa tabular representation of the crosswalk of the DOE mandatory factors for review to the WVDPaudit LOI.

In the April 24, 2014 request from DOE-WVDP for “a formal extent of condition review addressingall of the parameters in the referenced memorandum, including a corrective action plan” wasrequested. The following definitions were used for the deferred maintenance audit:

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Noteworthy/Commendable Practice — activity and practice that demonstrates gains ineffectiveness and/or efficiency in the areas of safety, compliance, quality, cost and/ordeliverables.

Finding/Issue — practice and procedure that is considered to be not in compliance with federalregulations, DOE Orders or other applicable regulatory and policy requirements. IssueReports will be generated per WVDP-357, “WVDP Issues Reporting Program.”

Observation — practice or procedure that is not considered non-compliant with requirements infederal regulations, DOE Orders or other applicable regulatory and policy requirements;however, if no remedial actions are taken could potentially result in a non-conformance.

Opportunity for Improvement — operational improvement suggested by Subject Matter Expertsor audit team members on recognized practices at other DOE sites or commercial companiesthat could be used to assist in continuous improvements.

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Table 1. Areas with Lines of Inquiry Developed by the Review Team

1. WVDP Corrective Maintenance relative to TSRs and LCOs2. Alarm Status and Configuration Control3. Tracking and trending preventive and predictive maintenance (PM) on equipment as well as

maintenance repairs4. Inoperable or Impaired Safety Systems/Configuration Control (PSO/FP)5. HEPA Filtered Ventilation System PMs (portable and vacuums] and Availability6. Audit of Maintenance Lock Out Tag Out (LO/TO)7. Configuration Management-Temporary Modifications8. Spurious Safety System Actuation and Spare Parts Availability9. Configuration Control of Structures10. Emergency Management Open Items/Action Items11. Conduct of Operations Self-Assessments12. Audit of Conduct of Operations Standing Orders13. Temporary Procedure Changes14. Human Performance Errors15. Radiological Control Instrument Availability16. Fire Protection System Availability17. Power/Backup power Availability18. Safety System Performance (Successful or Not) When Tested19. Procedure Non-Compliance Events20. Abnormal procedure entries/emergency procedure entries/unplanned process

shutdowns/unplanned automatic process shutdowns, and spurious safety system actuations21. Grievances/personal contamination events22. Personal chemical exposure events23. Management Observation System Data

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Table 2. Crosswalk to display that all Mandatory Factors requiring review were covered inone or more of the LOIs developed by the review team.

DOE Mandatory WVDP Audited ElementsReview Factors (Audit Title)

Number of unplanned TSR LCO 1. WVDP Corrective Maintenance relative to TSRs andentries LCOs

2. Number of inoperable control 2. Alarm Status and Configuration Controlroom indicators and controls 5. HEPA Filtered Ventilation System PMs (portable and

vacuums) and availability6. Audit of Maintenance Lock Out Tag Out (LO/TO)

3. Number of lit/alarming control 2. Alarm Status and Configuration Controlroom annunciators

4. Corrective maintenance 3. Tracking and trending preventive and predictivebacklog, age, and trend maintenance (PM) on Category 2 and Category 3

equipment, as well as maintenance repairs10. Emergency Management Open Items/Action Items

5. Preventative maintenance 3. Tracking and trending preventive and predictivebacklog, and in grace period, maintenance (PM) on Category 2 and Category 3and trend equipment, as well as maintenance repairs

6. Surveillances performed in 3. Tracking and trending preventive and predictivegrace period and trend maintenance (PM) on Category 2 and Category 3

. equipment, as well as maintenance repairs -

11. Conduct of Operations Self-Assessments7. Safety system availability 4. Inoperable or Impaired Safety

Systems/Configuration Control (PSO/FP)5. HEPA Filtered Ventilation System PMs (portable and

vacuums) and Availability9. Configuration Control of Structures15. Radiological Control Instrument Availability16. Fire Protection System Availability17. Power/Backup power Availability

8. Number of safety system 8. Spurious Safety System Actuation and Spare Partschallenges (number of times a Availabilitysafety system has been 12. Conduct of Operations Standing Ordersdemanded to respond or be 15. Radiological Control Instrument Availabilitymanually initiated) 16. Fire Protection System Availability

17. Power/Backup power Availability9. Number of unplanned safety 20. Abnormal procedure entries/emergency procedure

system actuations entries/unplanned process shutdowns/unplannedautomatic process shutdowns, and spurious safetysystem_actuations

10. Corrective action process 3. Tracking and trending preventive and predictive( issues management system) maintenance (PM) on Category 2 and Category 3items initiated and trend equipment, as well as maintenance repairs

10. Emergency Management Open Items/Action Items11. Conduct of Operations Self-Assessments

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11. Average age of open corrective 10. Emergency Management Open Items/Action Itemsaction process items (both open 11. Conduct of Operations Self-Assessmentsissues and open correctiveactions)

12. Number of corrective action 10. Emergency Management Open Items/Action Itemsprocess items overdue 11. Conduct of Operations Self-Assessments

13. Number and rate of human 14. Human Performance Errorsperformance_errors

14. Number of abnormal procedure 8. Spurious Safety System Activationentries 14. Conduct of Operations Standing Orders

20. Abnormal procedure entries/emergency procedureentries/unplanned_process

15. Number of emergency 20. Abnormal procedure entries/emergency procedureprocedure entries entries/unplanned process shutdowns/unplanned

automatic process shutdowns, and spurious safetysystem actuations

16. Number of unplanned process 20. Abnormal procedure entries/emergency procedureshutdowns entries/unplanned process shutdowns/unplanned


17. Number of unplanned 20. Abnormal procedure entries/emergenèy procedureautomatic process shutdowns entries/unplanned process shutdowns/unplanned


18. Number of procedure non- 19. Procedure Non-Compliance Eventscompliance_events

19. Number and age of LO/TO 6. Audit of Maintenance Lock Out Tag Out (LO/TO)hanging

20. Number and age of temporary 7. Configuration Management-Temporarymodifications Modifications

13. Temporary Procedure Changes21. Number and age of inoperable 4. Inoperable or Impaired Safety Systems /

safety systems Configuration Control (PSO/FP)22. Safety system performance 5. HEPA Filtered Ventilation System PMs (portable and

(successful or not) when tested vacuums) and Availability9. Configuration Control of Structures10. Emergency Management Open Items/Action Items15. Radiological Control Instrument Availability16. Fire Protection System Availability17. Power/Backup power Availability18. Safety System Performance (successful or not) when

tested

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23. Safety system performance 15. Radiological Control Instrument Availability(successful or not) in response 16. Fire Protection System Availabilityto actual demand 17. Power/Backup power Availability

18. Safety System Performance (successful or not) whentested

24. Number of spurious safety 8. Spurious Safety System Actuation and Spare Partssystem actuations Availability

15. Radiological Control Instrument Availability16. Fire Protection System Availability17. Power/Backup power Availability

25. Number of significant Not applicable; No production facilitiesunplanned production levelchanges

26. Number of temporary 13. Temporary Procedure Changesprocedure_changes

27. Number of grievances 21. Grievances/personal contamination events

28. Management observation 23. Management Observation System Datasystem data:• Number of observations by

• senior managers• Number of management

observations that identi1~,deficiencies and result incorrective_action

29. Number of personal 21. Grievances/personal contamination eventscontamination_events

30. Number of personal chemical 22. Personal chemical exposure eventsexposure events

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RESULTS AND CONCLUSIONS

Appendix 1 presents the data and analysis from the CHBWV-led audit in its entirety. The followingis an assessment of the findings from the audit

As the vitrification campaign ended and the site transitioned into the D&D phase, the site adopted aphilosophy where maintenance programs were run with limited vigor, and equipment which wasnot considered important to safety was attended to as necessary based on failures (i.e., run tofailure). Due to the inefficiencies encountered under the “run to failure” approach, approximatelythree years ago the site management instituted a shift in this philosophy. The following actionshave been completed in the last three years:

• A computerized maintenance management system, referred to as CHAMPS, was procuredand populated with all equipment and components to move the site PM/CM process from anantiquated system. This has provided a more reliable notification of PM cycles, as well as abetter means of tracking.

• The development of a Maintenance Implementation Plan (MIP) and a Master Equipment List(MEL) that clearly delineate the systems and equipment that are deemed important to safeand efficient operations. The completion of preventive maintenance for MEL listed systems,structures and components (SSCs) are tracked as part of the Performance, Objectives,Measures and Commitments (POM&Cs).

• An Executive Safety Review Board (ESRB), comprised of the contractor’s senior executivestaff, meets monthly, at a minimum, and is charted to provide thorough and comprehensivereview of all site safety programs. Maintenance Programs and the overall reliability of MELlisted SSCs is one of 16 site safety programs routinely evaluated to assess overall complianceand health of the program.

As a result of these initiatives, the site is in a much better position regarding the performance ofpreventative and corrective maintenance on all equipment that is important to maintaining safe andeffective operations. Generally, the audit team found that even though there is a relatively smallworkforce at the WVDP, due to the high level of experience, required maintenance activities [e.g.,preventative maintenance (PMs)] were being reliably accomplished on equipment and systemsimportant to safety. Also, in spite of aging equipment that may not be replaced or upgraded sincethis is a deactivation and demolition (D&D) site, safety system reliability and availability hasremained high, even as D&D progresses. The audit conducted determined that:

• For the period August 2013 through April 2014 (for available CHAMPS data), 1328 PMs forsystems and equipment either credited in the DSA, vital to safety or environmentalcompliance, or designated mission critical were due. Of these, there were 0% late and 1.5%(20) were waived or deferred. Typical reasons for waived or deferred PMs include lowusage of the equipment, equipment being replaced or new equipment being installed.

• Corrective Maintenance, while not being tracked as formally as the PM program, is beingadequately performed and has not been allowed to create any situations impacting safety ofoperations. The audit found that there are currently only 20 open CM actions, the longest ofwhich has been open for 13 months. Of these, only one was related to any of the safetysystems and equipment being evaluated in this review. It was open for about 2 weeks, andwas closed before the completion of the report.

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• There are no safety related systems or equipment that are out of service or otherwise notperforming their intended purpose.

While a significant improvement in maintenance programs has been instituted, the fact remainsthat the Main Plant and its attendant infrastructure systems that support its availability for safe andefficient performance of the deactivation work are long past their design life, and some systems andequipment are in danger of failure. Most notable among these are the Main Plant ventilationsystem, the site electrical distribution system, and the Main Plant facility structure itself(e.g., leaking roofs).

Faced with the choice of spending millions of dollars to upgrade these systems, management hasmade the decision to invest in maintaining the existing equipment to the extent possible, investinginstead in performing the work needed to prepare the building for demolition, and developing aplan to phase out reliance on these aging systems. For example, the current ventilation system willbe phased out of operation over the next 2 years as a temporary skid-based ventilation will bepermitted and installed to replace the current system. Also, the site is discussing a means toupgrade the reliability of the installed power supply and distribution system with the local utility;however, it will be likely 4 years before this can be fully accomplished. Currently demolition of theMain Plant is scheduled to commence in 2018.

Site management has strived to implement the concept of balanced priorities to maintainingfacilities and equipment in a safe and efficiently operating configuration and status whileminimizing expenditures for upgrades and improvements to systems and equipment that have avery limited life remaining. This balance is challenging, especially considering the recent history ofannual funding reductions experienced at the site, which have seen site budgets dwindle from apeak of over $100M/year in the late 1990’s and early 2000’s to $60M /year currently. In spite ofthis challenge, the site has been successful and should continue to be successful in maintaining asafe and efficient operation for the mission to be accomplished.

Since the review was conducted as a formal audit under governing site procedures, the reviewcaptured any and all conditions that appeared deficient or noteworthy in some manner. Asrequired, these were binned as observations (thus requiring corrective action), opportunities forimprovement, or noteworthy practices. (It is noted that no issue from the review was raised to thelevel of finding or concern.) Some common themes include:

• There is a need to reduce error prone situations that hinder human performance [e.g.,minimize nuisance alarms, use of high-efficiency particulate air (HEPA) status boards, etc.]

• There is an opportunity to upgrade some tracking systems to provide better access to dataand to generate effective performance indicators (e.g., deferred or waived maintenancegraphs) for informed management decisions.

• The reliance on expert-based performance, as opposed to process-based performance.There were several areas noted throughout the report where reliance on SMEs as amitigation of potential issues is discussed. Improved employee awareness of their roles andresponsibilities will become more important as experienced employees with WVDPhistorical knowledge retire.

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Overall, the review found the WVDP site to be properly maintaining safety systems in workingcondition. However, actions to prevent potential degradation of conditions and improve the siteconduct of operations were identified. The audit team identified several important areas requiringimprovement and corrective actions. Additionally, many Opportunities for Improvement (OFI)were found during the audits (i.e., aspects not critical to deferred maintenance, but changes thatcould improve site efficiency and effectiveness), along with recognition of Noteworthy Practices. Allsuch conclusions are listed below.

OBSERVATIONS AND CORRECTIVE ACTIONS

OBSERVATION: Many instances of nuisance alarms were found to exist throughout the plant site,potentially distracting operators in determining the need for and scope of response actions.

[CA-i] Systematically identify all nuisance alarms, and set up a prioritized corrective actionprogram to eliminate or minimize these alarms (e.g., termination of contacts, reprogramming,changes to operating procedures, etc.).

[CA-2] A new system replacement for the Keltron alarm system has been authorized and is beingprocessed for procurement. However, due to the Keltron alarm system age, unreliable behavior,potential for creating error prone situations, and difficulty of repair, this replacement procurementneeds to be given priority.

OBSERVATION: It was discovered that there are two systems in use for tracking Safety EquipmentRelease Form (SERF) information and that these did not agree at the time of the audit.

[CA-3] Eliminate dual tracking of Safety Equipment Release Forms (SERFs) by ceasing the practiceof tracking SERFs on turnover sheets and refer turnover status to the SERF log, which is readilyavailable online.

OBSERVATION: There does not exist a coherent and complete process is in place with clearlydelineated roles and responsibilities, including logbook requirements and responsibilities andmaintaining current status related to the use and control of PVUs and HEPA vacuums.

[CA-4] Revise Standard Operating Procedure SOP-15-28 and SOP-15-48, governing PortableVentilation Units (PVU5) and High Efficiency Particulate Air (HEPA) filtered vacuums. Ensure thereis a tie in to a status board (or equivalent) for HEPA vacuums.

OBSERVATION: There is a missing communication link that needs to be established to ensurePlant Shift Office (PSO) is kept aware of the Temporary Modification status in RHWF to ensure aninformed response during the off-shift.

[CA-5] Review SOPs and other instructions for TMs to ensure all roles and responsibilities are inplace and the system for ensuring the Plant Shift Operations (PSO) is made aware of all TMs is fullyfunctional.

OBSERVATION: On two occasions it has been discovered that an Alarm Response Procedure (ARP)was not updated to reflect a design change from an Engineering Change Notice (ECN). While onewas from a recent design change (and a CA was issued at that time), another since found was from alegacy ECN prepared several years ago that for which the ARP was not updated.

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[CA-61 Conduct a review of ECNs and ARPs to determine whether more legacy ECNs did not resultin a ARP update.

OPPORTUNITIES FOR IMPROVEMENT

[OFI-1] Set up the CHAMPS system to be able to extract the deferred and waived PM data fromCHAMPS and present that as a quarterly performance indicator for management. Implementationof this revision is underway.

[OFI-2] Trend all outstanding corrective/repair maintenance items from CHAMPS data or anequivalent stand-alone system, so that the entire scope of repair work to be done is visible andretrievable in a listing for operations and management review, prioritization and/or cancellation.

[OFI-3] Evaluate the need for implementation of a process to conduct formal periodic review of theMEL for completeness and accuracy and to ensure that information can be readily extracted.

[OFI-4] Although there is a project in the works for a replacement ventilation unit (RVU), it wouldbe prudent to form a team to evaluate and pre-engineer work-around solutions if the immediateneed to replace HEPAs in the contaminated plenums of non-redundant systems arises before theRVU is constructed and brought on line to minimize time lost on the WVDP D&D mission.

[OFI-S] The trouble call SOP-O0-56 could be enhanced by requiring documentation of thecircumstances leading to the application of a caution tag.

[OFI-6] While there has been only one minor TM having a safety related function (lower pressure infire pump until hydrant was fixed), having multiple “temporary” modifications over 9-months old,even with approvals as presently required, would indicate that more upper management attention,including priority and scope discussions, is warranted. Dissemination of the PSO Turnover sheet,with its status of temporary modifications, to appropriate personnel (e.g., Chief Engineer, FM, CSE,etc.) could give better visibility to these extended temporary modifications.

[OFI-7] Evaluate the current practice for control of safety system spare parts. Validate spare partsfor safety systems are maintained in controlled storage to ensure off-shift availability.

[OFI-8] The core boring procedure, and any other similar procedures, need to be reviewed todetermine whether there is a need to revise the language to ensure that the same level of reviewsare provided as is presently given to structural ECNs or TMs.

[OFI-9] Due to the age of the site telecommunications infrastructure and evolving conditionsassociated with facility decommissioning, an evaluation of the site’s communications systemsshould be conducted and necessary improvements made.

[OFI-lO] Evaluate modifying SOP 00-52, “Conduct of Operations” and/or other appropriate siteprocedures to establish a program for any new SOs to be issued with an expiration date, to takeactions to either close them or convert them to proper procedures/policy or get frequentmanagement attention to ensure a 60-day closure. Ensure any SO instructions contain roles andresponsibilities and a coherent system for creation and closure.

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[OFI-il] While overall the temporary procedure change process appears to be working asdesigned, it would be an improvement to modify Engineering Procedure EP-5-002 to requireidentification of steps in WIPs that supersede existing SOPs and are not part of an official TM.

[OFI-12] Set up training to ensure understanding of specific cause codes to be used with FactFindings, Issue and Occurrence Reports. This will assist in looking for HPI patterns and collectivesignificance which will then be added to cause code metrics, to help continuously improveoperations and reduce errors.

[OFI-13] Set up a planning document to delineate any needed plant recapitalization (e.g., replacecritical electrical distribution panels and switchgear, replace leaking fire water and gas lines, etc.].Given the expected timeline for full site D&D, the plan should prioritize needed infrastructureimprovements.

[OFI-14] In areas where it is feasible, set up a systematic process to routinely monitor and recordequipment run-times, and create a linkage to the CHAMPS system to trigger PMs based on specifiedrun-time criteria.

[OFI-15] Continue to track and trend procedure non-compliances, and review for commonelements, repeated errors, and collective significance. Based on the data, set up a program toeliminate or minimize repeat errors (training, Lessons Learned, etc.], and to identify weakperformance areas.

[OFI-16] While there are efforts underway to replace some aging system components, a programneeds to be established to cross-train for succession planning.

[OFI-17] Extracting data regarding abnormal and spurious events from the PSO logbooks was bothtedious and time consuming. A method could be established to highlight such off-normal events,and ultimately collect them in a manner that can be used to look for trends and patterns.

[OFI-18] Although Integrated Assessment Program results are available to all on the Intranet,quarterly summary or trend information could help identify key areas for improvement. Trendingand grouping the negative attribute or problem areas from MWVs and MAs would result in usefuldata about areas needing improvement, or collective significance for further emphasis or training.

NOTEWORTHY PRACTICES

[NP-i] The Maintenance Implementation Plan (MIP) should be commended as being a well-organized, comprehensive document with clear roles and responsibilities.

[NP-2] The PSO shift Turnover sheet reflects the status of site ventilation equipment, restrictedaccess areas, and maintenance items.

[NP-3] Recently all of the site’s electricians received breaker training from a Siemans Allistechnician, allowing for more efficient and comprehensive breaker repairs and troubleshooting

[NP-4] The site continues to perform quarterly power outages to test the operability of the backuppower system. In addition these outages are used to perform preventative maintenance that isdifficult to integrate with the on-going project work.

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[NP-S] Electrical PMs were consolidated to be more efficient by establishing a PM cycle on a two-year basis to reduce or eliminate duplicative PMs.

[NP-6] PMs on low run-time equipment are being deferred or waived, with the goal of setting upthe PM job cards to change from yearly activities to hours of run time and thereby increaseefficiency and reduce costs.

[NP-7] Thermal imaging has been used as an effective indicator of electrical system health.

[NP-8] Continuing and effective PM actions have contributed to the unusual long life of the site’saging electrical infrastructure.

[NP-9] When an actual emergency or abnormal situation occurs at the WVDP that requiresresponse from the Emergency Response Organization (ERO), Emergency Management uses andtreats the event as an exercise. As would be the case for planned drills, Emergency Managementevaluates and critiques the responses to the actual situation. These real emergencies aredocumented, opportunities for improvement are identified, and corrections are made to improvethe ERO. Examples of these types of emergencies include medical emergencies where off-siteassistance is requested, radiation alarms, and power outages.

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Appendix 1

CHBWV-led Audit Team Report

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Appendix 1Table of Contents

Audit Scope and Methodology A-3

II. Summary Overview and Audit Results A-41. Audit of WVDP Corrective Maintenance relative to TSRs and LCOs A-62. Audit of Alarm Status and Configuration Control A-73. Audit of tracking and trending preventive and predictive maintenance (PM] on

Category 2 and Category 3 equipment, as well as maintenance repairs A-84. Audit of Inoperable or Impaired Safety Systems/Configuration Control (PSO/FP) A-b5. Audit of HEPA Filtered Ventilation System PMs (portable and vacuums) and Availability A-il6. Audit of Maintenance Lock Out Tag Out (LO/TO) A-i27. Audit of WVDP Temporary Modifications A-138. Audit of Spurious Safety System Actuation and Spare Parts Availability A-i49. Audit of Configuration Control of Structures A-iS10. Audit of Emergency Management Open Items/Action Items A-iS11. Audit of Conduct of Operations Self-Assessments A-1612. Audit of Conduct of Operations Standing Orders A-1613. Audit of Temporary Procedure Changes A-i714. Human Performance A-i715. Audit of Radiological Control Instrument Availability A-iS16. Audit of Fire Protection System Availability A-i817. Audit of Power/Backup power Availability A-1918. Safety Systeni Performance (Successful or Not) When Tested A-20i9. Audit of Procedure Non-Compliance A-2020. Audit of abnormal procedure entries/emergency procedure entries/unplanned process

shutdowns/unplanned automatic process shutdowns, and spurious safety systemactuations A-2i

2i. Audit of grievances, and personal radiological contamination events over the pasttwo years A-23

22. Audit of personal chemical exposure events over the past two years A-2423. Audit of the Management Observation System Data A-24

Ill. Crosswalk of Audit Coverage versus DOE Required Audit Elements A-27

IV. Consolidated Listing of Corrective Actions, Opportunities for Improvement andNoteworthy Practices A-3i

V. Summary and Conclusions A-34

Attachment A: Consolidated Resumes

Attachment B: References Reviewed

Attachment C: Personnel Interviewed

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Audit Scope and Methodology

Due to the importance of this review, WVDP chose to perform this review as an “audit”under NQA-1, thereby ensuring sufficient rigor in the assessment CHBWV Audit TeamLeader (Barbara Hill), with a CH2M Hill company subject matter expert (Herb Berman) and aselected team of key CHBWV site personnel, along with personnel from WVDP DOE, kickedoff the Extent of Condition review on May 5,2014. The names of personnel participating inthis Extent of Condition review, along with their brief resumes, are shown in Attachment Ato this report.

Mapping DOE Factors to WVDP Activities and Operations

The WVDP is a nuclear remediation and cleanup site with no ongoing production mission.Many of the site’s facilities are scheduled for deactivation and demolition as part of thecurrent work scope. As such, many of the mandatory factors to be evaluated in this revieware not directly applicable to WVDP activities. Each of the DOE review elements werediscussed, relative to their meaning and applicability at WVDP in connection with defense-in-depth equipment at the WVDP and included: radiation-monitoring systems, ventilationsystems, effluent monitoring systems, fire protection systems, and passive confinementbarrier integrity.

The audit team developed Lines of Inquiry (LOI) that they felt could be used to cover thecomplete list of mandatory factors being requested by DOE-HQ. This resulted ifi thedefinition of 23 LOIs, encompassing all of the safety systems and equipment and acomprehensive sampling of the policies, procedures and controls used at WVDP to conductsite operations. The Audit Team considered how work was arranged at the WVDP, the30 mandatory factors to be considered and the focus on the defense in depth equipmentincluding the radiation monitoring systems, the passive confinement barrier integrity,ventilation systems, effluent monitoring systems and fire protection systems. Because therewere some areas where team members could review several DOE factors while observingand interviewing within a single facility or group of individuals, 23 audit areas wereidentified that would cover the targeted WVDP systems as well as the 30 mandatory factors.These LOI are listed in Table 1.

All DOE review elements were crosswalked to the WVDP LOI for this audit For a fewelements, a clear crosswalk did not exist. For example, number 25 above (“Number ofsignificant unplanned production level changes”) has little applicability at WVDP. Table 2presents a tabular representation of the crosswalk of the DOE mandatory factors for reviewto the WVDP audit LOl.

Extensive data gathering operations were conducted to support the analysis presented andthe conclusions drawn by this audit. While there are many WVDP computerized databasescontaining performance data [e.g., the Open Item Tracking System (OITS)), because of theD&D nature of the activities, some information required now resides in only in official shiftlogbook entries. Manual searches of data in logbooks were conducted to obtain thisinformation.

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Compiling Issues, Recommendations, Opportunities for Improvement, Conclusionsand Corrective Actions

Audit Team members were often able to extract and determine several DOE factors whileresearching a single information source. Similarly, interviews with cognizant WVDPpersonnel and procedure/report reviews also allowed multiple topics to be reviewedconcurrently. Table 2 of this report provides a crosswalk table between the DOE mandatoryelements and the WVDP audit coverage approach. As displayed on the Section III crosswalk,in many instances aspects of several DOE factors were touched upon by in a single WVDPaudit topic.

Individual auditor detailed audit notes, results, recommendations, and conclusions werecompiled and evaluated against the mandatory factors. Pertinent information on issues tobe resolved (observations), opportunities for improvement (OFI), and Noteworthy Practiceswere extracted and summarized. Finally, after factual accuracy checks and Teamdiscussions, recommended Corrective Action (CA) approaches were formulated, andidentified by bracketed symbols, where [CA-it] identifies a Corrective Action for an identifiedissue, [OH-it] identifies an Opportunity for Improvement and [NP-it] identifies aNoteworthy Practice. All these are extracted and compiled under report Section IV. A listingof the reviewed documents and references (by audit topical areas) is contained inAttachment B, and a listing of all personnel interviewed by audit topical areas is contained inAttachment C.

II. Summary Overview and Audit Results

The audits for the Extent of Condition review on deferred maintenance, including themandatory DOE factors, were accomplished for the WVDP site operations, and will bedetailed in this section.

Generally, the audit team found that, even though there is a relatively small workforce at theWVDP, due to the high level of experience, required maintenance activities [e.g., preventativemaintenance (PMs)] were being reliably accomplished. Also, in spite of aging equipment thatmay not be replaced or upgraded since this is a D&D site, safety system reliability andavailability has remained high, even as D&D progresses. Nevertheless, several importantareas requiring corrective actions were identified including:

• There is a need to reduce error prone situations that hinder human performance[e.g., minimize nuisance alarms, use of high-efficiency particulate air (HEPA) Statusboards, etc.].

• There is an opportunity to upgrade some tracking systems to provide better access todata and to generate effective performance indicators (e.g., deferred or waivedmaintenance graphs) for informed management decisions.

• The reliance on expert-based performance, as opposed to process-basedperformance. There were several areas noted throughout the report where relianceon SMEs as a mitigation of potential issues is discussed. Improved employeeawareness of their roles and responsibilities will become more important asexperienced employees with WVDP historical knowledge retire.

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Additionally, many Opportunities for Improvement (OFI) were found during the audit(i.e., aspects not critical to deferred maintenance, but changes that could improve siteefficiency and effectiveness), along with recognition of Noteworthy Practices (e.g., rate offrequency for performing PMs being based on run-time versus calendar).

The following sub-sections will go into detail on all the audits accomplished, and willindividually indicate which portions of the DOE mandatory factors are touched upon by theaudit results being discussed. Recommended corrective actions will also be part of each subsection, but all these will be extracted and summarized in Section IV, for ease of access andgeneration of corrective action plans.

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Individual Audit Details, Issues, OFIs, Noteworthy Practices, and Recommended Actions

Audit of WVDP Corrective Maintenance relative to TSRs and LCOs. This covers the DOEfactor #1. The audit of this area determined:

a. Technical Safety Requirements (TSRs) applicable to activities at the WVDP arepredominantly administrative programs and specific administrative controls (SACs).These are all related to the design basis accident involving an incident leading to therelease of nuclear material from TRU waste packages in storage. Therefore, designfeatures (e.g., allowing only use of approved containers for TRU waste packaging) arecredited in the DSA. Process Safety Requirements (PSR5) with surveillancerequirements and LCOs exist for worker risk reduction related to criticality governingactivities involving the packaging of certain types of materials during D&D andpossess large quantities of fissile materials.

b. There are no safety class or safety significant systems, structures, or equipment at theWVD P.

c. There have been no TSR or PSR violations or LCO entries in the last two years.

No CAs or OFIs were identified in this area.

2. Audit of Alarm Status and Configuration Control. This covers the DOE factors #2 and #3.

Alarms are used in the Main Plant to indicate abnormal conditions in plant ventilationsystems, facility vessels and cell sumps. Alarms are also used to indicate abnormaloperations in the Waste Tank Farm, Supernatant Treatment System/Permanent VentilationSystem (STS/PVS), and RHWF. These audible alarms are monitored remotely at PSO Hub(Control Room) and Utility Room (UR). Since the PSO Hub and the UR are not continuouslymanned areas, an additional audible alarm is provided in the main security guard house,which is a continuously manned area. Upon receipt of a Control Room alarm, a securityinspector notifies the PSO Supervisor of the alarm condition.

Detection (smoke and heat) and water flow alarms annunciate at the (Keltron) AlarmMonitoring Station located in the main security gate house. The Keltron Alarm ReceivingSystem consists of a network of components interconnected by telephone and wiring tovarious facilities throughout the site. This system is capable of monitoring various processesand operating parameters such as fire alarms, sprinkler system activation, sump alarms,ventilation alarms and stack alarms.

In addition to fire alarms, the Alarm Monitoring Station also is capable of monitoring variousprocess parameters (e.g., low building temperature, air supervision on dry pipe systems, andvalve supervision).

The audits of this area determined:

a. Past modifications account for a number of alarms, where modifications occurred inthe field but the corresponding changes were not made in the alarm system or insome cases the procedure. Three (3) CAM alarms at the PSO Hub have been “in

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alarm” for over 30 days. Even though not a direct safety issue (e.g., localannunciation) due to correct operation in the field locations and CAM redundancy,the fact that the alarms are continuous creates the possibility for desensitizing PSOpersonnel.

b. There are multiple nuisance, incorrect, or overcome by events alarms (e.g., no longerin service, or equipment modified or removed). Examples include:i. Multiple nuisance alarms in the P50 Hub monitors

ii. Keltron alarms “Trouble signal” from a panel that does not exist, and Hot Cellalarm from a disconnected/inactivated unit

iii. MPO sprinkler valve tamper alarm from removed sprinklersiv. MPO Fire Trouble (March 9, 2014) from removed sprinklers. The panel is

scheduled for removal in the summer of 2014.

c. There are multiple values circled on round sheets as being outside of normal,including:i. GCR Sumpii. CPC North Sump

iii. PVS North Train humidityiv. North Vitrification Cell (from plugged probes)

These out of specification areas are all on non-critical systems and the cause of the outside ofnormal readings is known and corrective actions are in process. The GCR Sump, CPC NorthSump and the Vitrification Sump are monitored each shift to maintain compliance with RCRAregulations and to monitor for water infiltration into these areas. The waste water system inthe Main Plant Process Building (MPPB) is no longer available due to ongoing deactivationactivities. However, the sumps still collect water (via rain water or ground waterpenetration); if water is present to a degree necessary to require action a work documentwill be prepared to pump the water from the sump.

The GCR Sump and North Vitrification Cell are still in service and have been identified ashaving plugged probes. Work documents are currently being developed to address this issue.

The CPC North Sump is currently out of range due to a roof leak in the MPPB that leaks intothe CPC door slot. A work document is currently being developed to seal the roof leak.

The PVS North Train humidity instrument has failed and a replacement part is on order.Until repairs are complete continuous monitoring of HEPA filter differential pressureensures excessive moisture is not an issue. Additionally the in train heater can be operatedmanually to correct this condition.

d. Many of the false alarms are from past modifications that have not been incorporatedinto the alarm procedure, drawing or system logic (e.g., a power alarm fromconfiguration changes for a rollup door.

e. Operators need to “compensate” for nuisance alarms from routine operations such asDay Tank filling, high level on diesel generator tank (e.g., if a fuel tank is overfilled, itwill stay in alarm until the diesel generator is used).

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E Off-Gas Trench sump alarm — trench units are air gapped (i.e., cut at ends since asthey are determine to contain only rainwater and to be safe as is), so operatorresponse is delayed until it is convenient to pump the water out.

g. Actual recent event where a Keltron 30 alarm was initially disregarded on the off-shift due to the assumption that it was a nuisance PVS heat trace fire panel alarm. Inactuality, the PVS and consequently the tank and vault drying systems had shut-downdue to a faulty power supply component. Power restored before any spread ofcontamination from the tank.

The number of nuisance alarms noted above create error prone situations and increase thelikelihood of missing important alarms, or not reacting in a timely manner. In effect, the highincidence of nuisance alarms may “train” operators to ignore alarms or give low priority tosome alarms.

OBSERVATION: Many instances of nuisance alarms were found to exist throughout theplant site, potentially distracting operators in determining the need for and scope ofresponse actions.

[CA-i] Systematically identify all nuisance alarms, and set up a prioritized corrective actionprogram to eliminate or minimize these alarms (e.g., termination of contacts,reprogramming, changes to operating procedures, etc.).

[CA-2] A new system replacement for the Keltron alarm system has been authorized and isbeing processed for procurement. However, due to the Keltron alarm system age, unreliablebehavior, potential for creating error prone situations, and difficulty of repair, systemupgrade needs to be given a top priority.

3. Audit of tracking and trending preventive and predictive maintenance (PM) onCategory 2 and Category 3 equipment, as well as maintenance repairs. This auditcovers DOE factors #4, #5, #6 and #10.

The computerized maintenance management system (CMMS) at WVDP is a commercialsystem called CHAMPS. The CHAMPS system is used to generate PM cards and track PMstatus. Equipment entered into the CHAMPS system for tracking of PMs is grouped as eitherCategory 2, defined as safety related or otherwise mission critical equipment and Category3, which is all non-essential equipment. It should be noted that there is no equipment inCategory 1, which is reserved for safety class or safety significant equipment. Also, a formerCategory 4 (run to failure) has been discontinued at WVDP, as an undesirable practice. A listof all PM jobs due for each work group is generated from CHAMPS and distributed by thefirst of each month.

a. For the period August 2013 through April 2014 (for available CHAMPS data), 1328Category 2 and 2316 Category 3 (total 3644) PMs were due.

b. Of the Category 2 PMs, there were 0% late and 1.5% (20) were waived or deferred. Ofthe Category 3, there were 4.7% late (111) and 7.3% waived or deferred. Overall a>95% performance.

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c. To waive or defer a PM there are specific controls and approvals required(i.e., supervisor, facility manager, and cognizant engineer, plus Quality and Safety forCategory 2 items). Typical reasons for waived or deferred PMs include low usage ofthe equipment equipment being replaced or new equipment being installed.

d. Trending of waived or deferred items has been embedded with all the data for PMperformance as determined by a random sampling. Since the data for waived anddeferred PMs is available and extractable from CHAMPS, it is recommended to usethis information to provide reports to management.

e. The Master Equipment List (MEL) reflects the priority level assigned to plantequipment and instrumentation and is embedded in the Category 2 listings. However,as presently configured, it was not readily extractable as a separate listing during theaudit. With significant effort and delay, it was finally provided to the team near theend of the audit

f. While it appeared from the evidence provided that a thorough and comprehensiveeffort was conducted to initially populate the MEL, there is no requirement thatrevalidation of the MEL be routinely performed and documented to ensure allpertinent equipment [described as safety-related by the Documented Safety Analysis(DSA), Radiation Protection program or Regulatory Affairs] is entered in CHAMPS andpreventative and predictive maintenance is being performed.

g. Mechanical and Electrical corrective maintenance is tracked in CHAMPS, but the workinstructions are physically developed outside of CHAMPS through Work InstructionPackages (WIPs) or Minor Work Requests (MWRs) that are issued in orange foldersto the cognizant supervisor for action. The audit found that there are currently only20 open CM actions, the longest of which has been open for 13 months. Of these, onlyone was related to any of the safety systems and equipment being evaluated in thisreview. It was open for about 2 weeks, and was closed before the completion of thereport.

h. All corrective work is authorized via the Plan of the Day, with some completed as “fillin” work and other more critical CM work given priority as necessary. This manualhandling of corrective or repair work adds a level of difficulty to defining andprioritizing site-wide needs and canceling long-term items that have been overcomeby events. While the Category 2, safety related corrective maintenance appears to betaken care of in a timely manner, actively utilizing a listing of all actions needingcorrective maintenance will increase efficiency.

While the overall PM performance is good, the reason for deferred or waived PMsneeds to be tracked and trended, and given management visibility. PMs that arewaived or deferred multiple times in a row should be given high visibility to avoiddecreasing the desired frequency of the PMs for such situations. Mechanisms to trenddata are well developed at CHEWy with Contractor Assurance reports (CAS) beingused for safety, environmental, quality and other areas monthly. The PM charts couldbe added to this report or distributed separately.

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j. There are no systems or equipment that are safety related that are out of service orotherwise not performing their intended purpose.

[OFT-i] Set up the CHAMPS system to be able to extract the deferred and waived PM datafrom CHAMPS and present that as a quarterly performance indicator for management.Implementation of this revision is underway.

[OFI-2] Trend all outstanding corrective/repair maintenance items in CHAMPS or anequivalent stand-alone system, so that the entire scope of repair work to be done is visibleand retrievable in a listing for operations and management review, prioritization and/orcancellation.

[OFT-3] Evaluate the need for implementation of a process to conduct formal periodic reviewof the MEL for completeness and accuracy and to ensure that information can be readilyextracted.


4. Audit of Inoperable or Impaired Safety Systems/Configuration Control (PSO/FP). Thisaudit covers DOE factors #7 and #21

a. Inoperable or Impaired Safety Systems are documented in Safety Equipment ReleaseForms (SERF). For this audit, the SERF log was compared to the posted SERFs in thePSO Hub and those reflected on the PSO turnover sheet to assess configurationcontrol.i. While 6 active impairments were reflected on the turnover sheet, 14 SERFs

were listed as active in the Impairment Log. After discussion with the systemengineer, the status was updated and corrected.

ii. One SERF (referring to fire door impairments) was listed as open in theimpairment log but was not posted in the PSO. Apparently, the annual firebarrier inspection was completed in April 2014, but the impairments found hadnot been posted on a SERF.

b. Additionally, SERF compensatory measures are not always accurately flowed onto thePSO turnover sheet In one instance, a SERF allows fire doors to be propped open forventilation purposes only when the facility is occupied. This is important for PSOOperators to know to effectively perform off-shift facility inspections.

c. Based on the above, there is an inconsistent methodology in getting the SERFinformation updated and recorded in the proper places. It appears that there is aneed for a standardized system to keep these listings aligned. The roles,responsibilities, authorities and accountabilities are defined in the related procedurebut a process of checks and balances is needed to keep SERF information accurateand in the right locations.

[NP-2] The PSO shift Turnover sheet reflects the status of site ventilation equipment,restricted access areas, and maintenance items.

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OBSERVATION: It was discovered that there are two systems in use for tracking SERFinformation and that these did not agree at the time of the audit

[CA-3] Eliminate dual tracking of SERFs by ceasing the practice of tracking SERFs onturnover sheets and refer turnover status to the SERF log, which is readily available online.

5. Audit of HEPA Filtered Ventilation System PMs (portable and vacuums) andAvailability — These audits cover DOE factors #2, #22, and #7

a. Testing of the HEPA filters of Portable Ventilation Units (PVU5) and Vacuums arebeing performed as required in SOPs. CHBWV limits the number of PVUs that may bein operation to 15 to be in compliance with the NESHAP permit conditions. Thenumber of units presently available for operation is 14.

b. As noted above, the WVDP has 14 units Portable Ventilation Units, so by default, theNESHAP limit cannot be exceeded. However, 2 or more units are forecasted to beprocured in the near future, and therefore, there is a need to formally andsystematically control the number of PVUs in operation. Presently, there is no formalprocess for PVU control in place. Discussions with the cognizant engineer indicatethat he is aware of this shortfall, and plans to take action to address the potentialissue.

c. The audit also found that although it is required by the SOP, there is no controlledlogbook in the LAG area to track the use of HEPA vacuums. The SOP also requires thesupervisor to sign the data are recorded in a logbook. While the cognizant systemengineer has a compilation of data, a review of that data found it was not complete(the latest 2 data sheets on PVU-01 and PVU-11 were missing). While the informalsystem is effective and status listings are brought into compliance, a codifiedapproach is missing.

d. Additionally, there are no criteria or responsibilities described for PVU logbookcreation, maintenance, and other responsibilities. As mentioned in 5.b. above, there isalso no description of responsibilities for ensuring the limit of 15 operational PVUs ismaintained. General Roles and Responsibilities are not clearly defined and thissituation requires corrective action.

e. HEPA Vacuums are also tested in accordance with a SOP, however, there is nocontrolled logbook maintained for testing of HEPA Vacuums. As with the PVUs, theSOP refers to an official logbook, and requires the supervisor to sign that the resultsare recorded in a logbook and the status board are updated. There are no criteria forlogbook maintenance and responsibilities, and there is no status board that tracksHEPA Vacuums. General Roles and Responsibilities are not defined, nor is themethodology for maintaining status. This also requires corrective actions.

E Many of the building HEPA filters in plenums are past their normal replacement cycle(most manufacturers use a 10-year figure). These HEPA filters are presently passingtheir Polyalphaolefin (PAO) efficiency/leak tests and have acceptable differentialpressure readings (~P) across the filter. With the present light dust loadings, thesefilters can be expected to perform within acceptable limits. There are several factors

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that would preclude any attempt to change out these filters. First, these are very olddesigns, and one-for-one replacements are not readily available. Second, replacementwould require manned entry, and the accumulated contamination and radiationlevels would make personnel entry difficult and potentially hazardous.

g. In spite of the age and condition of the system, availability of the MPPB ventilationsystem is extremely high, essentially at 100%. There may be impairments from time-to-time, but the system has always remained functional and operating well enough toperform its intended safety function.

h. While a project is planned for a replacement ventilation unit (RVU), as an OFI, theWVDP should investigate potential engineered intermediate work-around solutionsin the event present HEPA filters need to be replaced before the RVU is in place.

OBSERVATION: There does not exist a coherent and complete process is in place withclearly delineated roles and responsibilities, including logbook requirements andresponsibilities and maintaining current status related to the use and control of PVUs andHEPA vacuums.

[CA-41 Revise SOP 15-28 and SOP 15-48, governing PVUs and Vacuums. Ensure there is a tiein to a status board (or equivalent) for HEPA vacuums.

[OFI-4] Although there is a project in the works for a replacement ventilation unit (RVU), itwould be prudent to form a team to evaluate and pre-engineer work-around solutions if theimmediate need to replace HEPAs in the contaminated plenums of non-redundant systemsarises before the RVU is constructed and brought on line to minimize time lost on the WVDPD&D mission.

6. Audit of Maintenance Lock Out Tag Out (LO/TO). These audits cover DOE factors #2, and#19

a. LO/TO audits were done for the Remote Handled Waste Facility (RHWF), PSO Hub,and LAG storage area. There was only one LO/TO each in the RHWF and LAG areas,with no problems noted. The P50 logbook shows that there are over 650 permanentlocks in place at the WVDP. Additionally, there were six danger tags less than 3 yearsold in place for non-safety related equipment Two of the six danger tags hadassociated work documents and the others were the result of trouble calls. Lastly,there were 21 caution tags in place for non-safety related equipment at the time ofthis audit and approximately half were related to trouble calls.

b. The P50 logbook shows the required monthly audits were completed anddocumented. Locks remaining for extended periods are periodically replaced withpermanent locks. No safety-related (fire or ventilation system) equipment iscurrently locked out, and caution tags are appropriately used. However, a largenumber of tags are driven by trouble calls (i.e., skill of the craft), which provides nohistorical information or documentation. It would be an OFI to have the trouble callinformation associated with the danger tags.

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c. There is a new trouble call sop (00-56) for Unplanned Maintenance that has beenrecently implemented, which would facilitate the association of trouble callinformation with any resultant equipment tags.

[OFI-5] The trouble call SOP-00-56 could be enhanced by requiring documentation of thecircumstances leading to the application of a caution tag.

7. Audit of WVDP Temporary Modifications. This audit covers DOE factor #20

a. Listed in the P50, there are currently eight temporary modifications (TM5) and one inprogress for the Main Plant Process Building (MPPB) and ancillary facilities. All thosegreater than 3 months old were verified as being entered into the Open ItemTracking System (OITS) as required per SOP 00-49. Of the eight, three are greaterthan 9 months old.

b. The three TMs for the MPPB and ancillary facilities greater than 9 months old haveextensions of greater than 9 months that are approved by the Facility Manager, andcontinue to be reviewed by the Engineering Manager and System Engineer monthly,per procedure. While procedure allows these continued extensions, SOP 00-49,Rev. 6 requires that the system Engineer and Shift Supervisor re-evaluate the TMafter 6 months to determine if it needs to continue and obtain approval from theCognizant system Design Manager (CSDM) and Facility Manager (FM). The reason togrant long duration extensions must be compelling, and not just for convenience.Long extensions should have more visibility with upper management, as an OFI.

c. A potential issue was identified regarding TMs for the RHWF. While the PSO providescontinuous coverage for the MPPB, the PSO was not cognizant of TMs for the RHWF.

d. In the RHWF, four TMs were implemented in the prior two-year period. One TM(313-55) was initiated on May 1, 2013 and removed on September 16, 2013 when thepermanent modification was implemented (ECN #30193). It closed within theprevious 6-month requirement. However, this TM was not entered and tracked intoOITS upon the required 3-month period.

e. One RHWF TM (313-53) was open for S ½ months, and while it was entered andtracked in OITS after the 3-month period, it also remained open beyond the previous6-month requirement that was in effect at that time.

OBSERVATION: There is a missing communication link that needs to be established toensure P50 is kept aware of the Temp Mod status in RHWF to ensure an informed responseduring the off-shift.

[CA-S] Review SOPs and other instructions for TMs to ensure all roles and responsibilitiesare in place and the system for ensuring the P50 is made aware of all TMs is fully functional.

[OFI-6] While there has been only one minor TM having a safety related function (lowerpressure in fire pump until hydrant was fixed), having multiple “temporary” modificationsover 9-months old, even with approvals as presently required, would indicate that moreupper management attention, including priority and scope discussions, is warranted.

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Dissemination of the P50 Turnover sheet, with its status of temporary modifications, toappropriate personnel (e.g., Chief Engineer, FM, CSE, etc.) should give better visibility tothese extended temporary modifications.

8. Audit of Spurious Safety System Actuation and Spare Parts Availability — This auditcovers DOE factors #24 and #14

a. The P50 hub has a spurious PVS data gathering panel system heat trace alarm (56-TAL-002), which is tied into the same Keltron alarm (30) used for PVS ventilation orTank & Vault Drying system upsets, and this alarm comes in frequently even thoughno upset condition exists. The spurious alarm had not been identified as deficient onthe P50 turn-over sheet.

b. A Keltron 30 alarm, received recently on the off-shift, resulted in a delayed responseby the on-call PSO. His explanation for the delayed response was that it was due tothe assumption that it was the nuisance PVS heat trace fire panel alarm, whenactually the PVS ventilation system had shut down due to a faulty power supplycomponent (see also discussions under sub-section 2 on Alarm Status). This delayedresponse resulted in a ‘~-2-hour loss of Waste Tank Farm tank ventilation. The systemwas restored in accordance with the SOP. There were no radiological upsetsassociated with this incident. (It should be noted that Keltron alarms only indicatean area of an alarm, not the cause of the specific alarm. Operator response to the areais required to determine the specific cause of the alarm.)

NOTE: Corrective actions for nuisance alarms are covered in sub-section 2, and dealwith the situation that allowed for an initial false response. Though relatively minor,the event also brought out the additional issue of untimely Alarm ResponseProcedure (ARPs) updates, requiring corrective action.

c. The failed power supply component had to be ordered due to the lack of availablespares in controlled storage (although they were actually in the possession of thesystem engineer). It should be noted that the aging Keltron alarm system is becomingmore and more unreliable, and spare or like-for-like parts are becoming very difficultto obtain. (Note, as discussed previously, the Keltron system will be replaced verysoon, as procurement of a replacement system is in progress.)

d. In a separate and unrelated event, it was recently discovered that Engineering ChangeNotice 30051, which was issued in February 9,2012, fixed an alarm that was listed inSOP 55-17 but the procedure was not updated.

e. During this last winter, an instance was discovered where an ECN was issued, but animpacted ARP was not updated. An Issue Report (IR) was filed and a correctiveaction taken to remedy the finding.

OBSERVATION: On two occasions it has been discovered that an Alarm ResponseProcedure (ARP) was not updated to reflect a design change from an ECN. While one wasfrom a recent design change (and a CA was issued at that time), another since found wasfrom a legacy ECN prepared several years ago that for which the ARP was not updated.

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[CA-6] Conduct a review of ECNs and ARPs to determine whether more legacy ECNs did notresult in an ARP update.

[OFI-7] Evaluate the current practice for control of safety system spare parts. Validate spareparts for safety systems are maintained in controlled storage to ensure off-shift availability.

9. Audit of Configuration Control of Structures — This audit covers DOE factors #7, #22, and#23

a. Certain structures are credited with safety functions, usually confinement, and mustbe managed to ensure they are not changed or degraded such that they can no longerperform their safety function. At WVDP, any modifications to Zone 1 (containment ofradioactive material) cell structures potentially impacting their confinementcapability are configuration controlled with drawings and required structuralengineer approvals.

b. Work instruction packages (WIPs) for cell modifications (temporary or ECN)appeared adequate with appropriate subject matter expert (SME) reviews. It wasnoted, however, that SOP 15-88 was recently used to modif~, the Liquid Waste Cell(LWC) by boring penetrations into the cell to allow for tooling access and ventilation.Core boring activities are governed by the SOP, but the cognizant engineer has theresponsibility for a multidiscipline review for electrical, mechanical and structuralconcerns. Specifically, a calculation was performed to determine limits andcompensatory measures for the project The cognizant engineer was responsible forimplementation. Although discussions of these modifications do take placeinformally among the engineers, a comprehensive pre-modification review process isnot documented prior to making the modification.

c. Given that WVDP facility structures have experienced degradation associated withage, temperature variations, and/or exposure to hazardous materials, a cautiousstructural approach should be taken. This structural degradation concern wasreinforced with the recent discovery of a large (approx. 3 feet x 8 feet) spalled portionof the concrete wall surface in the Equipment Decontamination Room (EDR). Otheractivities in the EDR have included floor core boring.

[OFI-8] The core boring procedure, and any other similar procedures, need to be reviewedto determine whether there is a need to revise the language to ensure that the same level ofreviews are provided as is presently given to structural ECNs or TMs.

10. Audit of Emergency Management Open Items/Action Items — This audit covers DOEfactors #4, #10, #11, #12, and #22

a. The Emergency Management Program tracks actions through the site’s Open ItemTracking System (OITS). Action items are categorized as Priority 1, 2, 3 or 4.

i. Priority 1 being most important or critical items including critical safety items,compliance issues, contract requirements, and CHBWV Senior Managementconcerns.

ii. Priority 2 includes external commitments made to DOE and/or regulators.

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iii. Priority 3 includes internal CHEWy commitments.iv. Priority 4 items are non-regulatory actions and “Tickle Reminders”.

b. 235 Open Items related to the Emergency Management Program were identified sinceApril 2012. One (1) item was designated as Priority 1 relating to a malfunction of theSheltering Alarm during a weekly test. Compensatory measures were established andrepair and testing of the system was completed within 4-hours of the failed test.

c. Four (4) Priority 2 items were identified as late. The average time to complete theseitems was 8.5 days.

d. Ten (10) Open Items were identified relative to communications. These issuesincluded the inability to hear the “812 All-Page” in certain areas of the site, cell phonesignal strength and reliability of two-way radios.

[OFI-9] Due to the age of the site telecommunications infrastructure and evolving conditionsassociated with facility decommissioning, an evaluation of the site’s communicationssystems should be conducted and necessary improvements made.

11. Audit of Conduct of Operations Self-Assessments — This audit covers DOE factors #6, #10,#11, and #12

a. This audit reviewed 410 items generated from 3 lsConduct of Operations Self-Assessments for the period of May 1, 2012 through May 15, 2014. The WVDP auditfound a total of 42 items that could be considered relevant to the WIPP incident.These items were further broken down into the following five categories:i. Training

ii. Emergency Responseiii. System or Procedureiv. Firev. Equipment

b. Review of the 42 items and their subcategories indicated an adequate self-assessmentprogram is in place at the WVDP, with no significant issues.


12. Audit of Conduct of Operations Standing Orders — This audit covers DOE factors #8 and#14

a. This audit covered Standing Orders (SO) for the prior two years, and analyzed daysopen and average days open. In the WIPP event a Standing Order allowedmodification to the ventilation system. The WVDP Standing Order process would notallow a similar change.

b. The present management expectation is that SOs be monitored to ensure they areclosed within 60 days. The audit found that only 4 of 25 Standing Orders were closedin that timeframe, and the remainder have been open an average of 213 days. The

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long open average is primarily due to legacy issued SOs, where these prior SOs had notime limits or expiration dates.

c. The Conduct of Operations SOP (SOP-00-52) does not speci1~’ closure of SOs within60 days. Present management expectations have resulted in over 90% of StandingOrders being dispositioned and canceled with only 2 legacy SOs remaining in effect

[OFT-b] Evaluate modifying SOP 00-52, “Conduct of Operations” and/or other appropriatesite procedures to establish a program for any new SOs to be issued with an expiration date,to take actions to either close them or convert them to proper procedures/policy or getfrequent management attention to ensure a 60-day closure. Ensure any SO instructionscontain roles and responsibilities and a coherent system for creation and closure.

13. Audit of Temporary Procedure Changes — Audit covers DOE factors #20, and #26

a. Temporary procedure changes made over the last 2 years (3) were reviewed andfound to be approved by appropriate subject matter experts (SMEs). Temporaryprocedure changes that modify operating parameters of equipment also get the SMEreviews and are usually captured as temporary modifications (TM5).

b. Administration of Work Instruction Packages (EP-5-002) allows for excerptingportions of an SOP into a WIP, without reference to the SOP. There are instances of aWIP overriding steps in an SOP, but in an enhanced manner, such as addingadditional radiological controls or additional Personnel Protective Equipment (PPE).However, it is not always apparent to a reviewer that a WIP is superseding a SOP.Any action that is in conflict with a normal operation should be highlighted and theresulting impacts well understood by all potentially affected personnel.

c. The EP-5-0O2 procedure also allows for direct document changes which may be usedfor:i. Correcting administrative errors such as typos, worker designations, etc.

ii. Addition or deletion of steps if that does not affect intent or any critical stepsiii. Sequence of steps if that does not affect intent or any critical steps

d. Standing Orders were reviewed and determined not to supersede any SOPs.

e. One non-safety related equipment temporary procedure change has been in placeover 90-days, due to extended delay of the work (canal dredging).

[OFT-il] While overall the temporary procedure change process appears to be working asdesigned, it would be an improvement to modify EP-5-002 to require identification of stepsin WIPs that supersede existing SOPs and are not part of an official TM.

14. Human Performance Errors — Audit covers DOE factor #13

a. Audit for human performance improvement (HPI) errors was done via review of all2012 to 2014 Fact Finding Minutes (55), Incident Reports (155), and OccurrenceReports.

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b. The audit results show that HPI codes appeared in 19% of Incident Reports, 67% ofFact Finding Reports, and in 31% of all events in Occurrence Report fact-findingsection.

c. The HPI data and the various associated HPI codes (e.g., skill based error, knowledgebased error, etc.) are informative, and in each instance corrective actions were taken.However, it could be more useful to track and trend the frequency of each HPIelement for collective significance.

d. In analysis of the above break down, the majority of HPI errors could be investigatedback to system drivers such as management systems, process or procedural issues,flawed defenses, or equipment issues. One of the most pressing management issueshas been that of safety culture. These issues have been captured in the abovementioned processes and then analyzed further in Human Performance Investigationor Reviews. Many corrective actions have been taken as a result of theseopportunities to learn from our events. The safety culture issues are not a quick fixand we have a strategic improvement plan in place and working.

[OFI-12] Set up training to assure understanding of specific cause codes to be used with FactFindings, Issue and Occurrence Reports. This will assist in looking for HPI patterns andcollective significance which will then be added to cause code metrics, to help continuouslyimprove operations and reduce errors.

15. Audit of Radiological Control Instrument Availability — Audit covers DOE factors #7, #8,#22,#23,and#24

a. Instrument availability 95% over an 847-day period

b. Mean repair time for instrumentation is less than 24-hr.

c. 100% success rate of non-test challenges.

d. No spurious alarms during the 847-day period evaluated.


16. Audit of Fire Protection System Availability — Audit covers DOE factors #7, #8, #22, #23,and #24

a. The last two years were reviewed to evaluate the availability of the fire protectionsystem as indicated by safety equipment release form activity. Emergency lights andfire doors were excluded (see Audit Item 4, Inoperable Safety Systems).

b. The audit shows that the fire protection equipment has been maintained inaccordance with approved procedures, with impairments generally corrected in atimely manner. While a few impairments have been in place for extended lengths oftime, they were properly justified (e.g., reparability weather dependent, interferingactivities in the area such as demolition or D&D, etc.).

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c. A safety procedure implemented by CHEWy on combustible hazards andhousekeeping has proven to be effective. Housekeeping has significantly improved asnoted in internal and external assessments.


17. Audit of Power/Backup power Availability - Audit covers DOE factors #7, #8, #22, #23,and #24

a. There are no credited emergency power systems or requirements at the WVDP

b. The backup power systems are tested frequently in accordance with the applicableprocedures, and monitoring of critical parameters is documented during daily andoperational checks. The preventative maintenance on each component is prescribedby the Cognizant System Engineer and performed as scheduled. If an activity iswaived or suspended it is done per procedure.

The review of two years of site power events found that there were 34 outages, andeach time the standby diesel generators performed as designed, and site power wasrestored within minutes. There were 6 occasions where site equipment issues aroseas a result of the power outage. These issues were promptly addressed and resultedin no loss of power to critical equipment. Site power supply availability is extremelyhigh, essentially at 100% between normal utility power and backup diesel power.

c. Recent WVDP upgrades include the computer room Uninterruptible Power System(UPS) and DB-100 breaker retrofits. Vitrification Facility and RHWF UPS upgrades arein progress. A new Utility Room (UR) relay will also be installed later this year.

d. The audit showed that overall, maintenance and testing of the backup power systemsis excellent. However, for some equipment in the substation and UR switchgearroom, reliability is low due to the age (over 50 years old) and difficulty ofreplacement. Manufacturers’ recommend a service life of 20 years for mostcomponents, and the WVDP is 30 years beyond that figure. As a result, major WVDPelectrical components (substation & switchgear) in use are well beyond their servicelife and cannot be replaced with original equipment manufacturer components,forcing the use of aftermarket and retrofitted parts. The WVDP has the benefit ofelectrical SMEs who are very familiar with the aging equipment, but availableresources will be impacted by personnel retirements.

[OFI-13] Set up a planning document to delineate any needed plant recapitalization (e.g.,replace critical electrical distribution panels and switchgear, replace leaking fire water andgas lines, etc.). Given the expected timeline for full site D&D, the plan should prioritizeneeded infrastructure improvements.

[NP-3] Recently all of the site’s electricians received breaker training from a Siemens-Allistechnician, allowing for more efficient and comprehensive breaker repairs andtroubleshooting.

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[NP-4] The site continues to perform quarterly power outages to test the operability of thebackup power system. In addition these outages are used to perform preventativemaintenance that is difficult to integrate with the on-going project work.

18. Safety System Performance (Successful or Not) When Tested — Audit covers DOE factor#22 and #23

a. The safety-related equipment has been maintained in an efficient and cost-effectivemanner, despite the cost constraints and impending demolition of facilities on thesite.

b. Preventative maintenance activities have been performed in accordance withmaintenance plans and schedules using PMs/job cards.

c. Some deferred or potentially deferred maintenance items were identified throughinterviews with the cognizant engineers who have actions to correct maintenanceitems. These items include:i. Fire barrier breached on 1.5-hr. fire rated door from the MPPB to the Utility

Room by the installation of a ventilation filter in the door.ii. A Backup power Off (EPO) test has not been performed for the Computer

Room in the Annex in the three-year time frame. Current plan is to performthis test this summer.

[NP-5] Electrical PMs were consolidated to be more efficient by establishing a PM cycle on atwo-year basis to reduce or eliminate duplicative PMs.

[NP-6] PMs on low run-time equipment are being deferred or waived, with the goal ofsetting up the PM job cards to change from yearly activities to hours of run time and therebyincrease efficiency and reduce costs. [See OFI-14 below]


[NP-B] Continuing and effective PM actions has contributed to the unusual long life of thesite’s aging electrical infrastructure.

[OFI-14] Set up a systematic process to routinely monitor and record equipment run-times,and create a linkage to the CHAMPS system to trigger PMs based on specified run-timecriteria.

19. Audit of Procedure Non-Compliance Events — Audit covers DOE factor #18

a. In March of 2013, CHBWV added Procedure Compliance to the tracking and trendingContractor Assurance System Reports issued monthly by the Environmental, Safety,Health and Quality (ESH&Q) group. Additionally, Self-Assessments and FacilityRepresentative reports had periodically listed non-compliances, or deficiencies in thisarea.

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b. The Procedure Compliance tracking and trending reports standardized definitions asfollows:i. Noncompliance — a violation of regulatory or DOE requirements.

ii. Procedure Deficiency — regulatory requirements were met but otherprocedure requirements or stated expectations were not met.

iii. Program Deficiency — a non-regulatory issue that differs from the documentedprogram.

iv. Preventative/improvement issues:1. Issue was identified during pre-work activities. Actions were taken to

prevent circumstances that could lead to a non-compliance ordeficiency.

2. Issue that was identified during or after a work evolution to requiremodification of a process, to prevent a possible future noncompliance/deficiency or that would make a process more efficient.

c. Out of approximately 769 procedures that were reviewed, revised or had workpackages performed during the past 13 months 10 non-compliances, 30 proceduredeficiencies, 2 program deficiencies and 37 preventative or improvement actionshave occurred.

d. Deficiencies included: security checks and emergency pages not performedadequately, missing QA approvals on a procurement for waste department or JLGrecheck after annual maintenance; Engineering guidance not compliant with material~requirements or work controls on the Permeable Waste Treatment Wall; checklistinadequate for emergency lights and fire extinguisher and clapboard removalplanning did not identifS’ asbestos hazard.

e. In the context of the large number of procedure changes made in the last year, the5.5% non-compliances or deficiencies found and corrected is a credible rate.Continued improvements are needed, particularly in the areas of fire protection,assuring the appropriate quality level has been identified, and hazardidentification/chemical labeling.

[OFI-is] Continue to track and trend procedure non-compliances, and review for commonelements, repeated errors, and collective significance. Based on the data, set up a program toeliminate or minimize repeat errors (training, Lessons Learned, etc.), and to identi~’ weakperformance areas.

20. Audit of abnormal procedure entries/emergency procedure entries/unplannedprocess shutdowns/unplanned automatic process shutdowns, and spurious safetysystem actuations — Audit covers DOE factors #9, #14, #15, #16, #17 and #24

a. At the WVDP, many abnormal, emergency or unplanned shutdown events arerecorded and resolved with documentation existing in the CHBWV Open ItemTracking System (OITS) and in some cases also in the DOE Occurrence Reporting andProcessing System (ORPS).

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b. The audit reviewed field logbooks, fact-finding minutes, and work packages forinformation on these types of events. The paper trail was followed up throughresolution of the events.

c. A representative 5-month sampling of events, showed that there were 26 abnormalevents, 4 emergency or unplanned shutdowns, 1 auto-start, 1 auto-shutdown, and 13spurious alarms; as discussed below.

d. Abnormal Events Included:i. A diesel generator auto-started due to a faulty relay,

H. Blown fuses on various units,Hi. Plugged lines on equipment,iv. Sheltering alarm failures,v. Loss of power.

e. Back-up equipment typically performed as required during the above abnormalevents. However, older equipment sometimes had erratic performance requiringtroubleshooting, maintenance or Instrumentation and Control intervention to restorefunction.

f. Emergency alarms were the result of:i. Thunderstorms and power outages — standby diesels and back-up ventilation

performed as needed with normal line power restored in less than 2 hours.ii. An inoperable diesel generator — unit had a bad register and a vendor needed

to be called for repairs.Hi. Two instances of a CAM alarm occurred in the Depot compactor area (fact-

finding held, appropriate actions taken).

g. Auto-start or auto-shutdowni. Diesel generator started due to faulty relay in panel.

H. Interlock malfunction caused regeneration heater shut down.iii. PVS HEPA trains spuriously shutdown one train and auto-switched to the

second train — manually switched back and monitored.

h. Spurious Alarmsi. 4 spurious alarms were associated with the aging Keltron/Fire Detection,

cognizant engineer cleared (see [CA-2]).ii. 5 spurious alarms were associated with stack alarms particularly PVS Stack

(4 of5).Hi. 4 spurious CAM alarms in several instances where no work being done.

Larger Abnormal Eventsi. Site Power Outages (February 7, 2014 and February 12, 2014).

1. Both events associated with the site aging switchgear, specificallyerratic diesel breaker behavior (see also Item 17 on power availability).

H. HEV Trains Freezing issues 2-26-14.1. Freezing water in air lines for damper actuation.

Hi. Unable to switch HEV trains for monthly pressure instrument calibrations.Suspect failed actuator.

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[NP-9] When an actual emergency or abnormal situation occurs at the WVDP that requiresresponse from the Emergency Response Organization (ERO), Emergency Management usesand treats the event as a drill. As would be the case for planned drills, EmergencyManagement evaluates and critiques the responses to the actual situation. These realemergencies are documented, opportunities for improvement are identified, and correctionsare made to improve the ERO. Examples of these types of emergencies include medicalemergencies where off-site assistance is requested, radiation alarms, and power outages.

Details in logbooks and discussions about larger events point out that the response to theseevents at WVDP is essentially expert based. Experienced veterans work to consistently solvechallenging problems. However, problem solutions get delayed when all of the “experts” arenot available. This represents an area of potential risk in the future.

[OFI-16] While there are efforts underway to replace some aging system components, aprogram needs to be established to cross-train for succession planning.

[OFI-17] Extracting these abnormal and spurious events from the P50 logbooks was bothtedious and time consuming. A method should be established to highlight such off-normalevents, and ultimately collect them that can be used to look for trends and patterns, andperhaps permit more global solutions.

21. Audit of grievances, and personal radiological contamination events over the past twoyears — Audit covers DOE factors #28, and #29

a. The audit found no grievances associated with equipment, maintenance or deferredmaintenance.

b. The audit found one personal radiological contamination event associated with cranemaintenance, but below ORPS reportable levels, and one radiological skincontamination from re-lamping at the RHWF, also below ORPS reportable levels.

c. Positive information was found on previous actions taken when employees expressedconcerns about snow removal. Safety and Operations Managers immediately tookactions, identifying areas for improvement of snow removal; Supervisors & SeniorSpecialists reminded to use the call-in list as weather conditions warrant whichaddressed employee concerns.

d. Recent actions from potential safety concerns employees expressed during a factfinding on a hydraulic fluid spill from a JLG. The concerns were about the age anddeteriorating performance of the JLG that had leaked. The equipment was replacedwith newer leased equipment that addressed all issues.


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22. Audit of personal chemical exposure events over the past two years — Audit covers DOEfactor #30

a. Safety performs monitoring whenever chemicals are used that could present a healthhazard. The most common chemicals to be monitored at the WVDP are Lead,Mercury and Hexavalent Chromium. The decision to monitor is made by the sitesafety professionals.

b. A review of the Safety Sampling Database indicated that none of the sampling resultswere above Permissible Exposure Limits in the areas sampled. The results alsoindicated that there were no employee personal exposure events to hazardouschemicals.

c. As a further check, review of all event documentation (Fact Finding Minutes, IssueReports and Occurrence Reports], confirmed that there have been no chemicalexposure events at the WVDP.

d. These type of events (should they occur) are also tracked in the monthly ContractorAssurance System (CAS] reports reviewed by management Audit.


23. Audit of the Management Observation System Data - Audit covers DOE factor #28

a. Management Observations are made primarily during Management Workplace Visits(MWV5) and for assigned Management Assessments (MA5]. This audit reviewedManagement Observation system data for:i. Number of observations by senior managers.

ii. Number of management observations that identify deficiencies and result incorrective action.

b. For MWVs, both positive (good practices) and negative observations (deficiencies orproblems] are recorded on the Management Workplace Visit/Work Observationforms and entered into an Access database. Numbers of MWVs as well as the numberof positive and negative observation are tracked and trended monthly in a ContractorAssurance System (CAS] tracking/trending report.

c. Tracking and Trending Reports for MWVs were reviewed from May 2012 to April2014, and a sampling of individual reports was reviewed for types of attributes/issues identified and the resulting actions for deficiencies or problems identified.i. Observations of deficiencies or problems are reviewed for entry into the Open

Item Tracking System if they were not corrected on the spot (as is frequentlythe case).

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d. Management Assessments (MA5) — The majority of required assessments in theIntegrated Assessment Program (lAP] are Management Assessments or self-assessments on management systems. The CAS report tracks and trends thecompletions for these lAP assessments.i. There is a commitment to DOE-WVDP at the beginning of the calendar year

that the assessments on this lAP schedule be completed in a timely mannerwithin the quarter scheduled.

ii. Issues identified during these assessments are entered into the Open ItemTracking System (OITS] and tracked until completion after causal analysis andcorrective or improvement actions are developed.

e. This audit found that 1863 MWVs were performed during this period, with was 7347positive attributes and 878 negative or problem attributes observed. The MWVs areperformed most consistently by operations managers and managers fromRadiological Control, Security and Training, and all of EHSQ.

E The majority of observed problems were fixed immediately or the responsible partywas immediately contacted and issues were resolved within a short period of time.Additionally, subsequent MWVs are used for supervisor verifications of correctiveactions. The verifications are then documented in the Open Item Tracking System(OITS] database.

g. More complex issues observed during MWVs are entered directly into the OITS asIssue Reports or actions.

h. This audit also found that 129 lAP Management Assessments were completed fromMay 1, 2013 through April 30, 2014, with 90 issues identified and entered directlyinto OITS. These issues were then analyzed and corrective/improvement actionswere developed and tracked to completion.

This audit concludes that the WVDP has robust Management Observation and ManagementAssessment programs. The following opportunities for improvement were identified as aresult of the audit:

[OFI-18] Although Integrated Assessment Program results are available to all on theIntranet, quarterly summary or trend information could help identify key areas forimprovement. Trending and grouping the negative attribute or problem areas from MWVsand MAs would result in useful data about areas needing improvement, or collectivesignificance for further emphasis or training.

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Table 1. Areas with Lines of Inquiry, Developed by the Review Team

1. WVDP Corrective Maintenance relative to TSRs and LCOs2. Alarm Status and Configuration Control3. Tracking and trending preventive and predictive maintenance (PM] on equipment, as well

as maintenance repairs4. Inoperable or Impaired Safety Systems/Configuration Control (PSO/FP]5. HEPA Filtered Ventilation System PMs (portable and vacuums) and Availability6. Audit of Maintenance Lock Out Tag Out (LO/TO)7. Configuration Management-Temporary Modifications8. Spurious Safety System Actuation and Spare Parts Availability9. Configuration Control of Structures10. Emergency Management Open Items/Action Items11. Conduct of Operations Self-Assessments12. Audit of Conduct of Operations Standing Orders13. Temporary Procedure Changes14. Human Performance Errors15. Radiological Control Instrument Availability16. Fire Protection System Availability17. Power/Backup power Availability18. Safety System Performance (Successful or Not] When Tested19. Procedure Non-Compliance Events20. Abnormal procedure entries/emergency procedure entries/unplanned process

shutdowns/unplanned automatic process shutdowns, and spurious safety systemactuations

21. Grievances/personal contamination events22. Personal chemical exposure events23. Management Observation System Data

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III. Crosswalk ofAudit Coverage versus DOE Required Audit Elements

DOE Mandatory WVDP Audited Elements WVDP Report SectionReview Factors (Audit Title) Where Discussed WVDP Auditor

1. Number of unplanned TSR LCO 1. WVDP Corrective Maintenance relative to TSRs and Section 1 K. Mansfieldentries LCOs

2. Number of inoperable control 2. Alarm Status and Configuration Control Section 2 K. Mansfieldroom indicators and controls 5. HEPA Filtered Ventilation System PMs (portable Section 5

and vacuums) and Availability Section 66. Audit of Maintenance Lock Out Tag Out (LO/TO]

3. Number of lit/alarming control 2. Alarm Status and Configuration Control Section 2 K. Mansfieldroom annunciators B. Hill

H. Berman1. Baker

4. Corrective maintenance backlog, 3. Tracking and trending preventive and predictive Section 3 B. Hillage, and trend maintenance (PM) on Category 2 and Category 3 Section 10 H. Berman

equipment, as well as maintenance repairs J. Baker10. Emergency_Management Open_Items/Action_Items

S. Preventative maintenance backlog, 3. Tracking and trending preventive and predictive Section 3 D. Zerfasand in grace period, and trend maintenance (PM) on Category 2 and Category 3 J. Dudek

equipment as well as maintenance repairs B. Hill6. Surveillances performed in grace 3. Tracking and trending preventive and predictive Section 3 D. Zerfas

period and trend maintenance (PM) on Category 2 and Category 3 Section 11 1. Dudekequipment as well as maintenance repairs B. Hill

11. Conduct of Operations Self-Assessments H. Berman7. Safety system availability 4. Inoperable or Impaired Safety Section 4 J. Baker

Systems/Configuration Control (PSO/FP) Section 5 H. Berman5. EPA Filtered Ventilation System PMs (portable and Section 9 B. Hill

vacuums) and Availability Section 159. Configuration Control of Structures Section 1615. Radiological Control Instrument Availability Section 1716. Fire Protection System Availability17. Power/Backup power Availability

8. Number of safety system 8. Spurious Safety System Actuation and Spare Parts Section 8 J. Bakerchallenges (number of times a Availability Section 15 H. Bermansafety system has been demanded 12. Section 16 B. Hillto respond or be manually 15. Radiological Control Instrument Availability Section 17 D. Cookinitiated) 16. Fire Protection System Availability

17. Power/Backup_power Availability

A-27

DOE Mandatory WVDP Audited Elements WVDP Report Section. . . WVDP AuditorReview Factors (Audit Title) Where Discussed

9. Number of unplanned safety 20. Abnormal procedure entries/emergency procedure Section 20 J. Bakersystem actuations entries/unplanned process shutdowns/unplanned H. Berman

automatic process shutdowns, and spurious safety B.Hillsystem_actuations

10. Corrective action process (issues 3. Tracking and trending preventive and predictive Section 3 M. Schweickertmanagement system) items maintenance (PM) on Category 2 and Category 3 Section 10 J. Dudekinitiated and trend equipment, as well as maintenance repairs Section 11 M. Baldi

10. Emergency Management Open Items/Action Items B. Hill11. Conduct of Operations_Self-Assessments

11. Average age of open corrective 10. Emergency Management Open Items/Action Items Section 10 M. Schweickertaction process items (both open 11. Conduct of Operations Self-Assessments Section 11 J. Dudekissues and open corrective actions) M. Baldi

12. Number of corrective action 10. Emergency Management Open Items/Action Items Section 10 M. Schweickertprocess items overdue 11. Conduct of Operations Self-Assessments Section 11 J. Dudek

M. Baldi13. Number and rate of human 14. Human Performance Errors Section 14 S. Cook

performance errors C. Wozniak14. Number of abnormal procedure 8. Spurious Safety System Activation Section 8 J. Baker

entries 12. Section 20 P. Troescher20. Abnormal procedure entries/emergency procedure H. Berman

entries/unplanned process B. Hill15. Number of emergency procedure 20. Abnormal procedure entries/emergency procedure Section 20 J. Baker

entries entries/unplanned process shutdowns/unplanned H. Bermanautomatic process shutdowns, and spurious safety B. Hillsystem actuations J. Dudek

M. Baldi16. Number of unplanned process 20. Abnormal procedure entries/emergency procedure Section 20 J. Baker

shutdowns entries/unplanned process shutdowns/unplanned H. Bermanautomatic process shutdowns, and spurious safety B. Hillsystem_actuations

17. Number of unplanned automatic 20. Abnormal procedure entries/emergency procedure Section 20 J. Bakerprocess shutdowns entries/unplanned process shutdowns/unplanned H. Berman

automatic process shutdowns, and spurious safety B. Hillsystem_actuations

18. Number of procedure non- 19. Procedure Non-Compliance Events Section 19 B. Hillcompliance events H. Berman

19. Number and age of LO/TO hanging 6. Audit of Maintenance Lock Out Tag Out (LO/TO) Section 6 K. MansfieldD. Cook

A-28

DOE Mandatory WVDP Audited Elements WVDP Report Section ~DP A d~

Review Factors (Audit Title) Where Discussed U itor20. Number and age of temporary 7. Configuration Management-Temporary Section 7 K. Mansfield

modifications Modifications Section 1313. Temporary_Procedure_Changes

21. Number and age of inoperable 4. Inoperable or Impaired Safety Systems/ Section 4 J. Bakersafety systems Configuration Control (PS0/FP) B. Hill

H. Berman22. Safety system performance 5. HEPA Filtered Ventilation System PMs (portable Section 5 D. Cook

(successful or not) when tested and vacuums) and Availability Section 9 J. Baker9. Configuration Control of Structures Section 10 J. Prowse10. Emergency Management Open Items/Action Items Section 15 B. Hill15. Radiological Control Instrument Availability Section 16 H. Berman16. Fire Protection System Availability Section 1717. Power/Backup power Availability18.

23. Safety system performance 15. Radiological Control Instrument Availability Section 15 D. Cook(successful or not) in response to 16. Fire Protection System Availability Section 16 J. Bakeractual demand 17. Power/Backup power Availability . Section 17 B. Hill

18. H. BermanJ. Prowse

24. Number of spurious safety system 8. Spurious Safety System Actuation and Spare Parts Section 8 J. Bakeractuations Availability Section 15 B. Hill

15. Radiological Control Instrument Availability Section 16 H. Berman16. Fire Protection System Availability Section 17 J. Prowse17. Power/Backup power Availability

25. Number of significant unplanned Not applicable; No production facilitiesproduction_level_changes

26. Number of temporary procedure 13. Temporary Procedure Changes Section 13 K. Mansfieldchanges

27. Number of grievances 21. Grievances/personal contamination events Section 21 5. Cook

28. Management observation system 23. Management Observation System Data Section 23 B. Hilldata:• Number of observations by

senior managers• Number of management

observations that identi&deficiencies and result incorrective action

A-29

DOE Mandatory WVDP Audited Elements WVDP Report Section WVDP AuditorReview Factors (Audit Title) Where Discussed

29. Number of personal contamination 21. Grievances/personal contamination events Section 21 J. Prowseevents N. Bridges

D. Cook30. Number of personal chemical 22. Personal chemical exposure events Section 20 C. Wozniak

exposure events

A-30

IV. Consolidated Listing of Corrective Actions, Opportunities for Improvement, andNoteworthy Practices

OBSERVATIONS AND CORRECTIVE ACTIONS

OBSERVATION: Many instances of nuisance alarms were found to exist throughout theplant site, potentially distracting operators in determining the need for and scope ofresponse actions.

[CA-i] Systematically identii~, all nuisance alarms, and set up a prioritized corrective actionprogram to eliminate or minimize these alarms (e.g., termination of contacts,reprogramming, changes to operating procedures, etc.).

[CA-2] A new system replacement for the Keltron alarm system has been authorized and isbeing processed for procurement. However, due to the Keltron alarm system age, unreliablebehavior, potential for creating error prone situations, and difficulty of repair, thisreplacement procurement needs to be given priority.

OBSERVATION: It was discovered that there are two systems in use for tracking SafetyEquipment Release Form (SERF) information and that these did not agree at the time of theaudit.

[CA-3] Eliminate dual tracking of Safety Equipment Release Forms (SERFs) by ceasing thepractice of tracking SERFs on turnover sheets and refer turnover status to the SERF log,which is readily available online.

OBSERVATION: There does not exist a coherent and complete process is in place withclearly delineated roles and responsibilities, including logbook requirements andresponsibilities and maintaining current status related to the use and control of PVUs andHEPA vacuums.

[CA-4] Revise Standard Operating Procedure SOP-i5-28 and SOP-15-48, governing PortableVentilation Units (PVU5) and High Efficiency Particulate Air (HEPA) filtered vacuums.Ensure there is a tie in to a status board (or equivalent) for HEPA vacuums.

OBSERVATION: There is a missing communication link that needs to be established toensure Plant Shift Office (PSO) is kept aware of the Temporary Modification status in RHWFto ensure an informed response during the off-shift.

[CA-5] Review SOPs and other instructions for TMs to ensure all roles and responsibilitiesare in place and the system for ensuring the Plant Shift Operations (PSO) is made aware ofall TMs is fully functional.

OBSERVATION: On two occasions it has been discovered that an Alarm ResponseProcedure (ARP) was not updated to reflect a design change from an Engineering ChangeNotice (ECN). While one was from a recent design change (and a CA was issued at that time),another since found was from a legacy ECN prepared several years ago that for which theARP was not updated.

A-31

[CA-6] Conduct a review of ECNs and ARPs to determine whether more legacy ECNs did notresult in a ARP update.

OPPORTUNITIES FOR IMPROVEMENT

[OFI-1] Set up the CHAMPS system to be able to extract the deferred and waived PM datafrom CHAMPS and present that as a quarterly performance indicator for management.Implementation of this revision is underway.

[OFI-2] Trend all outstanding corrective/repair maintenance items from CHAMPS data or anequivalent stand-alone system, so that the entire scope of repair work to be done is visibleand retrievable in a listing for operations and management review, prioritization and/orcancellation.

[OFI-3] Evaluate the need for implementation of a process to conduct formal periodic reviewof the MEL for completeness and accuracy and to ensure that information can be readilyextracted.

[OFI-4] Although there is a project in the works for a replacement ventilation unit (RVU), itwould be prudent to form a team to evaluate and pre-engineer work-around solutions if theimmediate need to replace HEPAs in the contaminated plenums of non-redundant systemsarises before the RVU is constructed and brought on line to minimize time lost on the WVDPD&D mission.

[OFI-5] The trouble call SOP-OO-56 could be enhanced by requiring documentation of thecircumstances leading to the application of a caution tag.

[OFI-6] While there has been only one minor TM having a safety related function (lowerpressure in fire pump until hydrant was fixed), having multiple “temporary” modificationsover 9-months old, even with approvals as presently required, would indicate that moreupper management attention, including priority and scope discussions, is warranted.Dissemination of the P50 Turnover sheet, with its status of temporary modifications, toappropriate personnel (e.g., Chief Engineer, FM, CSE, etc.) could give better visibility to theseextended temporary modifications.

[OFI-7] Evaluate the current practice for control of safety system spare parts. Validate spareparts for safety systems are maintained in controlled storage to ensure off-shift availability.

[OFI-8] The core boring procedure, and any other similar procedures, need to be reviewedto determine whether there is a need to revise the language to ensure that the same level ofreviews are provided as is presently given to structural ECNs or TMs.

[OFI-9] Due to the age of the site telecommunications infrastructure and evolving conditionsassociated with facility decommissioning, an evaluation of the site’s communicationssystems should be conducted and necessary improvements made.

A-32

[OFI-1OJ Evaluate modi~’ing sop 00-52, “Conduct of Operations” and/or other appropriatesite procedures to establish a program for any new SOs to be issued with an expiration date,to take actions to either close them or convert them to proper procedures/policy or getfrequent management attention to ensure a 60-day closure. Ensure any 50 instructionscontain roles and responsibilities and a coherent system for creation and closure.

[OFI-li] While overall the temporary procedure change process appears to be working asdesigned, it would be an improvement to modib’ Engineering Procedure EP-5-002 to requireidentification of steps in WIPs that supersede existing SOPs and are not part of an official TM.

[OFI-12] Set up training to ensure understanding of specific cause codes to be used withFact Findings, Issue and Occurrence Reports. This will assist in looking for HP! patterns andcollective significance which will then be added to cause code metrics, to help continuouslyimprove operations and reduce errors.

[OFI-13] Set up a planning document to delineate any needed plant recapitalization (e.g.,replace critical electrical distribution panels and switchgear, replace leaking fire water andgas lines, etc.). Given the expected timeline for full site D&D, the plan should prioritizeneeded infrastructure improvements.

[OFI-14] In areas where it is feasible, set up a systematic process to routinely monitor andrecord equipment run-times, and create a linkage to the CHAMPS system to trigger PMsbased on specified run-time criteria.

[OFI-15] Continue to track and trend procedure non-compliances, and review for commonelements, repeated errors, and collective significance. Based on the data, set up a program toeliminate or minimize repeat errors (training, Lessons Learned, etc.), and to identi& weakperformance areas.

IOF!-161 While there are efforts underway to replace some aging system components, aprogram needs to be established to cross-train for succession planning.

[OFI-17J Extracting data regarding abnormal and spurious events from the P50 logbookswas both tedious and time consuming. A method could be established to highlight such off-normal events, and ultimately collect them in a manner that can be used to look for trendsand patterns.

[OFI-18] Although Integrated Assessment Program results are available to all on theIntranet, quarterly summary or trend information could help identilS’ key areas forimprovement. Trending and grouping the negative attribute or problem areas from MWVsand MAs would result in useful data about areas needing improvement, or collectivesignificance for further emphasis or training.

A-33

NOTEWORTHY PRACTICES


[NP-2] The P50 shift Turnover sheet reflects the status of site ventilation equipment,restricted access areas, and maintenance items.

[NP-3] Recently all of the site’s electricians received breaker training from a Siemens-Allistechnician, allowing for more efficient and comprehensive breaker repairs andtroubleshooting

[NP-4] The site continues to perform quarterly power outages to test the operability of thebackup power system. In addition these outages are used to perform preventativemaintenance that is difficult to integrate with the ongoing project work.

[NP-SI Electrical PMs were consolidated to be more efficient by establishing a PM cycle on atwo-year basis to reduce or eliminate duplicative PMs.

[NP-6] PMs on low run-time equipment are being deferred or waived, with the goal ofsetting up the PM job cards to change from yearly activities to hours of run time and therebyincrease efficiency and reduce costs.


[NP-B] Continuing and effective PM actions have contributed to the unusual long life of thesite’s aging electrical infrastructure.

[NP-9] When an actual emergency or abnormal situation occurs at the WVDP that requiresresponse from the Emergency Response Organization (ERO), Emergency Management usesand treats the event as an exercise. As would be the case for planned drills, EmergencyManagement evaluates and critiques the responses to the actual situation. These realemergencies are documented, opportunities for improvement are identified, and correctionsare made to improve the ERO. Examples of these types of emergencies include medicalemergencies where off-site assistance is requested, radiation alarms, and power outages.

IV. Summary and Conclusions

Generally, the audit team found that due to the highly experienced and relatively smallworkforce at WVDP, required maintenance activities (e.g., PMsJ were being reliablyaccomplished. Also, in spite of aging equipment that may not be replaced or upgraded sincethis is a D&D site, safety system reliability and availability has remained high, even as D&Dprogresses. Nevertheless, the audit team identified several important areas requiringimprovement and corrective actions, including:

• There is a need to reduce error prone situations that hinder human performance[e.g., minimize nuisance alarms, use of high-efficiency particulate air (HEPA) statusboards, etc.].

A-34

• There is an opportunity to upgrade some tracking systems to provide better access todata and to generate effective performance indicators (e.g., deferred or waivedmaintenance graphs) for informed management decisions.

• The reliance on expert-based performance, as opposed to process-basedperformance. There were several areas noted throughout the report where relianceon SMEs as a mitigation of potential issues is discussed. Improved employeeawareness of their roles and responsibilities will become more important asexperienced employees with WVDP historical knowledge retire.

Additionally, many Opportunities for Improvement (OFI) were found (i.e., aspects not criticalto deferred maintenance, but auditor noted changes that will improve site efficiency andeffectiveness), along with recognition of Noteworthy Practices (e.g., PM frequency onrotating equipment established by run-time versus calendar).

Overall, the audit found the WVDP site to be functioning properly to maintain safety systemsin working condition. However, important actions to prevent potential degradation ofconditions and improve the site conduct of operations were identified.

A-35

Attachment A

WVDP Audit TeamConsolidated Brief Resumes

Attachment A-i

Attachment A - Consolidated Biographical Listingfor WVDP Audit Team Members

Audit Team Leaders

Herbert £ Berman, Senior ConsultantMr. Berman, a graduate of the Massachusetts Institute of Technology, brings more than 42 years ofexperience in the management, supervision, and performance of nuclear/radiological work; clean-up ofradiological waste, and the establishment of appropriate safety basis, nuclear safety, and engineeringcontrols in a working plant environment. Along with his distinguished career in Chief Engineer positionsat the Pearl Harbor Naval Shipyard, the DOE Rocky Flats Plant the DOE Pantex Plant, and the DOEHanford Tank Farms, he is recognized for “turning around” the performance of engineering, nuclearsafety, and operations organizations, with integrated safety management approaches to embeddingsafety planning and controls into hazardous work activities.

He has demonstrated performance in managing and directing the institutional and cultural changesnecessary to transform previously troubled organizations into fully functional, standards-based entities,with responsibility and accountability vested in an integrated safety management structure for safe,seamless and efficient operations. This involved directing numerous investigations of engineering oroperations-related problems with nuclear and other hazardous materials, nuclear safety controlimplementation, radiological waste handling and storage, and industrial and nuclear facilities, andoperations safety bases.

Mr. Berman has a comprehensive understanding of the engineering, nuclear safety, operational,environmental, and safety requirements and practices in the DOE weapons complex and the NavalNuclear Propulsion Program. He has been an invited speaker at international nuclear safety forums,where he has addressed the challenges involved in integrating safety planning into nuclear workplanning. He also has run corporate workshops for creating and maintaining a world-class safety culture.In addition, he has significant experience and background in metallurgy and materials failure analyses.He also possesses a proven track record of managerial and program management accomplishments,successfully directing successively larger, more complex organizations and projects.

Barbara HillMs. Hill has over 25 years of Environmental, Safety/Health and Quality (ESHQ), technical andmanagement experience in DOE/government contracts, environmental/waste industries, andengineering firms. Management experience includes quality assurance programs, facility operations,environmental, health and safety, emergency programs, training, and radiological controls. Ms. Hill isDeputy ESHQ serves as Quality Manager and is a lead auditor at CHBWV at the West ValleyDemonstration Project Previous positions include Director SH&Q of the Waste Management Project inthe CH2M Hill Plateau Remediation Company at Hanford. This position also included performanceassurance, conduct of operations assessments, and management of the emergency management, trainingand procedures subcontracts. Additional positions include Deputy Analytical Technical Services, VicePresident 222-S Laboratory Complex CH2MHiII Hanford Tank Farms Contract (CHG); PerformanceAssurance Vice President Project Hanford Management Contract (PHMC); Waste Management lnc.(WM)Director of Quality and Business Improvement and ESHQ Director of WM Technology Center; Qualityand Project Manager, Donohue Engineering and Architects. Ms. Hill has Bachelor of Science degree inBiological Sciences.

Attachment A-2

Audit Team Members

James BakerJames Baker is the CHBWV Operations Manager at the WVDP, a position he has held for the past fiveyears. Mr. Baker has 20 years of DOE operations experience, and prior to that he completed a six-yearcommitment as a nuclear qualified Machinist Mate in the Naval Nuclear Power program.

Marjorie BaldiMarjorie Baldi has over 20 years of progressive experience in the industrial nuclear environment at theWVDP. Technical and professional positions she has held include: Instrument Specialist,Instrumentation and Control Supervisor, Maintenance Manager, and Training Administrator. Ms. Baldiis currently a Senior Emergency Management Specialist and is the only dedicated full-time CHBWVemployee providing oversight to the Emergency Management Program.

Nathan BridgesNathan Bridges has over 35 years of experience at numerous US Navy, Commercial, DOE and privatelyowned facilities and is currently the Radiation safety Manager for CHBWV. Mr. Bridges has beendirectly involved and managed the performance and oversight of deactivation and decontamination ofhigh activity hot cells, environmental remediation, dosimetry, air dispersion modeling, emergencyplanning and preparedness, radioactive waste management and nuclear power plant operations.

Mr. Bridges holds certification with the National Registry of Radiation Protection Technologists,(NRRPT) has a Bachelor of Science degree in Nuclear Technology and was a Chief Petty Officer as part ofthe US Navy Submarine Service. He has led Radiological Protection Programs at several locations,including the WVDP, the Idaho Cleanup Project and Envirocare of Utah.

David C CookDavid Cook is a General Engineer with the U.S. Department of Energy (DOE) at the WVDP, where he hasheld the position of Facility Representative since February 2000. Prior to his current assignment, Mr.Cook held DOE positions as an Operations and Engineering Team Engineer (1996-2000), andEngineering and Technology Team Engineer (1991-1996); U.S. Department of Defense positions asProject Manager and Engineer (1985-1988 and 1990-1991) and U.S Army Corps of Engineers CivilEngineer (1988-1990); Stone & Webster Engineering Corporation as a Senior Field Engineer (1982-1985); and as an engineering technician and project superintendent (1973-1978). Mr. Cook has over 37years of public and private sector experience in design, engineering, construction, and projectmanagement related to heavy industrial and nuclear facility design and construction. He has led andparticipated in numerous performance-based assessments at the WVDP and has a Bachelor of Sciencedegree in Civil and Environmental Engineering from Clarkson University.

Sharon CookSharon Cook is the current Human Performance and Reliability Manager for CHBWV. In this capacityshe is also leading Nuclear Safety Culture, Integrated Safety Management Systems, and VoluntaryProtection Program and is the Safety Conscious Work Environment Manager. Sharon most recentlywas the ES&H, Rad Con, Training and Human Performance Manager for the Nuclear Energy Group of theBabcock & Wilcox Companies. Sharon has over 25 years of experience developing and leading NuclearSafety Culture, Safety Conscious Work Environments, Human Performance, Industrial Safety, IndustrialHygiene, Radiological Controls, Training, Integrated Safety Management Systems, and VoluntaryProtection Programs in DOE, commercial nuclear plants, construction anddemolition/decontamination/decommissioning enterprises. Sharon is known for her ability to improvethe performance of organizations with the implementation of nuclear safety culture and humanperformance which strengthen all aspects of integrated safety management in the field. She has MastersDegrees in Industrial Hygiene and Human Performance.

Attachment A-3

Jeffrey DudekJeffrey Dudek is a Safety and Site Programs support contractor for the U.S. Department of Energy at theWVDP. Mr. Dudek has four years of experience at the WVDP and provides oversight of the EmergencyManagement Program, Conduct of Operations Program, and Maintenance Program. He has participatedin ISMS reviews and numerous audits and assessments of programs including Emergency Management,Environmental Protection, Conduct of Operations and Quality Assurance. Mr. Dudek also providesconstruction and safety oversight of various project activities.

Mr. Dudek has over 15 years of experience in engineering, quality control, health and safety andconstruction management and is a Professional Engineer (PE] registered with the State of New York. Heholds a Bachelor of Science in Civil Engineering from the University at Buffalo and a Bachelor of Sciencein Finance from Canisius College.

Kim MansfieldKim Mansfield is a Principal Project Leader for CHBWV, with 24 years of experience at the WVDP. Shehas worked in Plant Operations, Engineering and Nuclear Safety, participating in various operationalreadiness reviews, Integrated Safety Management effectiveness reviews and verifications, audits, rootcause analyses and program assessments. She is currently the Price-Anderson Amendments ActEnforcement Coordinator and has been on the event investigation team for 10 years.

James ProwseJames Prowse is a DOE subject-matter expert with over 25 years of experience at numerous DOEfacilities. He has been directly involved with performance and oversight of deactivation anddecontamination of high activity hot cells, sampling and treatment of high activity radioactive liquids,safety analyses, unreviewed safety questiondeterminations, environmental pathway analyses, doseassessments, dosimetry, shielding designs, air dispersion modeling, emergency planning andpreparedness, radioactive waste management, criticality safety, and waste incidental to reprocessingdeterminations.

Mr. Prowse is a Certified Health Physicist and has been the technical lead for reviews of DocumentedSafety Analysis and Technical Safety Requirements for nuclear facilities at the West ValleyDemonstration Project, Paducah Gaseous Diffusion Plant, and Hanford High Level Waste Tanks. He hasbeen the author of four DOE Safety Evaluation Reports and has participated in several DOE Type Binvestigations.

Michelle SchweickertMichelle Schweickert is a Senior Asset Management Specialist for CHBWV and has worked at the WVDPfor 27 years. Ms. Schweickert currently serves as the Conduct of Operations Program Coordinator at theWVDP for approximately 1-1/2 years and has performed various other functions including: Material &Property Manager, Procurement Card Program Administrator, warehousing, logistics, recordsmanagement, training, and procurement. She holds an MBA in Business Management and is a certifiedProject Management Professional.

Patrick TroescherPatrick Troescher is the Waste Facility and Logistics Manager for CHBWV. He has over 25 years ofexperience in the nuclear industry and is currently responsible for the WVDP’s Conduct of OperationsProgram. Mr. Troescher has experience in management and performance of remote handled waste operations,responsible for starting up new activities and demonstrating readiness to operate. This includesimplementation of safety basis requirements, development of training requirements, procedure development,and uses an integrated safety management approaches to embedding safety planning and controls intohazardous work activities. He graduated from Idaho State University with a Bachelor of Science in Chemistry.

Attachment 44

Cheryl WozniakCheryl Wozniak is a Senior Safety Engineer for CHBWV at the WVDP. Ms. Wozniak has 10 years ofexperience in the Safety Department and 2 years of experience with Human PerformanceImprovement. She holds a BS degree in Mechanical Engineering from GMI Engineering andManagement Institute and has worked at the WVDP for 20 years.

Debra ZerfasDebra Zerfas is the Computerized Maintenance Management System (CMMS) Administrator for CHBWVand has worked at the WVDP for 32 years. She has 20 years of administrative support experience withthe Maintenance Department, including 14 years working with the PM Program and CMMSadministrator functions.

Attachment A-S

Attachment 13

References Reviewed

Attachment B-i

Documents Reviewed/References

Audit of WVDP Corrective Maintenance relative to TSRs and LCOs. This covers the DOEfactor #1.

a. Occurrence Reports for CY2012-2014

2. Audits of Alarm Status and Configuration Control. This covers the DOE factors #2 and #3.a. SOP 313-18, RHWF Alarms and Alarm Responses, Rev. 9, 12/11/12b. SOP 00-29, Main Plant Surveillance Data Sheet Control, Rev. 39, 06/13/13c. SOP 00-52, Conduct of Operations, Rev. 9, 07/24/13d. SOP 00-56, Troubleshooting and Minor Mechanical Maintenance, Rev. 0, 11/26/13e. SOP 55-17, Waste Tank Farm Alarm Response, Rev. 9, 12/17/12f. SOP 56-02, Permanent Ventilation System, Rev. 11,07/25/11g. SOP 63-45, Vitrification Cell Sump Operation, Rev. 5, 07/11/11 INACTIVEh. SOP 63-81, Vitrification and Main Plant Facility Alarm Responses, Rev. 13, 06/13/13i. SOP 64-01, Vit Off-Gas System Equipment, Rev. 7, 08/03/2004j. SOP 313-18, RHWF Alarms and Alarm Responses, Rev. 9, 12/11/12k. WVNS-FAM-001, Keltron System Alarm Code Listing and Guidelines, Rev. 26, 1/22/14I. PSO Turnover Sheet 05/12/14m. SOP 00-29 Round Sheets

3. Audit of tracking and trending preventive and predictive maintenance (PM) onCategory 2 and Category 3 equipment, as well as maintenance repairs. This audit coversDOE factors #4, #5, #6 and #10.

a. PM Status Reports from CHAMPS - August 2013 through April 2014b. PMs Canceled - August 2013 through April 2014c. PMs Suspended - August 2013 through April 2014d. PMs Waived - August 2013 through April 2014e. Comments put in CHAMPS system - August 2013 through April 2014

4. Audit of Inoperable or Impaired Safety Systems/Configuration Control (PSO/FP). Thisaudit covers DOE factors #7 and #21a. PM Status Reports from CHAMPS - August 2013 through April 2014b. PMs Canceled - August 2013 through April 2014c. PMs Suspended - August 2013 through April 2014d. PMs Waived - August 2013 through April 2014e. Comments put in CHAMPS system - August 2013 through April 2014f. Combustible Loading Permit Logg. Daily SAC Reporth. Fire Door Deficiency Listi. Fire Barrier Repair List5. Impairment Logk. Keltron Alarm Printout1. PSO status boardm. PSO Turnover Sheetn. DangerTag Logbooko. Caution Tag Logbookp. SHIP-228, Combustible Control Program for Radiological Facilities, Rev. 2,4/22/13

Attachment B-2

q. SOP 33-16, Operation of Fire Alarm Panels, Draining and Filling of Sprinkler Systemsand Impairment Control, Rev. 7, 01/21/14

r. WVDP-177, WVDP Fire Protection Manual, Rev. 17, 12/19/13s. Combustible Loading Permit Logt. Fire Safety Inspections Pt Quarter 2014

5. Audit of HEPA Filtered Ventilation System PMs (portable and vacuums) andAvailability — These audits cover DOE factors #2, #22, and #7a. SOP 00-29 — Main Plant Surveillance Data Sheet Controlb. SOP 15-09 — Process Building VEC Exhaust Fansc. SOP 15-20 - Operation of Head End Ventilation Systemd. SOP 15-65 — Process Building HVAC Systeme. SOP 56-02 — Permanent Ventilation Systemf. SOP 67-01 — Vitrification Facility HVAC Systemg. SOP 15-28 — In Place Leak Test of HEPA Filtersh. SOP 15-48 — Portable Ventilation Unit Operationi. Filter Efficiency Data Sheetsj. PVU Filter Efficiency Data Sheetsk. LAG Status BoardI. PSO logbooksm. SOP 00-29 readingsn. Preventative and corrective maintenance

6. Audit of Maintenance Lock Out Tag Out (LU/TO). These audits cover DOE factors #2, and#19a. Plant Systems Operation (PSO) Lock and Tag (Danger Tag) Notebookb. P50 Lock and Tag (Caution Tag) Notebookc. Lag Lock and Tag (Danger Tag) Notebookd. Remote Handle Waste Facility (RHWF) Lock and Tag (Danger Tag) Notebooke. SOP 00-04, Lock, Tag and Confirm Procedures, Rev. 24, 02/13/14f. SOP 00-05, Use of Caution Tags, Rev. 8, 01/17/13

7. Audit of WVDP Temporary Modifications. This audit covers DOE factor #20a. Temp Mod Index items

i. PSO-TM-671, 07/13/2011ii. PSO-TM-689, 08/08/2012iii. PSO-TM-697, 05/16/2013iv. PSO-TM-700, 08/01/2013v. PSO-TM-701, 08/14/2013

vi. PSO-TM-704, 12/04/2013vii. PSO-TM-706, 02/24/2014viii. PSO-TM-707, date TBD

ix. PSO-TM-708, 04/19/2014b. Temp Mod 313-53 and 313-55c. SOP 00-49, Rev 6

Attachment B-3

8. Audit of Spurious Safety System Actuation and Spare Parts Availability — This auditcovers DOE factors #24 and #14a. CHBWV Weekly Project Status Report 4-10-14b. SOP 55-17, Waste Tank Farm Alarm Response, Rev. 9, 12/17/12c. SOP 056-02, Permanent Ventilation System, Rev. 11, 07/25/11d. WVNS-FAM-001, Keltron System Alarm Code Listing and Guidelines, Rev. 26, 1/22/14e. ECN 30051f. WVDP-242 Event Investigation and Reporting Manualg. EIP-10 1 Event Investigation Procedures: Categorization and Notification of Events

9. Audit of Configuration Control of Structures — This audit covers DOE factors #7, #22, and#23a. EP-3-007, Engineering Change Notice, Rev. 29, 10/31/12b. EP-3-029, Preparation and Control of Engineering Sketches, Rev. 6, 03/10/10c. SK-IDL-1 20513 Shi, ‘LWC - Core Drilling - 40-10/13 & 70-2 Tank Drilling’d. SK-JDL-120513 Sh2, ‘LWC - Core Drilling - Criticality Wall Grouting’e. SK-JDL-120913 Sh2, ‘LWC - Core Drilling - COA/LXA Core Drill Locations’f. SK-JDL-1 20913 5h2, ‘LWC - Core Drilling - Cross Section Detail’g. SOP 15-88, Appendix A, Core Bore Instructions:h. 2013-001 - LXAi. 2013-002 - XSA to Radiochem Labj. 2013-003 - LWC LXA/COA Core Bore for Tank Drilling and Crit Wall Groutingk. 2014-001 - LWC LXA/COA for UA and Camera1. 2014-002 - LXA LXA/COA for LWC Ceiling Support Installationm. W1301400, PVU Core Boring for LWCn. W1301928, Core Drill Penetration from Solvent Storage Terrace to Upper Warm Aisleo. W1304942, Core drill soil inspection holes in EDR floorp. W1400424, LWC - Criticality Wall Grouting Reinforcementq. WVDP-204, WVDP Quality Level “Q” Listr. EDR Videos. SOP 15-88, Core Boring Instructions, Rev. 0, 10/2013

10. Audit of Emergency Management Open Items/Action Items — This audit covers DOEfactors #4, #10, #11, #12, and #22a. IR-2176, Sheltering Alarm Malfunction, June 13, 2012b. OITS Query Results with Manager Completion Date, Richard Love, Dated May 8, 2014c. WV-101, External and Internal Open Items, Rev. 28d. WV-920, “812” All Page Speaker Annual Functional Test Rev. 4e. WVDP-171, WVDP Emergency Readiness Assurance Plan (ERAP), Rev. 24

11. Audit of Conduct of Operations Self-Assessments — This audit covers DOE factors #6, #10,#11, and #12a. 410 open items generated from 318 ConOps Self-Assessments (Numbers 2012-050

thru 20 14-051) that were completed during the timeframe of May 1,2012 thruMay 15, 2014

12. Audit of Conduct of Operations Standing Orders — This audit covers DOE factors #8 and#14a. Standing Order Index

Attachment B-4

13. Audit of Temporary Procedure Changes — Audit covers DOE factors #20, and #26a. DCIP-101, Controlled Document Review, Approval, and Emergent Change Process,

Rev. 13, 10/31/13b. EMD-007, Personnel Protective Equipment Expectations, Rev. 1, 08/20/12c. EP-5-002, Administration of Work Instruction Package, Rev. 37, 03/19/14d. SOP 00-49, Temporary Modification Control, Rev. 6, 09/30/13e. SOP 00-52, Conduct of Operations, Rev. 9,07/24/13f. Nuclear Operations and Storage (NOS) Standing Orders:g. 50-001, Rev 4, Plant Systems Operations Conduct of Operations Expectations,

04/30/13h. SO-005, Rev 2, Remote Worker Program, 02/05/13i. WVDP-011, WVDP Industrial Hygiene and Safety Manual, Rev. 34, 09/27/12

14. Human Performance Errors — Audit covers DOE factor #13All Fact Finding Minutes, Incident Reports and Occurrence Reports from 2012 through 2014.The assessment included 55 Fact Finding Reports and 155 Incident Reports.

15. Audit of Radiological Control Instrument Availability — Audit covers DOE factors #7, #8,#22, #23, and #24a. Radiological Controls Log Book CY2012b. Radiological Controls Log Book CY2013c. Radiological Controls Log Book CY2014d. Radiological Controls E-Log Book CY2014

16. Audit of Fire Protection System Availability — Audit covers DOE factors #7, #8, #22, #23,and#24a. SERF Log

17. Audit of Power/Backup power Availability — Audit covers DOE factors #7, #8, #22, #23,and #24a. SOP 00-29, Main Plant Surveillance Data Sheet Controlb. SOP 30-01, Main Plant Standby Power Generationc. SOP 30-03, STS Quarterly Electrical Outage Testd. SOP 30-04, UR SG Operations and Maintenancee. SOP 30-05, Main Plant Quarterly Power Outage Testf. SOP 30-08, STS/PVS Standby Generator Operationg. SOP 30-09, Site Substation Operation, Isolation and Maintenanceh. SOP 63-43, Uninterruptible Power Supply Operationi. SOP 63-83, Standby Diesel Generator and Electricalj. Distribution System Operation, Reviewed generator SOP data sheetsk. Reviewed FR notifications for last two years1. Review of Preventative and corrective maintenancem. CHBWV Weekly Project Status Report 05-01-14

18. Safety System Performance (Successful or Not) When Tested - Audit covers DOE factor#22 and #23

Attachment B-S

19. Audit of Procedure Non-Compliance Events — Audit covers DOE factor #18a. CHBWV Contractor Assurance Reports March 2013— April 2014b. WVDP-257 WVDP Manual for the Preparation, Review, Approval, Distribution and

Revision of Controlled Documents

20. Audit of abnormal procedure entries/emergency procedure entries/unplannedprocess shutdowns/unplanned automatic process shutdowns, and spurious safetysystem actuations — Audit covers DOE factors #9, #14, #15, #16, #17 and #24Documents Revieweda. WVDP-242 Rev. 19, Event Investigation and Reporting Manualb. EIP-101, Rev. 1, Event Investigation Procedures: Categorization and Notification of

Eventsc. 000-29, Rev. 039, Main Plat Surveillance Data Sheet Controld. 063-83, Rev. 008, Standby Diesel Generator and Electrical Distribution System

Operatione. 030-01, Rev. 025, Main Plant Standby Power GenerationE 015-09, Rev. 014, Process Building VEC Exhaust Fansg. 030-03, Rev. 009, STS Quarterly Electrical Outage Testh. 015-020, Rev. 015, Operation of Head End Ventilation Systemi. 030-004, Rev. 006, UR SG Operations and Maintenancej. 015-065, Rev. 003, Process Building HVAC Systemk. 030-005, Rev. 011, Main Plant Quarterly Power Outage1. 030-008, Rev. 009, STS/PVS Standby Generator Operationsm. 056-002, Rev. 012, Permanent Ventilation Systemn. 030-009, Rev. 004, Site Substation Operation, Isolation and Maintenanceo. 067-001, Rev. 009, Vitrification Facility HVAC System

Referenceso DOE 0 151.1C, Comprehensive Emergency Management Systemo DOE 0 232.2, Occurrence Reporting and Processing of Operation Informationo DOE 0422.1, Conduct of Operations

21. Audit of grievances, and personal radiological contamination events over the past twoyears — Audit covers DOE factors #28, and #29a. Grievance documentation August 2012-May 2014b. CHBWV Contractor Assurance Reports May 2012 — April 2014

22. Audit of personal chemical exposure events over the past two years — Audit covers DOEfactor #30a. CHEWy Contractor Assurance Reports May 2012 — April 2014

23. Audit of the Management Observation System Data — Audit covers DOE factor #28a. A representative sampling of lAP assessments were reviewed from 2012, 2013 and

2014.b. Tracking and trending charts from the Contractor Assurance Report.

Attachment 8-6

Attachment C

Personnel Interviewed

Attachment C-i

Personnel Interviewed/Contacted

Audit of WVDP Corrective Maintenance relative to TSRs and LCOs. This covers the DOEfactor #1.a. Joe Wolniewicz, Nuclear Safety/Criticality

2. Audits of Alarm Status and Configuration Control. This covers the DOE factors #2 and#3.a. Tim Ploetz, Plant Systems Operations Operatorb. Ed Raimonde, Engineering, Senior Engineerc. Rich Watson, Plant Systems Operations Supervisord. Paul Bednarz, Ventilation System Engineere. Pat Douglas, Fire Protection System Engineerf. Rich Haslinger, RHWF Engineer

3. Audit of tracking and trending preventive and predictive maintenance (PM) onCategory 2 and Category 3 equipment, as well as maintenance repairs. This auditcovers DOE factors #4, #5, #6 and #10.a. Matt Reed, Electrical Maintenance Managerb. Rick Myers, Maintenance Managerc. Debra Zerfas, CMMS Administrator

4. Audit of Inoperable or Impaired Safety Syitems/Configuration Control (PSO/FP). Thisaudit covers DOE factors #7 and #21a. Dave Kaczmarski, LAG Supervisorb. Paul Bendarz, Cognizant System Engineerc. Matt Reed, Plant S&M Electrical &Instrumentation Managerd. Rick Myers, Plant S&M Mechanical Managere. Debra Zerfas, CHAMPS Administratorf. Peg Brown, Fire Safety Specialistg. Pat Douglas, Fire Protection System Engineerh. Betty Ras, Security Officeri. Rich Watson, Plant Systems Operations Supervisor

5. Audit of HEPA Filtered Ventilation System PMs (portable and vacuums) andAvailability — These audits cover DOE factors #2, #22, and #7a. Jim Baker, Operations Manager

6. Audit of Maintenance Lock Out Tag Out (LO/TO). These audits cover DOE factors #2, and#19a. David Miller, Plant Systems Operations Operatorb. Kirby Perry, Plant Systems Operations Operatorc. Tim Ploetz, Plant Systems Operations Operatord. Jim Baker, Operations Managere. Rich Watson and David Miller, PSO Supervisor and PSO Operatorf. David Kaczmarski, Lag Logistics Supervisorg. Dan Mecca, RHWF Supervisor

Attachment C-2

7. Audit of WVDP Temporary Modifications. This audit covers DOE factor #20a. Dan Mecca, RHWF Supervisorb. Rich Watson, Plant Systems Operations Supervisor

8. Audit of Spurious Safety System Actuation and Spare Parts Availability. This auditcovers DOE factors #24 and #14a. Tim Ploetz, Plant Systems Operations Operatorb. Pat Douglas, Fire Protection System Engineerc. Ed Raimonde, Instrumentation System Engineerd. James Baker, Nuclear Operations Managere. Malt Reed, Electrical Maintenance Supervisorf. Rick Myers, Maintenance Supervisor

9. Audit of Configuration Control of Structures. This audit covers DOE factors #7, #22, and#23a. Mark Agnew, LWC System Engineerb. Pat Douglas, Fire Program System Engineerc. Jeremy Lons, D&D Plannerd. Allen Upshaw, Chief Engineere. Jim Woodworth, Plant Structures System Engineer

10. Audit of Emergency Management Open Items/Action Items. This audit covers DOEfactors #4, #10, #11, #12, and #22a. Marge Baldi, Sr. Emergency Management Specialistb. Rick Love, Safeguards and Security Managerc. Larry Myszka, Open Items Tracking System (OITS) Coordinator

11. Audit of Conduct of Operations Self-Assessments. This audit covers DOE factors #6, #10,#11, and #12a. Michelle Schweickert, Senior Asset Management Specialist

12. Audit of Conduct of Operations Standing Orders. This audit covers DOE factors #8 and#14a. Michelle Schweickert, Senior Asset Management Specialistb. Patrick Troescher, Waste Facility and Logistics Manager

13. Audit of Temporary Procedure Changes. Audit covers DOE factors #20, and #26a. Mark Trowbridge, Plant Systems Operations Operatorb. Bob Scharf, Plant Systems Operations System Engineerc. Rich Watson, Plant Systems Operations Supervisor

14. Audit of Human Performance Errors. Audit covers DOE factor #13a. Sharon Cook, Human Performance and Reliability Managerb. Barbara Hill, Deputy EHSQ

Attachment C-3

15. Audit of Radiological Control Instrument Availability. Audit covers DOE factors #7, #8,#22, #23, and #24a. Nate Bridges, Radiological Controls Managerb. Pete Loretto, Radiological Controls Supervisorc. Sarah Kinsman, Radiological Controls Supervisor

16. Audit of Fire Protection System Availability. Audit covers DOE factors #7, #8, #22, #23,and #24a. Margaret Brown, Fire Protection Technicianb. Pat Douglas, Fire Protection Engineer

17. Audit of Power/Backup power Availability. Audit covers DOE factors #7, #8, #22, #23,and #24Interviews:a. Rich Watson, Plant Systems Operations Supervisorb. William Sullivan, Electrical System Engineer

18. Safety System Performance (Successful or Not) When Tested. Audit covers DOE factor#22 and #23a. Rich Watson, Plant Systems Operations Supervisorb. Kirby Perry and David Miller, Plant Systems Operations Operatorsc. Margaret Brown, Fire Protection Techniciand. Pat Douglas, Fire Protection Engineere. Bill Sullivan, Electrical Engineer

19. Audit of Procedure Non-Compliance Events. Audit covers DOE factor #18a. Jim Baker, Nuclear Operations Managerb. Lori Kearney, Records Manager

20. Audit of abnormal procedure entries/emergency procedure entries/unplannedprocess shutdowns/unplanned automatic process shutdowns, and spurious safetysystem actuations. Audit covers DOE factors #9, #14, #15, #16, #17 and #24a. Jim Baker, Nuclear Operations Managerb. Matt Reed, Electrical Maintenance Supervisorc. Rick Myers, Maintenance Supervisord. Rich Watson, Plant Systems Operations Supervisor

21. Audit of grievances, and personal radiological contamination events over the past twoyears. Audit covers DOE factors #28, and #29a. Toni Sawyer, Human Resources Managerb. Nate Bridges, Radiological Controls Manager

22. Audit of personal chemical exposure events over the past two years. Audit covers DOEfactor #30a. Delwin AlIred, Safety Manager

23. Audit of the Management Observation System Data. Audit covers DOE factor #28a. Larry Myszka, Performance Assurance Coordinatorb. Delwin Allred, Safety Manager

Attachment C-4