TSDF Pilot Roundtable

Pete Yerace, U.S. Department of Energy Consolidated Business Center

Gene Grohs, Pacific Northwest National Laboratory

Patty Hunt, U.S. Department of Energy Thomas Jefferson Site Office

Susan Aderholdt, DOECAP Operations Team

1

Pros Definitely Outweigh the Cons

Pros:The DOECAP auditors are able to spend less time preparing for the on-site portion of the audit, since the checklists are filled out prior to the start of the audit.

Less of the TSDF staff’s time is needed during the on-site portion of the audit IF the checklist are filled out accurately and completely because the interviews can be shorter and more to the point, which saves the facility personnel time.

There are usually fewer document requests during the on-site portion of the audit if the checklist are accurate and complete and the associated documents from the TSDF are made available to the audit team well in advance of the audit.

DOECAP auditors can actually spend more time in the facility verifying and less time looking through documentation and filling out the checklists.

Cons:The TSDF staff has to fill out the checklist ahead of time.

2

Lessons Learned Discussion Points

Team Lead: One self-identified finding at a facility was documented on a checklist, but this was not noticed by the DOECAP auditor.

One solution: In the end, it is the team lead’s responsibility to ensure that every checklist has been screened to ensure all of the facility’s self-identified findings have been captured.

Another solution: The TSDF can be asked to provided a list of the self-identified findings at the opening meeting for the audit.

Suggestions?

One facility requested that an agenda with specific times for interviews be established prior to the start of the DOECAP audit.

This turned out to be quite helpful. It forced the auditors to prioritize and get to the point during their interviews with the facility subject matter experts (SMEs).

CAVEAT: The agreement needs to be established up front with the facility that if an auditor needs additional contact, the facility SME will be made available.

Suggestions?3

Lessons Learned Discussion Points

Auditors:One self-identified finding at a facility was documented on one checklist, but in fact, it really belonged in a different checklist (e.g., Environmental Compliance vs. Waste Operations).

Continue to streamline the checklists to eliminate redundancy between the audit discipline areas.

Suggestions?

Some checklists were completed by more than one SME at the facility, and none of the checklists identified the SME(s) that completed them.

This put a burden on the DOECAP auditors when they were trying to validate the checklist results.

One solution: The SME that filled out the checklist should be identified and able to defend every item to the DOECAP auditor.

Suggestions?4

Actions Taken Based on the Lessons Learned

The audit checklists have been modified so that each checklist section now contains a signature block for the facility SME that filled out that section of the checklist.

The audit checklists were also modified to accommodate the facility’s comments and the auditor’s comments.

5

Example of the Checklist Changes

Item Number

Lines of Inquiry StatusFacility

Response/CommentStatus

AuditorResponse/Comment

1.0 Quality Assurance Program    1.1  

Program Management Facility Reviewer__________________________________________

1.1.1 Are responsibilities for the establishment and implementation of the quality assurance program defined?

NQA-1 Requirement 1, Section 201(d)

       

1.1.2 Does the facility have a documented quality assurance program that is planned, implemented, maintained and consistent with license conditions?

NQA-1 Requirement 2

       

1.1.3 Does the documented quality assurance program describe the organizational structure, functional responsibilities, and levels of authority?

NQA-1 Requirement 2

       

1.1.4 Does the scope of the documented quality assurance program meet the applicable Quality Assurance criteria as licensed by the Nuclear Regulatory Commission (NRC) or a State under Agreement with the NRC?

Site Specific Radioactive Materials License

       

1.1.5 Does the organization establish and implement processes to detect and correct quality problems?

Integrated Safety Management and NQA-1 Requirement 2

       

6

Lessons Learned Discussion Points

Facility Feedback:Why are so many auditors here when we completed the checklists ourselves? We understand the need for auditors-in–training, but does there still have to be a DOECAP auditor for each checklist?

This was the first time the facility had completed the checklists, and the quality varied across checklists.

Perhaps the checklists could be reviewed in advance, and if the quality is high enough, one DOECAP auditor might be able to cover two checklists. Comments?

Since we are completing the checklists, why doesn’t DOECAP pick a focus area and drill down on a specific program?

Is it really DOECAP’s mission to drill down?

Wouldn’t the facility or its corporate management be better equipped for that type of audit? Comments?

7

Additional Value of DOECAP Audits

Most DOE facilities and some subcontractors utilize the DOECAP audits in place of their own audits, especially for quality assurance and data quality where off-site laboratories are concerned.

This saves the DOE facilities from having to conduct additional audits.

If the facility has been audited by DOECAP, some sites consider the facility to be “qualified” and will place it on their evaluated suppliers list.

Priority Level I and Level II findings must taken into account when adding a facility to the evaluated suppliers list.

Some sites have an off-site audit coordinator (OSC) that has the ultimate responsibility of determining which facilities may be used.

Most OSCs evaluate the DOECAP audit reports and determine if the facility may be used and for which waste streams.

Example: Some recyclers manage mercury very well but not batteries, so the OSC may place a restriction on individual waste streams.

8

How many audits and how often?

Some sites conduct one on-site per year to start with:

If there are no major issues after two to three years of on-site audits, then desk audits are performed every one to two years for five years.

Then it’s time for another on-site audit. If there are no issues , the site goes back to desk audits for five years.

Desk audits can be discipline-specific (e.g., RCRA, quality, data quality, radioactive waste).

Desk Audits:

Verify federal, state, and local compliance.

Include a review of completed checklists provided by the facility.

Include a review of the regulatory agency(ies) Letters of Violation and Letters of Noncompliance (or alleged noncompliance) since the last audit. These letters and the facility’s responses to them must be submitted with the completed checklists.

9

Lessons Learned – New Opportunities

As an offshoot of the TSDF Pilot and as a result of our discussions with the sites, it has come to our attention that a number of DOE sites use the DOECAP audits as the basis for additions to their evaluated suppliers list/approved vendor list.

DOECAP has been approached about adding auditors to the DOECAP audit teams from sites which are still performing vendor supply audits so that the facility would have even fewer audits.

This would benefit DOECAP by increasing the auditor cadre. However, these auditors would need to go through the qualification process just like any other DOECAP auditor-in-training.

The TSDFs and auditors are enthusiastic about the TSDF Pilot and, with few exceptions, the TSDFs that have participated are eager to implement the full initiative.

10

What other types of facilities should be audited?

Recycle Facilities:Estimated: Half of the U.S. Environmental Protection Agency and state fines issued in 2014 were for violations by recycling facilities.

Waste Brokers:Where is your waste really going?

Certificate of acceptance or destruction?

Landfills:Used by TSDFs.

Future CERCLA liabilities.

11

Why look at other kinds of waste facilities?

RCRA issues — Environmental compliance.

CERCLA issues — These facilities may end up being DOE’s responsibility.

Which sites pose the greatest risk?

Mixed waste?

Hazardous?

Recycling facilities?

12

Typical Lamp Recycle Facility Used by DOE

April 20, 202313

Nonradiological TSDF Fire

April 20, 2023 14

Another TSDF Fire

April 20, 2023 15

Explosion and Fire at Solvent Recycler

16

This is Where DOE’s Lithium Batteries Go

17

http://www.youtube.com/watch?v=dfQwYKqmfk4

TMTV News photograph of the 2009 battery recycling plant fire in Trail, British Columbia

Questions? Comments?