Barrier Change Root Cause Analysis

7/21/2019 Barrier Change Root Cause Analysis

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U.S. Department of Energy

Office of Environmental Management

Type B Accident Investigation Report

Radiological Contamination Event

Dring Separations !rocess Researc"

Unit Bilding #$ Demolition

Septem%er $&' $()(

*ovem%er $+' $()(



Disclaimer

This report is an independent product of the Type B Accident Investigation Board appointed by

Mark A. Gilbertson, Deputy Assistant Secretary for rogra! and Site Support, ".S. Depart!ent

of #nergy. The Board $as appointed to perfor! a Type B Accident Investigation and to prepare

an investigation report in accordance $ith Depart!ent of #nergy %D&#' &rder (().*A,

Accident Investigations.

The discussion of the facts as deter!ined by the Board and the vie$s e+pressed in the report do

not assu!e, and are not intended to establish, the e+istence of any duty at la$ on the part of the

".S. Govern!ent, its e!ployees or agents, contractors, their e!ployees or agents, or

subcontractors at any tier, or any other party.

This report neither deter!ines nor i!plies liability.



Release Authorization

&n &ctober ((, (*, a Type B Accident Investigation Board $as appointed to investigate the

Septe!ber (-, (* radiological conta!ination during Separations rocess esearch "nit

Building /( de!olition. The Board0s responsibilities have been co!pleted $ith respect to this

investigation. The analyses and the identification of the contributing causes, the root cause and

the 1udg!ents of 2eed resulting fro! this investigation $ere perfor!ed in accordance $ith

D&# &rder (().*A, Accident Investigations.

The report of the Accident Investigation Board has been accepted and the authori3ation to

release this report for general distribution has been granted.



i

Table of Contents

E,ective S mmary ....................................................................................................................... )

).( Introdction .............................................................................................................................. -

*.*. Bacgrond .................................................................................................................. -

*.(. /acility Description ...................................................................................................... 0

*.4. /acility Mission ............................................................................................................ 1

*.5. Environmental Restoration ......................................................................................... 1

*.). Contractal Relations"ip ............................................................................................ 2

*.6. Scope' !rpose' and Met"odology ............................................................................. 2

$. ( T" e /acts ................................................................................................................................ )(

(.*. Event Description ...................................................................................................... )(

(.(. C"ronology of Events ............................................................................................... )3

(.4. Event Response. ........................................................................................................ )0

(.4.*. eporting. ........................................................................................................ *7

(.4.(. 8ausal Analysis ............................................................................................... *9

(.5. E,amination of Evidence ......................................................................................... )2

(.5.*. Docu ! ents elating to the 8ontrol of : ork .................................................. *9

(.5.(. Authori3ation of : ork .................................................................................... (*

(.). !ost Event Anomalies ............................................................................................... $$

(.).*. &verflo$ing ;A8 Tank and <eaking Ber! #vents ..................................... ((

(.).(. /illsi d e Drain u ! p ;ailure ........................................................................... ((

(.).4. ;A8 Tank <abeling and osting Issues ....................................................... (4

(.).5. aper$ork Discrepancies ................................................................................ (4

(.6. Crrent Stats of Bilding #$ /ootprint ............................................................... $3

(.6.*. 8onta ! ination <evels ..................................................................................... (5

(.7. Investigativ e Readines s an d Scen e !reservation .................................................... $1

+. ( Analysi s o f /acts .................................................................................................................... $2

4.*. At"or i 4 ation of 5or ............................................................................................. $24.(. Radiological Controls ............................................................................................... $&

4.(.*. adiological : ork e r ! its ............................................................................. (-

4.(.(. elease Surveys .............................................................................................. 4*

4.(.4. &ther Surveys. ................................................................................................. 4(

4.(.5. Ai r Monitorin g esults ................................................................................... 44



i

4.(.). 8riti= u e of 8onta ! ination #vent .................................................................... 45

4.(.6. eporting of 8onta ! ination #vent ................................................................. 45

4.4. !revio s Event s an d 6esson s 6earned .................................................................... +0

4.4.*. Arc ;lash # vent ............................................................................................... 46

4.4.(. "nanticipated Airborne adioactivity ............................................................ 464.4.4. ersonnel Skin 8onta!ination ;ollo$ing #ntry into 8ell >* of

Building G( .....................................................................................................46

4.5. Condct of Operations ............................................................................................. +0

4.5.*. aper$ork Discrepancies ................................................................................ 49

4.). Integrated Safety Ma n agement ............................................................................... +2

4.).*. Define the Scope of : ork ............................................................................... 4-

4.).(. Analy3e the /a3ard ......................................................................................... 5

4.).(.*. Technical Basis for &pen Air De!olition ..........................................5

4.).(.(. Strontiu! 8onta!ination ?alues ........................................................5(4.).(.4. re@De!olition Survey .......................................................................54

4.).4. Miti g ate the /a3ards ....................................................................................... 55

4.).5. erfor! :ork $ithin 8ontrols ........................................................................ 56

4.).). rovide for ;eedback and I ! prov e !ent ......................................................... 57

4.).).*. 8ontractor Assurance Syste! .............................................................57

4.).6. Integrated S afety Manage ! ent Guiding rinciples ........................................ 57

4.6. Event and Casal /actors C"art ............................................................................. 32

4.7. Barrier Analysis ........................................................................................................ 3&

4.9. C"ange Analysis ........................................................................................................ 3&

3.( Conclsions and 7dgments of *eed ................................................................................... -(

-.( Board Signatres ................................................................................................................... -+

0.( Board Mem%ers' Advisors' Consltants ............................................................................. -3



ii

Appendi, A8 Appointment of Type B Accident Investigation Board .................Appendi, A9)

Appendi, B8 Barrier Analysis.................................................................................Appendi, B9)

Appendi, C8 C"ange Analysis ................................................................................Appendi, C9)

Appendi, D8 Events and Casal /actor Analysis .................................................Appendi, D9)



3

Figures

;igure *@* Aerial hotograph of "pper <evel <ooking South %hoto >A@*, *-97'......................6

;igure *@( Accident Investigation Ter!inology.............................................................................-

;igure (@* ;acing 2orth of the Building /( on the Afternoon of Septe!ber (), (* ..............*

;igure (@( Building /( 44( #levation .......................................................................................**

;igure (@4 ;lash 8olu!n being Si3e educed ............................................................................*(

;igure (@5 Building ;ootprint Taken Afternoon of &ctober (4, (* ........................................(5

;igure (@) Appro+i!ate Area of 8onta!ination .........................................................................(6

;igure 4@* Inco!plete Application of ;i+ative to Separator 8olu!ns Septe!ber (-, (* .... .5)

;igure 4@( Septe!ber (-, (* ost 8olu!n **4@A e!oval ...................................................5)

;igure D@* #vents and 8ausal ;actors Analysis .......................................................Appendi+ D@*

Tables

Table #S@* 8onclusions and 1udg!ents of 2eed...........................................................................4

Table (@* Su!!ary #vent 8hart and Accident 8hronology .......................................................*5

Table 4@* Isotopic Analysis of #ast Side eri!eter Air Sa!ples ................................................44

Table 4@( 8o!parison of &riginal and 8urrent S" D adiological Inventory ....................5

Table 5@* 8onclusions and 1udg!ents of 2eed ...........................................................................)

Table B@* Barrier Analysis ........................................................................................Appendi+ B@*

Table 8@* 8hange Analysis .......................................................................................Appendi+ 8@*



Legend

#* #lectrician

#&* #=uip!ent &perator C shear trackhoe operator

#&( #=uip!ent &perator C ha!!er trackhoe operator #&4 #=uip!ent &perator C inter!odal loader

#&5 #=uip!ent &perator C $ater spray operator

&M DD &perations Manager

8M adiological 8ontrols Manager

8T* adiological 8ontrols Technician

8T( adiological 8ontrols Technician

:S :aste Superintendent


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Acronyms

A<AA as lo$ as reasonably achievable

AA%s' applicable or relevant and appropriate re=uire!ents

BEA breathing 3one analy3er

c!(

S=uare 8enti!eter

8&A condition of approval

cp! counts per !inute

DA8 derived air concentration

dp! disintegrations per !inute

D&# "nited States Depart!ent of #nergy

D&# G D&# Guide

D&# & D&# &rder

D&# M D&# Manual

1/A 1ob /a3ard Analysis

1&2 1udg!ent of 2eed

FA< Fnolls Ato!ic o$er <aboratory

&S &ccurrence eporting and rocessing Syste!

&D lan of the Day

!hr !illiroentgenhour

2<;& &ffice of 2aval eactors <aboratory ;ield &ffice

8 radiological calculation

ad8on adiological 8ontrols

#M roentgen e=uivalent

!an

: adiological :ork er!it

S" Separations rocess esearch "nit

S"@D S" Disposition roHect

:A8 :aste Acceptance 8riteria

:GI :ashington Group International



Executive ummary

!ntroduction

&n Septe!ber (-, (*, a radioactive conta!ination event occurred $hile perfor!ing open air

de!olition of Building /( at the Separations rocess esearch "nit %S"' in 2iskayuna, 2e$

ork. Though initial indications de!onstrated that lo$ levels of conta!ination had been foundon $orkers shoes and on FA< property adHacent to the S" $ork activities, the !agnitude

and significance of the conta!ination event $ere not fully identified and understood by the

S" proHect for several days. Based on the esti!ated cost to re!ediate the accident and event

circu!stances, a Type B investigation $as ordered. &n &ctober ((, (*, Mark Gilbertson,

Deputy Assistant Secretary for rogra! and Site Support, ".S. Depart!ent of #nergy, &ffice of

#nviron!ental Manage!ent %D&#@#M', for!ally appointed a Type B Accident Investigation

Board to investigate the accident in accordance $ith D&# &rder (().*, Accident Investigations.

The Board began the investigation on &ctober (9, (*, co!pleted the investigation on 2ove!ber **, (*, and sub!itted findings to the Deputy Assistant Secretary for rogra! and

Site Support on 2ove!ber *(, (*.

Accident Descri"tion

By Septe!ber (-, (*, de!olition of Building /( had progressed to the point $here the roof

structure, the stack, and the e+terior and interior $alls $ith the e+ception of the north end above

the 44( building elevation had been de!olished and placed in inter!odal containers for

disposal. De!olition cre$s had re!oved an interior $all along the $est half of the north end of

the building the day before and $ere in the process of re!oving si+ evaporator syste!

co!ponents that e+tended above and belo$ the 44( elevation along the north@!ost outer $all.

;ollo$ing discussion in a 9 !orning !eeting on Septe!ber (-, (*, the 8leveland

:recking $ork group, $ith :ashington Group Internationals %:GI' concurrence, proceeded

to re!ove the follo$ing co!ponents fro! the north end of building footprint evaporator

condensers ((*@A and ((*@B, and colu!ns **(@A, **(@B, and **4@B, $hich e+tended fro! the

lo$er elevations of the building up above ground level, and si3e reduced condensers ((*@A,

((*@ B, and colu!n **4@B prior to identifying the spread of conta!ination event.

At appro+i!ately *(, the de!olition cre$ began to break for lunch. :orkers e+iting the

area

heard the frisker alar!ing and su!!oned a radiological controls technician %8T' for

assistance. The 8T discovered conta!inated dust on the frisker and re!oved it. ersonnel

$ere directed out of the i!!ediate area due to elevated background radiation readings in that

area and conducted a frisk, finding conta!ination on both boots of each of the four e=uip!ent

operators.

In response to the boot conta!ination event, further radiological surveys $ere conducted

outside the de!olition area and a revie$ of air sa!plers surrounding the area $as perfor!ed.



T$o peri!eter air sa!ples sho$ed elevated readings but :GI deter!ined these readings to be

belo$



2

reportable levels. Surveys $ere also conducted outside the de!olition area. :GI and D&#@

S" notified Fnolls Ato!ic o$er <aboratory %FA<' of the radiological %boot

conta!ination' event appro+i!ately at *5. FA< responded and started e+tensive surveys

outside the S" boundary. :GI discontinued $ork in the area pending further investigation.

During the ti!e of the event, FA< had $orkers perfor!ing asphalt !illing, road$ay

resurfacing preparations, and various other constructionoperations activities to the east of the

S" site. By the evening of Septe!ber (-, (* FA<s surveys had identified nu!erous

areas of conta!ination on the grounds and so!e roofs in an area about * yards s=uared near

the S" site. Based on survey results, FA< perfor!ed bioassays on over * $orkers that

$ere deter!ined to be in the area on Septe!ber (-, (* or $orkers that assisted in

radiological surveys or subse=uent clean up activities.

The ne+t day, Septe!ber 4, (* and into &ctober *, (*, the S" proHect e+perienced

e+ceptionally heavy rains due to Tropical Stor! 2icole, greater than the * year rain. ainfall

totals $ere recorded at or above 7 inches.

Direct# Root# and Contributing Causes

The Board identified the open air de!olition of the evaporator syste! co!ponents as the direct

cause of the accident.

The Board identified t$o root causes for the accident. #li!inating these $ould have prevented

the uncontrolled spread of conta!ination.

• The failures by :GI to fully understand, characteri3e, and control the radiological ha3ard.

• The failure by :GI to i!ple!ent a $ork control process that ensured facility conditionssupported proceeding $ith the $ork.

In addition, ( contributing causes $ere identified.

Conclusions and $udgments of %eed

Table #S@* su!!ari3es the conclusions and 1udg!ents of 2eed %1&2' deter!ined by the

Board.

The conclusions are those the Board considered significant and are based on facts and pertinent analytical results. 1udg!ents of 2eed are !anagerial controls and safety !easures believed by the Board to be necessary to prevent or !ini!i3e the probability or severity of arecurrence of this type of accident. 1udg!ents of 2eed are derived fro! the conclusions andcausal factors and are intended to assist !anagers in developing corrective actions.



Table E&1' Conclusions and $udgments of %eed

Conclusions $udgments of %eed

The Board concluded WGI placed an over-reliance on the application and effectiveness of

"fixative" to control contamination duringdemolition and prevent the spread ofcontamination off-site.

WGI needs to re-evaluate and justify thecontamination control techniues used during

demolition.

The Board concluded WGI did not applyfixative to the !lash olumn and #eparatorolumns in the $est "%ot" &vaporator cell.

WGI needs to ensure contamination controltechniues are $ell defined and executed as specifiedin $or' control documents.

The Board concluded the radiation protectionprogram $as ineffective in evaluating andcontrolling contamination sources duringdemolition activities.

The Board concluded the execution of the"(emo )rep" and "(emolition" $or' pac'ages

did not result in the identification and control ofcontaminated components.

The Board concluded the radiological dataused did not result in appropriatelycharacteri*ing and controlling the radiologicalha*ard.

WGI needs to evaluate the current +adiation)rotection )rogram and implement improvements thatdemonstrate competence and rigor, specifically asapplied to the characteri*ation and control ofradioactive contamination. This needs to include

strengthening the 'no$ledge, s'ills, and ailities ofthe +adiological ontrols Technicians.

The Board concluded that the WGI process for authori*ing $or' tas's did not ensure the $or'$as revie$ed y the appropriate #ujectatter &xperts at the )/( efore proceeding.

WGI needs to estalish a $or' planning andauthori*ation process that ensures revie$, approval,and authori*ation y cogni*ant management andsuject matter experts.

The Board concluded that (/& and WGI

oversight programs $ere ineffective in theidentification and correction of environment,safety and health programs deficiencies.

(/& #)+0 needs to strengthen their oversight

process and procedures to maintain sufficient'no$ledge of site and contractor activities to ma'einformed decisions aout ha*ards and ris' andevaluate contractor performance.

WGI needs to strengthen their ontractor 1ssurance#ystem to fully comply $ith (/& / 223.4,Implementation of Department of Energy Oversight

Assurance Program, $ith specific attention to criticalself-assessments and verification of effectiveness ofcorrective actions.

#ome $or'ers perceived schedule pressure

and $ere reluctant to ring up issues that mightslo$ progress.

WGI management needs to cultivate an atmosphere

of open communication and acceptance of employeefeedac' regarding $or' processes and safetyconcerns.



4


The Board concluded the freuent use ofterminology such as 5as reuired,6 5as needed,6and 5as necessary,6 contriuted to a failure tocomplete $or' steps as intended. The

flexiility incorporated into $or' documents ledto individual decision-ma'ing in determining$hat components in Building %2 $ould reuireadditional consideration.

WGI needs to strengthen the level of rigor anddiscipline in executing the $or' planning process suchthat $or' steps provide the necessary detail to ensuresteps are accomplished as planned.



1() !ntroduction

&n Septe!ber (-, (*, a radioactive conta!ination event occurred $hile perfor!ing open air

de!olition of Building /( at the Separations rocess esearch "nit %S"' in 2iskayuna, 2e$

ork. Though initial indications de!onstrated that lo$ levels of conta!ination had been found

on $orkers shoes and on FA< property adHacent to the S" $ork activities, the !agnitude

and significance of the conta!ination event $ere not fully identified and understood by the

S" proHect for several days. Based on the esti!ated cost to re!ediate the accident and event

circu!stances a Type B investigation $as ordered. &n &ctober ((, (*, Mark Gilbertson,

Deputy Assistant Secretary for rogra! and Site Support, ".S. Depart!ent of #nergy, &ffice of

#nviron!ental Manage!ent %D&#@#M', for!ally appointed a Type B Accident Investigation

Board to investigate the accident in accordance $ith D&# &rder (().*, Accident Investigations.

The Board began the investigation on &ctober (9, (*, co!pleted the investigation on

2ove!ber **, (*, and sub!itted findings to the Deputy Assistant Secretary for rogra! and

Site Support on 2ove!ber *(, (*.

In accordance $ith the appoint!ent letter, the Board focused the investigation on the

conta!ination event resulting fro! deconta!ination and de!olition $ork that occurred at the

S" /( facility on or about Septe!ber (-, (*. Subse=uent to the conta!ination event there

$ere t$o additional events related to the hillside drain syste!. Although the Board did not

thoroughly investigate these events, conta!ination control, $ork planning, and e+ecution

deficiencies $ere evaluated by the Board to be si!ilar to those identified in this report. The

Board strongly reco!!ends that D&#@S" and :GI corrective action plans include these

events in order to prevent recurrence.

The content of this report identifies additional issues that did not result in a conclusion or

a Hudg!ent of need. /o$ever, the Board reco!!ends they be considered $hen

developing corrective action plans.

4.4. *ac+ground

The Separations rocess esearch "nit %S"', located at the Fnolls Ato!ic o$er <aboratory

%FA<' near Schenectady, 2e$ ork, $as operated fro! *-) to *-)4 as a pilot plant to

research the #D&J and "#J che!ical processes to e+tract "raniu! and lutoniu! fro!

irradiated "raniu!. It supported operations at the /anford Site %:ashington State', and the

Savannah iver Site %South 8arolina'. The research $as perfor!ed on a laboratory scaleK S"

$as never a production plant.

8onstruction on Buildings /( and G( began in *-59, $ith co!pletion in *-5-. The research

operations conta!inated the S" facilities and land areas, resulting in the need tore!ediate the site. After *-)4, FA< continued to use Building /( into the late *--s for$aste processing %e.g. processing of adioactive Materials <aboratory reuse $ater and periodic cleanout of tank far! vaults'.



4.2. Facility Descri"tion

S", at FA<, is located appro+i!ately ( !iles east of the city of Schenectady in the

northeastern part of Schenectady 8ounty in 2e$ ork State. The S" proHect occupies

appro+i!ately ) acres of the appro+i!ate ( acres of land !anaged by Fnolls Ato!ic o$er

<aboratory.

The S" facility consists pri!arily of t$o interconnected buildings

• Building G( C housed the laboratories, hot cells, separations process testing e=uip!ent,and the tunnel syste! beneath Building G(. Building G( hot cells, e=uip!ent, ventilationprocess piping syste!s, and tunnels contain residual radioactive conta!ination. There is lo$ level radioactive conta!ination throughout the facility and syste!s.

• Building /( C used for li=uid and solid $aste processing. All areas of this building e+ceptthe entry$ay on the 44( elevation are under radioactive controls.

• /( Tank ;ar! %also kno$n as the tank vaults' C a series of underground concrete@enclosed

stainless steel tanks along the eastern side of Building /( used for storing li=uid radioactive$aste. The tanks have been consolidated into a single tank.

• ipe Tunnels C concrete passage$ays connecting the /( Tank ;ar!, Building /( to

Building G(, and Building G( to Buildings G* and #*. The ipe Tunnels contain residual

radioactive !ater ial.

Figure 1&1' Aerial ,hotogra"h of -""er Level Loo+ing outh .,hoto /A&1# 1023



4.7. Facility 4ission

The facility is currently undergoing deconta!ination and deco!!issioning activities under the

purvie$ of the Depart!ent of #nergys %D&#' &ffice of #nviron!ental Manage!ent %#M'. In

Septe!ber *--(, the Depart!ent0s &ffice of 2uclear #nergy, %current organi3ation is &ffice of 2aval eactors <aboratory ;ield &ffice L2<;&' and #M signed a Me!orandu! of

Agree!ent %M&A' on deconta!inating and deco!!issioning the S" facilities. The M&A

$as supple!ented $ith the S" ;unctions, Assign!ents, and esponsibilities Agree!ent

%;A' in (, %current evision (, dated ;ebruary, (-' establishing the roles and

responsibilities of each &ffice regarding the deconta!ination and deco!!issioning of S".

"pon the co!pletion of the de!olition and clean@up, and sa!pling to ensure the clean@up levels

have been !et, the land $ill be transferred back to the 2<;& for their continued !ission use.

The ;A at the Fnolls Ato!ic o$er <aboratory, Fnolls Site, provides the division of

responsibility and defines oversight protocols. #M is the S" roHect o$ner and responsible

for overall proHect coordination. 2<;& is the 8ogni3ant govern!ent agency for FA<. #Mand FA< !eet periodically to discuss integration and interferences $ith each others

operations. The e+tent of 2<;& overvie$ of D&#@S" and the :GI activities $ill be

co!!ensurate $ith the potential of adversely affecting FA<s operations.

4.8. Environmental Restoration

The S" site process facilities and adHacent land areas include appro+i!ately five acres and

are !anaged by the ".S. Depart!ent of #nergy. The proposed action is the deco!!issioning

and deconta!ination of four buildings and associated facility structures including tank far!s,

vaults and pipe tunnels, and re!oval of any conta!inated soils.

In April (6, #M co!pleted the 2uclear ;acility /istorical Site Assess!ent %/SA' for the

Separations rocess esearch "nit Disposition roHect. The /SA docu!ented the radiological

conditions of Building /(, including a description of the east and $est evaporator cells as

follo$s

The *-9- survey of the $est evaporator bay identified general area radiation of

.6 to 5 !illie! per hour closed $indo$ and .9 to 5 !illie! per hour open

$indo$. There $as a !a+i!u! reading on the sight glass isolation valve on the

side of the $est evaporator of *( !illie! per hour closed $indo$ and *)

!illie! per hour open $indo$. <oose surface conta!ination of floor areas

indicated up to 5) pico8uries per * s=uare centi!eters %up to ---

disintegrations per !inute' betaga!!a. <oose surface conta!ination on the

sight glass isolation valve indicated less than ) pico8uries per * s=uare

centi!eters %less than *** disintegrations per !inute' alpha and )5,

pico8uries per * s=uare centi!eters %**-,99 disintegrations per !inute'



betaga!!a %8@*-9, pp. (@4'. Based on this survey, the $est evaporator bay

is a high radiation area and a high conta!ination area. ;urther characteri3ation

is re=uired to assess any change in radiological conditions since the *-9- survey.



4.9. Contractual Relationshi"

&n Dece!ber *4, (7, D&# announced the a$ard of a four@year task order to :ashington

Group International %:GI' to provide deactivation, de!olition, and re!oval of the S"

nuclear facilities %Buildings G(, /(, the Tank #nclosures, and the connecting tunnel'K cleanup

and environ!ental restoration of the underlying and surrounding conta!inated soilK and the

deconta!ination of piping tunnel connecting the S" facilities to other operating facilities.

:GI $as a$arded additional funding fro! the A!erican ecovery and einvest!ent Act by

D&# to cover the costs associated $ith the current task order $ork scope as $ell as to accelerate

the co!pletion of the :GI contract scope fro! Dece!ber (** to Septe!ber (**.

4.3. co"e# ,ur"ose# and 4ethodology

The Board began its investigation on &ctober (9, (*, and co!pleted the investigation and

sub!itted its final report to Mark A. Gilbertson, Deputy Assistant Secretary for rogra! and

Site

Support, on 2ove!ber *(, (*. The Board revie$ed and analy3ed the circu!stances

surrounding the accident to deter!ine its cause including deficiencies, if any, in safety

!anage!ent syste!s and to understand lessons learned to reduce the potential for recurrence of

si!ilar accidents.

In addition, the Board $as re=uested to specifically address $ork planning and control, proHect

planning, radiological controls, personnel =ualifications and staffing, conduct of operations,

$ith a particular focus on higher ha3ard activities, event response and the contractor assurance

syste!.

The Board conducted its investigation using the follo$ing !ethodology

• ;acts relevant to the accident $ere gathered through intervie$s, docu!ent and evidencerevie$s, and e+a!ination of physical evidence.

• #vent and causal factor charting, along $ith barrier analysis and change analysis techni=ues,$ere used to analy3e the facts and identify the cause%s' of the accident.

• Based on the analysis of infor!ation gathered, Hudg!ents of need $ere developed

for corrective actions to prevent recurrence.



Accident Investigation Terminology

A casal factor is an event or condition in the accident se=uence that

contributes to the un$anted result. There are three types of causal

factors

direct cause%s', $hich is the i!!ediate event%s' or condition%s'that caused the accidentK root causes%s', $hich is the causal factor that, if

corrected, $ould prevent recurrence of the accidentK and the contributing

causal factors, $hich are the causal factors that collectively $ith the

other causes increase the likelihood of an accident, but $hich did not

cause the accident.

Event and casal factors analysis includes charting, $hich depicts the

logical se=uence of events and conditions %causal factors that allo$ed the

accident to occur', and the use of deductive reasoning to deter!ine the

events or conditions that contributed to the accident.

Barrier analysis revie$s the ha3ards, the targets %people or obHects' of

the ha3ards, and the controls or barriers that !anage!ent syste!s put in

place to separate the ha3ards fro! the targets. Barriers !ay be physical

or ad!inistrative.

C"ange analysis is a syste!atic approach that e+a!ines planned or

unplanned changes in a syste! that caused the undesirable results related

to the accident.

Figure 1&5' Accident !nvestigation Terminology



5() The Facts

2.4. Event Descri"tion

Deconta!ination and de!olition preparation activities occurred at the S" site for the several

!onths preceding the accident. De!olition, using heavy e=uip!ent, of Building /( began on

Septe!ber (4, (*.

Figure 5&1' Facing %orth of the *uilding 65 on the Afternoonof e"tember 57# 5)1)

rior to Septe!ber (-, (*, de!olition of Building /( had progressed to the point $here the

roof structure, the stack, and the e+terior and interior $alls $ith the e+ception of the north end

above the 44( building elevation had been de!olished. So!e of the de!olition debris had

been placed in inter!odal containers for disposal. De!olition cre$s had re!oved an interior

$all along the $est half of the north end of the building the day before and $ere in the process

of re!oving si+ evaporator syste! colu!ns that e+tended above and belo$ the 44( elevation

along the north@!ost outer $all.



Figure 5&5' *uilding 65 8859 Elevation

The D&# #S/N Manager $as at the 9 !eeting on Septe!ber (-, (*, $hen the re=uest

$as !ade to re!ove the evaporator syste! co!ponents that e+tended above the 44( elevation.

/e did not kno$ if this action $as appropriate and later that !orning, passed the infor!ation to

the D&# S" ;acility epresentative $ho co!!unicated the infor!ation to the D&# S"

Manager. Based on this discussion, though, the D&# S" Manager did not believe that

conta!inated co!ponents $ere being re!oved.

;ollo$ing the !eeting, the 8leveland :recking $ork group, $ith :GI concurrence, proceeded

to re!ove the follo$ing co!ponents fro! the north end of building footprint evaporator

condenserscolu!ns ((*@A and ((*@B, and colu!ns **(@A, **(@B, and **4@B, $hich e+tended

fro! the lo$er elevations of the building up above ground level, and si3e reduced

condensercolu!ns ((*@A, ((*@B, and colu!n **4@B prior to identifying the spread of

conta!ination event.



Figure 5&8' Flash Column being ize Reduced

Three $recking cre$ e=uip!ent operators $ere $orking on Building /( and a fourth $orker

$as spraying $ater for dust suppression. An e=uip!ent operator %#&*' $as on the east side in

the process of re!oving t$o condensercolu!ns fro! the east evaporator cell $hile a second

e=uip!ent operator %#&(' $as re!oving the separator colu!n %**(@A' fro! the $est evaporator

cell. The third e=uip!ent operator %#&4' $as loading de!olition debris into inter!odal

containers. #&* started si3e reducing the condensercolu!ns, and $as stopped $hen an

electrician %#*' and a radiological control technician %8T*' noticed a $hite OpuffP co!ing

fro! one of the condensercolu!ns. 8T* obtained a fla!!able gas !eter and checked the area

of the OpuffP for e+plosive gases and then allo$ed the cre$ to resu!e de!olition. 2o

radiological surveys $ere conducted at this ti!e. After the #&( re!oved the separator colu!n

fro! the $est evaporator cell, he repositioned his e=uip!ent to re!ove the flash colu!n and

separator colu!n fro! the east evaporator cells. The flash and separator colu!ns %**(@B, and

**4@B' $ere re!oved fro! the east evaporator cell and all three colu!ns $ere laid do$n on

Building /( footprint slab. The $ater spray operator %#&5' noted the $ind $as strong enough

that he needed to significantly redirect the no33le to correct for $indage.

:hile re!oving the separator colu!n fro! the $est evaporator cell, a bolt $as eHected into the

air and struck an electrical transfor!er outside the construction boundary. The bolt $as located,surveyed, found to have fi+ed conta!ination, and the bolt $as re!oved. 8T( stated that he

infor!ed his !anage!ent of the survey results. De!olition activities $ere halted and the area



surrounded by the safety fence $as enlarged, further fro! the de!olition area. The survey $asnot docu!ented until appro+i!ately one $eek later. 2o docu!entation of the Septe!ber (-

th

survey $as provided to the Board by :GI. 8T( $ho perfor!ed the survey $as on vacation

and provided survey results via telephone discussion $ith his supervisor, $ho subse=uently

docu!ented the survey indicating fi+ed conta!ination levels less than ), dp!* c!(

betaga!!a. The supervisor docu!enting the survey recorded the $rong type of instru!ent

$hich resulted in underesti!ation of the conta!ination levels. /ad the appropriate instru!ent

been recorded, the results $ould have been appro+i!ately (5, dp!* c!( betaga!!a.

At appro+i!ately *(, the de!olition cre$ began to break for lunch. #&5 $as $alking south

around the south east corner of Building /( $hen he heard a frisker alar!ing. About the sa!e

ti!e, a $orker fro! outside of Building /( $ork area heard the frisker and su!!oned 8T*

for assistance. 8T* discovered conta!inated dust on the frisker and re!oved it. The frisker

stopped alar!ing. 8T* then directed the de!olition cre$ and the $orker out of the i!!ediate

area due to elevated background radiation readings in that area and conducted a frisk, finding

conta!ination on both boots of each of the four e=uip!ent operators. The Board $as infor!ed

that $hen the egress frisker south of Building /( $as responded to by the 8T $ho believed

his indicationsK the :aste Superintendent =uestioned 8T*s response since he believed that the

alar!ing condition $as caused by radiation OshineP.

The highest levels recorded $ere over **, dp! betaga!!a under a *) c!( probe. The

conta!ination levels discovered on the boots of the $orkers $ere belo$ reportable levels per

D&# M (4*.*@(, Occurrence Reporting and Processing of Operations Information. As a

precaution, nasal s!ears $ere taken and found to be negative. Several days later, bioassay

sa!ples $ere also takenK results $ere not available at the ti!e of the Board revie$. The Board

received subse=uent notification that :GI received results and no assignable dose $as

identified for any of the four operators.

In response to the event :GI posted the area surrounding Building /( and bet$een Buildings

G( and /( as a 8onta!ination Area and an Airborne adioactivity Area. The de!olition area

of the /( slab $as surveyed by 8T* $ho recorded conta!ination levels in the debris piles up

to ), dp!* c!2 betaga!!a and **, dp!* c!

2alpha. &ne *6, dp!*

c!2 betaga!!a s$ipe $as obtained on the e+cavator shear.

Because of the boot conta!ination event, further radiological surveys $ere conducted outside

the de!olition area and a revie$ of air sa!pler data $as perfor!ed. T$o peri!eter air sa!plessho$ed elevated readings but :GI deter!ined these readings to be belo$ reportable levels.

Surveys $ere also conducted outside the de!olition area. :GI and D&#@S" notified FA<

of the boot conta!ination event appro+i!ately at *5. FA< responded and started e+tensive

surveys outside the S" boundary. :GI discontinued $ork in the area pending further

investigation. Based on initial surveys, :GI reduced the 8onta!ination Area posting to an area

closer to the Building /( pad and re!oved the Airborne adioactivity Area posting.



During the ti!e of the event, FA< had $orkers perfor!ing asphalt !illing, road$ay

resurfacing preparations, and various other constructionoperations activities to the east of the

S" site. By the evening of Septe!ber (-, (* FA<s surveys had identified nu!erous

areas of conta!ination on the grounds and so!e roofs in an area about * yards s=uared near

the S" site. Based on survey results, FA< perfor!ed bioassays on over * $orkers that

$ere deter!ined to be in the area on Septe!ber (-, (* or $orkers that assisted in radiological

surveys or subse=uent cleanup activities. :hile no bioassay results $ere available $hen the

Board $as on site, subse=uent infor!ation provided by FA< indicates that urinalysis results

have been received for the 55 people identified as the highest priority. All results $ere belo$ the

detection level, and thus, none of these 55 individuals received a !easurable dose.

The follo$ing day, Septe!ber 4, (*, in preparation for inco!ing Tropical Stor! 2icole, a

pile of debris Hust off the south end of the Building /( slab $as pushed back onto the slab $ith

heavy e=uip!ent. The $orkers sprayed fi+ative on the three debris piles and the evaporator

separator colu!ns on the slab of Building /(. &ther preparation $ork $as done to control stor!$ater runoff, including the establish!ent of a te!porary ber!. :GI conducted additional

conta!ination surveys that identified additional areas of conta!ination and posted those areas

accordingly. e!aining Building /( de!olition debris $as confir!ed as inside Building /(

footprint.

2<;& and FA< $ith D&#@S" in attendance !ade a telephone notification of the

conta!ination event to the 2e$ ork State Depart!ent of #nviron!ental 8onservation and the

2e$ ork State Depart!ent of /ealth.

During Septe!ber 4, (*, and into &ctober *, (*, the S" proHect e+perienced

e+ceptionally heavy rains due to Tropical Stor! 2icole, i.e., greater than a * year rain event.

ainfall totals $ere recorded at or above 7 inches.

2.2. Chronology of Events

The follo$ing is the Su!!ary #vent 8hart and Accident 8hronology as vie$ed by the Board.

Table 5&1' ummary Event Chart and Accident Chronology

Date:Time Event

8:7:2;;< #afety &valuation +eport for %2:G2 approved

3:42:2;;< (ecision to perform open air demolition $as made in (ecommissioning)lan

8:3:2;4; )lanner started $or' planning - first planning meeting

9:8:2;4; (emolition )reparation Wor' )ac'age #TW-!W)-4<<; issued

3:<:2;4; (emo )rep Wor' )ac'age #TW-!W)-4<<; #tarted



=:4:2;4; I## )hase II revie$



Date:Time Event

>:4;:2;4; Wor' )ac'age )))-!W)-247; is approved for demolition

>:42:2;4; #)+0-() !inal %a*ard haracteri*ation, !%-;;4, $as approved

<:43:2;4; +adiological characteri*ation completed for removale contamination%2

<:22:2;4; "(emo +eady hec'list" signed off in #TW-!W)-4<<;

<:27:2;4; (emolition started on %2 uilding 772? elevation

<:28-2<:2;4; &levated air sampler reading recorded y perimeter air monitors.

<:29:2;4; %2 #tac' $as demolished

<:2>:2;4; )/( eeting

<:2<:2;4; @ ;389 "#upervisor?s" eeting

<:2<:2;4; @ ;>;; ;>;; meeting

<:2<:4; @4;;; to@42;;

&/4 removed and si*ed heat exchanger vessels 224-1 and 224-B fromeast evaporator cell

&/2 removed separator vessel 442-1 from $est evaporator cell

&/2 removed separator column 447-B and flash column442-B from

east cell.

&/4 si*ed vessel 447-B

<:2<:2;4; @4;7; + and ()( noted vessels on the 772? level pad

0:50:5)1) -ncontrolled s"read of radioactive contamination duringdemolition of building 65

<:2<:2;4; @42;; Wrec'ing cre$ ro'e for lunch

<:2<:2;4; @42;; /perator noted fris'er alarming and called +T

<:2<:2;4; +T conducted surveys and made notifications

<:2<:2;4; 1ir samples east of %2 indicated increased activity

<:2<:2;4; (eris pile surveyed y #)+0 +Ts

<:2<:2;4; A1) $as notified of event

<:2<:2;4; A1) deployed @3; personnel to survey A1) facilities

<:2<:2;4; @4<;; (eris pile sprayed $ith encapsulation material

<:2<:2;4; @4<;; &xcavator trac' s$iped at @44,;;; ()

<:7;:2;4; Wor'ers pushed deris ac' onto %2 pad



Date:Time Event

<:7;:2;4; to4;:;4:2;4;

#ignificant rain overflo$s !+1 Tan'

4;:8:2;4; 1ir samples recounted and confirm increased activity

4;:9-=:2;4; #urveys on heavy euipment indicated varying levels of contamination

including a high of 3==,;;; () and deris pile at 4.9 to 4.= million()

4;:=->:2;4; overed the deris pile $ith tarps

4;:>:2;4; #)+0-() filed occurrence report &--WGI-G2%2-2;4;-;;;4

4;:44:2;4; #)+0-() Issued "#)+0 )roject Improvement orrective 1ction )lan"

4;:42:2;4; overed the tan's $ith tarps

4;:47-43:2;4; 772? elevation floor penetrations $ere covered

4;:47:2;4; #TW-!W)-4<<; closed out

4;:22:2;4; (/& declared Type B Investigation

4;:22:2;4; 1dditional heavy duty tarps added to deris piles:vessels

4;:29:2;4; #econd "$ater event" occurred

4;:2>:2;4; (/& Investigation Board arrived on site

4;:2>:2;4; 1pparent ause 1nalysis issued y #)+0-()

2.7. Event Res"onse

&n Septe!ber (-, (*, at appro+i!ately *(, a $orker found a frisker alar!ing that had been

staged for personnel access out of the building /( de!olition area. The $orker notified 8T*

$ho knocked the dust off of the probe and atte!pted to clear the alar! and reset the frisker.

After clearing and resetting the alar! it $as noticed that background levels had increased. 8T*

!ade notifications to $ork area supervision and co!!enced response actions that included

surveys of the four $orkers inside the $ork area, surveys of adHacent $ork areas, checks of

peri!eter air !onitors and breathing 3one air sa!ple analysis.

Additional surveys $ere conducted by 8Ts $ho responded to the frisker alar! that found a fe$

areas of conta!ination outside of the Building /( footprint. A bag of tools that an electrician had left at his $ork location $ere found to be conta!inated. The four e=uip!ent operators $ho

had been in the /( de!olition area $ere found to have conta!ination levels of **,

dp!probe area of *) c!(

on the botto! of their $ork boots. 2o other conta!ination of personnel $as identified. 2asal s!ears of $orkers in the area $ere negative and bioassay

sa!pling data $as not available. The Board received subse=uent notification that :GI received

results and no assignable dose $as identified for any of the four operators. :GI assessed that



the peri!eter air sa!ple results fro! peri!eter $ork area !onitors sho$ed elevated levels but

$ere belo$ Derived Air 8oncentration %DA8' li!it values.

Initial response surveys of areas surrounding the /( de!olition footprint $ere obtained using

s!ears that $ere taken on porous surfaces such as asphalt, gravel and dirt. epresentative

sa!ples of gross conta!ination levels $ere not obtained using this techni=ue. Direct frisks $ere

not initially perfor!ed, but $hen perfor!ed around *64 that afternoon, indicated elevated

conta!ination levels at several additional locations. FA< and 2<;& $ere notified of the

event about t$o hours after the initial frisker alar!. 2otification phone calls $ere !ade the

follo$ing day, Septe!ber 4, (*, to the 2e$ ork State Depart!ent of #nviron!ental

8onservation and the 2e$ ork Depart!ent of /ealth.

:GI infor!ed the Board that the radiologically@controlled area $as i!!ediately e+panded and

upgraded to an Airborne adioactivity Area and a 8onta!ination Area. At appro+i!ately *4

8T* $as directed to enter the area and take a conta!ination survey. The survey consisted of

4 s!ears. Appro+i!ately one half of the s!ears indicated conta!ination levels above :GIscriteria of * dp!* c!

( betaga!!a or ( dp!* c!

(alpha. The highest readings $ere

close to ), dp!* c!( betaga!!a and over *, dp!* c!

(alpha. evie$ of the

adiological :ork er!it %:' sign@in sheet indicated that 8T* had not signed in on the

: prior to entering. 8o!parison of the sign@in sheets $ith dates and ti!es 8Ts $ere in the

area conducting surveys sho$ed that, after the event, there $ere !any entries into the area by8Ts $ho had not signed in on the :. 8T* $ho entered the area the afternoon of

Septe!ber (-, (*, stated that his protective e=uip!ent consisted of booties and gloves. This

$as in violation of the : $hich re=uired additional protective e=uip!ent.

The ne+t !orning, :GI perfor!ed additional surveys of the area to the east of Building /( pad.

Ga!!a scans indicated conta!ination along the entire east side of the building. /o$ever, :GI

had not perfor!ed a baseline survey prior to the eventK therefore the increase in the readings

cannot be assessed.

Shortly after the identification of the four $orkers $ith boot conta!ination, the peri!eter air

sa!ples $ere collected. T$o sa!ples sho$ed elevated readings $hen they $ere counted at

appro+i!ately *45), Septe!ber (-th

. The sa!ples $ere counted again the !orning of &ctober

5, (* and :GI recogni3ed that they had an uncontrolled spread of radioactive conta!ination.

2.7.4. Re"orting

D&# M (4*.*@(, Occurrence Reporting and Processing of Operations Information details the

Depart!ents e+pectations for reporting specified occurrences to D&#.

&n &ctober 9, (*, :GI sub!itted &ccurrence eport, #M@@@:GI@G(/(@(*@* stating

OThe first event occurred on Septe!ber (-, (* at appro+i!ately *( during de!olition of

/(. An e=uip!ent operator noted a frisker alar!ing and atte!pted to reset it. :hen it

continued to alar!, the operator notified 8T*. 8T* discovered dust on the frisker head,



re!oved the dust and reset the frisker. 8T* !ade notifications and response actions including

surveys of $orkers inside the $ork area, surveys of adHacent $ork areas, checks of



environ!ental air !onitors and breathing 3one air sa!ples $ere conducted. <ess than

reportable levels of conta!ination $ere discovered on the four e=uip!ent $orkers boots.P

The &S report $as categori3ed as a !anage!ent concern involving operational $eaknesses

after evaluation of t$o non@reportable events.

2.7.2. Causal Analysis

:GI perfor!ed an OApparent 8auseP analysis in accordance $ith the re=uire!ents of D&# G

(4*.*@(, Occurrence Reporting Causal Analysis Guide, in response to the OS" roHect

I!prove!ent 8orrective Action lan, dated &ctober **, (*. This corrective Action plan $as

in response to t$o events, the conta!ination event and a O$ater eventP as it is described in the

occurrence report %#M@@:GI@G(/(@(*@*'.

2.8. Examination of Evidence

The Board arrived on site on &ctober (9, (*, (- days after the conta!ination event occurred.

#vidence $as collected fro! various sources, including :GI, D&# and 2<;& docu!entsK

:GI and D&# photographs taken bet$een Septe!ber (4, (* and &ctober 7, (*K oral

intervie$s $ith :GI, D&#, and 2<;& e!ployeesK and onsite inspections by the Board.

hotographs provided the Board $ith a chronological record of de!olition of Building /(

above ground structure, de!olition of the /( ventilation syste! stack, re!oval and disposition

of so!e evaporator syste! co!ponents, efforts taken in response to an approaching tropical

stor!, and subse=uent activities taken to isolate the debris piles.

Docu!ents, co!bined $ith oral intervie$s, provided the Board $ith valuable infor!ation

pertaining to $ork control and radiological protection concepts and practices that $ere in

place prior to and during the accident.

2.8.4. Documents Relating to the Control of ;or+

As part of the investigation, the tea! revie$ed :GI"Ss $ork planning proceduresK S"@ISM@(, SPRU DP Integrated Wor Control Program and S"@#S/@*, !o" #a$ard Analysis. Both docu!ents contain phrases such as, as needed, as applicable, if necessary and as

appropriate. The $ork docu!ents revie$ed belo$ also indicate that these types of phrases are

$idely used in the detailed $ork steps.

C*S9/5!9)+-(' Rev. (, %ent and Drain Piping& '(uipment and Components in )uilding #*%Date approved ;ebruary 5, (*, $ork started March *, (*, date co!pleted 1uly *, (*'

The scope of $ork $as to perfor! radiological surveys, !onitoring and set boundariesK identify

and post boundariesK identify <ockoutTagout %<&T&' points, tap and drain locationsK drain

piping, e=uip!ent co!ponents and su!psK and dispose of $aste per S"@:M@*.



The package $as $ritten and perfor!ed to re!ove li=uid fro! piping, co!ponents, and su!ps

in Building /( by installing hot taps $here installed valves could not be used, at syste! high

and lo$ points per Attach!ent A, #* +o, Point Drain -a"le, of the $ork package. &nce the hot

taps $ere installed, the vent and drain valves $ere operated and any li=uid residing in that

portion of the syste! $as collected for characteri3ation and disposal. Sa!pling of the bulk

li=uids $as perfor!ed in accordance $ith S"@8@**-, Sample Collection and S"@DD@

7, SPRU Disposition Proect C/aracteri$ation Plan. adiological 8ontrols personnel $ere

re=uired to perfor! surveys for conta!ination control. During intervie$s, the proHect

radiological engineers stated that the sa!pling perfor!ed during the e+ecution of this package

$as for the purpose of characteri3ing the $aste li=uid for disposal. 2one of the infor!ation $as

intended to be utili3ed to assess the condition of the re!aining syste! internals $ith regard to

de!olition.

ST59/5!9)&&(, #* Demo Prep

%Date approved May 5, (*, $ork started 1une -, (*, De!o eady 8hecklist co!pleted

Septe!ber ((, (*, date co!pleted &ctober *4, (* ho$ever, not yet closed out'

The scope of $ork $as to identify locations andor syste!s re=uiring additional characteri3ation

andor deconta!ination on Attach!ent A, co!plete an inventory of legacy $aste, obtain

concrete sa!ples for che!ical and radiological characteri3ation, stabili3e conta!ination prior to

$ork activities, deconta!inate surfaces per Attach!ent A, lock do$n %i.e. apply fi+ative to'

surfaces, co!plete De!o eady 8hecklist, docu!ent and dispose of $aste, follo$ radiological

calculation %8'@4(, &S@9, and 8@44, 82S@;:@*4), using ha3ard controls identified

in 1ob /a3ard Analysis %1/A'@*5 and :@>4).

The second note i!!ediately follo$ing the Scope heading read as follo$s

OS"@4(, Conditions for Demolition -ec/nical )asis, $ith stating that Ono

deconta!ination is re=uired prior to de!olition for off@site dose considerations aslong as the source ter! and !itigations are consistentP $ith the docu!ented

source ter! calculations.

The intent is to stabili3e the conta!ination $here necessary and de!olish the /(

Building in open air $ith e+cavator@!ounted e=uip!ent. This $ork package

provides instructions for deconta!inating target areas $hen a source ter! e+ceeds

e+pectations, $hen deconta!ination is needed for A<AA purposes, or $hen it is

re=uired by the :aste Acceptance 8riteria %:A8'.P

Section ).* covered evaluation of the 44( elevation for pre@de!olition activities by revie$ing

the radiological survey data and that adiological #ngineering $ould deter!ine $hether

additional radiological characteri3ation is necessary. Attach!ent A, #* 'levation 00* Demo

Prep Action Items, $ould be updated as necessary. 8olu!ns **(@A, **(@B, **4@A, and **4@B

and evaporator condensers ((*@A and ((*@B e+tended fro! the 4*- elevation through the 44(



elevation, ho$ever, they $ere not identified on Attach!ent A. 2one of the ite!s listed in the

attach!ent $ere considered to re=uire deconta!ination or lock do$n. The only ite!

encountered on the attach!ent $as ite! >*, $hich $as identified as OFA< legacy $aste, tank



sa!pling device.P The identified action $as to O8haracteri3e bo+ed legacy $aste and confir! it

can be left in the building.P 2o further characteri3ation $as identified on the 44( elevation as a

result of this effort. The section further states, OIf re=uired, obtain additional characteri3ation

data as described belo$ . . .P Step ).*.(%A through D' detail ho$ to perfor! characteri3ation

for surface areas, piping, ducts, and !aterials or other e=uip!ent Oas necessary.P

Subse=uent sections governed de!o preps for elevations 4*- and 4-. 2o evaporator colu!ns

or co!ponents $ere identified and docu!ented on Attach!ent A during e+ecution of these

sections.

&ther sections in the package included deconta!inationre!oval of piping, if re=uired and

deconta!inate process syste! co!ponents, if re=uired. &nly a single adioactive Material

<aboratory pipe $as identified. Additionally, there $ere sections directing Olock do$n structural

surfacesP and Olock do$n su!ps.P These sections resulted in the application of fi+ative as

governed by 8@4(. 2o verification of coverage or radiological survey $as re=uired follo$ing

the application of the fi+ative. There $ere no surveys provided to the Board for overhead

structures or co!ponent internal surfaces.

The re!aining sections covered the disposition of legacy $aste, and de!obili3ation. The

de!obili3ation section %).*(' contained the only hold point signature that $as obtained prior to

approval of Attach!ent B, #* Demo Ready C/eclist . The #M@(( trip report identified that the

re!aining t$elve hold point signatures had not been obtained during their visit on the *(th

of

&ctober. Subse=uently, a change $as !ade to the $ork package and the steps $ere signed off

on &ctober *(, (* and &ctober *4, (*. The signatures $ere obtained si+ $eeks after

approval of the #* Demo Ready C/eclist on Septe!ber ((, (*. 2one of the personnel

approving the checklist identified the !issing hold point signatures as a proble! at the ti!e ofapproval. Additionally, the checklist $as approved $ith un@!arked checkbo+es in Sections 5,), and 7 of the checklist.

ST59/5!9$)+(, G* 1 #* )uildings and G*#* -unnel Demolition%Started planning April 6, (*, date approved August *, (*, $ork started Septe!ber (4,

(*, date co!pleted in progress'

Scope of $ork regarding the de!olition of Building /( included /ot and 2eutrali3er cells,

loading and disposing of $aste per S"@D@4* and 4(.

@;:@(*4 indicated that the /( de!olition $as planned to be perfor!ed in an Oopen airP

environ!ent, $ith reliance on the application of fi+ative to Olock do$nP conta!ination in

e=uip!ent and co!ponents during e+ecution of ST:@;:@*--, co!bined $ith the use of

!isting during de!olition.

De!olition of Building /( began on Septe!ber (4, (*. A barrier, a chain@link fence, $as

erected around the structure. Additionally, although it $as not clear $hen, the area $as posted



as a adiological Buffer Area. /oses $ere staged for the application of $ater for dust

suppression.



:ork $as being conducted in Building G( under section ).5 of the $ork package. A /&<D

&I2T $as signed by the :S on Septe!ber *, (* signifying that an anti@proHectile fence is

in place around the east side of Building G(, although the previous step containing a /&<D

&I2T had yet not been co!pleted. This step $as later signed again on Septe!ber ((, (*

after the previous hold point condition had been !et.

Building /( $as confir!ed ready for de!olition by the DD &perations Manager on

Septe!ber (4, (*, as docu!ented in step ).).*. /( ventilation $as secured. De!olition $ork

progressed fro! the South face of the building to$ard the 2orth and $as docu!ented in the

:ork Status <og, although t$o separate versions of for! S"@(-, Wor Pacage Status +og ,

$ere found to be in use containing broken chronology. The $ork package record contains

several changes over the course of the $ork. In accordance $ith the S"@ISM@(, the

process involved inserting ne$ pages and $riting the $ord OsupersededP across the pages to be

re!oved. The last step found in any version of the @;:@(*4 regarding the above grade

de!olition of Building /( prior to &ctober ), (* $as to de!olish the /( stack in step ).).*(.The only !ention of tank re!oval appeared in Section ).*, Complete Demolition of )uilding

#*.

2.8.2. Authorization of ;or+

The daily operations at S" $ere planned and approved in accordance $ith the S"

Disposition roHect %S" D' integrated $ork control progra! docu!ent S"@ISM@(,

ev. **.

Section 6.6 states

Olan of the Day %&D' !eetings are held to discuss $ork perfor!ed in the

previous (5 hours and $ork to be perfor!ed during the ne+t (5 hours. &n;riday, the &D !eeting includes discussion of scheduled $eekend activities and$ork scheduled for the follo$ing Monday. esource loading for activities shall be discussed, if re=uire!ents are changed as co!pared to those previously planned at the &D !eeting. 8o!pleted activities should be identified andre!oved fro! the schedule prior to the ne+t &D !eeting.

Deviations fro! the schedule to allo$ for e!ergent $ork ite!s and other

unforeseen proble! areas shall be identified in the &D !eeting, and the $orkshall be scheduled accordingly.P

Section 6.7 statesK

OThe S" D $ork release process establishes !ultiple barriers for safe

acco!plish!ent of the $ork. The first barrier is a &D signed by the &M that is

used to authori3e $ork for the dayK the second barrier is the use of an integrated

$ork revie$ process that includes screening to the facility safety basis



docu!ents and the use of pre@re=uisite hold pointsK the third barrier is the

authori3ation of each $ork package by a designated release authority. :ork !ay

also be



authori3ed independently by the &M outside of the &D !eeting. At the &D,

planned $ork activities are revie$ed to ensure that individual $ork activities do

not i!pact other $ork activities.P

The Board observed the $ide@spread !isconception of hase I and hase II de!olition activities.

Ohase I,P $as intended for the de!olition of the aboveground structure, $hich $as pri!arily

the portions of the facility building structure $hich !et :GIs DD release criteria. Ohase IIP

referred to the de!olition of the belo$ grade %44( elevation', conta!inated portions of the

facility. The hase Ihase II approach is discussed inK *' the Stor!$ater ollution revention

lan %S', S"@#2?@(, and in the Stor!$ater Manage!ent lan, dated August ), (*,

included as Attach!ent / to @;:@(*4, G* 1 #* )uildings and G*#* -unnel Demolition.

2.9. ,ost Event Anomalies

2.9.4.<verflo=ing FRAC Tan+ and Lea+ing *erm Events

As reported by the D&# S" Manager, at about 7, on &ctober *, (*, D&# S"discovered a ;A8 tank, $hich $as used to collect $ater fro! the /( hillside drain su!p, to

be overflo$ing $ith untreated hillside drain su!p $ater. :GI did not have operators on duty

to i!!ediately s$itch the flo$ into the other tank.

:GI obtained sa!ples of the $ater, $hich $as found to be above regulatory discharge li!its.

The ;A8 tank had about *7, gallons of available capacity as of Septe!ber 4, (*. The

!a+i!u! a!ount of $ater previously collected in a day had been appro+i!ately 5, gallons.

:GI believed there $as a sufficient a!ount of capacity in the tank to handle the anticipated

rainfall but the rain fro! the tropical stor! e+ceeded the * year stor! records.

Additionally, D&#@S" discovered that $ater had also been leaking fro! a ber! that had been

constructed against the door leading fro! the escape tunnel of the /( base!ent. The $ater $as

flo$ing out onto the hillside $ithin a posted soil conta!ination area. Analysis of this $ater

indicated levels of radioactivity appro+i!ately * ti!es the discharge li!it for the S"treat!ent syste!. So!e conta!ination %about 5, dp! betaga!!a' $as found above the

discharge in the soil conta!ination area, but no elevated counts $ere found outside the soil

conta!ination area.

2.9.2. 6illside Drain ,um" Failure

At about (*5, on &ctober (), (*, during a steady rain, a :GI operator perfor!ing rounds

discovered that $ater overflo$ing fro! an overflo$ line to the culvert at the base of the hill

belo$ the S" site. The operator then discovered that the su!p pu!ps in the hillside drain

syste! $ere not $orking. A !alfunction in the control panel caused the su!p pu!ps to be

inoperable. Additionally, although the e!ergency generator $as not re=uired, the failure $as

such that the e!ergency generator $ould not have been able to supply po$er to the pu!ps.

:GI called in electricians and repairs $ere !ade $ithin about three hours of discovery. FA<

esti!ated that appro+i!ately 64 gallons of $ater $as released during the event.



2.9.7. FRAC Tan+ Labeling and ,osting !ssues

&n &ctober (9, (*, during a fa!iliari3ation tour of the area north of the /( pad, the Board

observed three ;A8 tanks. In response to the heavy rains and subse=uent overflo$ing of one

of the tanks, the three tanks had been piped together to provide additional capacity. The Board

observed, and infor!ed :GI of inconsistent and incorrect posting on the tanks. Specifically,

one tank $as labeled as e!ptyK t$o tanks had radiological $arning labels indicating internal

conta!ination $hile the other tank had a radiological label indicating radioactive !aterial. 2ot

all openings had radiological $arning labels attached. :hen the Board returned the follo$ing

$eek the labeling had not been corrected.

2.9.8. ,a"er=or+ Discre"ancies

The Board revie$ed nu!erous radiological surveys. The tea! noticed t$o re!ovable

conta!ination surveys conducted Septe!ber *, (*, had e+act conta!ination count readings

for the first *9 results indicating that $rong survey data $as used for one of the surveys.

The Board $as provided copies of : S"@D@5(, ev * dated 1une 4, (*, and S"@

D@*@5( ev , dated April 4, (*. The copies provided indicated a change to the :

fro! $ork package (*4 to *--. There $as no docu!entation of $ho !ade the change and the

changes $ere pen and ink to the copies provided to the Board.

Additionally, nu!erous other surveys revie$ed by the Board included pen and ink changes

!ade after the survey $as signed off by the original surveyor $ithout docu!entation of $ho

!ade the changes or $hen the change $as !ade.

The Board $as told that a survey of a bolt that $as eHected fro! the de!olition area $as perfor!ed on Septe!ber (-, (*. The survey $as not docu!ented until appro+i!ately one

$eek later. 2o docu!entation of the Septe!ber (-th

survey $as provided to the Board by :GI.8T( $ho perfor!ed the survey $as on vacation and provided survey results via telephone

discussion $ith his supervisor, $ho subse=uently docu!ented the survey indicating fi+ed

conta!ination levels less than ), dp!* c!( betaga!!a. The supervisor docu!enting

the survey recorded the $rong type of instru!ent $hich resulted in underesti!ation of the

conta!ination levels. /ad the appropriate instru!ent been recorded, the results $ould have

been appro+i!ately (5, dp!* c!( betaga!!a.

The de!obili3ation section %).*(' of $ork package ST59/5!9)&&(, #* Demo Prep contained

the only hold point signature that $as obtained prior to approval of Attach!ent B, #* Demo

Ready C/eclist . The #M@(( trip report identified that the re!aining t$elve hold point

signatures had not been obtained during their visit on &ctober *(, (*. Subse=uently, a change

$as !ade to the $ork package and the steps $ere signed off on &ctober *(, (* and &ctober

*4, (*. The signatures $ere obtained si+ $eeks after approval of the #* Demo Ready

C/eclist on Septe!ber ((, (*.



2.3. Current tatus of *uilding 65 Foot"rint

Building /( debris $as stabili3ed by !oving all of the $aste into a pile $ithin the footprint $ith

heavy e=uip!ent. ;i+ative $as liberally applied to the pile several ti!es. After Tropical Stor!

2icole passed, openings in process syste! colu!ns $ere covered. Several days later the sharp

edges $ere !itigated by placing pallets and hay bales $here potential proble!s $ere identified

prior to covering the debris pile $ith tarps. <ayers of tarps $ere then placed over the pile and

secured $ith sandbags. A 1ohn Deere e+cavator $as surveyed and released fro! the area to the

south end of the building. Building /( footprint re!ains posted as a 8onta!ination Area. DD

operations re!ain suspended, pending co!pletion of a co!prehensive corrective action plan.

Figure 5&>' *uilding Foot"rint Ta+en Afternoon of <ctober 58# 5)1)

2.3.4. Contamination Levels

adiological surveys taken on &ctober ) and &ctober 6, (* recorded on@site conta!ination

levels, on the Building /( slab, follo$ing atte!pts to lock@do$n the conta!ination after the

event, of close to *,7, dp!* c!(

%5 !radhr' re!ovable betaga!!a and over **,

dp!* c!

(

re!ovable alpha.

An 2<;& representative stated that conta!ination $as found over an area of appro+i!ately

*5, s=uare feet on the FA< site as a result of the incident. evie$ of FA< post Septe!ber (-, (*, survey results sho$s that there $ere nu!erous s!all areas spread over appro+i!ately one half of the *5, s=uare feet that had average readings of (, to 5,

dp!* c!( betaga!!a. There $as one s!all area $ith an elevated reading of appro+i!ately

*), dp!* c!( betaga!!a.



The 2<;& representative stated that the !aHority of these areas have been deconta!inated to

FA< conta!ination li!its. They also stated that air !onitoring sa!ples taken do$n hill at the

discharge area to the Moha$k iver, although belo$ any li!its, indicated so!e lo$ level of

elevated radioactivity. Additional !onitoring of this area !ay be needed to help =uantify the

e+tent of the conta!ination event.



/(

*.7M dp!*

c!(

re!ovable

G(

ed Q 5, Blue Q (, Green Q R*),

direct readings in dp!* c!( betaga!!a

Figure 5&7' A""roximate Area of Contamination

2ote FA< provided the Board $ith data that there $ere so!e spots of conta!ination %spots

less than *(, DM' on the roofs of Buildings #5#) that are not sho$n on the above !ap.

FA< stated that $orkers deconta!inated these spots.



5(2( !nvestigative Readiness and cene ,reservation

Several factors i!pacted the ability of the Board to !ake an appropriate assess!ent of :GIs

investigative readiness. &n Septe!ber 4, (*, actions $ere taken to control stor! $ater

runoff fro! inco!ing Tropical Stor! 2icole. Those preparations and the subse=uent record

rainfall e+acerbated both the conta!ination event and the ability to identify conta!ination

locations. The !agnitude of the event $as not identified for five !ore days, follo$ing the

stor!. :GI had a procedure for event reporting and investigation, S"@##S/@), ev 5,

'vent Investigation and Reporting 2anual . That procedure provided sufficient infor!ation and

direction that, if follo$ed, $ould result in proper categori3ation, notification, reporting, and

follo$@up for this event.

D&# appointed a Type B Accident Investigation tea! on &ctober ((, (*. The accident scene

$as not preserved.



8() Analysis of Facts

7.4. Authorization of ;or+

Sections 6.6 and 6.7 of S"@ISM@(, ev. **, SPRU3DP Integrated Wor Control Program

are conflicting. The Section, 6.6, states that e!ergent $ork shall be identified in the &D

!eeting and scheduled accordingly, $hile Section, 6.7 states that the &M can independently

authori3e $ork outside of the &D !eeting. See Section (.5.( Authori3ation of :ork.

The $ork planning, approval and e+ecution process for $ork conducted on the day of the event,

Septe!ber (-, (*, consisted of a &D !eeting at *)4 on Septe!ber (9, (*, that provided

an updated status of $ork in progress and planning for the $ork to be conducted the follo$ing

day. A docu!ent referred to as the &D sho$ed $ork package approval status and e+pected

$ork package start and finish dates. The &D docu!ent $as updated after this !eeting and a

revised &D $as issued around *- that evening that included the current scheduled $ork

updates. &n Septe!ber (-, (*, at 65), a supervisors !eeting occurred in preparation for a

7 !eeting $ith the $ork cre$. At 9, :GI !anage!ent held a $ork status !eeting.

rior to the 65) !eeting on the !orning of the event, the :S !entioned to the &perations

Manager %&M' that the evaporator colu!ns protruding on the 44( elevation of building /(

needed to be re!oved. The &M $as unsure $hether the colu!ns should be re!oved during

the current phase of the proHect so he discussed the feasibility of re!oving the colu!ns at the

9 production !eeting. At the 9 !anagers !eeting, the &M received no obHection totank re!oval fro! attendees at this !eeting. The &M then left the 9 !eeting and discussed

re!oval of the colu!ns $ith the #S/Nadiation 8ontrol Manager %8M' to get additional

verification that re!oving the colu!ns $ould not pose a ha3ard. The 8M indicated to the

&M that he did not see any reason $hy the colu!ns should not be re!oved. The re!oval of

the colu!ns, ho$ever, $as never added to the &D, nor $as it re=uired to be added to the

&D. The decision to re!ove the colu!ns $as passed do$n to the 8leveland :recking

Supervisor $ho directed re!oval of the colu!ns. #+ecution of $ork occurred $ithout the

kno$ledge of several key !e!bers of :GI !anage!ent, including the Deputy roHect

Director, the :ork lanner $ho $rote the package, and the S#8 Managerad rotection

Superintendent.

This se=uence of operations on the day of the event de!onstrate a failure in the planning and

$ork e+ecution process described in S"@ISM@(, ev. **, Section 6.6, Wor Coordination,

since the re!oval of the colu!ns $as not discussed at the &D the day before the event. In

addition, the barriers for safe conduct of $ork discussed in Section 6.7, Wor Release, $ere not

effective because the $ork $as not planned on the &D as re=uired by the first barrier. The

second barrier, use of an integrated $ork revie$ process that includes screening to the facility

safety basis docu!ents and the use of pre@re=uisite hold points, $as also not in place, since



further characteri3ation of the facility, specified in the safety basis docu!ents, does not appear

to the Board to have been perfor!ed. 8haracteri3ation of re!ovable conta!ination levels$ithin the process piping and colu!ns associated $ith the evaporation process !ay have

resulted in



hold points in the $ork package re=uiring careful revie$ of the $ork package to ensure

co!pliance $ith not only hold points but also $ork package scope prior to the event. ;inally,

the $ork package $as $ritten for the entire /(, G( and /(G( tunnel de!olition. Because of

the broad $ork package scope, there $as little opportunity for barrier three to be effective since

specific $ork release by a designated $ork release authority for Building /( de!olition $as

already perfor!ed *- days earlier. eleasing $ork this far in advance $ith no subse=uent

discussion at the &D !eeting of specific $ork to be conducted the ne+t day does not provide

the rigor needed to control e+ecution of ha3ardous $ork activities.

The Board revie$ed the Stor!$ater ollution revention lan %S', S"@#2?@(, and

the Stor!$ater Manage!ent lan dated August ), (*. The Board deter!ined that in

accordance $ith the stor! $ater plans, Ohase IIP de!olition actually co!!enced $hen either

building G( or /( roof $ere breeched, and a !eans to collect and control runoff $ere re=uired.

:hen the radioactive conta!ination event occurred, the entire roof and all $alls of the /( build

had been

de!olished.

7.2. Radiological Controls

7.2.4. Radiological ;or+ ,ermits

The de!olition of Building /( $as conducted under adiological :ork er!it %:' S"@D@*@)-, ev , Prep and Demolis/ and Stage for Disposal t/e #* )uilding and All

Associated Waste& dated Septe!ber (4, (*. The Board revie$ed the : and associated

surveys and discussed the re=uire!ents of the : $ith the $orkers $ho $ere in the area, the

8T* providing Hob coverage and the individual $ho $rote the :. evie$ of a Septe!ber

*6, (*, conta!ination survey sho$ed that the 44( elevation $orking areas had re!ovable

conta!ination levels belo$ * 8; 94) Appendi+ D values. <o$er elevations had selected

areas $ith conta!ination levels over -, dp!* c!( betaga!!a on the floor.

Associated pipes and co!ponents also had elevated levels of conta!ination. Accordingly, it

$as essential for personnel $orking in Building /( to have a very clear understanding of

restrictions fro!re!oving co!ponents for lo$er elevations. The Board identified the follo$ing $eaknesses in

the : and associated $ork control docu!ents

The : did not ade=uately describe the scope of $ork. The concept of a hase I %/(

superstructure de!olition' and hase II %Subsurface re!oval of e=uip!ent' $as not ade=uately

understood or described.

• evie$ of a Septe!ber *6, (*, conta!ination survey sho$ed that evaporator co!ponents

being re!oved and do$nsi3ed on Septe!ber (-, (* ca!e fro! an area $ith

conta!ination levels over -, dp! betaga!!a(

on the floor.

• The : did not re=uire 8T coverage for re!oval of the colu!ns. &pening of processinge=uip!ent $hich held radioactive !aterials typically $ould re=uire 8T surveying upon breaching a syste!.



• There $as an over reliance that the fi+ative $as going to be e+tre!ely effective in preventingthe spread of conta!ination. The interior of the flash colu!n $hich $as being si3e reduced



at the ti!e of the event, contained inaccessible voids and baffles inside the colu!n. It $as

e+tre!ely unlikely that fi+ative could have been applied to all surfaces. %See ;igure 4@*and

;igure 4@(.' Also pre@de!olition conta!ination surveys $ere not perfor!ed in elevated areas

$ithin the building.

• The radiological conta!ination li!iting conditions, ) ti!es the e+pected betaga!!a $ork area conta!ination levels did not reflect e+pected conditions.

• adiological surveys conducted after the fi+ative $as applied focused on re!ovable

conta!ination levels. The Board believed that de!olition activities involving co!ponents

$ith very high levels of fi+ed conta!ination $ould re=uire different radiological !onitoring

than those involving lo$ levels of fi+ed conta!ination. adiological surveys also $ere not

perfor!ed to evaluate the de!olition activities effect on disrupting the fi+ative.

• adiological s!ear surveys $ere not taken in upper elevations and in the interior of

co!ponents.

• 8onta!ination surveys to ensure co!pliance $ith 8onta!ination and /igh 8onta!inationArea posting and access control re=uire!ents $ere not re=uired.

• Air !onitoring to ensure co!pliance $ith Airborne adioactivity Area posting and access

control re=uire!ents $ere not re=uired. eri!eter air !onitoring indicated elevated airborneradioactivity levels of over DA8. /o$ever, these sa!ples $ere average values over ( and 5 hour ti!e periods. Integrated airborne conta!ination levels indicated levels $ell above * DA8@hour. Accordingly, !onitoring data is not available to de!onstrate that the

DA8 values $ere never e+ceeded. The Board noted that the breathing 3one air sa!pler for ade!olition $orker on Septe!ber (-, (* indicated airborne radioactivity levels in their $ork area $hich $ere $ell belo$ levels re=uiring posting or other controls.

• The : re=uired breathing 3one analy3ers %BEAs' for all e=uip!ent operatorsK only one of

the three individuals re=uiring BEAs $as issued one on Septe!ber (-, (*.

• The radiological li!iting condition of .4 DA8 $as e+ceededK ho$ever, this $as never evaluated in subse=uent revie$s and criti=ues.

• &n Septe!ber *, (-, a dose rate survey $as conducted on the 4*- foot elevation of the

$est evaporator roo!. 8ontact dose rates of up to 5) !hr $ere docu!ented on duct $ork.Despite this indicator of high internal radioactive conta!ination, $orkers $ere allo$ed to

breach the syste!s $ithout ade=uate conta!ination controls.

• The 8T* providing inter!ittent Hob coverage did not perfor! periodic surveys and

therefore did not keep $ork cre$s updated on radiological conditions as $ork progressed as

re=uired by the :. #ven after noticing a !ist or s!oke rising fro! so!e e=uip!ent

being si3e reduced, no radiological conta!ination survey $as conducted. The 8T* stated

that for industrial safety concerns, they $ere instructed not to enter the $ork area.

• The $ork $as not conducted under an engineered !ister as specified in the technical basis

docu!ent. A fire hose $as used for part of the activity but its use $as discontinued to $ash

the !ud off a truck during the $ork evolution.



• The : did not re=uire use of a Dust Boss to provide a !ist during de!olitionof conta!inated structures.

• The re=uire!ent to notify the 8T of areas to be entered $as not included on the :.

• 8o!parison of the sign@in sheets $ith dates and ti!es 8Ts $ere in the area conducting

surveys sho$ed that, after the event, there $ere !any entries into the area by 8Ts $ho hadnot signed in on the :.

adiation protection personnel stated that prior to de!olition $ork on Building /(, radiological

postings $ere re!oved $ith the intent that anyone entering the building $ould notify the 8T of

areas to be entered. Survey data de!onstrated that 8onta!ination Areas still e+isted in the

building and $ould re=uire posting per * 8; 94). The re=uire!ent to notify the 8T of areas

to be entered $as not specified on the :.

7.2.2. Release urveys

The Board revie$ed release surveys for ite!s and e=uip!ent releases fro! the area after the

event. :hile the survey of an electricians e=uip!ent bag $as thorough in ter!s of levels of

re!ovable conta!ination, it failed to record results of direct scanning.

The Board also revie$ed a survey perfor!ed for the release of one of the e+cavators fro! the

/( area conducted &ctober *5, (*. The Board found the release survey to be inade=uate for

the follo$ing reasons

• The survey consisted only of s!ear data points.

• There $ere no frisking or direct !easure!ents for total conta!ination.• There $as no evaluation of potential conta!ination of inaccessible areas.

• The :GI used a release value of * dp!* c!( betaga!!a $hich $as non@

conservative given the isotopic concentrations discovered.

The survey $as not perfor!ed in accordance $ith S"@8@*-, ev ), Performing Radiation

and Contamination Survey, dated Septe!ber (4, (* $hich states

• ).*.(.A @ Incorporate techni=ues $ith conta!ination surveys to detect both re!ovable and

fi+ed conta!ination. Both types of survey !easure!ents are re=uired e+cept in ;i+ed

8onta!ination Areas or areas in $hich the background radiation levels do not per!it a

direct

reading that is capable of detecting S"@8@*, Table (@( values

• ).*.(.8 @ Take s!ears of * c!(

and count using a proportional counter for alpha and

betaga!!a activity. The s!ears $ere not counted using a proportional counter. It $as

co!!on practice to count s!ears $ith types of instru!ents other than that specified in

the procedure.

In addition the survey $as not perfor!ed in accordance $ith S"@8@*9, ev 4,

Performing Surface Radioactivity 2easurements, dated March *, (*, of $hich Attach!ent



A provides a description of !ethods used to deconta!inate and release large e=uip!ent and

!aterials fro!



radiological controls. This attach!ent $as not co!pleted prior to the release. :GI personnel

stated that a !ore detailed survey specified in S"@8@*9 $ould be done prior to unrestricted

release. The Board noted that there $as an annotation on the survey, at so!e unspecified ti!e

after the survey $as $ritten, stating that the survey $as Oconditional fro! /( De!oP. /o$ever,

there is nothing in :GI procedures that describe OconditionalP releases and $hich $ould re=uire

any additional surveys. :GIs position $as that there are t$o levels of survey, de!onstrated by

post survey annotating survey docu!entation, $as inconsistent $ith the scope of S"@8@*9

$hich clearly stated OThis procedure applies to all types of surface radioactivity !easure!ents

perfor!ed by adiological 8ontrol Technicians at the S" including unrestricted release

surveys, and the docu!entation of the infor!ation and data.P

S"@ 8@*9 is inconsistent $ith S"@8@*- because it states in Section 5.*.*

OThe co!plete assess!ent of a surface shall include direct !easure!ents for radioactivity and !easure!ents for re!ovable radioactivity %s!ears' fro!

representative portions of the surface.

A. In so!e instances, only one type of assay !ethod !ay be needed for

evaluation purposes %e.g., re!ovable activity levels'.P

This step conflicts $ith Step ).*.(A of S"@8@*- as stated above.

In addition, as a Hob aid, the survey sheets should include a block indicating the survey ti!e,

$hich is re=uired by the procedure. So!e surveys revie$ed failed to include the ti!e.

7.2.7. <ther urveys

:hen 8T( surveyed the bolt $hich $as eHected fro! the $ork area during de!olition, he

found elevated fi+ed conta!ination readings and stated he notified his supervisor. This

indication of uncontrolled spread of radioactive !aterial pro!pted no corrective action fro!

S".

:hen 8T* frisked out the de!olition $orkers, on Septe!ber (-, (*, he had to relocate the

friskers because of an increase in background radiation levels. This change in background

readings $as not ade=uately evaluated.

&n the afternoon of Septe!ber (-, (*, :GI evaluated t$o peri!eter air sa!ples sho$ing

elevated readings $hen they $ere counted at appro+i!ately *45). A follo$ up assess!ent of

these sa!ples $as a ga!!a spectroscopy scan looking for 8esiu!@*47. Subse=uent analysis

sho$ed that the predo!inant isotope $as not 8esiu!@*47 %it $as Strontiu!'. /ad :GI done

ade=uate radiological characteri3ation before the event, a !ore appropriate analysis !ay have

been perfor!ed.



:hen 8T( perfor!ed additional surveys of the area to the east of Building /( on Septe!ber

4th

, he could not assess $hether there $as an increase in the counts due to the lack of a baseline

survey prior to the event. The survey techni=ue e!ployed $as based on an assu!ption that



radioactive conta!ination $ould be pri!arily 8esiu!@*47. /o$ever, subse=uent analysis

indicated that 8esiu!@*47 $as not the predo!inant isotope %it $as Strontiu!'. /ad :GI

co!pleted ade=uate radiological characteri3ation before the event, a !ore appropriate evaluation

!ay have been perfor!ed.

7.2.8. Air 4onitoring Results

rior to initiating open air de!olishing of the Building /(, on Septe!ber (4, (*, :GI began

!onitoring the peri!eter of the Building /( area $ith * air sa!plers. ;ollo$ing the

identification of the four e=uip!ent operators $ith personnel conta!ination e+iting the

Building /( $ork area, :GI analy3ed the peri!eter air sa!plers by counting the! on a

proportional counter both for alpha and betaga!!a conta!ination. The alpha readings are

used to evaluate lutoniu!@(4- and A!ericiu!@(5* airborne radioactivity levels and the

betaga!!a readings are used to evaluate Strontiu!@- and 8esiu!@*47 levels. The highest

readings $ere noted on the air sa!plers along the east side of the Building /(, adHacent to the

property line fence for FA<. The results indicated airborne radioactivity levels had reached

bet$een 7 to - of the * 8; 94) DA8 values.

"se of occupational DA8 values for evaluation of peri!eter air !onitoring results is very non@

conservative for $orker protection consideration. The peri!eter air !onitoring sa!ples did not

represent the breathing 3one of the $orkers. The * 8; 94) DA8 values are based on air

concentration values $hich, if a $orker $ere e+posed to, $ould result in an occupational dose at

the regulatory li!it for $orkers, $hich is ) e! Total #ffective Dose or ) e! Total

#=uivalent Dose to any organ. The dose li!its for offsite doses are significantly lo$er.

Subse=uent, to the event, :GI sent the air sa!ples to an offsite laboratory for isotopic analysis.

&n &ctober *9th

the offsite laboratory provided the sa!ple analysis results. As indicated in the

follo$ing table the isotopic analysis $as consistent $ith the earlier evaluation of the air sa!pleresults.

Table 8&1' !soto"ic Analysis of East ide ,erimeter Air am"les

!soto"e am"le 1& ,ercent DAC am"le 5 & ,ercent DAC

#r-<; ;.9C ;.9C

)u-27< 9=C =8C

1m-284 Dot detected Dot detected

s-47= ess than ;.4C ess than ;.4C

Total 9=C =8C



:GI deter!ined that they had not e+ceeded one DA8 at the peri!eter. /o$ever, since the

above sa!ples are average values for ti!e periods up to 5 hours, :GIs !onitoring $as

inade=uate to de!onstrate that this criteria $as not e+ceeded.

In addition, the Board revie$ed the Building /( peri!eter air sa!pling results for the ti!e

period leading up to the event %Septe!ber (4 to Septe!ber (9, (*'. Although the results

$ere significantly less than those discussed above, the Board noted that several %eight' of the

peri!eter air sa!ple results sho$ed positive signs of airborne radioactive !aterial. Since the

results $ere belo$ the : <i!iting 8ondition of .4 derived air concentration %DA8' there

$as no follo$@up to identify the source. These results !ay have been an indication that the

lock do$n of activity $ithin the Building /( $as not * effective or that conta!inated

syste!s $ere being breached.

7.2.9. Criti?ue of Contamination Event

A criti=ue of the incident $as conducted on &ctober ), (*. The Board revie$ed the criti=ue

and noted the follo$ing

• The criti=ue stated that on Septe!ber (-, (* peri!eter air !onitoring results $ere $ell belo$ alpha and beta DA8 action values. The criti=ue used an incorrect DA8 action level of * DA8. The : li!iting condition $as .4 DA8. As noted above, the DA8 values ont$o of the peri!eter air sa!plers e+ceeded the : li!iting condition and site air !onitoring $as inade=uate to de!onstrate that DA8 values $ere not e+ceeded.

• Also, both the criti=ue and the &ccurrence eporting and rocessing Syste! %&S' eportstated that BEA sa!ples $ere counted and $ere negative. evie$ of :GI docu!entation

sho$s that only one of the three e=uip!ent operators had been provided a BEA as re=uired

by the :. This $as not addressed in the criti=ue.

• The criti=ue contained incorrect infor!ation on the results of conta!ination !onitoring.

• The :GI criti=ue discussed the conta!ination levels in ter!s of cp!. 2ot convertingthe values to dp! !akes it i!possible to assess !agnitude of the conta!ination level.The Board found this discrepancy on other criti=ues.

7.2.3. Re"orting of Contamination Event

&n &ctober 9th

, :GI sub!itted &S, #M@@@:GI@G(/(@(*@*. This $as reported as a

!anage!ent concern involving operational $eaknesses after evaluation of t$o non@reportableevents.

The Board does not agree $ith the assess!ent that the event of Septe!ber (-, (* $as non@

reportable. The Board believes that the follo$ing t$o reporting criteria apply

• :rop 0 @ Contamination;Radiation ControlSubgroup B Spread of adioactive 8onta!ination



%*' Identification of radioactive conta!ination offsite due to D&# operationsactivities

that e+ceeds applicable D&#@approved authori3ed li!its. %See D&# )5.) or, if

there are none, the values found in * 8; art 94), Appendi+ D'

L2ote All releases of property containing or potentially containing residual

radioactivity are subHect to re=uire!ents in D&# )5.). 8o!pliance $ith * 8;

art 94), Appendi+ D values does not necessarily satisfy the re=uire!ents in D&#

)5.).

%(' Identification of onsite radioactive conta!ination greater than * ti!es the total

conta!ination values %see * 8; 94) Appendi+ D' and that is found outside of the

follo$ing locations 8onta!ination Areas, /igh 8onta!ination Areas, Airborne

adioactivity Areas, adiological Buffer Areas, and certain areas that are controlled

Ldefined in * 8; 94).**(%c'.

:GI personnel stated that after the Septe!ber (-, (* conta!ination event, they posted the

area as a 8onta!ination Area and accordingly, any subse=uent conta!ination found $as in a

posted 8onta!ination Area. The Board disagrees $ith this position it appeared likely that

before the area $as posted the conta!ination levels e+isted.

In addition, the Board observed that the area around Building /( pad $as posted as a

8onta!ination Area. evie$ of &ctober ) and &ctober 6, (* survey data sho$s that a !ore

appropriate posting $ould be a /igh 8onta!ination Area. &n the pad after atte!pting to

lockdo$n the conta!ination after the event, surveys in the debris pile of close to *,7,

dp!* c!(

%5 !AD per hour' re!ovable betaga!!a and over **, dp!* c!(

re!ovable alpha $as identified. :GI stated that because the area $as under a tarp it did not

re=uire additional posting. The Board disagreesK the use of a tarp does not !ake the area

inaccessible.

:GI personnel also stated that FA< $as considered part of their site. /o$ever, FA<soperations are not under the :GIs adiation rotection rogra! or other controls. The Board

bases this deter!ination on revie$ of radiological survey reports and !aps $hich $ere

developed post the Septe!ber (-, (* event. These surveys sho$ FA< site conta!ination

levels in the range of (, to 5, dp!* c!( betaga!!a over several thousand s=uare

feet.

The Board revie$ed the :GI Apparent 8ause Analysis dated &ctober (9, (*. The Board

noted that $hile the occurrence report $as filed as a Significance 8ategory (, the resulting

!onetary and other i!pacts drove this event to be investigated as a Type B Accident

Investigation. That corrective action plan stated a Origorous causal analysisP $ould be

co!pleted, ho$ever, the Apparent 8ause Analysis !ethodology !ay not lead to identification

and correction of root causes identified using !ore rigorous cause !ethodologies.



7.7. ,revious Events and Lessons Learned

The follo$ing three events and their corrective actions highlight $eaknesses in both $ork

planning and control and the radiological protection progra!.

7.7.4. Arc Flash Event

&n Septe!ber *9, (-, $hile perfor!ing utility isolations in building G( panel *@(, in order to

achieve a Ucold and darkU condition for the established $ork area, an arc flash $as generated

upon cutting a 59 volt electrical line. There $ere no inHuries due to this event. The pri!ary

causes of the event $ere ineffective e+ecution of the $ork control process for !aking and

obtaining approval for changes, coupled $ith i!proper acco!plish!ent of 3ero energy checks.

7.7.2. -nantici"ated Airborne Radioactivity

&n 1anuary (), (*, five days follo$ing the e+it of five individuals fro! oo! *4 in G(, an

air sa!ple taken by 8T* covering the entry $as counted and indicated 6.- DA8 alpha and .4

DA8 betaga!!a. The area $as subse=uently posted as an Airborne adioactivity Area.

8orrective actions focused on obtaining bio@assay sa!ples for the individuals involved and

ensuring future sa!ples are representative of the breathing 3one. <essons learned focused on

sa!pling location as $ell.

7.7.7. ,ersonnel +in Contamination Follo=ing Entry into Cell /1 of *uilding@5

&n ;ebruary (6, (*, an 8T received skin conta!ination and an asbestos $orker alar!ed a

8M upon e+iting fro! 8ell >* of Building G(. The event identified poor posting of anti@8

doffing instructions, failure to establish co!!unication and provide for backup personnel upon

e+it, and $eak task instruction and procedure co!pliance.

7.8. Conduct of <"erations

The S" @D 8onduct of &perations rogra! is i!ple!ented by S"@8&&@*, Conductof Operations Program. S"@8&&@*, ev. , including a co!pliance !atri+, $asconditionally approved by the D&# 8ontracting &fficer epresentative by letter S"@I2@*on May *), (9, pending incorporation of nine D&# co!!ents. D&# 8o!!ent 2o. - relating

to 8hapter *6, e=uire!ent 8.7, stated

O2eeds to state or provide the e+ception that procedures and $ork packages $ill

be follo$ed step by step !anner unless other$ise specified.P

The S" Disposition roHect Manager responded to the D&# 8ontracting &fficer

epresentative by letter D#@AM-@)S((5*5@9@)(, on 1une **, (9, that included S"@

8&&@*, ev. *.



The docu!ent currently in effect is S"@8&&@*, ev. 4, dated May *(, (*. Deviations,

#+ceptions, and 8larifications associated $ith individual re=uire!ents have changed

significantly after evision *, but it is not evident that D&# has been involved in approving

those changes. evision * included t$o Deviations, si+ #+ceptions, and (( 8larifications,

$hile evision 4 includes (7 Deviations, 46 #+ceptions, and *5 8larifications.

8ontractor !anage!ent $as not a$are of feedback fro! the $orkgroups that fi+ative

application did not ensure * coverage for so!e co!ponents. %#M@(( S" Trip eport'

The #M@(( evaluation of conduct of operations as $as docu!ented in the S" Trip eport

identified the follo$ing areas of deficiency

• Several hold point signatures $ere not co!pleted during the perfor!ance of Building /(.

• De!olition rep $ork package %ST:@;:@*--', ho$ever $ork continued and the absenceof the signatures $as not noted until #M@(( re=uested a copy of the package.

• Misting $as utili3ed during the building de!olition for dust and airborne radioactivity

suppression. T$o individuals indicated, ho$ever, that on the day of the conta!ination event,

Septe!ber (-, (*, the !isting hose $as directed a$ay fro! de!olition activities to $ash

the tires on a truck leaving an adHacent area.

• Deficiencies $ere noted $ith the $ork package sign@off process. &n Building /( de!olition$ork package %@;:@(*4' and associated checklists, one individual signed off as the

Deconta!ination and deco!!issioning %DD' Supervisor, the adiological 8ontrol Supervisor, and the adiological #ngineer %signing off for both the DD group and the group represents a conflict of interest'. It $as also noted an alternate to the &perations

Supervisor signed and authori3ed $ork under $ork package @;:@(*4K ho$ever, intervie$ of this alternate identified they $ere not fa!iliar $ith building de!olition

activities.

• ;or!s used to docu!ent pre@Hob briefings $ere generic and provided no details on $hat $asdiscussed in the briefing.

The #M@(( S" Trip eport also docu!ented that co!!unications $ere ineffective bet$een

the participating organi3ations and $orkgroups. The Ohase Ihase IIP approach for de!olition

$as not understood by the $ork planners.

The Board validated the issues identified in the #M@(( S" Trip eport, $ith the e+ception

that the activity referred to as O!istingP in the report $as actually $etting of the construction

area $ith an inch and one@half fire hose rather than using a ODust BossP that is associated $ith

!isting. The Board also identified si!ilar and additional e+a!ples of the #M@(( identified

issues, $hich are included in the $ork control section of this report.



7.8.4. ,a"er=or+ Discre"ancies

The Board revie$ed nu!erous radiological surveys. The tea! noticed t$o re!ovable

conta!ination surveys conducted Septe!ber *, (*, had e+act conta!ination count readings

for the first *9 results indicating that $rong survey data $as used for one of the surveys.

The Board $as provided copies of : S"@D@5(, ev * dated 1une 4, (*, and S"@

D@*@5( ev , dated April 4, (*. The copies provided indicated a change to the :

fro! (*4 to *--. There $as no docu!entation of $ho !ade the change and the changes $ere

pen and ink to the copies provided to the Board.

Additionally, nu!erous other surveys revie$ed by the Board included pen and ink changes !ade

after the survey $as signed off by the original surveyor $ithout docu!entation of $ho !ade the

changes or $hen the change $as !ade.

The Board $as told that a survey of a bolt that $as eHected fro! the de!olition area $as perfor!ed on Septe!ber (-, (*. The survey $as not docu!ented until appro+i!ately one

$eek later. 2o docu!entation of the Septe!ber (-th

survey $as provided to the Board by :GI.

8T( $ho perfor!ed the survey $as on vacation and provided survey results via telephone

discussion $ith his supervisor, $ho subse=uently docu!ented the survey indicating fi+ed

conta!ination levels less than ), dp!* c!( betaga!!a. The supervisor docu!enting

the survey recorded the $rong type of instru!ent $hich resulted in underesti!ation of the

conta!ination levels. /ad the appropriate instru!ent been recorded, the results $ould have

been appro+i!ately (5, dp!* c!( betaga!!a.

The de!obili3ation section %).*(' of $ork package ST59/5!9)&&(, #* Demo Prep contained

the only hold point signature that $as obtained prior to approval of Attach!ent B, #* Demo Ready C/eclist . The #M@(( trip report identified that the re!aining t$elve hold point

signatures had not been obtained during their visit on the *(th

of &ctober. Subse=uently, a

change $as !ade to the $ork package and the steps $ere signed off on &ctober *(, (* and

&ctober *4, (*. The signatures $ere obtained si+ $eeks after approval of the #* Demo

ReadyC/eclist on Septe!ber ((, (*.

The Board $as concerned $ith the nu!erous instances of =uestionable docu!entation practices.

7.9. !ntegrated afety 4anagement

:GI utili3es S"@ISM@(, SPRU DP Integrated Wor Control Program to prepare, authori3e

and conduct $ork. Although lacking detail in so!e areas such as the categori3ation of $ork,

approval and change control process, the board deter!ined that overall, the $ork planning

procedure provided sufficient guidance to produce an ade=uate $ork docu!ent. This is also

supported by the #M@(( Trip eport conclusion regarding $ork planning and control.



7.9.4. Define the co"e of ;or+

The Board deter!ined that the !aHority of docu!ents revie$ed contained detailed scope of

$ork sections that provided sufficient detail to the planning group to prepare the $ork package.

/o$ever, the detailed $ork steps developed fro! the scope lacked the necessary level of rigor

and detail to ensure that the scope of $ork $ould be e+ecuted as described in the proHect plans

and technical basis docu!ents. &ne specific e+a!ple that $as a key decision point related to the

event $as step ).*.* of ST:@:@*--. The step stated

Oevie$ e+isting conditions for /( #levation 44( by perfor!ing the follo$ing

A. evie$ the radiological survey data. adiological #ngineering shall

deter!ine $hether additional radiological characteri3ation is necessary.

"pdate Attach!ent A, /( Building #levation 44( De!o rep Action Ite!s as

necessary.P

The step did not provide radiological criteria for !aking the deter!ination as to $hat =ualified

as needing further characteri3ation. This $as left up to the opinion of the adiological

#ngineering.

During intervie$s, the proHect radiological engineers stated that the sa!pling perfor!ed during

the e+ecution of the vent and drain $ork package $as for the purpose of characteri3ing the $aste

li=uid for disposal. 2one of the infor!ation $as intended to be utili3ed to assess the condition of

the re!aining syste! internals $ith regard to de!olition. The Board identified this as a !issed

opportunity to further understand the conta!ination that $ould be encountered $hen

disasse!bling syste! co!ponents.



7.9.2. Analyze the 6azard

Table 8&5' Com"arison of <riginal and Current ,R- D, Radiological !nventory1

%uclide !nventory Descri"tion:Location

urface urface ResidualContamination Contamination Contamination Total ,R- D,

=ithin @5 and 65 =ithin Tan+ Farm =ithin Tan+ Farm ActivityFacilities Tan+s Tan+s 5)1) Facility

5)1) Facility 5)1) Facility 5)1) Facility EstimateB

EstimateB.Ci3

5EstimateB

.Ci3EstimateB

.Ci3.Ci3

#r-<; 4.;;:E2.;;F 2.>4:E2.>4F 7<.;;:E23.94F 82.>4:E74.72F

s-47= 2.8;:E47.9;F 3.89:E3.89F 28.;4:E7<.37F 72.>3:E9<.9>F

)u-27< ;.28:E4.9>F ;.<;:E;.<;F >.<4:E>.38F 4;.;9:E44.42F

1m-284 ;.;7:E;.22F ;.4;:E;.4;F 4.43:E4.;3F 4.2<:E4.7>F

Totals 7.3=:E4=.7F 4;.23:E4;.23F =7.;>:E=9.>F >=.;4:E4;7.8F

Infor!ation included in S"@;/8@*, evision *, SPRU Disposition Proect 4inal #a$ardCategori$ation, dated August *(, (*, included an increase in radiological inventory in the G(

and Building /( facilities. Surface conta!ination activity values for u@(4- $ithin the G( and

Buildings increased fro! .(5 8i to *.)9 8i. The a!ount of u@(4- necessary to e+ceed the *8; 94) li!it of ) e! co!!itted effective dose %8#D' to the bone surface is about *(

nano8i %*( + *@-

8i'.

The proposed !ethod of de!olition $as open air $ith the use of fi+atives to control the spread

of radioactive conta!ination. Based on the relatively large a!ount %*.)9 8i' of u@(4-

esti!ated to be contained in surface conta!ination, release of a very s!all fraction could

result in an unacceptable dose.

4.).(.*. Technical Basis for &pen Air De!olition

&n Septe!ber (-,(*, DD $ork continued at Building /(. The $ork $as evaluated in

S"@8@4(, SPRU DP 4acility 5 Conditions for Demolition -ec/nical )asis Document ,

dated March *6, (*. This docu!ent states OThe de!olition of the G(/( facility and

* Source S"@;/8@*, ev *

( 8i data outside brackets $ere included in D&#@S#@*, evision , dated March 4*, (-, and 8i data inside brackets $ere included in S" Disposition roHect ;inal /a3ard 8ategori3ation S"@;/8@*, evision *,dated August *(, (*.



associated tank far! is constrained by offsite dose considerations to a !a+i!ally e+posed offsite

individual %M#&SI' for airborne releases. The #A has established an offsite dose li!it of *

!re! per calendar year that the roHect !ust satisfy. This paper reports the result of dose

calculations using an approved path$ays co!puter code %8A99@8' to de!onstrate co!pliance

$ith airborne release li!its.P

This technical basis docu!ent applies an inventory esti!ate developed by :illia! Duggan

%private correspondence' based on the *-9- !easure!ents that $ere reported in *--(

O8haracteri3ation $ork to evaluate the inventory in the different parts of S"

$as carried out in several investigations detailed in the reli!inary #valuation of

the Status of the Separation.P

The technical basis docu!ent describes the de!olition as

OThe proposed !ethod for preparation prior to de!olition of the buildings

includes applying fi+ative to the accessible surfaces of the $alls, floors, ceiling

and e=uip!ent in the process cells and support corridors. The colu!ns $ill be

e!ptied, if re=uired, under /#A ventilation, and then fogged. iping $ill be

left attached to the colu!ns. A Dust Boss $ill provide a !ist during de!olition

of conta!inated structures. A surfactant or tacking agent !ay be added to the

$ater to i!prove dust suppression during load out operations. The buildings $ill

be de!olished in open air. The building debris $ill be si3e reduced as re=uired

and loaded into radioactive $aste shipping containers for transportation and

disposal

in open air.P

The technical basis also states

OA Dust Boss $ill provide a !ist during de!olition of conta!inated structures.P

"se of a Dust Boss results in an offsite dose reduction factor of .4.

The technical basis concludes

OThe G(/( facilities can be re!oved in open air in co!pliance $ith #A and

D&# regulations for offsite dose to the e+tent that the source ter! herein is

validated by sa!ple analysis and assu!ed !itigation !ethods are effective asindicated.P

The Board found that the source ter! $as not validated by sa!ple analysis and the !itigation

!ethods $ere not effectively i!ple!ented and their effectiveness $as not assessed.

The technical basis assu!es an isotopic co!position $ith 8esiu!@*47 contributing over 6 of

the activity and Strontiu!@- contributing appro+i!ately (). Air sa!ple data obtained after

the Septe!ber (-th

event indicated that this assu!ption $as incorrect, the Strontiu!@-



contributed to the !aHority of the activity. 2 personnel stated that their analysis of the

conta!ination fro! the Septe!ber (-, (* event indicated that Strontiu!@- $as the !aHor



co!ponent of the activity %6 ti!es greater than the 8esiu!@*47 activity'. The Board revie$ed

several radioactive $aste profile records for various Building /( $aste strea!s. Sa!ple data

fro! the spring and su!!er of (* indicated several $aste strea!s $here Strontiu!@-

activity predo!inated over the 8esiu!@*47 activity. ;or e+a!ple, a resin sa!ple fro! March

(* sho$ed a Strontiu! to 8esiu! ratio of 4 to *. This infor!ation $as never used to revise or

validate assu!ptions in the technical basis. It appeared that additional radiological

characteri3ation is $arranted for Building /( activities.

4.).(.(. Strontiu! 8onta!ination ?alues

Appendi+ D to * 8; 94) lists surface conta!ination values. &ne ro$ states

OThis category of radionuclides includes !i+ed fission products, including the Sr@

- $hich is present in the!. It does not apply to Sr@- $hich has been separated

fro! the other fission products or !i+tures $here the Sr@- has been enriched.P

D&# provides guidance on !eeting this re=uire!ent in D&# G 55*.*@*8 Radiation

Protection Programs Guide for Use ,it/ -itle 67 C4R 809& Occupational Radiation Protection,dated )@ *-@9.

Section **.). states

The follo$ing application of ;ootnote ) in Appendi+ D of * 8; 94) to Sr@-

co!bined $ith !i+ed fission products is considered an acceptable approach for

co!pliance $ith * 8; 94)

• :here the Sr@- fraction is ) percent or less, the !i+ed fission productssurface activity values apply.

• :here Sr@- fraction is bet$een ) percent and - percent of the total

activity, surface radioactivity values should be 4 dp!* c!(

or less.

• :here the Sr@- fraction e+ceeds - percent the total activity, Sr@- surface

radioactivity values should be applied to the !aterial.

S"@8@4(, SPRU DP 4acility 5 Conditions for Demolition& -ec/nical )asis Document ,dated March *6, (*, indicates that Building colu!ns have !ore than half of their source

inventory $as fro! Sr@-. In addition, the Board revie$ of isotopic air sa!ple results indicated

that the isotopic !i+ture consisted of close to - of the activity being fro! Sr@-. As stated

above, 2 and $aste profile data indicate that !ore conservative Strontiu! values !ay be

appropriate.

/o$ever, revie$ of :GIs conta!ination surveys indicated that :GI $as using the !i+ed

fission products surface conta!ination values of * dp!* c!( betaga!!a for re!ovable

and ) dp!* c!( betaga!!a for total for assessing Building /( surface radioactivity

values. Discussions $ith :GIs radiation protection !anage!ent indicated that :GI $as

initiating use of the lo$er Sr@- re!ovable value of ( dp!* c!( betaga!!aK ho$ever,



this has not been reflected in :GIs procedures and the rationale for continued use of )dp!* c!

( betaga!!a for total surface radioactivity has not been developed.

4.).(.4. re@De!olition Survey

The Board revie$ed several of the surveys conducted prior to de!olition activities. The surveysevaluated re!ovable conta!ination levels. Discussion $ith survey personnel and revie$ of

docu!entation indicated that overhead elevations $ere not surveyed. The surveys $ere

conducted to de!onstrate that areas surveyed !et de!olition criteria fro! 8@4( as specified

belo$

OAverage conta!ination greater than * dp! alpha on a * c!(

s!ear or

greater than ), dp! betaga!!a on a * c!(s!ear

• Suitable fi+ative shall be applied to accessible surfacesK

• Apply fogging to inaccessible surfaces, as necessary %e.g. co!plicatedgeo!etry, colu!ns'.

• Average conta!ination greater than ( dp! alpha up to * alpha on a *

c!(s!ear or * dp! beta up to ), dp! beta on a * c!

(s!ear

• <ate+ fi+ative or fogging !ay be providedperfor!ed as applicable

• <egacy covered or labeled conta!ination

• Apply fi+ative in accessible locations to distinguish conta!ination during

de!olition and load out

• &ther$ise do not stabili3e.P

The Board noted that fogging $as never applied as described above. Also post lock do$n

surveys did not include surveying overhead structures and the interior of co!ponents.

The Board re=uested but did not receive radiological surveys results $hen the !an@$ays $ere

re!oved to spray fi+ative inside the colu!ns.

The Board revie$ of the data indicated that the assu!ptions in 8@4( placed unreasonable

e+pectations on the effectiveness of placing fi+ative on conta!inated surfaces.

S"@;/8@*, evision , DO' Safety 'valuation Report for Separations Process Researc/

Unit Disposition Proect 4inal #a$ard Categori$ation, dated March 4*, (-, contained the

follo$ing condition of approval %8&A'

O8ondition of Approval >*, state, O"S:D shall develop and i!ple!ent a

radiological inventory !onitoring and evaluation process and periodically

revie$s ne$ facility characteri3ation data to ensure that the assu!ptions in the



S" D ;/8 re!ain representative and bounding %$ithin the !argins

established in 8&A

>( belo$'. The radiological inventory !onitoring and evaluation process should

$ork in conHunction $ith the change control process re=uired by 8&A .P



D&# S" specified co!pletion of 8&A >* $as due $ithin 6 days of receipt of the D&#

approval of the S" D ;/8 %March 4*, (-'.

DO' Safety 'valuation Report Addendum A 4or Revision 6 Of -/e Separations Process Researc/ Unit Disposition Proect 4inal #a$ard Categori$ation :SPRU3P#C3776& Revision 6;,

evision , dated August **, (*, accepted all 8&As, including 8&A >*, in the originalSafety #valuation eport as having been ade=uately addressed. The Board concluded that characteri3ation of the facility $as not ade=uate to support open air de!olition of radioactive

co!ponents in the Building facility.

7.9.7. 4itigate the 6azards

The de!olition of Building /( $as conducted under adiological :ork er!it %:' S"@

D@*@)-, ev , Prep and Demolis/ and Stage for Disposal t/e #* )uilding and All Associated Waste& dated Septe!ber (4, (*. See Section 4.(.* for a description of ho$ this

docu!ent $as ineffectively i!ple!ented.

The spraying of Ofi+ativeP appears to have been associated $ith a belief that doing so $ould

preclude the possibility of any spread of radioactive conta!ination, so !uch so, that the ter!

Olocked do$nP $as fre=uently and generally used by !anage!ent, staff, and $orkers to describe

ho$ the fi+ative $as used for conta!ination controlK a clear over@reliance on the application

!ethodology. The Board noted that ;igure (@4, ;igure 4@* and ;igure 4@( illustrate that fi+ative

$as not applied to several surfaces of the evaporator syste! co!ponents.

1/A 2u!ber *5, ev. $as included as part of $ork package ST:@;:@*--. The 1/A

identified the $ork package as a Type * and associated : S"@D@*@4) $ith the 1/A.

The 1/A for $ork tasks $ith radiological conditions included OAdhere to : S"@D@*@4).P /o$ever, $ork $as docu!ented in areas under radiological control fro! 1une -, (*

through August *9, (*. The : start date and authori3ation to $ork signatures $ere August

(), (*.



Figure 8&1' !ncom"lete A""lication of Fixative to e"arator Columns e"tember 50# 5)1)

Figure 8&5' e"tember 50# 5)1) ,ost Column 118&A Removal



7.9.8. ,erform ;or+ =ithin Controls

D&#@S" personnel $ere present at the 9 !eeting $hen the re=uest to re!ove the

evaporator syste! co!ponents out $as !ade. The infor!ation $as shared $ith other D&#@S" personnel. Based on this discussion, though, the D&# S" Manager did not believe

that conta!inated co!ponents $ere being re!oved. The Board noted that there $as no apparent

D&# follo$@up to ensure that :GI $as $ithin the bounds of the approved $ork docu!ent.

:ork activities as recorded in the Wor Pacage Status +og covered the period fro! 1une -,

(*, through August *9, (*. &n &ctober *, (*, a change to the $ork package $as issued

to re!ove steps ).*.5, ).(.5, and ).4.5 fro! the $ork package. All three steps contained the

follo$ing $ording

Oadiological #ngineering, #nviron!ental, Industrial /ygiene and :aste

Acceptance 8riteria %:A8' representatives shall revie$ the /( #levation Lthree

elevations listed Data Sheet, survey results, and characteri3ation results, if any,

to deter!ine $hether deconta!ination or lock@do$n is necessary or if the area

can be left as is for open air de!olition.

Is deconta!ination necessary es V 2o V

Is lock@do$n necessaryW es V 2o VP

#ach of these steps also included hold points signifying that the data collected had beenrevie$ed by signature and Attach!ent A, #* )uilding Source Reduction Data S/eet $as

updated by the adiological #ngineering, #nviron!ental, Industrial /ygiene and :A8

representatives. This change $as docu!ented on the last page of the Work Package Status Log

$ith the co!!ent

OXthis confir!ation of necessary and co!pleted actions is captured by the full

set of signatures on the De!o eady 8hecklist.P

The De!o eady 8hecklist does not !ake the sa!e affir!ation that the data has been updated

and has three areas for $hich no OyesP or OnoP check bo+ is checked to indicate the specific ite!s have been co!pleted.

In addition to the *( out of *4 hold points not signed prior to the $ork, the Board also noted that

nu!erous hold points $ere re!oved fro! the $ork package after the event. The re!oval of

these hold points $as not e+plained and not ade=uately docu!ented by issuing the $ork

package as a ne$ revision.



The adiological #ngineer hold points addressed that radiological characteri3ation results are

consistent $ith the actions specified to be authori3ed. adiological data, such as posted lock@

do$n conta!ination and radiation survey results $ere not revie$ed $hen these hold points $ere

signed on &ctober *4, (*.



7.9.9. ,rovide for Feedbac+ and !m"rovement

Type * $ork packages are re=uired by procedure to co!plete Olessons learnedP as soon after the

$ork package co!pletion as possible. The Board revie$ed the only available Separations

rocess esearch "nit Disposition roHect S"@D ;eedback 8hecklist associated $ith 82S@

;:@*4), and found the docu!ent to be ade=uate. The discovery of an une+pected energy

source and reco!!endations for i!proving the task $ere included in the checklist. The Board

also revie$ed criti=ue !inutes for several events and found the feedback section to generally be

ade=uate. /o$ever, it is not evident that lessons learned identified during perfor!ance of $ork

and event criti=ues $ere incorporated into future activities.

4.).).*. 8ontractor Assurance Syste!

:GI has established ele!ents of a 8ontractor Assurance Syste! %8AS'. Integrated Safety

2anagement System Description, S"@(9@ISM@*, evision ), dated Septe!ber (9, (*,

lists D&# & ((6.*, Performance Assurance LIncorrect title, as the reference, and indicates that

the Assurance lan per D&# & ((6.* LThe current docu!ent is D&# & ((6.*A is integrated

throughout the feedback !echanis!s in the ISMS $hich is pri!arily i!ple!ented through the

roHect Nuality Assurance lan. Proect Specific <uality Assurance Plan, S"@NA@*,

evision ), dated May (6, (*, contains Attach!ent A, S" D Contractor Assurance

System. It $as noted that 2anagement Assessments, S"@N@*-, evision *, March (6,

(-, does not reference D&# & ((6.*A. The Board did not re=uest, and did not revie$, the

D&# docu!ent that approved the :GI 8AS progra! description.

The Board confir!ed the deficiencies identified in the #M@(( Trip eport that the !aHority ofissues related to $ork@planning and conta!ination control had been identified by D&#, rather

than by the contractor, and that a revie$ of the issue tracking syste! identified prior issues

si!ilar to perfor!ance issues noted during the accident, $hich indicated the e+istence of

potential recurrent proble! areas.

T$o $eeks prior to the accident :GI co!pleted an assess!ent of the :GI adiation rotection

rogra! relating to radiological !onitoring co!pliance $ith D&#@STD@*-9@(9, Article *45$as co!pleted as part of a corrective action for a previously D&# identified issue. The

assess!ent $as conducted over a seven $eek period, and identified no issues. The Board noted

that several assess!ent criteria that $ere deter!ined to be fully co!pliant during the assess!ent $ere de!onstrated $eaknesses during the accident.

8(7(( !ntegrated afety 4anagement @uiding ,rinci"les

During the intervie$s conducted by the Board, several personnel provided infor!ation about

perceived production pressure. It is not clear to the Board $hat caused this production pressure,

but appears to have been driven by proHect supervision and !anage!ent personnel. &f specific

!ention $ere the Deputy roHect Director and the :aste Superintendent. It $as perceived that



these t$o $ere brought into the proHect $ith the purpose of i!proving production and in one

intervie$ it $as !entioned that they had been successful in perfor!ing this function. The

!anage!ent style used by these t$o individuals appears to the Board to have created an



at!osphere of fear a!ong the $orkforce to speak up about issues of concern. During a &D

!eeting, attended by t$o of the board !e!bers, on Thursday, 2ove!ber 5, (*, a strong

production push $as perceived for the acco!plish!ent of scheduled $ork $ith little to no

allo$ance for discussion fro! the $orkforce about any proble!s encountered in perfor!ing the

$ork. The $ork planning staff reported that e+tre!e schedule pressure e+isted $hen $riting

the package that $ould cover the 8leveland :recking $ork, since 8leveland :recking $as on

site and needed to start $ork. The conceptual drive for production is co!!ended by the Board,

ho$ever, open discussion bet$een the $ork force and !anage!ent about the $ork should be

encouraged so that a =uestioning attitude is developed $ithin the $orkforce. 8oncerns or

=uestions about the $ork planned should be resolved before $ork is allo$ed to proceed. It

should be clear to all $orkers on the proHect that there $ill be no retribution if they e+ecute their

stop $ork authority.

&n the day of the event, there $ere $orkers at the site $ho felt unsure about $hether the tanks

should be re!oved but $ere afraid to e+press their concern to !e!bers of !anage!ent

controlling the $ork. 8Ts $ere not allo$ed into the Building de!olition area because of a

concern for their safety. The Board =uestions $hether the decision to re!ove radiological

controls technician oversight fro! the de!olition activity $as !ade $ith production as the

focus rather than focusing on the $orkers radiological protection. :hen a concern $as

e+pressed to an 8T due to an abnor!al noise heard by an electrician during si3e reducing of

one of the condensers, the 8T stopped $ork to perfor! e+plosive gas sa!ples. &nce these

sa!ples $ere co!pleted, ho$ever, the Board $as infor!ed that the :aste Superintendent

ad!onished the 8T for stopping $ork indicating that the noise $as to be e+pected during the

!aterial shearing

process. It $as also reported that a fe$ hours later, $hen the egress friskersouth of Building /( $as responded to by the 8T $ho believed his indicationsK the :aste

Superintendent =uestioned 8T*s response since he believed that the alar!ing condition $as

caused by radiation OshineP.

:GI supervision and !anage!ent should e!ploy !anage!ent techni=ues that $ill i!prove

co!!unication bet$een !anagers and $orkers. Nuestions should be encouraged during pre@ Hob briefings. :ork should not be co!!enced and should be stopped, if in progress, if there areunans$ered =uestions fro! $orkers. A production driven environ!ent should not e+ist suchthat unsafe $ork practices are allo$ed or perceived to e+ist by the $orkforce.

7.3. Event and Causal Factors Chart

After perfor!ing the barrier and change analyses, the Board assigned results fro! each analysis

to events on the chronology of events. This involved assigning the analyses results as

conditions that $ere related or caused the events on the chronology. Assigning these conditions

$ith events resulted in the events and causal factors %#8;' chart as seen in Appendi+ D. &nce

conditions $ere assigned, the Board e+a!ined the chart to deter!ine $hich events $ere

significant %!eaning $hich events played a role in causing the accident'. The Board then



assessed the significant events %and the conditions of each' to deter!ine the causal factors of the

accident.



7.=. *arrier Analysis

After a basic chronology of events $as developed, the Board perfor!ed a Barrier Analysis of the

accident. To start the Barrier Analysis, the Board chose a target %the person or ite! to be

protected' and the ha3ard %$hat the person or ite! is to be protected fro!'. The Barrier Analysis

is presented in Appendi+ B.

7.>. Change Analysis

To further support the develop!ent of causal factors, the Board perfor!ed a 8hange Analysis of

the accident. The Board e+a!ined the planned and unplanned changes that caused the undesired

results or outco!es related to the event. The 8hange Analysis is presented in Appendi+ 8.



>() Conclusions and $udgments of %eed

1&2s are the !anagerial controls and safety !easures deter!ined by the Board to be necessary

to prevent or !ini!i3e the probability or severity of a recurrence. These 1&2s are linkeddirectly to the casual factors $hich are derived fro! the facts and analysis. They for! the basis

for corrective action plans $hich !ust be developed by line !anage!ent. The Boards

conclusions and 1&2s are listed belo$ in Table 5@*.

The Board concluded this accident $as preventable.

The direct cause of the accident $as the open air de!olition of the evaporator syste!

co!ponents.

The root causes of the accident $ere

• The failures by :GI to fully understand, characteri3e, and control the radiological ha3ard.

• The failure by :GI to i!ple!ent a $ork control process that ensured facility conditions

supported proceeding $ith the $ork.

It is anticipated that S" $ill revie$ the Incident Analysis reports $hen finali3ed and infor!

#M if any additional actions are re=uired.

Table >&1' Conclusions and $udgments of %eed


The Board concluded WGI placed an over-reliance on the application and effectiveness of"fixative" to control contamination duringdemolition and prevent the spread ofcontamination off-site.

WGI needs to re-evaluate and justify thecontamination control techniues used duringdemolition.

The Board concluded WGI did not applyfixative to the !lash olumn and #eparatorolumns in the $est "%ot" &vaporator cell.

WGI needs to ensure contamination controltechniues are $ell defined and executed as specifiedin $or' control documents.

The Board concluded the radiation protection

program $as ineffective in evaluating andcontrolling contamination sources duringdemolition activities.

The Board concluded the execution of the"(emo )rep" and "(emolition" $or' pac'agesdid not result in the identification and control ofcontaminated components.

The Board concluded the radiological dataused did not result in appropriatelycharacteri*ing and controlling the radiologicalha*ard.

WGI needs to evaluate the current +adiation)rotection )rogram and implement improvements thatdemonstrate competence and rigor, specifically asapplied to the characteri*ation and control ofradioactive contamination. This needs to includestrengthening the 'no$ledge, s'ills, and ailities ofthe +adiological ontrols Technicians.




The Board concluded that the WGI process for authori*ing $or' tas's did not ensure the $or'$as revie$ed y the appropriate #ujectatter &xperts at the )/( efore proceeding.

WGI needs to estalish a $or' planning andauthori*ation process that ensures revie$, approval,and authori*ation y cogni*ant management andsuject matter experts.

The Board concluded that (/& and WGIoversight programs $ere ineffective in theidentification and correction of environment,safety and health programs deficiencies.

(/& #)+0 needs to strengthen their oversightprocess and procedures to maintain sufficient'no$ledge of site and contractor activities to ma'einformed decisions aout ha*ards and ris' andevaluate contractor performance.

WGI needs to strengthen their ontractor 1ssurance#ystem to fully comply $ith (/& / 223.4,Implementation of Department of Energy Oversight

Assurance Program, $ith specific attention to criticalself-assessments and verification of effectiveness ofcorrective actions.

#ome $or'ers perceived schedule pressureand $ere reluctant to ring up issues that mightslo$ progress.

WGI management needs to cultivate an atmosphereof open communication and acceptance of employeefeedac' regarding $or' processes and safetyconcerns.

The Board concluded the freuent use ofterminology such as 5as reuired,6 5as needed,6and 5as necessary,6 contriuted to a failure tocomplete $or' steps as intended. Theflexiility incorporated into $or' documents ledto individual decision-ma'ing in determining$hat components in the Building %2 $ouldreuire additional consideration.

WGI needs to strengthen the level of rigor anddiscipline in executing the $or' planning process suchthat $or' steps provide the necessary detail to ensuresteps are accomplished as planned.

The Board identified the follo$ing contributing causes to the accident

• There $as no plan for application of fi+ative. The interior construction of the vessel%s' $asnot kno$n to the $orkers applying fi+ative.

• There $as no verification of the coverage or effectiveness of the fi+ative.

• There $as overconfidence in the effectiveness of the fi+ative to Ulockdo$nU conta!ination.

• It $as not specific to ho$ fi+ative $as to be used $hen re!oving vessels, tanks, or other co!ponents having internal configurations.

• Deconta!ination $as not used during re!oval of the evaporator syste! vessels.

• The $ork package did not integrate the ha3ard controls identified in the 1/A and specifically

84(, ev *.



• The $ork package e+ecution did not assure all process vessels in Building /( $ere identifiedand characteri3ed.

• :s $ere $ritten in generic ter!s and not specific to the task being perfor!ed.

• Steps in $ork packages relating to identifying ha3ards $ere not co!pleted.

• The responsible SM#s approved $orking level docu!ents $ithout fully ensuring the ha3ardcontrols $ere identified.

• @;:@(*4, G(/(, 84(, : $ork plan for doing radioactive $ork $ere not

ade=uate to i!ple!ent appropriate radiological controls for the $ork being perfor!ed.

• @;:@(*4 addresses the use of $ater for dust control vs. conta!ination control.

• The use of the UDust BossU for conta!ination control identified in 8@4( $as not includedin the $ork package.

• 2o criteria $as established and approved to color code vessels for special handling.

• The roHect did not recogni3e the i!portance of understanding historical process andsyste! kno$ledge.

• e=uire!ent to fully characteri3e S" for DD $as not co!pleted.

• <ack of rigor in e+ecuting the characteri3ation plan.

• rocedure allo$s $ork to be conducted outside of the &D revie$ and discussion process

• rogra!!atic deficiencies $ere not identified and corrected.

• D&# S" &versight did not assure progra!!atic deficiencies $ere identified and

corrected.



5

7() *oard ignatures



() *oard 4embers# Advisors# Consultants

*oard 4embers8hairperson T. 1. 1ackson, 8hair, #M8B8

Me!ber Steven Ahrendts, Board Me!ber, D&#@ID

Me!ber oger 8layco!b, Board Me!ber, D&#@ID

Me!ber eter &8onnell, Board Investigator, /S@**

Me!ber obert Seal, Board Me!ber, D&#@ID

Advisor:*oard Coordinator

Technical Advisor :illia! McNuiston, MAS 8onsultants

Administrative Coordinator

8onsultant Susan Feffer, roHect #nhance!ent 8orporation



A""endix A'A""ointment of Ty"e * Accident !nvestigation *oard



Appendi+ A@*



A""endix *' *arrier Analysis

Appendi+ B@*



Appendi+ B@*

Barrier analysis is based on the pre!ise that ha3ards are associated $ith all tasks. A barrier is any !eans used to control, prevent, or

i!pede a ha3ard fro! reaching a target, thereby reducing the severity of the resultant accident or adverse conse=uence. A ha3ard is the

potential for an un$anted condition to result in an accident or other adverse conse=uence. A target is a person or obHect that a ha3ard

!ay da!age, inHure, or fatally har!. Barrier analysis deter!ines ho$ a ha3ard overco!es the barriers, co!es into contact $ith a

target %e.g., fro! the barriers or controls not being in place, not being used properly, or failing', and leads to an accident or adverse

conse=uence. The results of the barrier analysis are used to support the develop!ent of causal factors.

Table *&1' *arrier Analysis

6azard' Radiological contamination Target' ;or+ers and environment

;hat =ere the barriers 6o= did each barrier"erform

;hy did the barrier fail 6o= did the barrier affectthe accident

1pplication of "fixative" tocontaminated surfaces

1s applied to the vesselsH inuestion, the fixative $asineffective to controlcontamination spread.

There $as no plan for application.The interior construction of thevesselsH $as not 'no$n to the$or'ers.

There $as no verification of thecoverage or effectiveness of thefixative.

There $as overconfidence in theeffectiveness of the fixative to"loc'do$n" contamination.

!ailure to properly and fullyapply fixative to the vesselsHinternals increased theproaility of the spread ofcontamination.*1

Wor' )ac'age )))-!W)-247;for the (( activities

!ailed The $or' pac'age did notintegrate the ha*ard controlsidentified in the J%1 andspecifically +7;2, +ev 4.It $as not specific to ho$ fixative$as to e used $hen removingvessels, tan's, or othercomponents having internalconfigurations.

The $or' pac'age $as notspecific in identifying thecomponents eing removed.*5






Wor' )ac'age #TW-!W)-4<<;,%2 (emo )rep

!ailed #teps relating to identifyingha*ards $ere not completed.

+eady for (emo hec'list $assigned as complete giving afalse sense of safety.*8

0se of suject matter expertiseto identify and control theha*ards

!ailed The responsile #&?s approved$or' level documents $ithout fullyensuring the ha*ard controls $ereidentified.

)otential radiological ha*ards$ere not controlled.*>

+adiological Wor' )ermitsspecial instructions used tocontrol:limit spread ofcontamination.

!ailed +W)s $ere $ritten in genericterms and not specific to the tas'eing performed.

!ailed to estalish on-siteradiological monitoring duringuilding demolition.*7

onfinement structure EtentFprevents spreadH

Dot used Dot used 0se of a confinement structurecould have prevented the spreadof contamination eyond theimmediate $or' area.*

+adiological ontrol )ractices !ailed to prevent the spread ofcontamination

)))-!W)-247;, G2:%2, +7;2,+W) $or' plan for doingradioactive $or' $ere notadeuate to implementappropriate radiological controlsfor the $or' eing performed.

!ailure to implement the proper controls contriuted to thespread of contamination.*2






isting for contamination control The (ust Boss identified in +-7;2 $as not used.

0se of a fire hose for dust control

$as used intermittently.

)))-!W)-247; addresses theuse of $ater for dust control.

The use of the "(ust Boss" for

contamination control identified in+-7;2 $as not included in the$or' pac'age.

#pread of radioactivecontamination $as not controlledas discussed in +7;2.*

%old )oints are used to verifycompletion of $or' steps prior tocontinuing $or'.

%old points in $or' pac'age#TW-!W)-4<<; $ere ypassedand suseuently removed yrevision after the last $or' steps$ere recorded in the $or'pac'age status log.

anagement did not enforce thereuirements in the $or' controlprogram regarding the executionof hold points.

%2 (emo )rep $or' pac'age$as completed $ithout theinitially reuired sources eingidentified.*0

#TW-!W)-4<<; - preparation of Building %2 for demolition

!ailed The $or' pac'age execution didnot assure all process vessels in%2 $ere identified andcharacteri*ed.

!ailure to identify the evaporator process vessels as a potentialcontamination source, lead to aloss of control of radiologicalcontamination.*1)

haracteri*ation of radiologicalha*ards

!ailed to identify the processcomponents in %2 as radiologicalha*ards reuiring specialcontrols.

ac' of rigor in executing thecharacteri*ation plan.

!ailure to identify the processcomponents that ultimatelyresulted in the radiological event.*11

olor coding of specialcomponents

Kessels $ere not identified andmar'ed.

Do criteria $as estalished andapproved to color code vessels for special handling.

(emolition of the evaporatorvessels $as not controlledresulting in spread of radioactivecontamination.*15






)rocess 'no$ledge Wor'ers and #&s $ere notfamiliar $ith the operation andpotential impacts of theevaporator systems.

The )roject did not recogni*e theimportance of understandinghistorical process and system'no$ledge.

)roject did not recogni*e thepotential sources for spread of contaminated material.*18

(econtaminate componentsprior to si*ing

Dot used. (econtamination $as not usedduring removal of the evaporatorsystem vessels.

omponents $ere notdecontaminated.*1>

#)+0-() (ecommissioning)lan#)+0-((-;;8H

!ailed +euirement to fully characteri*e#)+0 for (( $as notcompleted.

ac' of characteri*ation dataresulted in a failure to identifyradiological ha*ard duringremoval of the vessels.*17

ontractor 1ssurance/versightH

!ailed )rogrammatic deficiencies $erenot identified and corrected.

!ailed to identify and correct$ea'nesses in the radiologicalprotection and $or' controlsprograms*1

Wor' is controlled y )/(approval

!ailed )rocedure allo$s $or' to econducted outside of the )/(revie$ and discussion process

ost opportunity to have the$or' revie$ed y #&s*12

(/& /versight ess than adeuate )rogrammatic deficiencies $erenot identified and corrected.

!ailed to identify $ea'nesses inthe radiological protection and$or' controls programs andvalidate corrective actions.*1



A""endix C' Change Analysis



Appendi+ 8@*

8hange is anything that disturbs the ObalanceP of a syste! fro! operating as planned. 8hange is often the source of deviations in

syste! operations. 8hange can be planned, anticipated, and desired, or it can be unintentional and un$anted. 8hange analysis

e+a!ines the planned or unplanned disturbances or deviations that caused the undesired results or outco!es related to the accident.

This process analy3es the difference bet$een $hat is nor!al %or OidealP' and $hat actually occurred. The results of the change

analysis are used to support the develop!ent of causal factors.

Table C&1' Change Analysis

Accident ituationAccident Free# ,rior or !deal

ituationDifference

Evaluation of the Effect on theAccident

(emolit ion $as performed in (emolit ion is performed in +adioactive contamination $hen The accident $ould not occur.open air tent:cover or other confinement. performing demolition $ould not C1

e spread outside the demolitionarea.

!ixative $as not applied to the$est cell evaporator vesselexteriors

!ixative is applied to all vesselexteriors and interior surfaces

oose radioactive contaminationis availale for dispersal in openair.

oose radioactive contaminationis significantly reduced.C5

haracteri*ation of Building %2did not identify the location andconcentration of radioactivecontamination hold up in process

piping and vessels.

haracteri*ation of Building %2documented the location andconcentration of radioactivecontamination in piping and

vessels internals.

Wor' planners and #&s $oulde a$are of the location anduantities of radioactivecontamination and develop

effective mitigation.

itigation against uncontrolledspread of radioactive materials istailored to the specific tas's.C8

+emoval of the evaporator cellvessels $as not discussed at the)/( meeting

1ll $or' planned to eaccomplished is authori*ed at the)/( meeting and discussed

1ppropriate #&s $ere notavailale to revie$ and:or discussthe $or' to e accomplished.

ost opportunity for the #&s torevie$ the $or' to e done andthe $or' pac'age and revie$ha*ards.C>

0se of fixatives replaceddecontamination as the primarymethod of contamination control.

(econtamination to prescriedlevels of activity $ould estalish a'no$n and controllale level ofradioactive contamination.

ontamination levels $ould e'no$n after decontamination andthe level of radiological ha*ard$ould e etter defined.

oose radioactive contaminationis significantly reduced.C7



Accident ituationAccident Free# ,rior or !deal

ituationDifference

Evaluation of the Effect on theAccident

Wor' pac'age is overly flexileand left the final decision pointsto the discretion of the $or'er.

1deuate detail is provided toperform the $or' as planned. If $or' cannot e performed asexpected, $or'er stops untilprolems are resolved.

Wor' pac'age is clear and doesnot use statements as "asapplicale," "$hen necessary,and "if reuired."

+igorous $or' planning $ould ein the pac'age and steps $oulde completed as planned

C



A""endix D' Events and Causal Factor Analysis


http://slidepdf.com/reader/full/barrier-change-root-cause-analysis 92/101Appendi+ D@*

An events and causal factors analysis $as perfor!ed in accordance $ith the D&# :orkbook

Conducting Accident Investigations. The events and causal factors analysis re=uires deductive

reasoning to deter!ine those events andor conditions that contributed to the accident. 8ausal

factors are the events or conditions that produced or contributed to the accident, and they consist

of direct, contributing, and root causes. The direct cause is the i!!ediate event%s' or condition%s'

that caused the accident. The contributing causes are the events or conditions that, collectively

$ith the other causes, increased the likelihood of the accident, but $hich did not solely cause the

accident. oot causes are the events or conditions that, if corrected, $ould prevent recurrence of

this and si!ilar accidents. The causal factors are identified in ;igure D@* #vents and 8ausal

;actors Analysis on pages D@* through D@9.

/igre D9)8 Events and Casal /actors Analysis

oncern aout tan's

Conditions#&+ identified

potential ha*ards andcharacteri*ation

&nvisioned fourseparate $or'pac'ages

Events

Decision to "erform o"enair demolition =as madein Decommissioning ,lan

afetyEvaluation

Re"ort for 65:@5a""roved

,lanner started =or+"lanning & first "lanning

meeting

Date:Time :15:5))0 >:8:5))0 >::5)1)

*arriers

omponents $erenot decontaminated.

*1>

)otential radiologicalha*ards $ere not

controlled.*>

Changes

0se of a confinementstructure could have

prevented the spread of contamination eyond

the immediate $or' area.*

)roject did notrecogni*e the potentialsources for spread of

contaminated

material.*18

)roject did not recogni*ethe potential sources for spread of contaminated

material. *18

oose radioactivecontamination is

significantlyreduced. C5

The accident $ouldnot occur.

C1



+igorous $or' planning$ould e in the

pac'age

and steps


http://slidepdf.com/reader/full/barrier-change-root-cause-analysis 93/101Appendi+ D@(

$ould e

completed asplanned. C



+-7;2, +ev 47:43:2;4;H $as usedin

the development of the

$or' pac'age.

(emo +eady

hec'list

$asfinali*ed <:22:4;

&ast West &vaporator cells sho$n as +1:1

on 1tt. (, pg 2:7 updatedon 4:49:;<

J%1 $ritten 8:42:4;Hspecifies use of +W)

#)+0-()-4;-;79.+ad

$or' $as accomplished

in

June and July 2;4;.The

+W) $as $ritten andauthori*ed >:29:4;.

+ecommended mgt approve I##system

J%1 L427 isapproved as part of the $or' pac'age.

#torm$ater anagement )hase I

approved $ith I(W1 as 1ttachment %

Wor' )ac'age )))-!W)-247; isapproved for

demolition

Demolition ,re"aration;or+ ,ac+age T;&

F;,&100) issued

Demo ,re" ;or+,ac+age T;&F;,&

100) tarted

!4 ,hase !! revie=;or+ ,ac+age ,,,&F;,&518) is a""roved for

demolition

7:>:5)1) :0:5)1) 2:1:5)1) :1):5)1)

!ailed to identify$ea'nesses in the

radiological protectionand

$or' controlsprograms and validate

corrective actions.*1

)roject did not

recogni*e

the potentialsources for spread of

contaminated

material.*18

!ailed to identify$ea'nesses in the

radiological protectionand $or' controls

programs andvalidate corrective

actions. *1

ac' of characteri*ationdata resulted in a

failure

to identifyradiological ha*ard

during removal

of thevessels.

*17

)otential radiological

ha*ards $ere notcontrolled.

B8


*1>

!ailed to identify andcorrect $ea'nesses in the

radiological protectionand

$or' controlsprograms *1

)otential radiologicalha*ards $ere not

controlled.*>


contaminatedmaterial. *18

omponents $ere notdecontaminated.

*1>


significantly reduced.C5



+igorous $or' planning$ould e in the pac'age

and steps $ould ecompleted as planned.

C



)roject did not recogni*ethe potential sources for spread of contaminated

material. *18

!ailure to identify the

process components

thatultimately resulted

in theradiological event. *11



The $or' pac'age $asnot specific in identifyingthe components eing

removed.*5

!ailure to identify theevaporator process

vessels as a potentialcontamination source,lead to a loss of control

of radiologicalcontamination.

*1)



+igorous $or' planning

$ould e in thepac'age and steps

$ould e completed asplanned. C



#&+ 1ddendum 1 signed >:44:4;$ith onditions of 1pproval

)lanned comp measuresrelied upon excess materialeing

removed or fixed inplace

,R-&D, Final 6azardCharacterization# F6C&))1# =as

a""roved

Rad characterization com"leted for removable contamination65

:15:5)1) 0:1:5)1)

itigations against uncontrolledspread of radioactive materials

are tailored to the specific tas's.C8

!ailed to identify $ea'nesses inthe radiological protection and $or'

controls programs and validatecorrective actions.

*1

)roject did not recogni*e thepotential

sources for spread of contaminated material. *18

!ailed to identify and correct$ea'nesses in the

radiological protection and

$or' controls

programs*1

!ailure to identify the processcomponents that ultimately resulted

in the radiological event.

*11

(emolition of the evaporator vessels$as not controlled resulting in

spread

of radioactive contamination.*15

oose radioactive contaminationis

significantly reduced.

C5

oose radioactive contamination

is




%2 (emo +eady

hec'list complete

Demo Ready Chec+list signed off in T;&F;,&100)

0:55:5)1)

!ailed to identify $ea'nesses inthe

radiological protection and $or'controls programs and validate


%2 (emo )rep $or'pac'age $as completed

$ithout the initiallyreuired

sources eingidentified.

*0

!ailure to properly and fullyapply fixative to the

componentsH internalsincreased the proaility of

the spread of contamination.*1

ac' of characteri*ation dataresulted in a failure to identify

radiological ha*ard duringremoval

of the evaporator systemcomponents.

*17

(emolition of theevaporator vessels $as

not controlled resulting in

spread of radioactivecontamination.

*15

+eady for (emo hec'list$as signed as complete giving

a

false sense of safety.*8

!ailure to identify the processcomponents that ultimately

resulted in the radiological event.*11


contaminated

material.*18


*1>

!ailure to identify the evaporator system components as a potential

contamination source, lead to aloss of control of radiological

contamination.*1)

)otentialradiological

ha*ards$ere not

controlled.*>


radiological protection and$or' controls programs

*1

+igorous $or' planning $ould ein

the pac'age and steps $ould ecompleted as planned.

C



Do communication of readings

Wrec'ing cre$ used $ater streamto control fugitive dust

Do evidence of any actions ta'enin response to elevated readings

Demolition started on 65 building 885 elevationElevated air sam"ler reading recorded by

"erimeter air monitors(

0:58:5)1) 0:5>&50:5)1)

!ailed to identify $ea'nesses inthe

radiological protection and $or'controls programs and validate


#pread of radioactivecontamination $as not

controlled

as discussed in+7;2.

*

!ailed to identify $ea'nesses inthe radiological protection and $or'

controls programs and validatecorrective actions.

*1

ac' of characteri*ation dataresulted in a failure to identify

radiological ha*ard duringremoval of the evaporator system

components.*17

0se of a confinement structurecould have prevented the

spread

of contamination eyondthe immediate $or' area.

*


radiological

protection and$or' controls programs

*1

)roject did not recogni*e thepotential sources for spread

of

contaminated material. *18

!ailed to estalish on-siteradiological monitoring

during

uilding demolition.*7

0se of a confinement structure couldhave prevented the spread of

contamination eyond theimmediate $or' area.

*


resulted

in the radiological event.*11

!ailure to implement the proper controls contriuted to thespread

of contamination.*2

)roject did not recogni*e thepotential sources for spreadof

contaminated material.*18

!ailure to identify the evaporator system components as a potential

contamination source, lead to aloss of control of radiological

contamination.*1)

omponents $erenot

decontaminated.*1>

#pread of radioactivecontamination

$as not controlled asdiscussed in

+7;2.*

(emolition of the evaporator

components $as not controlledresulting in spread of

radioactive contamination.*15

!ailed to identify and correct$ea'nesses in theradiological

protection and$or' controls programs

*1

omponents $ere

not

decontaminated.*1>

oose radioactive contaminationis


oose radioactivecontamination is significantly

reduced.C7



1uthori*ed outside the)/( meeting y the/

Kessel removal authori*ed outsidethe )/( meeting y the /

+emoval of the evaporatorsystem components $as notdiscussed

Waste #uperintendent as'ed ((/ aout removing the

components.

(( / as'ed + after meeting aout removing

components. + said it $as /A.

,<D 4eeting u"ervisors 4eeting ))) meeting

0:5:5)1) 0:50:5)1) )>7 0:50:5)1) )))

ost opportunity to have the$or'

revie$ed y #&s*12


of

contaminated material. *18

!ailed to identify $ea'nessesin the radiological protectionand

$or' controls programsand

validate corrective actions.

*1

ost opportunity for the #&sto revie$ the to-e done and

$or'

pac'age and revie$ha*ards.

C>

(emolition of the evaporator system components $as notcontrolled resulting in spreadof radioactive contamination.

*15


of contaminated material. *18

The $or' pac'age $as notspecific in identifying the

components eing removed.*5

(emolition of the evaporator system components $as notcontrolled resulting in spread

of

radioactive contamination.*15

ost opportunity for the #&sto

revie$ the to-e done and$or' pac'age and revie$

ha*ards. C>

The $or' pac'age $as notspecific in identifying the

components eing removed.*5

ost opportunity for the #&sto

revie$ the to-e done and$or' pac'age and revie$

ha*ards. C>



1 olt $as "thro$n" outsidethe

footprint $hen removingone of the columns

&vaporator system

components

extend aove the772? floor

elevation and do$nto the 74<? elevation floor.

omponents $ere "violently"pulled up from the 74<?

elevation and laid do$n onthe 727? floor elevation.

E<5 removed heat exchanger vessels 551&A and 551&* from east eva"orator cell

E<1 removed se"arator vessel 115&A from =est eva"orator cell

0:50:1) G1))) to G15))


radiological

protection and$or' controls

programs*1


*1>

#pread of radioactivecontamination $as not controlled as

discussed in

+7;2.*

ost opportunity to have the

$or'

revie$ed y #&s*12


of


!ailure to implement the proper controls

contriuted to the spread of

contamination.*2

!ailed to identify $ea'nessesin the radiological protectionand $or' controls programs

and

validate corrective actions.*1

(emolition of the evaporator vessels$as not controlled resulting in

spread of radioactive contamination.*15

0se of a confinement structure couldhave prevented the spread of

contamination eyond theimmediate $or' area.

*

ac' of characteri*ation dataresulted in a failure to

identify radiological ha*ardduring

removal of the

components.

*17


resulted in the radiological event.*11

oose radioactive contaminationis significantly reduced.

C5

!ailed to estalish on-siteradiological monitoring

during

uilding demolition.*7

!ailure to identify the evaporator process vessels as a potential

contamination source, lead to aloss

of control of radiologicalcontamination.

*1)



Wrec'ing cre$ applied $ater using a fire hose for dust

suppression. Windy enough tohave to adjust spray.

+ad tech stopped $or'and monitored columns for

flammale gas

Three individuals noted a"puff" come from the si*ing of

one of the 224 vessels.

+ notedhose spray used to $ash truc'.

-ncontrolled s"read of radioactive contamination

E<5 started sizing vessels 551&A and &*

RC4 and D,D notedeva"orator system

com"onentson the 885 level

"ad

during demolition of *uilding65(

0:50:5)1) 0:50:5)1) G1)8) 0:50:5)50


radiological

protection and$or' controls

programs*1

!ailure to identify the

evaporator

process vessels asa potential

contaminationsource, lead to a loss of controlof radiological contamination.

*1)

)roject did not recogni*e the

potential sources for spread of contaminated material.*18

!ailed to identify $ea'nessesin the radiological protectionand

$or' controls programsand validate corrective actions.

*1

!ailure to implement theproper controls contriuted tothe

spread of contamination.*2

/ver reliance on fixative -lac'

of rigor in $or'planning

ac' of characteri*ation dataresulted in a failure to

identify

radiological ha*ardduring removal of the

components

*17

#pread of radioactive

contamination $as notcontrolled as discussedin

+7;2.*

0nusual condition not

recogni*ed y#upervisors

)roject did not recogni*e thepotential sources for spreadof


0se of a confinement structurecould have prevented thespread of contamination

eyond the immediate $or'

Barrier Change Root Cause Analysis

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