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Tank S-102 Waste Spill

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Tank S-102 Waste Spill

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    1. Tank S-102 Waste Spill Shirley Olinger Manager Shirley welcomes and make introductions.Shirley welcomes and make introductions.

    2. CHG0711-01.1 (Jerry) Im going to give you the details of an event that occurred on July 27 of this year. Before I go into specifics about the cause of the event, let me show you an 3-D animation that gives a clear account of the events of that day. (Jerry) Im going to give you the details of an event that occurred on July 27 of this year. Before I go into specifics about the cause of the event, let me show you an 3-D animation that gives a clear account of the events of that day.

    3. (Jerry) Events as they occurred: As procedures, workers reversed the pump and pump shut down After several minutes tried pump with auto reverse (Cleans the pump and clears the line) Pump shuts down a second time Workers fix the VFD and hit reverse button again Amp goes up to 75amps and shuts down Finally get it to pump in reverse (Jerry) Events as they occurred: As procedures, workers reversed the pump and pump shut down After several minutes tried pump with auto reverse (Cleans the pump and clears the line) Pump shuts down a second time Workers fix the VFD and hit reverse button again Amp goes up to 75amps and shuts down Finally get it to pump in reverse

    4. CHG0711-01.3 (Jerry) (Jerry)

    5. CHG0711-01.4 S-102 Event Summary Dilution Hose Source of Spill Spill occurred between 2:05 a.m. and 2:20 a.m. while pump was operated in reverse direction No personnel in the tank farm Abnormal radiation dose rate readings identified at 2:20 a.m. Splash pattern consistent with release near dilution hose at NW corner of pump pit Spill pool consistent with near surface release Bathtub ring along north side of pump pit between pit and dilution hose No discoloration near potential release points from pit or pump box Transfer pit and pump riser extension box unlikely sources of spill Pump box drains into transfer pit OR into the tank Leak detector in transfer pit Transfer pit drains to tank Transfer pit is below grade with a void volume of over 1,500 gallons Drainage collected from dilution hose resulted in high dose rates confirming waste was in dilution hose (Jerry) The dilution hose was the most probable scenario for the source of the spill. Splash patterns appeared on jersey barriers, back side of chair, scaffolding and stairway. No splash pattern was located on the wood platform, top of pump box, and top of pump pit. The Sparge hose was not in the vicinity of the spray pattern. The Leak detector in transfer pit had no indication of leak. If it came from the pit, it would have had to have had 1,500 gallons of waste before it could leak out of pit to ground. (Jerry) The dilution hose was the most probable scenario for the source of the spill. Splash patterns appeared on jersey barriers, back side of chair, scaffolding and stairway. No splash pattern was located on the wood platform, top of pump box, and top of pump pit. The Sparge hose was not in the vicinity of the spray pattern. The Leak detector in transfer pit had no indication of leak. If it came from the pit, it would have had to have had 1,500 gallons of waste before it could leak out of pit to ground.

    6. CHG0711-01.5 S-102 Event Investigations Several Investigations DOE/ORP Reviews DOE Type A Complete 09/19/07 DOE EM-60 Complete 09/27/07 DOE/ORP Reviews: ORP Response Complete 8/29/07 HPI Complete 10/23/07 Assessment of ORP Management Systems Complete 11/09/07 CH2M HILL Internal Investigation Event Investigation/Root Cause Analysis Completed 9/17/07 Emergency Response Investigation Completed 8/27/07 Health Effects Investigation Completed 10/4/07 Engineering Design Program Review Completed 10/9/07 Direct Cause: Over-pressurization and rupture of the dilution water supply hose as a result of a plugged pump suction during reverse pump operation DOE/ORP Reviews: Requested Type A Investigation Complete 9/19/07 Conducted Investigation of ORP Actions Related to the Tank S-102 Spill Complete 8/29/07 Conducted Human Performance Improvements Review Complete 10/23/07 Assessment of ORP Management Systems draft issued 10/31/07 ECD 11/9 CH2M HILL Internal Investigation: Event Investigation/Root Cause Analysis Completed 9/17/07 Emergency Response Investigation Completed 8/27/07 Health Effects Investigation Completed 10/4/07 Engineering Design Program Review Completed 10/9/07 DOE/ORP Reviews: Requested Type A Investigation Complete 9/19/07 Conducted Investigation of ORP Actions Related to the Tank S-102 Spill Complete 8/29/07 Conducted Human Performance Improvements Review Complete 10/23/07 Assessment of ORP Management Systems draft issued 10/31/07 ECD 11/9 CH2M HILL Internal Investigation: Event Investigation/Root Cause Analysis Completed 9/17/07 Emergency Response Investigation Completed 8/27/07 Health Effects Investigation Completed 10/4/07 Engineering Design Program Review Completed 10/9/07

    7. CHG0711-01.6 (Shirley) Direct Cause Over-pressurization and rupture of the dilution water supply hose as a result of a plugged pump suction during reverse pump operation Root Causes Engineering Design Less Than Adequate (LTA) The design review and hazards evaluation for the S-102 retrieval system did not consider the raw water supply system as a potential waste transfer misroute path (physically connected), despite requirements contained in safety basis Inadequate change management process for process safety management S-102 retrieval system software, hardware and process control changes were not adequately evaluated against the safety basis accident analyses for local impacts Contributing Causes Formality of Operations LTA Radiological Controls Survey Techniques LTA Tank Farm Lighting LTA Abnormal Operating Procedures (AOP) LTA Process Controls LTA Training LTA (Shirley) Direct Cause Over-pressurization and rupture of the dilution water supply hose as a result of a plugged pump suction during reverse pump operation Root Causes Engineering Design Less Than Adequate (LTA) The design review and hazards evaluation for the S-102 retrieval system did not consider the raw water supply system as a potential waste transfer misroute path (physically connected), despite requirements contained in safety basis Inadequate change management process for process safety management S-102 retrieval system software, hardware and process control changes were not adequately evaluated against the safety basis accident analyses for local impacts Contributing Causes Formality of Operations LTA Radiological Controls Survey Techniques LTA Tank Farm Lighting LTA Abnormal Operating Procedures (AOP) LTA Process Controls LTA Training LTA

    8. CHG0711-01.7 S-102 Corrective Actions Comprehensive Corrective Action Plan Type A - Justification of Needs (JONs) CH2M HILL Investigation Findings EM-60 Input DOE ORP Internal Reviews Coordination of CAP Critical 2 Field Offices: ORP and RL 3 Contractors CH2M HILL Event Owner Fluor Hanford Emergency Management Advance Medicine Hanford Medical Evaluations/Communication (Shirley) CAP includes Corrective Actions (CA) from 3 Prime Contractors and 2 Field Offices Provided for review and comment to EM (and HSS) on 10/31/07 CAP to be approved by EM-1 by 11/17/07 CAP for Type A Judgments of Need CH2M HILL 50 CAs Fluor Hanford 23 CAs Advance Medicine Hanford 7 CAs ORP 13 CAs RL 2 CAs In addition, the other reviews have generated: - DOE ORP CAs from internal reviews: 11 corrective actions plus corrective actions from ORP Oversight Assessment - CH2M HILL CAs: 53 corrective actions: event root cause analysis 47 event response investigation 2+ health effects investigation 4 engineering design review CAs included in other CAPs (Shirley) CAP includes Corrective Actions (CA) from 3 Prime Contractors and 2 Field Offices Provided for review and comment to EM (and HSS) on 10/31/07 CAP to be approved by EM-1 by 11/17/07 CAP for Type A Judgments of Need CH2M HILL 50 CAs Fluor Hanford 23 CAs Advance Medicine Hanford 7 CAs ORP 13 CAs RL 2 CAs In addition, the other reviews have generated: - DOE ORP CAs from internal reviews: 11 corrective actions plus corrective actions from ORP Oversight Assessment - CH2M HILL CAs: 53 corrective actions: event root cause analysis 47 event response investigation 2+ health effects investigation 4 engineering design review CAs included in other CAPs

    9. CHG0711-01.8 S-102 Corrective Actions (cont.) Focus areas of CAP for ORP Engineering and Quality Oversight Heavily focused on Authorization Basis document review and approval and SSO oversight Need for increased oversight of process/system engineering recognized Need for internal assessments of ORP Conduct of Operations Although routine operations observed, emphasis has been on known higher risk/higher consequence evolutions Increase oversight of more routine operational activities, including backshift operations (i.e., tank retrieval operations) Heighten alertness when activities not occurring as planned (pump stuck or need for reverse operation) Radiological and Industrial Hygiene Coverage Programmatic reviews conducted Improve field operations coverage Factor in lessons learned ORP Response/Human Factors Investigations Strengthen the DOE Facility Representatives ability to properly respond to abnormal and emergency events (Shirley) Engineering and Quality Oversight: Re-organization with focus on Engineering and QA Chief Engineer reporting directly to site manager Organization would include existing authorization basis engineers New positions with focused responsibility on process/system engineering; more robust Hazops Analysis for operational upsets Evaluate/verify processes for flow-down of technical/operational requirements Evaluate SS classification for waste transfer systems Conduct of Operations Period of improving performance indicators observed over 3 year period (i.e., frequency of occurrences, consequence of occurrences, traditional safety indicators, etc.) Most significant recent occurrence was Tank C-202 work in September 2005 CH2 executives continued to appropriately demonstrate a high level of attention to small operational issues Evaluating best way to refresh technical oversight staff (FRs, SMEs) Evaluating how to best assess the discipline and rigor of operations Radiological and IH Coverage Integration of actions with procedural requirements Communications with field operations personnel (S/M, pic, etc.) Command and control of field activity (Authority) Instrument use Focus directly on specific actions of Health Physics Technicians Seeking to hire field knowledgeable radiological control experts (Nuclear Navy/Shipyards) ORP Response/Human Factors Investigations Increase engineering staffing, reviews and oversight Evaluate Contractors engineering organization, including subcontractors Conduct investigation into the human factors of the ORP response Strengthen the DOE Facility Representatives ability to properly respond to abnormal and emergency events Clarify TSR Definition for PHYSICALLY CONNECTED Improve processes to prepare Facility Representatives to perform on-call duties Improve processes to prepare personnel for management duties for event response Independent Investigation of ORP Oversight Integrate and strengthen the ORP management systems, including the assessment program Strengthen the ORP engineering oversight role increase staff, supplement with support contractors; increase assessment activities; resist collateral duties; evaluate the contractors engineering processes Increase ORP quality assurance staffing; Perform internal assessments of ORP (QA group to perform) Improve ORP oversight program expand the use of the Operational Awareness database (Shirley) Engineering and Quality Oversight: Re-organization with focus on Engineering and QA Chief Engineer reporting directly to site manager Organization would include existing authorization basis engineers New positions with focused responsibility on process/system engineering; more robust Hazops Analysis for operational upsets Evaluate/verify processes for flow-down of technical/operational requirements Evaluate SS classification for waste transfer systems Conduct of Operations Period of improving performance indicators observed over 3 year period (i.e., frequency of occurrences, consequence of occurrences, traditional safety indicators, etc.) Most significant recent occurrence was Tank C-202 work in September 2005 CH2 executives continued to appropriately demonstrate a high level of attention to small operational issues Evaluating best way to refresh technical oversight staff (FRs, SMEs) Evaluating how to best assess the discipline and rigor of operations Radiological and IH Coverage Integration of actions with procedural requirements Communications with field operations personnel (S/M, pic, etc.) Command and control of field activity (Authority) Instrument use Focus directly on specific actions of Health Physics Technicians Seeking to hire field knowledgeable radiological control experts (Nuclear Navy/Shipyards) ORP Response/Human Factors Investigations Increase engineering staffing, reviews and oversight Evaluate Contractors engineering organization, including subcontractors Conduct investigation into the human factors of the ORP response Strengthen the DOE Facility Representatives ability to properly respond to abnormal and emergency events Clarify TSR Definition for PHYSICALLY CONNECTED Improve processes to prepare Facility Representatives to perform on-call duties Improve processes to prepare personnel for management duties for event response Independent Investigation of ORP Oversight Integrate and strengthen the ORP management systems, including the assessment program Strengthen the ORP engineering oversight role increase staff, supplement with support contractors; increase assessment activities; resist collateral duties; evaluate the contractors engineering processes Increase ORP quality assurance staffing; Perform internal assessments of ORP (QA group to perform) Improve ORP oversight program expand the use of the Operational Awareness database

    10. CHG0711-01.9 CH2M HILL Corrective Actions Engineering Improve engineering design review and hazards analysis/evaluation process Review strategies for controlling waste leaks prevention instead of mitigation Management System Analyze, develop and deliver conduct of operations training Review effectiveness of causal analyses and corrective actions for significant events since January 1, 2003 Strengthen management oversight plans for waste retrieval activities Refine work control process Safety and Health Ensure potentially exposed personnel are examined and documented by on-site medical provider Develop consistent notifications to patients regarding test results Strengthen post-exposure medical monitoring process Continue medical monitoring and surveillance of potentially affected workers (Jerry) Engineering - Organization - strengthen the Design Authority function Design Review/Approval - increase independence and quality Process Hazards Analysis - including high probability/low consequence events Process Control Plan quality and flow down to operating procedures Management of Change process implementation similar to 29 CFR 119 Control strategy to prevent or mitigate potential waste leaks, including the identification of a safety significant boundary for all above grade waste transfer components. Safety Basis document revisions to incorporate. Management Systems- Reinvigorate conduct of operations by training employees and follow-up with assessments Improve oversight of transfers and retrievals Revise transfer and retrieval procedures to incorporate S-102 Lessons Learned Work Control- - Better define troubleshooting controls - Improve compliance with existing requirements for minor work - Require compliance with minimum lighting requirements of HAZWOPER - Develop and implement technologies for small-quantity waste spill detection Safety & Health- Revise Abnormal Operating Procedures (AOP) to ensure that chemical monitoring is done in conjunction with radiological evaluations. Provide additional training and information for shift managers, operations managers, industrial hygienists, and industrial hygiene technicians on proper response to abnormal events. Implement a process for identifying potentially affected workers after an event. Collect additional chemical analytical data from S-102. Continued monitoring and surveillance of potentially affected workers from S-102. Improve medical monitoring documentation and accountability of individuals with health concerns following an event. Improve job hazard analysis to identify the appropriate work controls. Identify jobs and operations that require continuous industrial hygiene monitoring, train industrial hygienists on continuous monitoring methods, and implement this monitoring. Establish lighting standards for tank farms and improve lighting where needed.(Jerry) Engineering - Organization - strengthen the Design Authority function Design Review/Approval - increase independence and quality Process Hazards Analysis - including high probability/low consequence events Process Control Plan quality and flow down to operating procedures Management of Change process implementation similar to 29 CFR 119 Control strategy to prevent or mitigate potential waste leaks, including the identification of a safety significant boundary for all above grade waste transfer components. Safety Basis document revisions to incorporate. Management Systems- Reinvigorate conduct of operations by training employees and follow-up with assessments Improve oversight of transfers and retrievals Revise transfer and retrieval procedures to incorporate S-102 Lessons Learned Work Control- - Better define troubleshooting controls - Improve compliance with existing requirements for minor work - Require compliance with minimum lighting requirements of HAZWOPER - Develop and implement technologies for small-quantity waste spill detection Safety & Health- Revise Abnormal Operating Procedures (AOP) to ensure that chemical monitoring is done in conjunction with radiological evaluations. Provide additional training and information for shift managers, operations managers, industrial hygienists, and industrial hygiene technicians on proper response to abnormal events. Implement a process for identifying potentially affected workers after an event. Collect additional chemical analytical data from S-102. Continued monitoring and surveillance of potentially affected workers from S-102. Improve medical monitoring documentation and accountability of individuals with health concerns following an event. Improve job hazard analysis to identify the appropriate work controls. Identify jobs and operations that require continuous industrial hygiene monitoring, train industrial hygienists on continuous monitoring methods, and implement this monitoring. Establish lighting standards for tank farms and improve lighting where needed.

    11. CHG0711-01.10 CH2M HILL Corrective Actions (cont.) Emergency Management Evaluate low consequence, high probability hazards for emergency response Evaluate technologies for identifying small waste leaks Revise/clarify procedures for activating response teams for non-emergency events Work Control Eliminate use of verbal work packages for activities comparable to manual pump rotation which required application of specific torque limits provided by vendor Industrial Hygiene Implement methods for continuous monitoring of vapors during waste transfers Integrate Industrial Hygiene response to abnormal events that may involve chemical release into abnormal response procedures. Sampling requirements should be specified Radiological Protection Clarify radiological monitoring requirements associated with TSR and leak detection (Jerry) Emergency Management- Revise Abnormal Operating Procedures (AOPs)to incorporateS-102 Lessons Learned Training and drills. Increasenumber of drills toassure understanding of AOPs Improve accountability ofpersonnel affected by events Work Control- Better define troubleshooting controls Improve compliance with existing requirements for minor work Require compliance with minimum lighting requirements of HAZWOPER Develop and implement technologies for small-quantity waste spill detection Industrial Hygiene- Refine methods for continuous industrial hygiene monitoring during waste disturbing operations Incorporate IH monitoring requirements in abnormal and emergency operating procedures Improve IH specific procedures to compliment abnormal operating procedures Radiological Protection Clarify radiological monitoring requirements associated with TSR and leak detection Provide training on procedures and expectations for abnormal and emergency response radiation monitoring methods(Jerry) Emergency Management- Revise Abnormal Operating Procedures (AOPs)to incorporateS-102 Lessons Learned Training and drills. Increasenumber of drills toassure understanding of AOPs Improve accountability ofpersonnel affected by events Work Control- Better define troubleshooting controls Improve compliance with existing requirements for minor work Require compliance with minimum lighting requirements of HAZWOPER Develop and implement technologies for small-quantity waste spill detection Industrial Hygiene- Refine methods for continuous industrial hygiene monitoring during waste disturbing operations Incorporate IH monitoring requirements in abnormal and emergency operating procedures Improve IH specific procedures to compliment abnormal operating procedures Radiological Protection Clarify radiological monitoring requirements associated with TSR and leak detection Provide training on procedures and expectations for abnormal and emergency response radiation monitoring methods

    12. CHG0711-01.11 CH2M HILL Lessons Learned Worst-to-Best DOE Complex Safety Statistics From 2005 to 2007: Total Recordables dropped 71% DART Rates dropped 82% Lost Workday Case Rate dropped 61% Stop Work process dramatically dropped 100% Occurrence Reports dropped 71% Skin and Clothing Contamination Reports (ORPS Reportables) dropped 100% Employee Concerns dropped by 62% (Jerry) Our safety stats are good, our stop works have reduced even though employees continue to have the authority, they work through the issues with their management team (Jerry) Our safety stats are good, our stop works have reduced even though employees continue to have the authority, they work through the issues with their management team

    13. CHG0711-01.12 Lessons Learned CH2M HILL Engineering Design / Hazards Analysis Formalize design review process and evaluate some total of all modifications. Conduct of Operations Complacency: lighting, notifications, radiation readings, etc. More focus on ConOps training and implementation. Emergency Response Drills: practice is important Focus on chemical hazards as well as radiological hazards Engineering Design & Hazards Analysis Configuration of retrieval pump dilution line not considered physically connected to the waste transfer system when originally designed in 2002 DSA analyzed waste leak accidents from raw water supply lines connected to pumping systems, such as dilution lines Dilution line terminated inside a strainer basket external to pump suction Mindset of engineers analyzing S-102 design -- dilution line was not connected, therefore backflow prevention TSR requirements were not applicable Design review comment regarding potential to pressurize dilution line during reverse flow was not addressed Pump modifications in 2007 did not prompt reevaluation Dilution line supply location moved - integral to pump suction cavity Suction screen replaced with strainer plate that reduced exit area by more than 50% Reverse pump speed tripled, increasing pressure in suction cavity 9X Conduct of Operations Tank farm lighting did not meet HAZWOPER standards Radiological control technicians did not recognize importance of open window beta readings during response to unexpected high radiation levels Operators unaware of design basis radiation levels Operating and response procedures did not provide sufficient direction for response to upset conditions Operations support personnel not trained on system operation Some notifications delayed or incomplete Work control deficiencies Emergency Response Response limited to radiological hazard - Insufficient attention to potential chemical hazard Potential health effects of chemical exposure not adequately evaluated Affected personnel not identified in a timely manner Alert levels did not include high probability low consequence events such as small quantity waste spill Lessons Learned Develop alert levels for local impact events below DSA accident analysis thresholds Conduct small-scale local-impact drills to evaluate abnormal/emergency response Engineering Design & Hazards Analysis Configuration of retrieval pump dilution line not considered physically connected to the waste transfer system when originally designed in 2002 DSA analyzed waste leak accidents from raw water supply lines connected to pumping systems, such as dilution lines Dilution line terminated inside a strainer basket external to pump suction Mindset of engineers analyzing S-102 design -- dilution line was not connected, therefore backflow prevention TSR requirements were not applicable Design review comment regarding potential to pressurize dilution line during reverse flow was not addressed Pump modifications in 2007 did not prompt reevaluation Dilution line supply location moved - integral to pump suction cavity Suction screen replaced with strainer plate that reduced exit area by more than 50% Reverse pump speed tripled, increasing pressure in suction cavity 9X Conduct of Operations Tank farm lighting did not meet HAZWOPER standards Radiological control technicians did not recognize importance of open window beta readings during response to unexpected high radiation levels Operators unaware of design basis radiation levels Operating and response procedures did not provide sufficient direction for response to upset conditions Operations support personnel not trained on system operation Some notifications delayed or incomplete Work control deficiencies Emergency Response Response limited to radiological hazard - Insufficient attention to potential chemical hazard Potential health effects of chemical exposure not adequately evaluated Affected personnel not identified in a timely manner Alert levels did not include high probability low consequence events such as small quantity waste spill Lessons Learned Develop alert levels for local impact events below DSA accident analysis thresholds Conduct small-scale local-impact drills to evaluate abnormal/emergency response

    14. (Shirley) ORPS Recurring Events: 1Q FY07 Inadvertent forklift impacts Electrical Safety: 4Q FY06 Energized wire found while performing safe-to-work check of field electrical skid Environmental Permits: 3Q FY07 Temporary transfer line management plan NOV. (Shirley) ORPS Recurring Events: 1Q FY07 Inadvertent forklift impacts Electrical Safety: 4Q FY06 Energized wire found while performing safe-to-work check of field electrical skid Environmental Permits: 3Q FY07 Temporary transfer line management plan NOV.

    15. CHG0711-01.14 (Shirley) TSRs: 1Q FY07 - Violation of Technical Safety Requirement during a Waste Transfer; 2Q FY 2007, where a Caustic Flush of 702-AZ Ventilation Condensate Drain System Causes AZ-301 Waste to Fall Outside of Waste Category L Criteria.(Shirley) TSRs: 1Q FY07 - Violation of Technical Safety Requirement during a Waste Transfer; 2Q FY 2007, where a Caustic Flush of 702-AZ Ventilation Condensate Drain System Causes AZ-301 Waste to Fall Outside of Waste Category L Criteria.

    16. CHG0711-01.15 Lessons Learned Good safety performance metrics can give a false sense of security Key performance indicators TRC/DART, Radiological, TSR, Electrical Safety, ORPs, PERs, etc. ISMS performance measures Safety culture indicators VPP, Safe Work Environment personnel survey results, Hanford Concerns Council Reduction in employee concerns ORP assessments more is not necessarily better ORP completed 38 assessments of the TFC in FY2007 Facility Representative oversight of retrieval operations: no procedure compliance problems Quarterly Assessment Program evaluations, Quarterly recurring events evaluations did not indicate negative trend in operational performance Facility Representative observations of S-102 retrieval operations 1 and 2 days prior to the event indicated good conduct of operations Past successes do not guarantee future success Successfully completed 7 tank retrievals Successfully deployed similar retrieval system at tank S-112 (Shirley) CH2 went from one of worst in 2002/3 to one of best in 2006/7. Recently voted as one of safety companies in nation TRC = 0.32; DART = 0.32 - lowest rate since January 1994 - DOE 2006 TRC = 1.6 - TFC has reached over one million hours worked without a lost time injury 3 times since January 2006 Most all metrics on dashboard green, especially in the last 4 qtrs Safety Culture good (VPP, SWE, HCC, ECP, workers and mgmt working together). They seemed to get it, good safety results in good work and $$ to company. Decrease in ORPs; Recurring Events 38 assessments of the TFC conducted in FY07: 6 assessments on the Safety Basis; 5 SSO/Engineering assessments; 13 operations/Integrated Safety Management; 2 Quality Assurance; 5 Radiological Controls The last TF spill of rad/chemical tank waste was January 6, 2000, during saltwell pumping of tank S-103. (Shirley) CH2 went from one of worst in 2002/3 to one of best in 2006/7. Recently voted as one of safety companies in nation TRC = 0.32; DART = 0.32 - lowest rate since January 1994 - DOE 2006 TRC = 1.6 - TFC has reached over one million hours worked without a lost time injury 3 times since January 2006 Most all metrics on dashboard green, especially in the last 4 qtrs Safety Culture good (VPP, SWE, HCC, ECP, workers and mgmt working together). They seemed to get it, good safety results in good work and $$ to company. Decrease in ORPs; Recurring Events 38 assessments of the TFC conducted in FY07: 6 assessments on the Safety Basis; 5 SSO/Engineering assessments; 13 operations/Integrated Safety Management; 2 Quality Assurance; 5 Radiological Controls The last TF spill of rad/chemical tank waste was January 6, 2000, during saltwell pumping of tank S-103.

    17. CHG0711-01.16 Lessons Learned (cont.) Hind-sight indicators provide vital information Several contractor lay-offs due to funding cuts Contractor senior manager for Closure Operations distracted due to medical and other reasons S Tank Farm housekeeping less than adequate Vacant position for Retrieval FPD, rad engineer, industrial hygiene for several months Inadequate DOE oversight of contractor engineering programs Not enough FTEs to oversee 2 major projects (Shirley) Contractor Lay-offs/Unengaged Closure Ops VP should have alerted us to watch more closely and insist on more indep oversight by CH2 Last 2-3 years cleaning up all farms but S-Farm (AP, AN, C) ORP STAFF ISSUES: Managed contract not contractor was basis for reducing the FTE ceiling at ORP from 150 need in Bostons regime to less than 100 in Schepens regime. I believe we need closer to the 150 FTE ceiling to adequately be cognizant of all the technical aspects of these 2 major projects where we arent reducing the footprints but rather significantly increasing the footprints. Dont have flexibility in TF funding to hire GSSCs to supplement fed oversight like we have w/WTP ACTIONS: Increase Engineering staff and perform more formal assessments of TFC engineering processes (not just DSA) Establish Internal Assessment program to look at us Routinely conduct FRs surprise/backshift area surveillances Designate an Honest Broker when evaluate data. Establish coach for FRs to sharpen their skills Establish a minimum cadre (includes experience not just #s) using rules of thumb (Shirley) Contractor Lay-offs/Unengaged Closure Ops VP should have alerted us to watch more closely and insist on more indep oversight by CH2 Last 2-3 years cleaning up all farms but S-Farm (AP, AN, C) ORP STAFF ISSUES: Managed contract not contractor was basis for reducing the FTE ceiling at ORP from 150 need in Bostons regime to less than 100 in Schepens regime. I believe we need closer to the 150 FTE ceiling to adequately be cognizant of all the technical aspects of these 2 major projects where we arent reducing the footprints but rather significantly increasing the footprints. Dont have flexibility in TF funding to hire GSSCs to supplement fed oversight like we have w/WTP ACTIONS: Increase Engineering staff and perform more formal assessments of TFC engineering processes (not just DSA) Establish Internal Assessment program to look at us Routinely conduct FRs surprise/backshift area surveillances Designate an Honest Broker when evaluate data. Establish coach for FRs to sharpen their skills Establish a minimum cadre (includes experience not just #s) using rules of thumb

    18. CHG0711-01.17 Next Steps Issue Independent ORP Oversight Assessment Report and develop Corrective Actions EM-1 Approve Type A CAP Complete ISMS Declaration Conduct Contractor Readiness Assessment to resume retrieval of tank C-109; ORP Manager start-up approval authority (Shirley)(Shirley)

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