ML22206A213
| ML22206A213 | |
| Person / Time | |
|---|---|
| Site: | National Bureau of Standards Reactor |
| Issue date: | 08/01/2022 |
| From: | Mark Lombard NRC/OE |
| To: | Dimeo R US Dept of Commerce, National Institute of Standards & Technology (NIST) |
| Jones D | |
| References | |
| EA-21-148 | |
| Download: ML22206A213 (40) | |
Text
August 1, 2022
EA 148
Dr. Robert Dimeo, Director National Institute of Standards and Technology NIST Center for Neutron Research U.S. Department of Commerce 100 Bureau Drive, Mail Stop 8561 Gaithersburg, MD 20899-8561
SUBJECT:
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, CENTER FOR NEUTRON RESEARCH - CONFIRMATORY ORDER
Dear Dr. Dimeo:
The enclosed Confirmatory Order is being issued to you as a result of a successful alternative dispute resolution (ADR) mediation session. The commitments outlined in the C onfirmatory Order were made as part of a settlement agreement between the National Institute of Standards and Technology (NIST), Center for Neutron Research (NCNR or licensee) and the U.S. Nuclear Regulatory Commission (NRC). The settlement agreement concerns seven apparent violations of NRC requirements by the licensee, as discussed in our letter dated March 16, 2022 (Agencywide Documents Access and Management System (ADAMS)
Accession No. ML22056A361).
Our March 16, 2022, letter provided you with the results of an NRC special inspection that was conducted in response to an event at NCNR. Specifically, on February 3, 2021, NCNR made an emergency declaration ( Alert) in response to an automatic reactor shutdown initiated by the detection of high radiation from the confinement exhaust stack. Subsequently, NCNR determined that a damaged fuel element caused the exhaust stack radiation alarm.
The NCNR reactor has not been operated since the event. NCNR is currently conducting clean-up and repair activities. In accordance with Title 10 of the Code of Federal Regulations 50.36(c)(1) and NCNR Technical Specifications, NCNR must obtain NRC approval prior to resuming operations. The NRCs decision to approve any restart would be informed by, but would not be solely reliant upon, the Confirmatory Order discussed below.
The NRCs special inspection for the February 3, 2021, event documented seven apparent violations, the most significant being an apparent violation of NCNR Technical Specification 2.1, Safety Limit, which states that the reactor fuel cladding temperature shall not exceed 842°F for any operating conditions of power and flow. The NRC inspectors observed once-molten material in and around a fuel element indicating that the fuel cladding temperature safety limit had been exceeded.
D. Dimeo 2
In our March 16, 2022, letter, the NRC offered NCNR the opportunity to (1) attend a predecisional enforcement conference or (2) participate in an ADR mediation session. In response, NCNR requested to participate in an ADR mediation session.
A full-day ADR mediation session was held o n May 10, 2022, with shorter virtual meetings held on May 19, 2022, and June 2, 2022. The NRC and NCNR reached a preliminary settlement agreement on June 3, 2022, as confirmed by the signed Consent and Hearing Waiver Form (Enclosure 2), dated July 21, 2022, in which NCNR agreed that a Confirmatory Order would be issued as settlement of the apparent violations. The Confirmatory Order confirms the commitments made as part of the preliminary settlement agreement. The elements of that agreement, formulated and agreed to at the mediation sessions, are incorporated in the enclosed Confirmatory Order (Enclosure 1). In light of corrective actions that NCNR has taken and subject to the satisfactory completion of the additional actions that NCNR has committed to take, as described in the Confirmatory Order, the NRC will not issue a Notice of Violation for the apparent violations discussed in its letter dated March 16, 2022, and will not issue an associated civil penalty. The NRCs concerns associated with the apparent violations will be addressed by making the NCNR commitments legally binding through the Confirmatory Order.
Pursuant to Section 223 of the Atomic Energy Act of 1954, as amended, any person who willfully violates, attempts to violate, or conspires to violate, any provision of this Confirmatory Order shall be subject to criminal prosecution as set forth in that section.
Violation of this Confirmatory Order may also subject the person to a civil monetary penalty.
The NRC staff plans to inspect the requirements in the Confirmatory Order through supplemental inspections. Additional inspections will also be performed to inform any decision by the NRC staff on the request to restart the reactor submitted by the licensee on October 1, 2021 (ADAMS No. ML21274A018) and to provide increased oversight after any such restart of reactor operations until the staff determines that routine inspections in accordance with NRC Inspection Manual Chapter 2545, Research and Test Reactor Inspection Program, are adequate to ensure safe operations.
Apart from the actions required by the enclosed Confirmatory Order, you are not required to respond to this letter. However, if you choose to provide a response, please provide it to me within 30 days at the following address: Mailstop O14A50, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001. Should you have questions concerning the enclosed Confirmatory Order, please contact David Jones at 301-287-9525.
In accordance with 10 CFR 2.390, Public inspections, exemptions, requests for withholding, a copy of this letter and its enclosures will be made available electronically for public inspection in the NRC Public Document Room and in the NRCs ADAMS, accessible from the NRC w ebsite at https://www.nrc.gov/reading-rm/adams.html. To the extent possible, your response, if you choose to provide one, should not include any personal privacy, proprietary, or safeguards information so that it can be made available to the public without redaction.
D. Dimeo 3
The NRC also includes significant enforcement actions on its website at https://www.nrc.gov/reading-rm/doc-collections/enforcement/actions/.
Mark D. Lombard, Director Office of Enforcement
Docket No. 50-184 License No. TR-5
Enclosures:
As stated
SUBJECT:
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, CENTER FOR NEUTRON RESEARCH - CONFIRMATORY ORDER DATED: August 1, 2022
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Test, Research and Training Reactor Newsletter Attention: Amber Johnson Dept. of Materials Science and Engineering University of Maryland 4418 Stadium Drive College Park, MD 20742-2115
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PUBLIC AVeil, NRR MShams, NRR CCarusone TTate, NRR RTaylor, NRR JBowen, NRR KRoche, NRR MKeefe-Forsyth, NRR JBorromeo, NRR PBoyle, NRR BHughes, NRR CCauffman, NRR DHardesty, NRR NParker, NRR CMontgomery, NRR WSchuster, NRR POBryan, NRR CBassett, NRR SAnderson, NRR RClement, NRR EHelvenston, NRR MBalazik, NRR MLombard, OE TMartinez Navedo, OE JPeralta, OE DWillis, OE LJarriel, OE DJones, OE RCarpenter OGC M Lemoncelli, OGC P Molding, OGC SBurnell, OPA DTifft, Region I DJackson, Region I MGray, Region I RidsNrrDanuUnpo Resource OE r/f
Publicly Available ADAMS Accession No.: ML22206A213 ADAMS Package Accession No.: ML22202A419 OFFICE OE/EB OE/ EB NRR/DANU OGC/NLO OE/ D NAME DJones JPeralta JBowen RCarpenter MLombard DATE 07/26/22 07/26/22 07/27/22 07/28/22 08/01/22 OFFICIAL RECORD COPY Enclosure A
UNITED STATES OF AMERICA
NUCLEAR REGULATORY COMMISSION
In the Matter of ) Docket No.: 05000184
) License No.: TR-5 National Institute of Standards and Technology )
Center for Neutron Research )
U.S. Department of Commerce ) EA-21-148
CONFIRMATORY ORDER MODIFYING LICENSE
EFFECTIVE UPON ISSUANCE
The National Institute of Standards and Technology (NIST), Center for Neutron
Research (NCNR or licensee), U.S. Department of Commerce (DOC) is the holder of
License No. TR-5, issued by the U.S. Nuclear Regulatory Commission (NRC or
Commission) pursuant to Part 50 of Title 10 of the Code of Federal Regulations (10
CFR). NIST refers to the larger National Institute of Standards and Technology
organization while NCNR refers specifically to the licensee and operator of the National
Bureau of Standards Test Reactor (NBSR or reactor). The license authorizes the
operation of the NBSR in accordance with conditions specified therein. The facility is
located on the NIST campus in Gaithersburg, Maryland.
This Confirmatory Order (CO) is the result of an agreement reached during an
Alternative Dispute Resolution (ADR) mediation session conducted on May 10, 2022,
May 19, 2022, and June 2, 2022, to address seven apparent violations.
II
The NBSR is a heavy-water (D2O)-moderated-and-cooled, enriched-fuel, tank-
type reactor designed to operate at 20 megawatts thermal (MW(t)) power. The facility
operates continuously during a 7 -week operational cycle that consists of approximately
38 days of operation, followed by 10-day refueling and maintenance outages.
On December 20, 2020, operators shut down the reactor for a refueling outage.
During the refueling outage on January 4, 2021, fuel elements were shuffled within the
reactor vessel during day shift. After the fuel elements were placed in each core
position, height verification was performed using a height gauge to ensure that the fuel
elements were fully latched in the lower grid plate. Following the February 3, 2021,
event discussed below, the NRC inspectors reviewed video footage of the placement of
fuel element S-1175 in the J-7 core position and determined that the fuel element was
initially latched after placement. However, the inspectors observed that operators had
difficulty lowering the tool to fuel element S-1175 during the subsequent height
verification. Performance of this height verification likely contributed to fuel element S-
1175 becoming unlatched. Further, the inspectors observed that the operators
improperly performed the latch verification rotation checks on the evening shift.
Through post-event interviews and observation of the video footage of the refueling and
latch verification evolutions, the inspectors determined that fuel element S-1175 was
likely not fully latched in the J-7 core position at the end of fuel handling operations on
January 4, 2021.
On February 3, 2021, following the refueling outage, NCNR reactor operators
were performing a normal reactor startup when the reactor automatically shut down in
response to indications of high confinement exhaust stack radiation. Once the reactor
was placed in a safe condition, all personnel evacuated the control room and reactor
confinement. The reactor was then monitored by operators from the remote
Emergency Control Station. NCNR subsequently declared an alert in accordance with
the facility emergency plan and procedures. During the event, six NCNR reactor
personnel became externally contaminated and were monitored for internal exposure to
radioactive materials. Following the event, NCNR personnel performed environmental
monitoring at the confinement exhaust stack and at the 400-meter emergency planning
site boundary, which is located within the fence line of the NIST Gaithersburg campus.
Environmental sampling for radioactive material releases, as well as radiological
surveys, confirmed that release amounts were a small fraction of the alert and
notification of unusual event criteria in the emergency procedures, which led to event
termination by NCNR later that day.
On March 2, 2021, NCNR submitted a related event notification (EN 55120) to
inform the NRC that it had violated the fuel cladding temperature safety limit for
damaged fuel element S-1175. During subsequent visual inspection activities where
NCNR moved fuel elements from the reactor core to the fuel storage pool, the NRC
inspectors observed melted material deposited on the lower grid plate. The inspectors
also observed that the damaged fuel element S-1175 nozzle was almost completely
blocked by melted material. The inspectors noted that additional tests would need to
be performed to determine the exact composition of the melted material. The damaged
fuel element S-1175 is currently in a container located within the fuel storage pool
awaiting shipment for further analysis. The licensee has contracted with Framatome to
clean up the reactor vessel and remove the melted material from the lower grid plate,
vessel, and primary piping. Framatome is assisting with various operations during this
recovery.
On March 16, 2022, the NRCs Office of Nuclear Reactor Regulation, Division of
Advanced Reactors and Non-Power Production and Utilization Facilities, issued a
special inspection report to the licensee. The inspection report included the following
seven apparent violations, five of which NCNR identified in its own review and reported
to NRC staff:
- 1. Apparent Violation of Technical Specification 2.1, Safety Limit, which states that the
reactor fuel cladding temperature shall not exceed 842°F (420°C) for any operating
conditions of power and flow. The NRC inspectors observed once-molten material in
and around the fuel element nozzle of element S-1175 in the J-7 grid position
indicating that the licensee exceeded the fuel temperature safety limit.
- 2. Apparent Violation of Technical Specification 3.1.3, Core Configuration, which
states that [t]he reactor shall not operate unless all grid positions are filled with full
length fuel elements or thimbles, except during subcritical and critical startup testing
with natural convection flow. The NRC inspectors observed that the fuel element S-
1175 was not latched, was raised approximately 3-4 inches above the upper grid
plate, and was angled out of its proper position, causing it to rest on the lower grid
plate surface.
- 3. Apparent Violation of Technical Specification 6.4, Procedures, which states, in part,
that [w]ritten procedures shall be prepared, reviewed and approved prior to initiating
any of the activities listed in this section [including] [f]uel loading, unloading, and
fuel movement within the reactor vessel. The NRC inspectors determined that the
procedure for fuel handling activities was not suitable for the circumstances and did
not contain necessary information to ensure that the fuel elements were latched prior
to startup. As a result, the inspectors determined that the fuel handling procedure
was inadequate to ensure that the fuel element in question was latched during
refueling activities on January 4, 2021.
- 4. Apparent Violation of Technical Specification 6.4, Procedures, which states, in part,
that [w]ritten procedures shall be prepared, reviewed and approved prior to initiating
any of the activities listed in this section [including] [s]tartup, operation, and
shutdown of the reactor. The reactor startup procedure instructs the operators to
monitor for abnormal fluctuations or oscillations on nuclear channel indications.
However, the NRC inspectors found that the procedure does not provide amplifying
guidance for operators to use when conducting this monitoring.
- 5. Apparent Violation of Technical Specification 6.4, Procedures, which states, in part,
that [w]ritten procedures shall be prepared, reviewed and approved prior to initiating
any of the activities listed in this section [including] [i] mplementation of required
plans such as emergency or security plans. The NRC inspectors determined that
NCNR emergency response procedures were not suitable for the circumstances and
caused NCNR to unnecessarily (although still within the required timeframe) delay
their response to the event.
- 6. Apparent Violation of Technical Specification 3.9.2.1, Fuel Handling; Within the
Reactor Vessel, which states that [f]ollowing handling of fuel within the reactor
vessel, the reactor shall not be operated until all fuel elements that have been
handled are inspected to determine that they are locked in their proper positions in
the core grid structure. This shall be accomplished by one of the following methods:
(1) Elevation check of the fuel element with main pump flow. (2) Rotational check of
the element head in the latching direction only. (3) Visual inspection of the fuel
element head or latching bar. The NRC inspectors determined that NCNR
operators failed to implement one of the methods required by the technical
specifications to ensure that fuel element S-1175 was adequately latched.
- 7. Apparent violation of 10 CFR 50.59, Changes, tests and experiments, paragraph
(c)(1), which states, in part, that a licensee may make changes in the facility without
obtaining a license amendment only if a change to the technical specifications is not
required. The NRC inspectors determined that NCNR made changes to the refueling
tooling that should have required a change to the technical specifications because
dimensional differences of the new tooling invalidated the capability of operators to
verify that a fuel element was adequately latched.
For the seven apparent violations, the NRC offered NCNR an opportunity to (1)
attend a pre-decisional enforcement conference or (2) to participate in an ADR
mediation session to resolve this concern. In response to the NRCs offer, NCNR
requested the use of the NRCs ADR process to resolve the seven apparent violations.
On May 10, 2022, the NRC and NCNR conducted an ADR session mediated by a
professional mediator, arranged through Cornell Universitys Scheinman Institute on
Conflict Resolution. The ADR process is one in which a neutral mediator, with no
decision-making authority, assists the parties in reaching an agreement to resolve any
differences regarding the dispute. This CO is issued pursuant to the agreement
reached as a result of the full-day mediation session that occurred on May 10, 2022,
and two subsequent virtual meetings that occurred on May 17, 2022, and June 2, 2022.
The NRC and NCNR signed the agreement in principle (AIP) for the mediation session
on June 3, 2022.
III
NCNR and the NRC reached a preliminary settlement agreement during mediations.
The elements of the agreement included (1) corrective actions completed by NCNR, (2)
corrective actions planned by NCNR, (3) additional agreed upon future actions by
NCNR, and (4) general provisions. Additionally, the NRC and NCNR agreed that the
apparent violations described in Section II of this Order were violations of regulatory
requirements. The NRC and NCNR agreed that the safety significance of these
violations is normally characterized at Severity Level 1 in accordance with the NRC
Enforcement Policy. Additionally, the NRC concluded that a civil penalty of up to
$432,000 would normally be proposed for this violation, as assessed in accordance with
the civil penalty assessment process discussed in Section 2.3.4 of the NRC
Enforcement Policy. However, due to the robust nature of corrective actions taken and
planned by NCNR as documented in Sections III and V, the NRC determined that
waiving a civil penalty is appropriate in this case.
The parties agreed in the AIP to refine the language of the AIP to reflect the
appropriate level of detail when included in Section III of the CO. The following is the
refined language:
- 1. Based on a review of the incident, NCNR completed corrective actions and
enhancements to preclude recurrence of the violation, including but not limited to the
following:
- a. NIST/NCNR Safety Culture
- i. NCNR staff secured additional funds for the Nuclear Safety Culture
Improvement Program (NSCIP), with additional funds included in current
budget proposals.
ii. NCNR staff has drafted the NSCIP program documents addressing
problem identification and resolution, root cause investigations, training,
procedures, and oversight. These will be used to develop a request for
proposals to assist the NCNR in program development and
implementation.
iii. NCNR has identified comparable reactor facilities for purposes of
benchmarking various safety culture programs, with in-person visits
planned or completed. Results from these benchmarking visits will be
used to inform further development of the NSCIP.
iv. NCNR staff reevaluated the root cause analysis with an emphasis on
nuclear safety culture and is using this evaluation to develop the NSCIP
plan.
- b. Management
Commerce leadership for oversight and secured additional funding for
corrective actions (including additional operations personnel) and reactor
recovery and clean-up.
ii. NCNR currently staffs four rotating shifts during normal operation and is
challenged to complete additional work such as training, employee
development, and emergent maintenance. NCNR leadership has initiated
hiring actions to establish a fifth operating shift dedicated to training and
maintenance.
iii. Elevated Enterprise Risk Management of NCNR to institutional (NIST)
level through the chartered NIST Enterprise Risk Management Council.
The Council, which includes NIST Senior Executives, identifies NIST
enterprise-level risks, tracks those risks and their impacts, and reviews
risk mitigation progress and strategy.
iv. NCNR leadership appointed a permanent Chief of Reactor Operations to
provide more continuity and stability.
program. This position will provide oversight of communications between
engineering and operations to help ensure that identified issues are
resolved.
vi. NCNR confirmed or updated management Performance Plans to ensure
that expectations for procedure use and adherence with consequences
for failure to follow required procedures is part of employee reviews.
vii. Licensee staff including Reactor Operations and Engineering leadership
took part in safety culture training given by NCNR staff experienced in
safety culture training. The training covered the following topics:
- 1. Human Performance Tools
- 2. Procedure Use and Adherence
- 3. Procedure Writing and Routing Guides
- 4. SharePoint Use
- 5. Procedure Theory
- 6. Hazard Review
- 7. Risk Assessment
- 8. Mitigation Actions
- 9. Pre-Job Brief and Post-Job Critique
viii. NCNR conducted leadership training for reactor supervisors. The training
was led by the Chief of Reactor Operations and included the following
modules of leadership training for the Commerce Learning Center:
- 1. Accountable Leadership
- 2. Influencing and Persuading Others
- 3. Becoming an Emotionally Intelligent Leader
- 4. Networking to Improve Leadership Effectiveness
- 5. New Leadership Transitions
- 6. Leading Others through Conflict
- c. Corrective Action Program
- i. NCNR implemented Safety Good Catch/Good Idea program to
incentivize staff to identify, raise, and address safety concerns in April
2021.
ii. Established Safety Evaluation Committee (SEC) subcommittee to track
and oversee corrective actions.
iii. Established the Engineering Change Management Program to provide an
administrative gate for 50.59 screening and execution for facility and
procedure modifications.
- d. Procedures
and Adherence, which guides conduct of operations, to strengthen the
oversight role supervisors must play and to require that all personnel be
trained. The required procedure use and adherence training has been
completed.
ii. Drafted and approved AR 5.1, Procedure Writers Guide, related to
procedure writing, which includes addressing improvements to writing
quality.
iii. Identified procedures that will be updated according to new guidance in
AR 5.1 prior to reactor startup.
iv. Updated procedure standards to comply with PPA AP-907- 005,
Pro cedure Writers Manual.
- v. Implemented AR 1.1, Human Performance Tools, related to improving
training on a continuous basis.
vi. Modified Operating Instruction (OI) 1.1, Reactor Startup, to provide
detailed guidance on evaluation of abnormal fluctuations in nuclear
instrumentation.
- e. Technical
- i. NCNR conducted 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> of proficiency training for all Operations Staff,
emphasizing the importance of latching and procedural compliance.
ii. Established proficiency requirements for operators performing fuel
handling, including core loading, shuffle, rotational latch checks, and
visual latch checks.
iii. Created Emergency Instructions (EI) 3.8, Recovery Operations, and 3.9
Confinement Re -entry, to provide detailed guidance on building
reoccupation. In addition, EI 0.4, Control Room Evacuation, and EI 0.5,
Post -evacuation Checklist, were created to include an evacuation
checklist required to be used during an evacuation to ensure confinement
is safe for operator re-entry.
iv. Performed Latch Improvement Safety Analysis to document that
improved latching and latch check processes provide adequate defense
against unlatching.
- v. Assessed the efficacy of all tools used in refueling to determine whether
improvements are needed and concluded that, given the discontinuation
of height checks, the tools are adequate to meet all new refueling and
latch check requirements.
vi. Conducted analysis as to whether no-flow height checks should be
continued and concluded that the equipment does not support height
checks with sufficient precision; height -related latch checks are no longer
prescribed.
vii. Reinstituted requirement for latch checks prior to final pump restart and
modified OI 2.1.1, Startup of the Primary System for Criticality, and OI
1.1.0, Reactor Startup Checklist.
viii. Instituted a required rotation latch check, performed by a second
individual and modified OI 6.1, Fueling and Defueling.
ix. Instituted a redundant Technical Specifications required method of visual
checks (using a digital camera plus image analysis software) and
modified Operating Instruction (OI) 6.1.
- x. Verified that the index plate is consistently positioned by the use of
alignment pins and that rotational fiduciary marks are clear to ensure fuel
movement evolutions are performed properly.
xi. Modified OI 6.1 series and OI 1.1A CL to ensure that there will be no tool
contact with fuel head following final visual latch verification prior to
reactor startup.
xii. Submitted License Amendment Request to NRC to modify Technical
Specification 3.9.2.1 to require latch verification through both mechanical
rotational and visual methods.
- 2. Based on a review of the incident, NCNR plans to complete additional corrective
actions, including but not limited to the following:
- a. Management Systems
- i. Conduct regular briefings of NIST and DOC leadership regarding the
progress of operational safety and corrective actions, and review of
safety culture.
ii. Participate in Enterprise Risk Management reviews twice a year to
assess elevated risk impact of NCNR for NIST.
iii. Develop and implement a change management framework to
evaluate sufficiency of existing change management processes and
identify gaps and areas for improvement.
iv. Develop a system for knowledge and skills management in the
presence of personnel attrition.
- v. Develop a plan for involving staff in continuous improvement of
reactor operations, through participation in a preventive action
program that encourages and rewards proactive efforts to improve
quality, safety, and efficiency of operations.
vi. Hire a Deputy Chief of Reactor Operations to provide additional
oversight and consistent leadership.
vii. Increase management engagement by implementing AR 5.4,
Observation Program, which details requirements for management
and others to perform observations with documentation of findings
and suggested improvements.
viii. Define requirements for qualification as Crew Chief and implement
Crew Chief leadership and development training.
- b. Qualification and Training
- i. Develop a technical training program for robust qualification and training
of supervisors, operators, and candidates for: moving and handling fuel;
proficiency checks on key refueling tasks; and proficiency checks for core
loading, shuffle, rotational latch checks and visual latch checks. The
program will include training materials (e.g., qualification cards) and
practical experience with the use of the fuel handling stand, reflecting
stated learning objectives.
ii. Provide consistent and structured training and immediate and continual
feedback to Non-Licensed Operators (NLO) during on-the-job training to
ensure comprehension of performance expectations.
iii. Develop consistent standard by which all supervisors evaluate
qualifications.
iv. Develop a continuous formal operator training program to provide
ongoing training through rotating assignments of operators to a fifth shift
dedicated to training, procedure development, and maintenance.
- v. Implement mandatory oversight training for supervisors.
vi. Require additional training in leadership training and reactor supervisor
leadership training.
vii. Conduct proficiency training prior to all future refueling events.
- c. Procedures
- i. Rewrite Operating Instruction (OI) series 6.1, Fueling and Defueling,
and OI 6.2, Operation of the Fuel Transfer System, to capture detail of
fuel and latch movements to align with training.
ii. Revise procedures necessary prior to any reactor restart to be consistent
with INPO 11-003, Guideline for Excellence in Procedure and Work
Instruction Use and Adherence, and conducted training on procedure
protocols.
iii. Complete revision to procedures required for startup.
iv. Design, test, and install noise gates on selected nuclear instrumentation
channels to alert operator of abnormal signal in progress.
- d. Event Response
- i. Develop guidelines that outline methods for making measurements,
interpreting results, performing calculations, and making dose projections
(e.g., dose projections that are used as basis for 10 radiological protective
action recommendations and those used to upgrade and downgrade
emergency classes).
ii. Develop a process to communicate and track deficiencies in emergency
drills and exercises identified during follow-up critiques; ensure corrective
and preventive actions are assigned appropriately and tracked for timely
resolution.
iii. Implement an ethernet-based data display for the emergency control
station, post-reactor startup to improve remote monitoring and control
capabilities.
- 3. Based on NCNRs review of the incident and NRCs concerns with respect to precluding
recurrence of the violation, NCNR agrees to implement corrective actions and
enhancements in the following areas:
- a. Communications
- b. Nuclear safety program assessments to include:
- i. Nuclear safety culture assessment
ii. Nuclear program assessment(s)
iii. Problem Identification and Resolution program
iv. Employee concerns
- v. Safety Culture Monitoring Panel
- c. Training
- d. Procedures
- e. Benchmarking
- f. Employee engagement
- g. Leadership accountability
- h. Technical issues
- 4. Based on the completed and planned actions described above, and the commitments
described in Section V of this Order, the NRC agrees to reduce the civil penalty to $0,
refrain from issuing a cited notice of violation, and not pursue any further enforcement
action based on the seven apparent violations identified in the NRCs March 16, 2022,
letter.
- 5. The NRC will consider the Confirmatory Order an escalated enforcement action with
respect to any future enforcement actions.
- 6. On July 21, 2022, NCNR consented to the issuance of this Confirmatory Order with the
requirements, as described in Section V below. NCNR further agreed that this
Confirmatory Order is to be effective upon issuance, the agreement memorialized in this
Confirmatory Order settles the matter between the parties, and that the licensee has
waived its right to a hearing.
IV
Any decision of the NRC to approve restart under 10 CFR 50.36(c)(1) would be
informed by but not solely reliant upon this CO.
I find that the actions completed by NCNR, as described in Section III above,
combined with the commitments as set forth in Section V are acceptable and
necessary, and conclude that with these completed actions and commitments the
public health and safety are reasonably assured. In view of the foregoing, I have
determined that public health and safety require that NCNRs commitments be
confirmed by this Order. Based on the above and NCNRs consent, this Confirmatory
Order is effective upon issuance.
V
Accordingly, pursuant to Sections 104b, 161b, 161i, 161o, 182, and 186 of the
Atomic Energy Act of 1954, as amended, and the Commissions regulations in 10 CFR
2.202 and 10 CFR Part 50 as applicable, IT IS HEREBY ORDERED, EFFECTIVE
UPON ISSUANCE, THAT LICENSE NO. TR-5 IS MODIFIED AS FOLLOWS:
- 1. Communications
- a. Within 3 months of issuance of the Confirmatory Order, the NIST Director will
issue a statement to NIST employees communicating the specific strategy to
improve NCNRs nuclear safety culture. The communication will include (1) a
summary regarding the Nuclear Safety Culture Improvement Program, (2) the
NRCs concerns expressed in its Special Inspection Report, (3) specific lessons
learned from previously applied corrective actions, and (4) corrective actions both
taken and planned. At least 30 days prior to issuing the statement, NIST will
provide the statement for NRC staff review. Within 15 days of receiving the
statement, the NRC staff will provide feedback to NIST. NIST will incorporate
NRC staff feedback and notify the NRC when the statement is issued.
all-hands meeting with NCNR employees for management to discuss the
importance of the above communication. NCNR will require and document
attendance for the all-hands meeting and maintain that documentation in the
NCNR employees training records.
- 2. Nuclear safety program assessments
- a. Nuclear safety culture assessment
- i. Within 6 months of issuance of the CO, NCNR will hire a third-party,
independent nuclear consultant (consultant) to conduct an independent
third-party nuclear safety culture assessment. The contract will specify
that the consultant will assist NCNR in the implementation of the
recommendations and corrective actions identified in the assessment to
prevent recurrence of the February 3, 2021, event or similar events at the
NBSR.
ii. Prior to issuance of the Request for Quotations, NCNR will include criteria
equivalent to the those described in Section 03.02.c.1, c.2, and c.3 of
Inspection Procedure 95003, Supplemental Inspection for Repetitive
Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple
Yellow Inputs or One Red Input, dated June 7, 2022, to ensure a
consultant with the appropriate qualifications is identified.
iii. Within 6 months of contract award to the consultant, NCNR will submit a
copy of the safety assessment report and NCNRs written response to the
assessment report to the NRC. NCNRs written response will either
address how it will implement the recommendations and corrective
actions of the assessment report, including a proposed timeline; or
provide an explanation and justification for why the recommendation(s)
and corrective action(s) will not be implemented.
iv. Within 2 months of submitting the assessment report to the NRC, the
NCNR Director shall issue written and verbal communications providing
the results of the assessment, recommendations, and corrective actions
to the NCNR staff. At least 30 days prior to issuing the written
communication, NCNR will provide the statement for NRC staff review.
Within 15 days of receiving the statement, the NRC staff will provide
feedback to NCNR staff. NCNR will notify the NRC when the statement is
issued.
- v. The assessment will include employee surveys, the review of anonymous
reports, and contractor-conducted interviews and focus groups to assess
the effectiveness of the programs.
vi. NCNR will ensure this consultant is provided with all necessary materials,
reports, and access to personnel to complete its assessment. The
reports shall include the NRC special inspection report dated March 16,
2022, future NRC inspections reports regarding the February 3, 2021,
event, and NCNR safety evaluation committee and safety assessment
committee (SEC/SAC) reports.
vii. Within 12 months of completing the initial assessment, the consultant will
perform a second assessment to ensure the sustainability and
effectiveness of the corrective actions within the identified areas. Within
30 days of receiving the report, NCNR will submit a copy of the second
assessment report to the NRC.
viii. Within 12 months of completing the second assessment, the consultant
will conduct a third assessment to ensure long term sustainability and
effectiveness of the identified recommendations and corrective actions.
Within 30 days of receiving the report, NCNR will submit a copy of the
third assessment report to the NRC.
- b. Nuclear program assessment(s)
- i. Within 12 months of the issuance of the CO, NCNR will hire one or more
third-party, independent nuclear consultant(s) to conduct an independent
third-party assessment(s) and notify the NRC of the timeline for the
completion of the assessment(s). The contract will specify that the
nuclear consultant(s) will assist NCNR in the implementation of the
recommendations and corrective actions identified in the assessment(s)
to prevent recurrence of the February 3, 2021, event or similar events at
the NBSR. The consultants (or consultants) assessment(s) will include
recommended corrective actions in the following areas:
- 1. Problem Identification and Resolution
- 2. Event Root Cause
- 3. Training
- 4. Procedures
- 5. Safety Assessment Committee
- 6. Safety Evaluation Committee independence and effective
oversight
ii. Within 3 months of issuance of the assessment report(s) (or within 3
months of the issuance of the last report, if multiple contracts are
awarded), NCNR will submit a copy of the safety assessment report(s)
and NCNRs written response to the assessment report(s) to the NRC.
NCNRs written response will either address how it will implement the
recommendations and corrective actions of the assessment report(s),
including a proposed timeline; or provide an explanation and justification
for why the recommendation(s) and corrective action(s) will not be
implemented.
iii. Within 2 months of submitting the assessment report(s) to the NRC, the
NCNR Director shall issue written and verbal communications providing
the results of the assessment, recommendations, and corrective actions
to the NCNR staff. At least 30 days prior to issuing the written
communication, NCNR will provide the statement for NRC staff review.
Within 15 days of receiving the statement, the NRC staff will provide
feedback to NCNR staff. NCNR will notify the NRC when the statement is
issued.
iv. NCNR will ensure this consultant is provided with all necessary materials
and access to personnel to complete its assessment, including NRC
inspection reports, SEC/SAC reports, and the interim and final special
inspection reports.
- c. Problem Identification and Resolution program
- i. By September 30, 2022, NCNR will develop an Observation program with
program goals to provide for periodic management oversight of
procedures and procedure adherence.
ii. By September 30, 2022, NCNR will develop a System Review Team
program with program goals of reviewing system changes, including but
not limited to components and procedures, and generating reports for the
Aging Reactor Management review.
iii. By October 31, 2022, NCNR will develop and implement the Level 3
Corrective Action Program.
iv. By December 31, 2022, NCNR will develop and implement the Level 2
Corrective Action Program.
- v. By March 31, 2023, NCNR will develop and implement the Level 1
Corrective Action Program.
vi. Within 1 month of program finalization, NCNR will submit program
documentation to the NRC for review and comment.
vii. Within 3 months of NRC comment, NCNR will incorporate NRC staff
feedback.
viii. The NCNR will maintain these programs to track, trend, and correct
failures and deficiencies to prevent recurrence.
- d. Employee concerns
- i. Within 6 months of issuance of the CO, NCNR will develop a formal
program for NCNR employees to raise concerns. The program will
describe and include methods to address the following types of concerns:
- 1. anonymous employee concerns
- 2. employee protection
- 3. nuclear safety culture
- 4. chilling effect
ii. Within 1 month of program development, NCNR will submit program
documentation to the NRC for review and comment.
iii. Within 2 months of NRC comment, NCNR will incorporate NRC staff
feedback and implement and maintain the program.
- e. Safety Culture Monitoring Panel
- i. Within 9 months of issuance of the CO, NCNR will develop a formal
program to monitor the nuclear safety culture informed by the elements of
NEI 09-07, Fostering a Healthy Nuclear Safety Culture, Revision 1.
ii. Within 1 month of program development, NCNR will submit program
documentation to the NRC for review and comment.
iii. Within 2 months of NRC comment, NCNR will incorporate NRC staff
feedback and implement and maintain the program.
- 3. Training
In addition to the recommendations and corrective actions related to training
identified during the above assessment (see Provision 2.b.i):
- a. Prior to any restart, NCNR will conduct training of all licensed operators on the
performance of fuel loading and latch checking procedures in accordance with
ANSI/ANS-15.4-2016, American National Standard Selection and Training of
Personnel for Research Reactors. NCNR will maintain records of training
completion for all licensed operators.
- b. Within 3 months of issuance of the CO, NCNR will modify its requalification plan
to specify that every reactor operating test or evaluation portion of NCNR
licensed operator requalification training must include other reactivity tasks
including fuel movements, insertion and removal of experiments, and rod
exchange or movements without power change as one of the five tasks selected
from Section 5.4 (as specified in Section 6.2.5) of ANSI/ANS -15.4-2016,
American National Standard Selection and Training of Personnel for Research
Reactors.
- 4. Procedures
- a. Prior to any restart, NCNR will develop, implement, and maintain a written
procedure that covers procedural use and adherence in accordance with the
most recent version of INPO 11-003, Guideline for Excellence in Procedure and
Work Instruction Use and Adherence.
- b. Procedures referenced in paragraph 1.d of Section III of this CO will be subject to
inspection prior to any restart.
- c. Within 30 months of issuance of the CO, NCNR will develop, implement, and
maintain all procedures involving reactor operations activities in accordance with
the most recent version of PPA AP-907-005, Procedure Writers Manual.
- 5. Benchmarking
- a. Starting 12 months after CO issuance, NCNR will benchmark one program (e.g.,
training, procedure process, corrective action program, configuration
control/change management etc.) each calendar year, to include site visits and
observations at another facility. Because NCNR is much larger in both thermal
output and staffing than most research and test reactors (RTRs) and operates at
a cadence similar to commercial power reactors, NCNR will not solely
benchmark RTRs. Conversely, the NCNR is a much smaller organization than a
commercial power reactor, so NCNR will also not solely benchmark power
reactors. NCNR shall be strategic when deciding the appropriate facility to
benchmark, selecting a facility with a program commensurate to the one NCNR
is benchmarking. NCNR should also consider input from the nuclear consultants
identified in Provisions 2.a and 2.b on the appropriate facility programs to
benchmark (i.e., a commercial power reactors safety culture program; Advanced
Test Reactors problem identification and resolution program, etc.). Furthermore,
benchmarking shall include multiple levels of NCNR staff and shall not be limited
to NCNR senior management. NCNR will document this activity, observations,
and decisions regarding changes to NCNRs programs.
- b. For 3 years following issuance of the CO, at least one NCNR staff member shall
attend 2 of the following relevant industry conferences per calendar year:
- i. National Organization of Test, Research and Training Reactors (TRTR)
ii. National Association of Employee Concerns Professionals (NAECP)
iii. NRCs Regulatory Information Conference (RIC)
iv. American Nuclear Society (ANS)
- v. Department of Energy (DOE), if applicable
- 6. Employee engagement
Within 6 months of the issuance of the CO, NCNR will establish and maintain a rewards
and recognition program to encourage employees to raise concerns and will incorporate
a safety recognition program into the performance evaluation process. The program will
include the following:
- a. encourage informal recognition of safety achievements;
- b. establish a formal recognition program with tangible rewards;
- c. encourage the staff to seek advice and to proceed with caution;
- d. communicate expectations and ensure that safety correspondence such as near
misses, good catches, operating experience, and safety flash communications
are developed and communicated to the workforce.
- 7. Leadership accountability
- a. Within 12 months of consultant contract award, NCNR will provide the NRC with
documentation of any revisions to the Safety Evaluation Committee charter as
informed by the nuclear consultant(s) selected under item 2.b.
- b. Within 12 months of the contract award discussed in Provision 2.b, NCNR will
conduct training for all senior leaders, with support of the nuclear consultant
selected under Provision 2.b, and which will include training on NUREG-2165,
Safety Culture Common Language (INPO 12- 012, Traits of a Healthy Nuclear
Safety Culture, Revision 1). NCNR will incorporate this leadership training into
an annual required safety culture refresher training for senior leaders.
- c. By the beginning of fiscal year 2023, NCNR will develop and maintain
performance appraisal assessment criteria for periodic annual evaluations of
NCNR supervisors and managers to assess their performance regarding nuclear
safety culture.
- d. Within 12 months of the issuance of the CO, NCNR will present at a publicly
attended annual conference (such as TRTR, NAECP, ANS). If asked by the
NRC, NCNR will also present at the RIC. The presentation will address the
cause of the February 3, 2021, event and corrective actions taken by NCNR and
will include a discussion of the NRCs findings. Two months prior to the
conference, NCNR will submit the presentation to the NRC for review and
comment, and NCNR will incorporate any comments from the NRC staff into the
final presentation.
- e. Within 3 months of issuance of the CO, NCNR will provide a timeline to address
staffing challenges to the NRC for review.
- 8. Technical issues
- a. Within 3 months of the issuance of the CO, NCNR will provide an assessment of
options to replace NCNRs reliance upon administrative controls/actions to
ensure that fuel assemblies are adequately latched.
- b. Within 6 months of any restart of regular reactor operations (defined as the return
to 24 hour/day operations at 20 MW), NCNR will implement the condition-based
monitoring systems for nuclear instrumentation that could provide a very early
warning to control room operators of mechanical anomalies during reactor
startup.
- c. Within 12 months of the issuance of the CO, NCNR will develop an engineered
solution to automatically secure carbon dioxide following a major SCRAM.
NCNR will implement the proposed solution using the appropriate regulatory
process or provide the NRC with an engineering analysis that includes a
justification for not implementing a design change.
- d. Within 12 months of issuance of the CO, NCNR will provide an assessment of
the configuration management process and how it is incorporated with problem
identification and resolution processes.
- 9. Upon completion of the terms of items of the CO, NCNR will provide the NRC with a
letter discussing its basis for concluding that the requirements of this Order have been
adequately implemented.
In the event of the transfer of the license of NCNR to another entity, the terms
and conditions set forth hereunder shall continue to apply to the new entity and
accordingly survive any transfer of ownership or license.
The Director, Office of Enforcement, may, in writing, relax, rescind, or withdraw
any of the above conditions upon demonstration by NCNR or its successors of good
cause.
VI
In accordance with 10 CFR 2.202 and 10 CFR 2.309, any person adversely
affected by this CO, other than NIST/NCNR, may request a hearing within 30 calendar
days of the date of issuance of this CO. Where good cause is shown, consideration will
be given to extending the time to request a hearing. A request for extension of time
must be made in writing to the Director, Office of Enforcement, U.S. Nuclear Regulatory
Commission, Washington, DC 20555, and include a statement of good cause for the
extension.
All documents filed in NRC adjudicatory proceedings, including a request for
hearing and petition for leave to intervene (petition), any motion or other document filed
in the proceeding prior to the submission of a petition, and documents filed by
interested governmental entities that request to participate under 10 CFR 2.315(c),
must be filed in accordance with the NRCs E-Filing rule (72 FR 49139; August 28,
2007, as amended at 77 FR 46562; August 3, 2012). The E-Filing process requires
participants to submit and serve all adjudicatory documents over the internet, or in
some cases to mail copies on electronic storage media. Detailed guidance on making
electronic submissions may be found in the Guidance for Electronic Submissions to the
NRC and on the NRC Web site at https://www.nrc.gov/site-help/esubmittals.html.
Participants may not submit paper copies of their filings unless they seek an exemption
in accordance with the procedures described below.
To comply with the procedural requirements of E-Filing, at least 10 days prior to
the filing deadline, the participant should contact the Office of the Secretary by email at
hearing.docket@nrc.gov, or by telephone at 301-415-1677, to (1) request a digital
identification (ID) certificate, which allows the participant (or its counsel or
representative) to digitally sign submissions and access the E-Filing system for any
proceeding in which it is participating; and (2) advise the Secretary that the participant
will be submitting a petition or other adjudicatory document (even in instances in which
the participant, or its counsel or representative, already holds an NRC-issued digital ID
certificate). Based upon this information, the Secretary will establish an electronic
docket for the hearing in this proceeding if the Secretary has not already established an
electronic docket.
Information about applying for a digital ID certificate is available on the NRCs
public website at https://www.nrc.gov/site-help/e-submittals/getting-started.html. Once
a participant has obtained a digital ID certificate and a docket has been created, the
participant can then submit adjudicatory documents. Submissions must be in Portable
Document Format (PDF). Additional guidance on PDF submissions is available on the
NRCs public website at https://www.nrc.gov/site-help/electronic-sub-ref-mat.html. A
filing is considered complete at the time the document is submitted through the NRCs
E-Filing system. To be timely, an electronic filing must be submitted to the E-Filing
system no later than 11:59 p.m. Eastern Time on the due date. Upon receipt of a
transmission, the E-Filing system time-stamps the document and sends the submitter
an email notice confirming receipt of the document. The E-Filing system also
distributes an email notice that provides access to the document to the NRCs Office of
the General Counsel and any others who have advised the Office of the Secretary that
they wish to participate in the proceeding, so that the filer need not serve the document
on those participants separately. Therefore, applicants and other participants (or their
counsel or representative) must apply for and receive a digital ID certificate before
adjudicatory documents are filed so that they can obtain access to the documents via
the E-Filing system.
A person filing electronically using the NRCs adjudicatory E-Filing system may
seek assistance by contacting the NRCs Electronic Filing Help Desk through the
Contact Us link located on the NRCs public website at https://www.nrc.gov/site-
help/e-submittals.html, by email to MSHD.Resource@nrc.gov, or by a toll-free call at 1-
866-672-7640. The NRC Electronic Filing Help Desk is available between 9 a.m. and 6
p.m., Eastern Time, Monday through Friday, excluding government holidays.
Participants who believe that they have good cause for not submitting
documents electronically must file an exemption request, in accordance with 10 CFR
2.302(g), with their initial paper filing stating why there is good cause for not filing
electronically and requesting authorization to continue to submit documents in paper
format. Such filings must be submitted by (1) first class mail addressed to the Office of
the Secretary of the Commission, U.S. Nuclear Regulatory Commission, Washington,
DC 20555- 0001, Attention: Rulemaking and Adjudications Staff; or (2) courier, express
mail, or expedited delivery service to the Office of the Secretary, 11555 Rockville Pike,
Rockville, Maryland 20852, Attention: Rulemaking and Adjudications Staff. Participants
filing adjudicatory documents in this manner are responsible for serving the document
on all other participants. Filing is considered complete by first-class mail as of the time
of deposit in the mail, or by courier, express mail, or expedited delivery service upon
depositing the document with the provider of the service. A presiding officer, having
granted an exemption request from using E-Filing, may require a participant or party to
use E-Filing if the presiding officer subsequently determines that the reason for granting
the exemption from use of E-Filing no longer exists.
Documents submitted in adjudicatory proceedings will appear in the NRCs
electronic hearing docket which is available to the public at https://adams.nrc.gov/ehd,
unless excluded pursuant to an order of the Commission or the presiding officer. If you
do not have an NRC-issued digital ID certificate as described above, click cancel
when the link requests certificates and you will be automatically directed to the NRCs
electronic hearing dockets where you will be able to access any publicly available
documents in a particular hearing docket. Participants are requested not to include
personal privacy information, such as social security numbers, home addresses, or
personal phone numbers in their filings, unless an NRC regulation or other law requires
submission of such information. For example, in some instances, individuals provide
home addresses in order to demonstrate proximity to a facility or site. With respect to
copyrighted works, except for limited excerpts that serve the purpose of the
adjudicatory filings and would constitute a Fair Use application, participants are
requested not to include copyrighted materials in their submission.
The Commission will issue a notice or order granting or denying a petition,
designating the issues for any hearing that will be held, and designating the Presiding
Officer. A notice granting a hearing will be published in the Federal Register and
served on the parties to the hearing.
If a person (other than NIST/NCNR) requests a hearing, that person shall set
forth with particularity the manner in which his interest is adversely affected by this CO
and shall address the criteria set forth in 10 CFR 2.309(d) and (f). If a hearing is
requested by a person whose interest is adversely affected, the Commission will issue
an order designating the time and place of any hearings. If a hearing is held, the issue
to be considered at such hearing shall be whether this CO should be sustained.
In the absence of any request for hearing, or written approval of an extension of
time in which to request a hearing, the provisions specified in Section V above shall be
final 30 days from the date of this CO without further order or proceedings. If an
extension of time for requesting a hearing has been approved, the provisions specified
in Section V shall be final when the extension expires if a hearing request has not been
received.
FOR THE NUCLEAR REGULATORY COMMISSION
Mark D. Lombard, Director Office of Enforcement
Dated this 1 st day of August 2022