ML22206A213

Letter to National Institute of Standards and Technology, Center for Neutron Research - Confirmatory Order (EA-21-148)

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

cc:

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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

Dr. Thomas H. Newton, Deputy Director National Institute of Standards and Technology NIST Center for Neutron Research U.S. Department of Commerce 100 Bureau Drive, Mail Stop 6101 Gaithersburg, MD 20899-6101

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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

i. NCNR leadership has engaged the NIST Director and Department of

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.

v. NCNR hired a new Chief of the Aging Reactor Management (ARM)

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

i. NCNR modified Administrative Requirement (AR) 5.0, Procedure Use

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.

b. Within 2 months of the NIST Directors statement, the NCNR Director will hold an

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