[Federal Register Volume 80, Number 232 (Thursday, December 3, 2015)]
[Notices]
[Pages 75665-75673]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-30562]


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DEFENSE NUCLEAR FACILITIES SAFETY BOARD

[Recommendation 2015-1]


Emergency Preparedness and Response at the Pantex Plant

AGENCY: Defense Nuclear Facilities Safety Board.

ACTION: Notice, recommendation.

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SUMMARY: Pursuant to 42 U.S.C. 2286a(b)(5), the Defense Nuclear 
Facilities Safety Board has made a recommendation to the Secretary of 
Energy concerning the need to address specific deficiencies with, and 
strengthen regulatory compliance of, the emergency preparedness and 
response capability at the National Nuclear Security Administration's 
Pantex Plant that require timely resolution.

DATES: Comments, data, views, or arguments concerning the 
recommendation are due on or before January 4, 2016.

ADDRESSES: Send comments concerning this notice to: Defense Nuclear 
Facilities Safety Board, 625 Indiana Avenue NW., Suite 700, Washington, 
DC 20004-2001.

FOR FURTHER INFORMATION CONTACT: Mark Welch at the address above or 
telephone number (202) 694-7000. To review the figures referred to in 
Recommendation 2015-1, please visit www.dnfsb.gov.

    Dated: November 27, 2015.
Joyce L. Connery,
Chairman.

Recommendation 2015-1 to the Secretary of Energy

Emergency Preparedness and Response at the Pantex Plant, Pursuant to 42 
U.S.C. 2286a(b)(5) Atomic Energy Act of 1954, as Amended

Dated: November 23, 2015

    The Defense Nuclear Facilities Safety Board (Board) recommends that 
deficiencies identified with the implementation of existing 
requirements in Department of Energy (DOE) Order 151.1C, Comprehensive 
Emergency Management System, be corrected at the Pantex Plant to ensure 
adequate protection of workers and the public. During a series of 
interactions,\1\ we identified three areas of concern regarding the 
site's emergency preparedness and response capability. Pantex Plant 
personnel took action in response to some of the concerns identified, 
but significant concerns still exist. We conclude that each area of 
concern by itself has the potential to threaten the adequate protection 
of the public health and safety in the event of an operational 
emergency. Those areas of concern are (1) inadequate drill and exercise 
programs, (2) no demonstrated capability to provide timely, accurate 
information to the public regarding off-site radiological consequences, 
and (3) inadequate technical planning bases and decision-making tools. 
We believe that DOE and the National Nuclear Security

[[Page 75666]]

Administration (NNSA) must address these concerns in order to ensure 
the adequate protection of the public and the workers at the Pantex 
Plant.
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    \1\ Interactions included the Board's March 2013 public meeting 
and hearing in Amarillo, TX, two Board technical staff reviews in 
October 2012 and December 2014, and exercise observations in January 
and August 2014 and February 2015.
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    The Board communicated its concerns with emergency preparedness and 
response across the DOE complex in its Recommendation 2014-1, Emergency 
Preparedness and Response. The issues identified in this report are 
specific to the Pantex Plant and concern the NNSA Production Office 
(NPO) and contractor's \2\ inadequate implementation of existing DOE 
requirements.
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    \2\ Consolidated Nuclear Security, LLC, became the management 
and operating contractor in July 2014. The previous contractor was 
Babcock & Wilcox Technical Services Pantex.
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    Background: Emergency Preparedness and Response Capability. 
Personnel at the Pantex Plant conduct work vital to our national 
defense. Due to the nature of the operations and the spectrum of 
materials in use at the site, the range of possible accidents varies 
widely. Working with high explosives, hazardous chemicals, and 
radioactive materials results in the potential for operational 
emergencies ranging from industrial process-related accidents to 
significant material releases due to energetic events. The site is also 
subject to a range of natural phenomena hazards; tornados, high winds, 
lightning strikes, rain-induced flooding, and earthquakes are all 
possible in the region. Of particular concern to us are those accident 
scenarios that may cause radioactive material to be dispersed and 
deposited off site. Given the short distance from some facilities to 
the site perimeter and the average wind speeds at the site, these 
materials may affect public lands in the emergency planning zone within 
a short period of time.
    Board Finding: Drill and Exercise Programs. Based on our 
observations, we conclude that the Pantex Plant contractor has not 
demonstrated adequate capabilities through its drill and exercise 
programs. The Pantex Plant contractor's execution of emergency drills 
and exercises is insufficient to provide opportunities for all 
personnel to develop and demonstrate proficiency at emergency response. 
No site-wide exercises conducted since 2011 have simulated any 
significant radiological consequences. No site-wide exercise was 
conducted in 2013 (although a hurriedly executed, unchallenging small-
scale scenario in January 2014 purportedly fulfilled the 2013 site-wide 
exercise requirement). The Board also observed that both NPO and 
contractor capabilities to assess site performance in drills and 
exercises are inadequate, and believes this limits the effectiveness of 
the existing programs. A robust drill and exercise program would be 
varied enough to address all response elements across the spectrum of 
hazards and facilities over time.
    Board Finding: Timely, Accurate Information to the Public Regarding 
Off-Site Radiological Consequences. Our review found no demonstrated 
capability to provide timely, accurate information to the public 
regarding off-site radiological consequences. State radiological 
monitoring response teams are located in Austin, TX, and must travel 
nearly 500 miles before they are available to monitor affected 
areas.\3\ The Pantex Plant emergency response organization develops and 
provides models of radioactive material releases to state and county 
officials, but no verification of these models with real-world 
measurements is performed until state radiological monitoring response 
teams arrive.\4\ Pantex Plant contractor assets may be released at the 
plant's discretion in accordance with existing memoranda of 
understanding and agreement between the site and the counties/state. 
However, we found no instance in the last five years where the 
contractor exercised off-site monitoring. Finally, we note that while 
existing DOE requirements establish a thirty minute threshold for off-
site notification, the proximity of some Pantex Plant facilities to the 
plant boundary is such that material could contaminate off-site 
locations in a shorter time period.
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    \3\ The DOE Radiological Assistance Program (RAP) is a national 
emergency response asset that provides around-the-clock first-
response capability to assess radiological emergencies, and has a 
team stationed in Amarillo, TX. This team may not be consistently 
available due to competing priorities and may not have sufficient 
local resources to support a response outside the Pantex Plant. DOE 
has not incorporated the RAP into the Pantex Plant's existing 
exercise program, leaving to question the capability of the RAP 
resources to provide off-site support. Additionally, there is 
potential that the RAP team could be deployed elsewhere at the time 
of an incident, precluding the use of that resource.
    \4\ The dispatch of state radiological monitoring response 
assets may also be delayed due to the issues identified with the 
Pantex Plan decision-making tools.
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    Board Finding: Technical Planning Basis and Decision-Making Tools. 
The Board reviewed the technical planning bases and decision-making 
tools for the Pantex Plant's emergency management program and found 
that they are inadequate to demonstrate protection from time-sensitive 
events and do not consider all hazards at the site. Decision-making 
tools \5\ lack significant details and include built-in delays that 
hinder effective execution. While the existing decision-making tools, 
such as emergency action levels (EALs), may minimize the risk of false 
alarms, their design precludes providing timely, accurate, and 
conservative recommendations to the public.
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    \5\ Decision-making tools currently available exist to aide 
operators and first responders with a quick determination of the 
likely magnitude of accident consequences, communicate protective 
actions to workers, and ensure protective action recommendations are 
delivered to public decision-makers in a timely manner.
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    Conclusion. The mission of the Pantex Plant is vital to our 
nation's defense, and the consequences of a significant accident would 
be difficult to overcome. A robust, comprehensive, tested, and 
sustainable emergency preparedness and response capability is vital to 
ensure the adequate protection of the public health and safety during 
operational emergencies. Specifically, deficiencies must be addressed 
in the drill and exercise programs, in demonstrating the capability to 
provide timely, accurate information to the public regarding off-site 
radiological consequences, and in the technical planning bases and 
decision-making tools.
    Recommendations. To address the deficiencies summarized above, the 
Board recommends that DOE and NNSA take the following actions at the 
Pantex Plant:
    1. Ensure the Pantex Plant drill and exercise programs 
comprehensively demonstrate proficiency in responding to emergencies 
for all hazards, all facilities, and all responders, consistent with 
the technical planning bases and any updates to them, over a five-year 
period in accordance with DOE Order 151.1C (or subsequent revisions). 
As part of this demonstration of proficiency:
    a. Develop and institute a basis for conducting the drill program 
in support of emergency operations.
    b. Strengthen the exercise program to provide an adequate number of 
challenging scenarios per year, including at least one full-scale, 
site-wide exercise, in order to maintain qualifications and ensure 
proficiency of the emergency response organization and first 
responders.
    c. Conduct a comprehensive assessment of the drill and exercise 
programs bases, schedule, and execution against a risk-ranked set of:
    i. All hazards;
    ii. All facilities; and
    iii. All response elements.
    d. Evaluate and improve the effectiveness of the NPO and contractor 
processes used to critique drills and exercises.
    2. Develop and implement processes and demonstrate the capabilities 
to:

[[Page 75667]]

    a. Ensure the timeliness and accuracy of notifications to state and 
local authorities is commensurate with the initiation of off-site 
release of radioactive material at the Pantex Plant.
    b. Provide consistent radiological monitoring support if an 
accident releases radiological material off-site, until state resources 
arrive and can assume responsibility for off-site monitoring.
    3. Evaluate, incorporate, and validate (correctness, completeness, 
and effectiveness), the following changes to the Pantex Plant decision-
making tools and notification processes:
    a. Evaluate the emergency action level (EAL) process for those 
accident scenarios identifiable solely via instrumented systems to 
reduce delays in determining and implementing protective actions.
    b. For those accident scenarios that are not identifiable solely 
via instrumented systems, evaluate the range of emergency conditions 
and potential indicators, and identify where new monitoring systems can 
be added or existing administrative controls can be modified to improve 
timeliness of response.
    c. For all scenarios, evaluate if some protective actions should be 
initiated based solely on initial indicators (i.e., a precautionary 
evacuation) while confirmatory indicators are sought.
    d. Upon completion of these evaluations, incorporate new guidance 
and training for any changes made to the EAL decision-making tools and 
notification processes into the drill and exercise program.

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Joyce L. Connery,
Chairman.

Recommendation 2015-1 to the Secretary of Energy

Emergency Preparedness and Response at the Pantex Plant

Findings, Supporting Data, and Analysis

    Introduction. During the past three years, members of the Defense 
Nuclear Facilities Safety Board's (Board) staff conducted several 
activities to gain and maintain awareness of the state of emergency 
preparedness and response at the Pantex Plant. In October 2012, the 
staff team conducted a wide-scope program review supporting 
preparations for the Board's March 2013 public meeting and hearing in 
Amarillo, TX. After the public meeting and hearing, members of the 
Board's staff interacted with the National Nuclear Security 
Administration (NNSA) Production Office (NPO) and the contractor \1\ to 
address supplemental questions and clarify statements made during the 
hearing. In 2014, members of the Board's staff observed two site-wide 
emergency response exercises. In December 2014, the Board's staff team 
conducted another program review to examine specific aspects of the 
Pantex Plant emergency management program. The Board's staff team 
observed the execution of certain emergency management program elements 
during a site-wide emergency response exercise conducted in February 
2015. In addition, the Board's Site Representative at Pantex, who is 
stationed there on a full-time basis, made observations regarding the 
emergency preparedness and response capability of the Pantex Plant as 
part of his routine oversight of the Pantex Plant facilities and 
operations.
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    \1\ Consolidated Nuclear Security, LLC, became the management 
and operating contractor in July 2014. The previous contractor was 
Babcock & Wilcox Technical Services Pantex.
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    During each of these activities, the Board's staff team provided 
on-site feedback to NPO and the contractor, and culminated this 
exchange with a formal teleconference close-out brief on March 17, 
2015. Pantex Plant personnel took action in response to some of the 
concerns identified during the activities noted above, but significant 
concerns still exist. The following section expands on observations 
provided to the Pantex Plant during the March 2015 teleconference and 
provides the technical basis for further Board action.
    Observations. The Board's staff team's observations are organized 
into three main sections: the drill and exercise programs, notification 
and support to off-site agencies, and technical planning bases and 
decision-making tools.\2\
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    \2\ The focus of the Board's staff reviews was not comprehensive 
in all elements of the emergency management program. Additional 
problems may exist in other elements of the program, such as federal 
oversight and the quality of the site's agreements with off-site 
stakeholders.
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    Drill and Exercise Programs--Based on its observations, the Board's 
staff team concludes that the Pantex Plant contractor has not 
demonstrated adequate capabilities through its drill and exercise 
programs. The Board's staff team found that the Pantex Plant emergency 
drill and exercise programs do not provide sufficient opportunities for 
personnel to develop and demonstrate proficiency at emergency response 
with respect to all response elements across the spectrum of hazards 
and facilities. The drill program does not act as part of a 
comprehensive training and qualification program, but during the last 
few years has mainly supported preparation for the site's annual 
exercises.
    Department of Energy (DOE) Order 151.1C Comprehensive Emergency 
Management Program [1] outlines several requirements for drill and 
exercise programs. Specifically, Section 4.b (Exercises) states:
     A formal exercise program must be established to validate 
all elements of the emergency management program over a five-year 
period.
     Each exercise must have specific objectives and must be 
fully documented (e.g., by scenario packages that include objectives, 
scope, timelines, injects, controller instructions, and evaluation 
criteria).
     Exercises must be evaluated.
     A critique process, which includes gathering and 
documenting observations of the participants, must be established.
     Corrective action items identified as a result of the 
critique process must be incorporated into the emergency management 
program.
    Additionally, specified facility-level requirements include:
     Each DOE/NNSA facility subject to this chapter must 
exercise its emergency response capability annually and include at 
least facility-level evaluation and critique.
     DOE evaluations of annual facility exercises (e.g., by 
Cognizant Field Element, Program Secretarial Officer, or Headquarters 
Office of Security and Safety Performance Assurance) must be performed 
periodically so that each facility has an external DOE evaluation at 
least every three years.
     Site-level emergency response organization elements and 
resources must participate in a minimum of one exercise annually. This 
site exercise must be designed to test and demonstrate the site's 
integrated emergency response capability. For multiple facility sites, 
the basis for the exercise must be rotated among facilities.
    Scope of Exercise Scenarios: Based on observing implementation 
across DOE's sites, the Board's staff team summarized these 
requirements as the need to exercise all facilities, all hazards, and 
all response elements. The following sections describe the Board's 
staff team's observations of the Pantex Plant's implementation of drill 
and exercise requirements.
    For the five-year period (2011-2015) reviewed by the Board's staff 
team, the following scenarios represent the totality of Pantex Plant's 
site-wide exercises:

[[Page 75668]]

     2011: Explosion in a nuclear explosive facility with no 
contamination outside the facility.
     2012: Seismic event leading to building damage (no 
radiological or hazardous material release).
     2014a: Liquid nitrogen release from a truck accident 
(make-up for no exercise in 2013).
     2014b: Severe event (tornado) table-top.
     2015a: Severe event (seismic) with a transportation 
accident, wildfire, and mass casualty (no radiological or hazardous 
material release).
     2015b: Security event with hazardous material release.
    The Board's staff team reviewed documentation that showed some 
facilities at the Pantex Plant did not hold an evaluated activity to 
demonstrate response capability, regardless of whether the activity was 
a site-wide exercise, limited scope exercise, or other form of 
evaluation.\3\ The plant's analysis of the hazards for emergency 
preparedness and response is organized into a single emergency planning 
hazards analysis (EPHA), effectively identifying the plant as one 
facility when in reality there are numerous facilities with diverse 
hazards. This organizational structure contributes to the limited 
number of evaluated exercises at the Pantex Plant. Pantex is currently 
undertaking an effort to reevaluate the organization of the EPHA (i.e., 
dividing the single EPHA into multiple EPHAs). The Board's staff team 
received conceptual information about this effort and will continue to 
review any proposed changes to the organization of the Pantex EPHA, 
since such a change may provide a formal basis for additional facility 
exercises.
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    \3\ The Pantex Plant is a collection of buildings of various 
designs that house a variety of activities and operations that occur 
at the plant. There are bays and cells, which come in several 
variations and can be standalone or collocated, in which assembly 
and disassembly of nuclear explosive assemblies is conducted. There 
are buildings in which non-nuclear operations, such as explosive 
operations, are conducted. There is a variety of storage areas 
including storage of nuclear materials, nuclear explosive 
assemblies, explosives, and other hazardous materials. There are 
also various transportation activities within operational areas and 
across the site. For the purposes of exercises, various areas or 
types of operations could be grouped as representing different types 
of facilities. In the context of the layout of facilities at the 
Pantex Plant, the Board's staff team believes that it would be 
appropriate to conduct some type of exercise or other form of 
evaluation for each representative type of activity and operation.
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    The Pantex Plant has a range of hazards that may challenge 
emergency responders and decision-makers. Natural phenomena such as 
tornados, fires, lightning strikes, and rain-induced flooding exist 
alongside operational activities involving hazardous and radiological 
materials. The Board's staff team observed, directly and by document 
review, the range of exercise scenarios being conducted and found them 
to be too limited compared to the range of hazards at the plant. Often 
these scenarios were simplistic and not sufficiently challenging to 
truly demonstrate response capability for the hazard being exercised. 
DOE Guide 151.1-3, Programmatic Elements, Section 3.0 ``Exercises'' [2] 
provides a method of scheduling exercises to ensure coverage of all 
hazards at a site over a five-year period. However, it is the opinion 
of the Board's staff team that hazards with a higher frequency of 
occurrence, significance of consequences, or complexity of emergency 
response may need to be exercised more frequently than other hazards. 
Exercise scenarios from the past three years included a nitrogen spill, 
a primarily table-top tornado event, and a simulated earthquake with no 
radiological material impact.
    The potential for more significant consequences and complicated 
responses exists at the Pantex Plant's facilities. For example, a high 
explosive violent reaction has the potential to release radioactive 
material both on site, outside of the nuclear explosive facility (i.e., 
a bay), as well as off site. Fires in areas containing radioactive 
material have the potential to drive more significant radiological 
response actions by plant personnel. It is the opinion of the Board's 
staff team that the Pantex Plant should more frequently exercise 
challenging radiological responses.
    The Pantex Plant has not consistently exercised all response 
elements between 2011 and 2015, which is insufficient to meet DOE 
requirements. There does not appear to be a deliberate approach to 
demonstrating integrated emergency response capability. For example, 
the August 2014 exercise [3] relied on to meet the annually required 
site-wide demonstration of proficiency, postulated a tornado affecting 
the site. This was the plant's first significant effort at exercising a 
severe event, but was also credited as the annual site-wide exercise. 
The Board's staff team observed that few field participants 
demonstrated their response capabilities. While this was a valuable 
training and planning activity for a severe event, this exercise was 
the sole site-wide event for that time period. The Board's staff team 
believes that it is appropriate to exercise a more complete array of 
site response elements, not just fire and rescue responders, 
demonstrating their proficiency. The 2013 exercise (conducted in 
January 2014) and the February 2015 exercise also did not involve 
significant field participation other than fire and rescue services. 
Within the last five years, Pantex has not completed a full 
participation exercise (i.e., all on-site employees participating 
through protective actions and response); site-wide exercises have only 
included participation from a small subset of the plant population.
    Training and Qualification of Emergency Responders: The limited 
number and scope of exercises conducted each year also affects the 
training, qualification, and proficiency of emergency responders. The 
Pantex Plant's emergency response organization is made up of three 
shifts of responders on a rotating watch bill. It is unclear to the 
Board's staff team how the site can demonstrate proficiency and support 
training and qualification across all responders when an insufficient 
number of facility and site-wide exercises are being scheduled to 
support a three-shift emergency response organization. The Pantex Plant 
training, drill, and exercise program plan authorizes participation in 
a limited-scope evaluated activity (e.g., functional exercises or 
limited scope performance demonstrations) to maintain qualification 
within the emergency response organization [4]. Pantex Plant exercise 
after action reports document repeated emergency response organization 
shortcomings during site-wide exercises,\4\ and demonstrate that these 
limited-scope opportunities are not sufficiently rigorous to qualify 
and maintain proficiency of personnel at emergency operations.
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    \4\ The Board's staff team observed the past three site-wide 
exercises and also noted poor performance by the emergency response 
organization.
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    Exercise Assessment: The Board's staff team believes that the 
Pantex Plant's development and assessment of exercise objectives 
contributes to the continuing limited effectiveness of the emergency 
exercise program. The staff team assessed the exercise objectives and 
does not consider them to be effective tools for identifying problems 
that can be analyzed and corrected.
    First, the objectives reviewed by the staff team were not always 
adequate to evaluate the effectiveness of actions taken by responders. 
For example, objectives do not always differentiate between taking an 
action and taking the right action in a timely fashion. The February 
2015 exercise evaluation guide for the Plant Shift Superintendents 
(PSS) [5] included four criteria to evaluate the PSS's objective of

[[Page 75669]]

implementing protective actions (see Figure 1); the criteria do not 
address whether protective actions are implemented in time to be 
effective and whether the corrective protective actions are correct for 
the event.
    Another example of an objective from the February 2015 exercise 
that the staff team believes was not adequate involved processing 
information (see Figure 2). This objective evaluates the collection of 
information by the PSS, but does not evaluate communication of this 
information to responders. The PSS received information about trapped 
victims involved in an on-site transportation accident event involving 
a passenger vehicle and a material transporter, but did not verify that 
the Incident Commander took the correct response. In fact, the Incident 
Commander was not notified that the on-site transportation accident had 
occurred, and no action was taken for almost an hour, at which point 
the Fire Department responded. During the controller/evaluator after 
action critique, the objective was evaluated as ``Met'' based on the 
fact that the PSS received the information; although the controller/
evaluator did note in the After Action Report that ``No communication 
with the Incident Commander was observed'' [6]. This objective did not 
require the controller/evaluator to adequately consider the quality of 
the action taken upon receipt of the information.
    Second, if all objectives are weighted equally, the importance of 
certain actions over others cannot be distinguished. The Pantex Plant 
is undertaking an effort to change the grading scheme for emergency 
exercises to focus only on objective-by-objective performance and not 
incorporate any objective and criterion weighting or overall grade 
scheme. In the objective shown in Figure 1, selecting the correct 
protective action is a single criterion,\5\ which could be missed. Yet 
if all other criteria are completed, the objective may still be met. 
The overall objective--to implement time-urgent protective actions--
seems to be more valuable to an effective response than objectives that 
simply measure adherence to administrative procedures. It is the 
opinion of the Board's staff team that, without some indication of an 
objective's overall importance, the plant is likely to have difficulty 
interpreting the exercise results and will be challenged to prioritize 
and apply resources to those response elements that require additional 
attention and to address corrective actions.
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    \5\ Note that the criterion actually asks, ``What protective 
action(s) was implemented.'' This discussion addresses the intent of 
that criterion (i.e., the Board's staff team believes that the 
intent of the criterion was to determine ``Was the correct 
protective action implemented?'').
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    Last, the Pantex Plant could meet all of its exercise objectives 
but still fundamentally fail to protect the workers and public. The 
February 2015 exercise is an example. During the participant hot wash 
and controller/evaluator after-action critique, most objectives were 
determined to be ``Met.'' Yet, on-site first responders were 
potentially exposed to an off-site chemical hazard. This was not 
considered an objective and, therefore, did not influence the positive 
perception of the exercise results by the participants, controllers, 
and evaluators. Developing meaningful objectives requires a balance 
between criteria that are reasonably observable versus the need to 
confirm a subjective quality (e.g., effectiveness). The ability to 
measure the quality of action taken, sometimes by independent 
oversight, is a necessary part of objective evaluations.
    The Board's staff team believes that deficiencies in assessing 
performance in exercises also contribute to the continuing limited 
effectiveness of the emergency management program. Exercise 
participants conduct hot washes at the end of each exercise. The hot 
washes are intended to be a vehicle for participants to self-critique 
their response performance, including both positive and negative 
aspects, and to identify potential areas for improvement. The hot 
washes that the Board's staff team observed at the Pantex Plant tended 
to focus on faults with the exercise scenario rather than issues with 
emergency response performance. The participants raised issues such as 
the perception that a scenario was unrealistic or that controllers did 
not have adequate simulations for what the participants would observe 
in real-life. Many participant observations focused on deficiencies in 
administrative equipment and tools, such as printer or fax machine 
problems. While the readiness of these resources is important to an 
adequate response, the purpose of the exercise program is to 
demonstrate proficiency. Many participant observations also focused on 
the positive results of their actions, but failed to identify whether 
the actions taken would have been effective during the given emergency 
scenario. As a best practice, mature organizations tend to have an 
experienced functional team leader (e.g., the Emergency Operations 
Center (EOC) Emergency Director) lead the hot wash, rather than rely on 
the exercise controller/evaluator for this role. Most response elements 
at the Pantex Plant do not incorporate this practice.
    For each exercise, controllers and evaluators conducted after 
action critiques to collect data and observations about the performance 
of exercise response participants, as well as concerns with exercise 
control. While these were preliminary data gathering activities, the 
Board's staff team noted the same lack of critical assessment among the 
exercise evaluators. Evaluators did not explicitly compare the actions 
taken by participants to the expected or most desirable responses as 
they related to the fundamental purpose of emergency response. For 
example, while data on when a particular communication was faxed may 
have been collected, the quality and usefulness of the communication to 
inform its addressee were not evaluated. Discussions focused on 
specific functional area performance, as assessed against binary 
objectives such as a checklist, but did not address the effectiveness 
of interfaces between functional areas.
    For example, during the February 2015 exercise, the EOC received 
information concerning an off-site release of a hazardous chemical from 
a train accident. The consequence assessment team performed modeling to 
inform decision-makers of the effect on plant personnel, including 
first responders. Fire Department personnel who responded to the on-
site transportation accident were within the projected plume while 
performing rescue operations. Neither the PSS nor the EOC informed the 
Fire Department personnel of the potential exposure (e.g., type of 
material, quantity, timing, or recommended personal protective 
equipment). This information was eventually provided to the incident 
command late in the scenario. Exercise objectives were evaluated as 
``Met'' for these individual functional areas during the evaluator 
after action critique. The effectiveness of organizational interfaces 
can be masked by such stove-piped evaluations.
    Emergency Management Drill and Exercise Program Oversight: The 
Board's staff team considers it a significant deficiency that NPO and 
contractor oversight did not identify the issues discussed in this 
section. Other than the emergency management program manager, the 
Board's staff team observed limited evidence of interaction with NPO 
functional area subject matter experts in the evaluation of exercise 
reports. NPO review of exercise assessments appears weak in that

[[Page 75670]]

exercises with observed deficiencies do not result in reports with 
commensurate findings. Where issues are identified, the contractor's 
causal analyses are often weak or superficial, leading to development 
of ineffective corrective actions and recurrence of the same issues in 
subsequent exercises. The concern with ineffective corrective actions 
is also evident when DOE's independent oversight organizations observe 
exercises and provide reports to the plant. DOE's Office of Emergency 
Management Oversight (formerly HS-63 and also OA-30) provided reports 
highlighting concerns with the Pantex Plant's emergency management 
program; these reports also identify recurring issues that the 
contractor has not effectively addressed [7, 8, 9, 10].
    Timely, Accurate Information to the Public Regarding Off-site 
Radiological Consequences--The Board's staff team found no demonstrated 
capability to provide timely, accurate information to the public 
regarding off-site radiological consequences. Accident scenarios 
postulated at the Pantex Plant may result in the release of radioactive 
material or other hazardous materials from facilities. The released 
material may then be carried across the site boundary and contaminate 
public roads and land. The proximity of some facilities at the plant to 
the site boundary is such that in certain scenarios, material could 
contaminate off-site locations within a short period of time.
    Notification to off-site organizations provides two important 
functions: first, it warns members of the public to take protective 
action in response to an accident; second, it initiates off-site 
response assets that can control access and conduct radiological 
monitoring. The notification processes used at the Pantex Plant may not 
provide enough time for protective action recommendations to be issued 
and executed before radioactive material is dispersed off-site. Any 
delay in notification adds to the time necessary for state response 
assets to deploy. Notification may be delayed due to the emergency 
action level (EAL) decision-making processes. Additionally, state 
radiological monitoring assets may be delayed in reaching the vicinity 
of Amarillo due to geographic constraints.\6\ The response teams, 
located in Austin, TX, must travel nearly 500 miles before they are 
available to monitor the affected area. Notification delays would also 
impede instituting access control to public use areas around the site. 
While the Pantex Plant emergency response organization develops and 
provides models of radioactive material releases to state and county 
officials, actual monitoring to verify material deposition off site may 
not be proactively performed by the site's radiological response 
assets; these assets may be released at the plant's discretion in 
accordance with existing memoranda of understanding between the site 
and the counties/state. Pantex Plant radiological support personnel do 
not exercise this monitoring function during drills and exercises, and 
do not have processes in place to describe how off-site field 
monitoring would be executed.
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    \6\ The DOE Radiological Assistance Program (RAP) is a national 
emergency response asset that provides around-the-clock first-
response capability to assess radiological emergencies, and has a 
team stationed in Amarillo, TX. This team may not be consistently 
available due to competing priorities and may not have sufficient 
local resources to support a response outside the Pantex Plant. DOE 
has not incorporated the RAP into the Pantex Plant's existing 
exercise program, leaving to question the capability of the RAP 
resources to provide off-site support. Additionally, there is 
potential that the RAP team could be deployed elsewhere at the time 
of an incident, precluding the use of that resource.
---------------------------------------------------------------------------

    There are limited requirements in DOE Order 151.1C that specify how 
the site will plan for these events and handle off-site radiological 
monitoring. The Board's staff team notes that the Pantex Plant has made 
agreements, via memoranda of understanding, with state and local 
authorities to create communication channels for much of this 
information. However, these existing mechanisms do not provide the 
proactive support from the plant to the local community that is 
necessary to ensure any release of contamination is accurately tracked 
in a timely manner to ensure the protection of the public. Given that 
the Pantex Plant is close to public roads and land, and has the 
potential to release radiological material off site within minutes of 
an initiating event, stronger requirements in the Order are needed to 
ensure the plant performs effective off-site monitoring until the 
necessary State of Texas resources arrive.
    Technical Planning Bases and Decision-making Tools--The Board's 
staff team found that the technical planning bases and decision-making 
tools for the Pantex Plant's emergency management program are 
inadequate to demonstrate protection from time-sensitive events and do 
not consider all hazards at the site. For the set of hazards analyzed, 
the technical planning tools developed to respond to emergencies are 
inadequate to ensure timely notification of the need for protective 
actions to the workers and recommended protective actions to the 
public.
    To meet DOE Order 151.1C emergency planning element requirements, a 
site must conduct an all-hazard analysis. From this survey, certain 
accident sequences are selected for additional consideration in the 
EPHA. The EPHA provides the basis for developing the site's EALs. EALs, 
which are also required by DOE Order 151.1C, are used during an 
emergency event to determine the categorization and level of 
classification of the emergency event. When using an EAL, emergency 
response decision-makers attempt to answer two questions. First, is the 
event an operational emergency? Second, if so, what is the potential 
area of impact and the degree of emergency response? The safety basis 
development process uses a similar hazard analysis process. When 
developing a safety basis, some infrequent accidents may be screened 
out of further analysis if they have a low probability of occurrence. 
However, for the purposes of EPHAs, low-probability, high-consequence 
events should be further analyzed to determine the magnitude of 
potential consequences and the expected level of response. Guidance is 
provided in DOE's Emergency Management Guide 151.1-1a, Emergency 
Management Fundamentals and the Operational Emergency Base Program. 
``The DOE approach requires some planning even for events whose 
severity exceeds the design basis for safety controls; the facility/
site or activity must be prepared to take actions to limit or prevent 
adverse health and safety impacts to workers and the public'' [11]. 
While these analyses of low-probability events may be less 
quantitative, they still need to be performed to ensure DOE and its 
contractors are cognizant of potential consequences and conduct an 
appropriate level of planning.
    For events that Pantex Plant emergency management personnel have 
analyzed, the site uses EALs as a tool to determine if an operational 
emergency is occurring and the classification of the event, to notify 
site workers of the need for protective actions, and to notify the 
public of recommended protective actions. As currently developed, these 
EALs include a confirmatory step that may delay decision-makers 
providing these notifications and recommendations for protective 
actions for several minutes, possibly up to 30 minutes. The ability to 
provide notifications and recommendations for protective actions to 
workers and the public in a timely manner significantly increases the 
safety of these groups during operational emergencies. DOE

[[Page 75671]]

Order 151.1C specifies a 15-minute window to notify DOE Headquarters 
and the public of events in progress [1].
    Pantex Plant emergency management personnel chose to use a decision 
tree model in their EALs, visually guiding an operator through 
decisions being made in response to an event on site. The example in 
Figure 3 below, taken from the Pantex EALs [12], shows the flow-path 
through decision making to action.
    An operator--in the case of the Pantex Plant, the PSS--enters the 
EAL with relevant information concerning an emergency event. This leads 
the PSS to a conservative emergency categorization and classification. 
These classifications (Alert, Site Area Emergency, and General 
Emergency) ensure appropriate responses are taken given the anticipated 
magnitude of the accident consequences. In most radiological EALs at 
the Pantex Plant, the PSS receives initial information of emergency 
conditions from an instrumented signal. For example, coincident fire 
and radiation monitor alarms would indicate the presence of a possible 
fire with radioactive material release.
    The Pantex Plant EALs also include confirmatory indicators as an 
explicit step in the decision-making process before classification can 
be performed. These are typically in the form of personnel providing 
eyewitness confirmatory statements about the nature of an event. From 
the EAL front matter [12], page 8:

The PSS or Emergency Manager must rely on information resulting from 
communication with whoever is in command at the emergency scene, 
emergency responders, and plant personnel to supply confirmatory 
information necessary to make emergency classification decisions.

From page 11:

Using the appropriate EAL, the PSS or Emergency Manager follows the 
decision tree and attempts to identify initial and confirmatory 
indicators of an actual emergency event while simultaneously 
continuing to gather information on the situation from Incident 
Command, emergency responders, and plant personnel. [If these 
resources are not already there, they are dispatched.] During this 
time, initial protective actions may be implemented [emphasis added] 
to protect plant personnel.

If EAL confirmatory indicators are present and detected, the PSS or 
Emergency Manager follows the decision-tree to the classification 
area. This section may require retrieval of information on the 
quantity and type of material involved in the incident from the Move 
Right System or use of inserted tables. Once determined, the PSS or 
Emergency Manager classifies the emergency based on the EAL 
information.

    These classification decisions allow the PSS to determine what, if 
any, protective actions are necessary for personnel on site and 
recommended protective actions for the public off site. Waiting for 
confirmation from first responders, if not provided by some other 
source, may cause a delay in the PSS issuing notifications and 
recommendations for protective actions to the workforce and the public. 
For example, in the following EAL, if no confirmatory information is 
provided, someone must be dispatched to confirm if an explosion truly 
occurred [12].
    Similarly, note the reliance on personnel observations and 
inferences to assist the decision maker through appropriate 
classification of a fire in a nuclear explosive or special nuclear 
material facility [12].
    In the following example, radiological support personnel must be 
dispatched, if not immediately available at the scene, to confirm the 
validity of a tritium release alarm before the appropriate emergency 
classification and protective actions are determined [12].
    In the following example, it is not clear what a ``Convincing 
Report'' or combination of fire indicators is without further training 
or guidance on expectations for those who may report such events [12].
    The specific examples provided, which are not intended to be all 
encompassing, demonstrate that the Pantex Plant emergency management 
strategy is reliant on confirmatory indicators and does not always 
provide sufficient guidance on how to accomplish the required 
confirmation. Immediate (or precautionary) protective actions, which 
protect the site workers in the short-term, would be delayed while 
additional assessment is performed. Such additional assessment would 
also delay notifying the off-site public of protective action 
recommendations. The Board's staff team believes changes to these 
procedures, or incorporation of additional instrumentation of adequate 
reliability, would provide the level of protection necessary to ensure 
a time-sensitive response to radiological accidents while minimizing 
false alarms.
    Conclusions. The Board's staff team considers the concerns 
described above to be significant and concludes that the Pantex Plant's 
emergency management program will require Board action to influence DOE 
to address these deficiencies. The plant has made changes to specific 
programmatic elements; however, significant improvements have not yet 
been realized. Focused effort at addressing the concerns will 
substantially ensure protection of the workers and public at the Pantex 
Plant. Some specific actions to address these concerns include:
     Ensure the Pantex Plant drill and exercise programs 
comprehensively demonstrate proficiency in responding to emergencies 
for all hazards, all facilities, and all responders, consistent with 
the technical planning bases and any updates to them, over a five-year 
period in accordance with DOE Order 151.1C (or subsequent revisions). 
As part of this demonstration of proficiency:
    [cir] Develop and institute a basis for conducting the drill 
program in support of emergency operations.
    [cir] Strengthen the exercise program to provide an adequate number 
of challenging scenarios per year, including at least one full-scale 
site-wide exercise, in order to maintain qualifications and ensure 
proficiency of the emergency response organization and first 
responders.
    [cir] Conduct a comprehensive assessment of the drill and exercise 
programs bases, schedule, and execution against a risk-ranked set of:
    [ssquf] All hazards;
    [ssquf] All facilities; and
    [ssquf] All response elements.
    [cir] Evaluate and improve the effectiveness of the NPO and 
contractor processes used to critique drills and exercises.
     Develop and implement processes and demonstrate the 
capabilities to:
    [cir] Ensure the timeliness and accuracy of notifications to state 
and local authorities is commensurate with the initiation of off-site 
release of radioactive material at the Pantex Plant.
    [cir] Provide consistent radiological monitoring support if an 
accident releases radiological material off-site, until state resources 
arrive and can assume responsibility for off-site monitoring.
     Evaluate, incorporate, and validate (correctness, 
completeness, and effectiveness), the following changes to the Pantex 
Plant decision-making tools and notification processes:
    [cir] Evaluate the emergency action level (EAL) process for those 
accident scenarios identifiable solely via instrumented systems to 
reduce delays in determining and implementing protective actions.
    [cir] For those accident scenarios that are not identifiable solely 
via instrumented systems, evaluate the range of emergency conditions 
and potential indicators, and identify where new monitoring systems can 
be added or existing administrative controls can

[[Page 75672]]

be modified to improve timeliness of response.
    [cir] For all scenarios, evaluate if some protective actions should 
be initiated based solely on initial indicators (i.e., a precautionary 
evacuation) while confirmatory indicators are sought.
    [cir] Upon completion of these evaluations, incorporate new 
guidance and training for any changes made to the EAL decision-making 
tools and notification processes into the drill and exercise program.
    The Board's staff team believes these problems will not be 
adequately addressed by Board's Recommendation 2014-1, Emergency 
Preparedness and Response [13]. Recommendation 2014-1 identifies 
specific concerns with DOE as a regulator, including a failure to 
maintain an adequate requirement set, which led to inconsistent 
implementation across DOE, as well as a lack of rigor in federal and 
contractor oversight that let problems persist. While some of DOE's 
actions to address Recommendation 2014-1 may provide a framework for 
the Pantex Plant to improve its emergency preparedness and response, 
the staff team believes the concerns noted above exist due to 
inadequate implementation of the current requirements. As a result, the 
staff team believes that timely resolution of these concerns requires 
separate Board action.

Risk Assessment for Recommendation 2015-1

Emergency Preparedness and Response at the Pantex Plant

    The recommendation addresses vulnerabilities in the Pantex Plant's 
implementation of Department of Energy (DOE) requirements for emergency 
preparedness and response. In accordance with the Defense Nuclear 
Facilities Safety Board's (Board) enabling statue and Policy Statement 
5 (PS-5), Policy Statement on Assessing Risk [14], this risk assessment 
was conducted to support the Board's Recommendation 2015-1, Emergency 
Preparedness and Response at the Pantex Plant. As stated in PS-5,

    The Board's assessment of risk may involve quantitative 
information showing that the order of magnitude of the risk is 
inconsistent with adequate protection of the health and safety of 
the workers and the public . . . the Board will explicitly document 
its assessment of risk when drafting recommendations to the 
Secretary of Energy in those cases where sufficient data exists to 
perform a quantitative risk assessment.

    DOE's hazards assessments address initiating events, preventive and 
mitigative controls, and consequences. Initiating events in these 
assessments include operational and natural phenomena events. 
Preventive and mitigative controls are design basis controls identified 
in safety analysis documents. Consequences cover a wide spectrum, 
ranging from insignificant to catastrophic effects.
    The emergency management program exists at the Pantex Plant because 
the risk associated with its facilities is acknowledged by DOE and is 
required by law. Emergency response provides the ``last line of defense 
in the event of . . . [an] accident'' [15]. Therefore, the emergency 
management program needs to function effectively to protect the workers 
and the public.
    This recommendation is focused on improving the effectiveness of 
the Pantex Plant's emergency management program. A quantitative risk 
assessment on the effectiveness of this program requires data on 
probability and consequences. Detailed data on the probability of 
failure in emergency management program elements are not available for 
the Pantex Plant, nor do effective comparisons exist. Therefore, it is 
not possible to do a quantitative assessment of the risk of these 
elements to provide adequate protection of the workers and the 
public.\1\
---------------------------------------------------------------------------

    \1\ Members of the Board's staff conducted research on other 
sources of risk information related to emergency management programs 
and noted the U.S. Nuclear Regulatory Commission (NRC) evaluates 
commercial nuclear production and utilization facilities against a 
set of sixteen ``standards,'' similar to DOE's concept of fifteen 
program elements found in DOE Order 151.1C, Comprehensive Emergency 
Management System. Of the sixteen NRC standards, four are considered 
``risk significant'' and are weighted differently in the application 
of the NRC's reactor oversight process, a regulatory scheme applied 
to certain licensees to characterize the severity of findings [16, 
17]. Under this scheme, findings identified within these standards 
are considered more significant. Three of the four standards, 
``Classification,'' ``Notification,'' and ``Protective Action 
Recommendations,'' parallel the nature of the concerns with elements 
of the Pantex Plant's emergency management program stated by the 
Board in this recommendation.
---------------------------------------------------------------------------

    The Board believes that more robust implementation of existing 
requirements would reduce the risk associated with the spectrum of 
accidents postulated at the plant, regardless of the cause, including 
process upsets, the effects of natural phenomena, and man-made 
initiating events, as well as provide additional margin to respond to 
those events considered beyond the design basis.

Cited References

[1] Department of Energy, Comprehensive Emergency Management System, 
DOE Order 151.1C, November 2, 2005.
[2] Department of Energy, Programmatic Elements: Emergency 
Management Guide, DOE Guide 151.1-3, July 11, 2007.
[3] Pantex Plant Safeguards, Security, and Emergency Services, Full 
Participation Exercise 2014-1 (FPE 14-1) Exercise Plan (Twister-14), 
August 6, 2014.
[4] Pantex Plant Safeguards, Security, and Emergency Services, 
Emergency Management Training, Drill, and Exercise Program Plan, 
Issue 011, EM-PLN-0023, (undated).
[5] Pantex Plant Safeguards, Security, and Emergency Services, Full 
Scale Exercise 2015-1 (FSE 15-1) Exercise Evaluation Guides (Shaker-
15), February 4, 2015.
[6] Pantex Plant, February 4, 2015 Shaker-15 Exercise After Action 
Report, (undated).
[7] Department of Energy, Office of Independent Oversight and 
Performance Assurance, Volume II, Inspection of Emergency Management 
at the Pantex Plant, November 2002.
[8] Department of Energy, Office of Security and Safety Performance 
Assurance: Office of Independent Oversight and Performance 
Assurance, Inspection of Emergency Management at the Pantex Site 
Office and the Pantex Plant, August 2005.
[9] Department of Energy, Office of Health, Safety and Security: 
Office of Independent Oversight: Office of Emergency Management 
Oversight, Independent Oversight Inspection of Emergency Management 
at the Pantex Site Office and the Pantex Plant, June 2008.
[10] Department of Energy, Office of Health, Safety and Security: 
Office of Independent Oversight, Independent Oversight Review of 
Emergency Management at the Pantex Site Office and Pantex Plant, 
November 2010.
[11] Department of Energy, Emergency Management Fundamentals and the 
Operational Emergency Base Program: Emergency Management Guide, DOE 
Guide 151.1-1a, July 11, 2007.
[12] Babcock & Wilcox Technical Services Pantex, Emergency Action 
Levels, MNL-190884, Issue No. 007, (undated).
[13] Defense Nuclear Facilities Safety Board, Emergency Preparedness 
and Response, Recommendation 2014-1, September 3, 2014.
[14] Defense Nuclear Facilities Safety Board, PS-5 Policy Statement 
on Assessing Risk, August 15, 2013.
[15] Department of Energy, Office of Emergency Management Mission, 
accessed at: http://nnsa.energy.gov/ourmission/emergencyresponse, 
accessed April 24, 2015.
[16] U.S. Nuclear Regulatory Commission, Emergency Plans, Title 10, 
Code of Federal Regulations, Subsection 50.47.
[17] U.S. Nuclear Regulatory Commission, Emergency Planning and 
Preparedness for Production and Utilization Facilities, Title 10, 
Code of Federal Regulations, Part 50, Appendix E.

General References

Babcock & Wilcox Technical Services Pantex, NNSA Emergency Readiness 
Assurance

[[Page 75673]]

Plans--FY 2012 Submission: Completed Activities For FY 2012 and 
Projected Activities For FY 2013, Pantex ERAP, (undated).
Defense Nuclear Facilities Safety Board, Public Meeting and Hearing 
for Safety Culture, Emergency Preparedness, and Nuclear Explosive 
Operations at Pantex, Amarillo, TX, March 14, 2013.
Defense Nuclear Facilities Safety Board, Status of Emergency 
Management at Defense Nuclear Facilities of the Department of 
Energy, Technical Report-21, March 1999.
Erhart, S.C., Pantex Emergency Management Exercise (EMEX 13-1) 
January 2014, memorandum to J. Maisonet, December 19, 2013.
Erhart, S. C., Public Hearing and Meeting Regarding Safety Culture, 
Emergency Preparedness, and Nuclear Explosive Operations at Pantex, 
communication to Peter S. Winokur, June 12, 2013.
Pantex Plant Safeguards, Security, and Emergency Services, 
Operational Emergency Manual, Issue No. 003, MNL-352187, (undated).
Pantex Plant Safeguards, Security, and Emergency Services, Pantex 
Plant Comprehensive Emergency Management Plan, Issue No. 007, EM-
PLN-0019, (undated).
Pantex Plant Safeguards, Security, and Emergency Services, Pantex 
Plant Emergency Planning Hazards Assessment, Issue No. 009, MNL-
190881, (undated).

[FR Doc. 2015-30562 Filed 12-2-15; 8:45 am]
BILLING CODE 3670-01-P