NE-ID--BEA-ATR-2016-0014 FINAL
Occurrence Report
After 2003 Redesign

Advanced Test Reactor


(Name of Facility)

Category "A" Reactors


(Facility Function)

Idaho National Laboratory Battelle Energy Alliance, LLC


(Laboratory, Site, or Organization)

Name: Hill, Shawn Ashley
Title: ADVANCED TEST REACTOR OP. FACILITY M Telephone No.: (208) 533-4128


(Facility Manager/Designee)

Name: OWENS, MARJORIE A
Title: ATR OPERATIONS FACILITY ADMINISTRATI Telephone No.: (208) 533-4563


(Originator/Transmitter)

Name: Jeffrey L. Garner Date: 09/21/2016


(Authorized Classifier (AC))

  1. Occurrence Report Number: NE-ID--BEA-ATR-2016-0014

      Contaminated Soil Outside Warm Waste Evaporation Pond at the ATR Complex

  2. Report Type and Date: FINAL

Date Time
Notification: 05/17/2016 16:29  (ETZ)
Initial Update: 06/20/2016 16:47  (ETZ)
Latest Update: 09/21/2016 13:42  (ETZ)
Final: 09/21/2016 13:42  (ETZ)

3. Significance Category: 3


  4. Division or Project: ATR Programs

  5. Secretarial Office: NE - Nuclear Energy, Science and Technology

  6. System, Bldg., or Equipment: ATR Evaporation Pond

  7. UCNI?: No

  8. Plant Area: Evap Pond

9. Date and Time Discovered:     05/12/2016    16:10  (MTZ)

10. Date and Time Categorized:     05/12/2016    17:20  (MTZ)

11. DOE HQ OC Notification:

Date Time Person Notified Organization
NA NA NA NA

12. Other Notifications:

Date Time Person Notified Organization
05/12/2016 17:29  (MTZ) J. Duplessis DOE-ID

13. Subject or Title of Occurrence:

      Contaminated Soil Outside Warm Waste Evaporation Pond at the ATR Complex


14. Reporting Criteria:

6B(3) - Identification of onsite radioactive contamination greater than 10 times and no greater than 100 times the total contamination values in 10 CFR Part 835, Appendix D, exclusive of footnote 3 to Appendix D, and that is found outside of the following locations: areas routinely posted, controlled and monitored for contamination, areas controlled in accordance with 10 CFR Section 835.1102(c), and, per Section 835.604(a), any non-posted area that is under the continual observation and control of an individual knowledgeable of and empowered to implement required access and exposure control measures. For tritium, the reporting threshold is 10 times the removable contamination values in 10 CFR Part 835, Appendix D.
[Notes:
a) This does not apply to contamination from residual radioactive material meeting applicable DOE-approved authorized limits.
b) This does not apply to legacy radioactive contamination, which is to be reported under a separate criterion below.
c) The exclusion from reporting contamination in a Radiological Buffer Area applies only when the area has been established for a Contamination Area, High Contamination Area or Airborne Radioactivity Area and its exit requirements have adopted guidance from Article 338.2 of DOE-STD-1098-2008.
d) This reporting criterion does not apply to packages monitored in accordance with 10 CFR Section 835.405 that meet DOT contamination limits specified in 49 CFR Section 173.443(a).]


15. Description of Occurrence:

At 1610 on 12 May 2016, the ATR Control Room Supervisor received a report from the Radiological Control Manager that contaminated soil was discovered outside of the contamination area north of the ATR evaporation ponds. Pre-work surveys were being performed in preparation for the ATR Complex Warm Waste Evaporation Pond liner replacement project.

A Radiological Buffer Area (RBA) had been established the morning of 12 May 2016 to support surveys of the area surrounding the evaporation pond contamination area. A normally unoccupied area was surveyed and contamination was found in the soil. Further surveys off of the pond berm elevation, and downwind of the pond, found contamination levels to be as high as 250,000 disintegrations per minute (dpm)/100 centimeters (cm)2. Following the discovery, the area was posted as a "Soil Contamination Area." Surveys of the road around the evaporation pond were conducted and no contamination was found.


16. Is Subcontractor Involved? No


17. Operating Conditions of Facility at Time of Occurrence:

The ATR was shut down in support of the Cycle 159A-1 outage.


18. Activity Category:

      02 - Maintenance


19. Immediate Actions Taken and Results:

Appropriate levels of BEA management and DOE-ID were notified of this event.

The area surrounding the evaporation pond was posted as a "Soil Contamination Area." RadCon will survey and identify all areas of contamination, which will be covered with dirt and the posting downgraded to "Underground radioactive material area and an RBA."

Contamination levels will be monitored and downwind air sampling with continue.


20. ISM:

      2) Analyze the Hazards


21. Cause Code(s):

A4B5C04 - Risks / consequences associated with change not adequately reviewed / assessed


22. Description of Cause:

An Apparent Cause Analysis was performed in accordance with LWP-13480, Issues Management, and the following cause was determined:

A4B5C04 - Risks/consequences associated with change not adequately reviewed/assessed. At the ATR evaporation ponds, contamination controls were not implemented in a way that ensured contamination did not transfer outside the boundary by either weather or wildlife. Regular processes that discourage wildlife were discontinued, and as such, animals are attracted to the area and spread contamination.

Different waste has been introduced into the pond; contaminant type and concentration are different than what was intended for the ponds' original use. As a result of this change, the weather spreads both different contaminants and at higher radiation levels. (See corrective actions #1 thru #9)

Analysis of this event determined that implementation of the Integrated Safety Management System (ISMS) failed during the use of the following core function:

Core Function 2 - Analyze the Hazards. Not all hazards associated with contamination being spread from the evaporation pond outside the established Radiation Area (RA)/Contamination Area (CA) were identified and analyzed. As non-routine operations introduced additional hazards, the new hazards were not identified and analyzed.

An Extent of Conditions determined there are no other ponds at the ATR Complex that are vulnerable to the same contamination spread.


23. Evaluation (by Facility Manager/Designee):

There were no programmatic impacts as a result of this event.

08/24/2016: The Apparent Cause Analysis due date for this event has been extended to 8 September 2016 due to additional reviews and comments resolution; therefore, the final ORPS report will be submitted no later than 22 September 2016. DOE-ID has been informed.

08/08/2016: The Apparent Cause Analysis due date for this event has been extended to 25 August 2016 to accommodate review and comment resolution; therefore, the final ORPS report will be submitted no later than 8 September 2016. DOE-ID has been informed.

07/18/2016: The Apparent Cause Analysis for this event has been extended to 28 July 2016; therefore, the final ORPS report will be submitted no later than 25 August 2016. DOE-ID has been informed.

06/20/2016: An Apparent Cause Analysis is in progress for this event and is expected to complete on 14 July 2016; therefore, the 45-day requirement for final ORPS will be missed. As such, the final ORPS report will be submitted no later than 28 July 2016. DOE-ID has been notified.


24. Is Further Evaluation Required?: No


25. Corrective Actions
Local Tracking System Name: LabWay

        1.
Establish preventive maintenance for vegetation sterilization of the berm surrounding the ATR evaporation ponds.
Target Completion Date: 03/30/2017 Tracking ID: CO 2016-1364, CA 2016-1314
        2.
Establish preventive maintenance for addition of aquatic plant life removal chemicals.
Target Completion Date: 03/30/2017 Tracking ID: CO 2016-1364, CA 2016-1315
        3.
Review the current RadCon routine sheets, and change or add details to ensure RCTs perform surveys per MCP-139 and per management's expectations. Include instruction to verify radiological boundaries.
Target Completion Date: 06/24/2016 Tracking ID: CO 2016-1520, CA 2016-0810
        4.
Send the attached timely reminder of survey guidelines from MCP-139, Rev. 21, to ATR RCTs in order to ensure management expectations are communicated.
Target Completion Date: 06/08/2016 Tracking ID: CO 2016-1520, CA 2016-0811
        5.
Prepare contaminated sediment/resin/sludge in the East evaporation pond for winter to prevent further spread of contamination.
Target Completion Date: 10/20/2016 Tracking ID: CO 2016-1364, CA 2016-1316
        6.
Remove vegetation in the Soil Contamination Area around the evaporation pond fence and cover with 30 cm of clean fill.
Target Completion Date: 06/29/2017 Tracking ID: CO 2016-1364, CA 2016-1317
        7.
Work in conjunction with ATR RadCon and Environmental to install snow and silt fences to mitigate contamination migration.
Target Completion Date: 10/20/2016 Tracking ID: CO 2016-1364, CA 2016-1318
        8.
Remove contaminated resin from East evaporation pond.
Target Completion Date: 06/29/2016 Tracking ID: CO 2016-1364, CA 2016-1319
        9.
Perform a cost-benefit analysis of a system to trap/filter resin and contaminants downstream of TRA-605 prior to the ATR evaporation pond.
Target Completion Date: 06/29/2017 Tracking ID: CO 2016-1364, CA 2016-1320`


26. Lessons Learned:

It is essential to identify and mitigate all hazards associated with work evolutions. This event highlights the need to explore the job-site, not only for the hands-on work area, but for the adjacent areas and surroundings to identify any other potential industrial safety and/or environmental hazards.


27. Similar Occurrence Report Numbers:

NE-ID--EGG-RTC-1991-1003


28. User-defined Field #1:

G100

29. User-defined Field #2:


30. HQ Keyword(s):

01B--Inadequate Conduct of Operations - Loss of Configuration Management/Control
01O--Inadequate Conduct of Operations - Inadequate Maintenance
06B--Radiological - Facility/Equip/Site Contamination
12M--EH Categories - Radiological Control (Other)
14D--Quality Assurance - Documents and Records Deficiency
14E--Quality Assurance - Work Process Deficiency


31. HQ Summary:

On May 12, 2016, the Advanced Test Reactor (ATR) Control Room Supervisor received a report from the Radiological Control Manager that contaminated soil was discovered outside of the contamination area north of the ATR evaporation ponds. Pre-work surveys were being performed in preparation for the ATR Complex Warm Waste Evaporation Pond liner replacement project. A radiological buffer area had been established to support surveys of the area surrounding the evaporation pond contamination area. A normally unoccupied area was surveyed and contamination was found in the soil. Further surveys off of the pond berm elevation, and downwind of the pond, found contamination levels to be as high as 250,000 disintegrations per minute /100 centimeters squared. Following the discovery, the area was posted as a soil contamination area. Surveys of the road around the evaporation pond were conducted and no contamination was found. Management was notified.


32. DOE Facility Representative Input:


33. DOE Program Manager Input:


34. Approvals:
 
Approved by: Hill, Shawn Ashley, Facility Manager/Designee
Date:09/21/2016
Telephone No.:(208) 533-4128