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HTTable of Contents

1.0 INTRODUCTION ........................................................................1

2.0 POSITIVE ATTRIBUTES .............................................................3

3.0 WEAKNESSES ............................................................................5

4.0 SUMMARY ASSESSMENT .........................................................9

5.0 CONCLUSIONS ........................................................................ 12

6.0 RATINGS ................................................................................... 14

APPENDIX A - SUPPLEMENTAL INFORMATION ......................... 15

APPENDIX B - SITE-SPECIFIC FINDINGS ..................................... 17

Abbreviations Used in This Report

AGHCF Alpha-Gamma Hot Cell FacilityANL Argonne National LaboratoryAPS Advanced Photon SourceASO Argonne Site OfficeCFR Code of Federal RegulationsDOE U.S. Department of EnergyDSA Documented Safety AnalysisEH DOE Office of Environment, Safety, and HealthEMS Environmental Management SystemES&H Environment, Safety, and HealthISM Integrated Safety ManagementOA DOE Office of Independent Oversight and

Performance AssuranceOSHA Occupational Safety and Health AdministrationPFS Plant Facilities and ServicesPPE Personal Protective EquipmentSAR Safety Analysis ReportSC DOE Office of ScienceTSR Technical Safety RequirementUSQ Unreviewed Safety QuestionWMO Waste Management Operations

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Introduction1.0

The U.S. Department of Energy (DOE) Officeof Independent Oversight and PerformanceAssurance (OA) inspected environment, safety,and health (ES&H) programs at the DOE ArgonneNational Laboratory (ANL) during April and May2005. The inspection was performed by the OAOffice of Environment, Safety and HealthEvaluations. OA reports to the Director of theOffice of Security and Safety PerformanceAssurance, who reports directly to the Secretaryof Energy.

Within the DOE, the Office of Science (SC)has line management responsibility for ANL. SCprovides programmatic direction and funding forresearch and development, facility infrastructureactivities, and ES&H program implementation atANL. ANL also receives funding from other DOEprogram offices and other government and industryorganizations. At the site level, the Argonne SiteOffice (ASO) has line management responsibilityfor ANL and reports to SC. The SC IntegratedService Center, which encompasses the ChicagoOperations Office and the Oak Ridge OperationsOffice, provides support to ASO in several areas(e.g., legal, human resources, and employeeconcerns) and may provide technical ES&Hspecialists to support ASO. Under contract toDOE, ANL is managed and operated by theUniversity of Chicago, which has operated ANLsince the Manhattan Project.

ANL’s mission is to serve DOE and nationalsecurity by advancing the frontiers of knowledge,by creating and operating preeminent scientificuser facilities, and by providing innovative andeffective approaches and solutions to energy,environmental, and security challenges to nationaland global well-being, in the near and long term,as a contributing member of the DOE laboratorysystem. Most ANL research activities are in theareas of basic science, energy resources,environmental stewardship, and national security.ANL also operates various scientific facilities thatare used by scientists from ANL, other DOEorganizations, other government organizations,academia, industry, and other nations.

ANL activities involve various hazards thatneed to be effectively controlled. These hazardsinclude exposure to external radiation, radiologicalcontamination, beryllium, hazardous chemicals, andvarious physical hazards associated with facilityoperations (e.g., machine operations, high-voltageelectrical equipment, pressurized systems, andnoise). Radioactive materials and hazardouschemicals are present in various forms andquantities at ANL.

The purpose of this OA inspection was toassess the effectiveness of ES&H programs atANL as implemented by the University of Chicagounder the direction of ASO. OA used a selectivesampling approach to evaluate a representativesample of activities at ANL, including itsmanagement systems, facilities operations,maintenance, construction, and engineered safetysystems. Specifically, the sampling approach wasused to evaluate:

• ANL1 implementation of the core functions ofintegrated safety management (ISM) forselected activities, including maintenance workduring the scheduled maintenance shutdownat the Advanced Photon Source (APS), wastemanagement and work activities performed by

1 Consistent with common practice, the term “ANL” is usedto refer to both the physical facility and onsite contractormanagement.

Aerial View of ANL

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the Waste Management Operations (WMO)organization, and selected aspects of construction,building maintenance, and craft work performedby the Plant Facilities and Services (PFS)organization. OA focused primarily onimplementation of ISM at the facility and activity/task levels.

• SC, ASO, and ANL feedback and continuousimprovement systems and selected aspects ofmanagement roles, responsibilities, and authorities.

• Functionality of essential safety systems that aredesigned to prevent and mitigate accidents at theAlpha-Gamma Hot Cell Facility (AGHCF),including the hot cell structural barriers, firesuppression system, ventilation system, nitrogensystem, and supporting systems and components.

• ASO and ANL effectiveness in managing andimplementing selected aspects of the ES&Hprogram that OA has identified as focus areas,including implementation of DOE Order 450.1,Environmental Protection Program,requirements; hoisting and rigging; the chronicberyllium disease prevention program; safetysystems oversight; and corrective actionmanagement. OA selects focus areas—areas thatwarrant increased attention across the DOEcomplex—based on a review of operating eventsand inspection results.

The scope of the review of ANL considered theresults of the 2002 OA inspection, which identifiedgenerally effective systems in a number of importantareas. Specifically, in 2002, ASO (which was at thattime an area office within the Chicago OperationsOffice) and ANL had worked cooperatively to establishand implement the institutional ISM program, such asresponsibilities for ISM implementation and ensuringthat individuals are trained and qualified to implementtheir safety responsibilities. For the most part, systemsin these areas were effective. In addition, OAdetermined that many aspects of the ISM program forexperimental activities were effectively implementedby ASO and ANL in the 2002 timeframe. The safeconduct of experiments had received considerableattention, and an institutional experiment safety reviewprocess system was being effectively implemented atthe division level. As a result of the analysis of previousresults, on this 2005 inspection, OA focused primarily

on areas where performance in 2002 was notsufficiently effective, such as in non-experimental work,nuclear safety systems, radiation protection, andfeedback and improvement.

Sections 2 and 3 provide a discussion of the keypositive attributes and weaknesses identified during thisreview. Section 4 provides a summary assessment ofthe effectiveness of the major ISM elements reviewedon this inspection. Section 5 provides OA’s conclusionsregarding the overall effectiveness of SC, ASO, andANL management of the ES&H programs. Section 6presents the ratings assigned during this review.Appendix A provides supplemental information,including team composition. Appendix B identifies thespecific findings that require corrective action andfollow-up.

Volume II of this report provides four technicalappendices (C through F) containing detailed results ofthe OA review. Appendix C provides the results of thereview of the application of the core functions of ISMfor ANL work activities. Appendix D presents theresults of the review of SC, ASO, and ANL feedbackand continuous improvement processes andmanagement systems. Appendix E presents the resultsof the review of essential safety system functionality,and Appendix F presents the results of the review ofsafety management of the selected focus areas. Foreach of these areas, OA identified opportunities forimprovement for consideration by DOE and contractormanagement. The opportunities for improvement arelisted at the end of each appendix so that they can beconsidered in the context of the status of the areasreviewed.

Alpha-Gamma Hot Cell Facility

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Positive Attributes2.0

Several positive attributes were identified inES&H implementation at ANL, in such areas asenvironmental management system implementationand focused improvement initiatives by certainorganizations.

The ANL ES&H Manual effectivelyidentifies applicable site-specificrequirements and regulatory requirements.The manual is effective in identifying regulatoryrequirements applicable to ANL and providingspecific and useful information for ANL personnel.For example, the ES&H Manual section onchemical carcinogens provides a composite listingof applicable carcinogens, thereby eliminating theneed for workers and line managers toindependently analyze a variety of listings of known,suspect, and likely carcinogens, and arriving atconclusions that are often inconsistent. In addition,the ES&H Manual includes guidance forimplementing some industry good practices thatare not mandated by regulations. For example,although a written safety program for lead is notrequired by the Occupational Safety and HealthAdministration (OSHA), ANL has recentlyincorporated requirements and guidance for leadusage and surface contamination levels within theES&H Manual.

Several ANL organizations have madeimprovements in various aspects of workplanning and control processes. Several ANLorganizations have made improvements in workplanning and control for their activities. Most workperformed by WMO is governed by a work

clearance permit, which is now accompanied by aspecific operating procedure or job plan, as well asa job safety assessment, to define the discretescope of work, the hazards, and the controlsapplicable to the work. With these mechanisms,WMO has successfully refined their process tomore effectively analyze and tailor the definedhazards and controls to the specific work beingperformed. At APS, many activity/task-levelhazards are adequately identified and analyzedusing the procedure development, review, andapproval process. For example, the process foretching chromium films is well described in aprocedure that addresses hazards and theappropriate hazard controls. Additionally, an APSdivision-level organization is developing a newfacility hazards analysis process, which is a usefultool for activities in APS fabrication and machineshops. With additional definition, rigor, and maturity,elements of these new organization-specificprocesses may warrant consideration by other ANLorganizations.

ASO provides effective direction to andoversight of ANL for the development andimplementation of an environmentalmanagement system (EMS), and ANL hasmade considerable progress in implementingthe EMS. ASO has driven enhanced performanceby ANL in achieving EMS milestones by usingperformance measures specific to these milestones.ASO and ANL environmental personnel who havebeen assigned EMS responsibility are well qualified.ANL has established a detailed environmentalpolicy as part of the EMS requirement and hascommitted to integrating environmental protectionaccountability into day-to-day activities and long-term planning processes. ANL is implementing anEMS as part of their ISM systematic approach tomanaging continuous ES&H improvement. ANLcontinues to implement a pollution preventionprogram that includes recycling programs for suchmaterials as paper, glass, batteries, fluorescentbulbs, and excess chemicals. ANL received aWhite House Closing the Circle Award forNoteworthy Practice for its reuse of nuclear targets.

APS Main Entrance

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SC has increased its focus on communicatinglessons learned, including Office of Environment,Safety, and Health (EH) safety and health alerts,to SC site offices and laboratories. SC has alsointerfaced with ASO and its other site offices to ensurethat the site offices monitor their laboratory performancein the area relevant to the lessons learned. For example,SC required its site offices and laboratories to reviewand strengthen their hoisting and rigging programs,which has resulted in the development of improvementinitiatives for the ANL hoisting and rigging program.As another example, SC required its site offices to takea number of actions to enhance electrical safetyfollowing the electrical incident at the Stanford LinearAccelerator Center, resulting in some improvements inANL electrical safety practices. In addition, SC isconducting reviews of laboratory systems and

processes for electrical hot work at all of its laboratoriesto provide assistance and promote lessons learned fromthe incident at the Stanford Linear Accelerator Center.SC site offices will be required to address, implement,and report the status of corrective actions taken inresponse to SC review team recommendations. SChas also continued its focus on performance measuresand worked with laboratories to achieve improvements.For example, SC’s monitoring of ANL performancemetrics indicated a need for improvement in ANLefforts to meet as-low-as-reasonably-achievable(ALARA) and person-roentgen equivalent man (rem)goals. SC, in coordination with ASO and ANL, thenidentified funding for ANL upgrades to AGHCFwindows/shielding and replacement remote manipulatorarms, which contributed to lower radiation dose rates.

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Weaknesses3.0

Although some improvements have been made,there are weaknesses in safety systems, in variousES&H programs (e.g., radiation protection andmedical surveillance), and in the implementationof hazards analysis and control processes thatprotect workers. There also are weaknesses infeedback and improvement processes that havehindered the effectiveness of corrective actions.

ANL has not established adequateprocesses for ensuring that all applicablerequirements are identified, responsibilitiesfor implementation are assigned, appropriateimplementing documents/procedures aredeveloped, and effective implementation isverified by management. ANL has notimplemented some applicable institutionalrequirements in a number of areas, such asradiation protection, feedback and improvementprocesses, the cognizant system engineer program,medical surveillance, lockout/tagout assessments,hoisting and rigging, lead control, and berylliumprogram assessments. A common theme in thesedeficiencies is that ANL does not have adequateprocesses for ensuring that applicable requirementsare implemented. ANL has not clearly definedroles, responsibilities, authorities, and requirementsfor developing and implementing key ISM processesin institutional Tier 2 documents, and some safetyrequirements have not been flowed down into lineorganization Tier 3 documents. Although subjectmatter experts have been assigned who areresponsible for specific sections of the ES&HManual, the institutional-level ownership of safetyprograms and processes is unclear. In addition,the authority and importance of some requirementsdelineated in Tier 2 documents are not understoodor accepted by line organizations, as reflected inthe number of ES&H Manual and quality assuranceprogram plan requirements not implemented by lineorganizations. ANL management has notadequately ensured the establishment and effectiveimplementation of some ISM processes.

The ANL institutional radiation protectionprogram does not ensure effective sitewideradiation protection performance andcompliance with 10 CFR 830 and 10 CFR 835

requirements. The ANL institutional radiationprotection program fails to meet minimum DOEexpectations in such key areas as organization andadministration, implementing procedures, radiationcontrol technician training and qualifications, andtechnical basis documentation. These weaknessescontribute to fundamental deficiencies in linemanagement implementation of requirements insuch areas as posting and labeling, radiologicalsurveys and monitoring, radiological recordkeeping,air sampling, and radiation work permits.Corrective actions taken to address prior concernsfrom the 2002 OA inspection have not resolvedrecurring weaknesses, as evidenced by continuingand similar deficiencies. Senior ANL managementaction since 2002 to correct previous problems,such as the appointment of a radiation safety officerand new coordinating committee, has provided onlylimited improvement, due in a part to the lack ofsufficiently defined roles, responsibilities,authorities, and accountabilities for these positions.

Medical surveillance requirements forsome ANL workers and ANL subcontractorsare not being performed for beryllium, lead,and respiratory protection as required by DOEorders, OSHA standards, and ANLprocedures. ANL has developed the elements(e.g., procedures, computer databases) requiredfor an effective medical surveillance program.However, these elements are not integrated andare not consistently implemented. As a result, ANLdoes not meet all applicable medical surveillancerequirements of DOE orders and OSHA standards.Specific concerns were identified in medicalsurveillance for beryllium, lead, and respiratoryprotection. The deficiencies in beryllium medicalsurveillance include failure to offer medicalsurveillance and screening for beryllium workers,as required by the beryllium rule. Prior to this OAinspection, approximately 70 ANL workers wereenrolled in the ANL lead medical surveillanceprogram. However, recently the ANL Medical staffrecognized that many of the ANL workers whohad been identified as lead workers or lead usersthrough the job hazard questionnaire process hadnot been enrolled in the lead surveillance program

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or evaluated or screened by ANL Medical staff. As aresult, enrollment in the lead surveillance program hasnow surged to over 300 ANL workers. Although someof these workers may not need to be in the lead medicalsurveillance program, a medical review is required todetermine their actual status. ANL Medical is currentlydeveloping screening criteria for the lead surveillanceprogram. Furthermore, the thresholds for enrollmentinto the lead surveillance program are inconsistentbetween the ES&H Manual requirements and the ANLMedical lead surveillance program requirements. Inaddition, some ANL workers who wear respirators andhave maintained annual respirator fit testing and trainingrequirements are not current with respect to theirmedical certification or certification updates. Arespirator wearer is required by OSHA, DOE, and theANL ES&H Manual to be medically certified prior tobeing fit tested. The ANL ES&H Manual requiresthat respirator wearers who have previously completeda medical questionnaire provide the Medical Departmentan updated questionnaire before undergoing fit testing.In some cases, the medical updating process is beingmissed. According to ANL Medical, some respiratorwearers have not had their medical status updated inover three years, although they have been fit testedand trained annually during this period. Furthermore,some construction workers are wearing filtering facepiece respirators without the OSHA-required training,fit testing, or medical surveillance.

Implementation of ES&H requirements andwork control processes at the activity level hasnot been effective for some non-experimentalwork activities. Some improvements have been madein all of the organizations reviewed, includingestablishment of work control and hazards analysisprocesses. However, these efforts have not been

sufficiently rigorous and comprehensive, as indicatedby the deficiencies in implementation of the ISM corefunctions for all of the organizations reviewed. Forsome APS activities, hazards and hazard controls(including exposure assessments and the resultantrequisite controls) have not been sufficientlydocumented at the activity level in procedures or otherwork documents to ensure that risks to workers andthe environment have been adequately identified,analyzed, and controlled. APS line management hasnot ensured that all applicable ANL ES&H Manualand Waste Handling Procedures Manual requirementsflow down to activity-level work control documentation.The definition, rigor, and quality assurance associatedwith preparation of some work planning and controldocuments in WMO are not sufficient to ensureconsistent and effective implementation of controls.Some radiological control requirements in WMO andAPS were not being effectively implemented. WMOworkers are not always meeting facility procedurecompliance expectations outlined in the WMO Conductof Operations Manual. For other PFS organizations,requirements for hazards analysis methods presentedin the ES&H Manual and the PFS SupervisoryHandbook do not provide sufficient performance criteriaand descriptions to ensure that all hazards areadequately analyzed and result in identification of theappropriate controls. Collectively, these deficienciesreduce the assurance that workers are adequatelyprotected.

The safety-significant fire suppression systemat AGHCF is inoperable due to inadequateavailable water pressure, and therefore a fireoutside a hot cell could compromise cellconfinement and shielding and could result ingreater worker exposure than is currentlyanalyzed. The safety-significant AGHCF firesuppression system design is inadequate to perform itssafety analysis report (SAR)-defined safety function.It has insufficient water pressure in areas adjacent tothe hot cells to be operable. With the current condition,workers may be placed in greater danger than iscurrently analyzed as a result of a fire that couldcompromise the hot cell confinement. In addition, thecurrent fire suppression system administrative controllimit static header pressure of 65 pounds per squareinch gauge (psig) is inadequate for system operability.These conditions had been previously identified in a1993 fire hazards analysis and/or the 2002 OAassessment but corrective actions were not adequate.Because of OA’s observations, the facility staff hasdecided to aggressively remove combustibles and

APS Storage Ring Sector

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flammable liquids from the facility. However, additionalcompensatory measures are needed, such as a firewatch.

The AGHCF and G and K Wing Laboratoriesdocumented safety analysis (DSA) and SAR lacksufficient supporting documentation; contain anumber of non-conservative assumptions, errors,omissions, and inconsistencies; and do not havean adequate unreviewed safety question (USQ)process. The current AGHCF SAR does not meet10 CFR 830 requirements. AGHCF was not able toproduce formal documentation (e.g., analyses andrigorous calculations that are independently verified)to support the SAR conclusions/assumptions. AGHCFsubsequently determined that a detailed analysis waswarranted and decided that a potentially inadequatesafety analysis (PISA) existed. Currently, correctiveactions are being planned that will include revising theSAR and associated technical safety requirements(TSRs) to ensure that they are 10 CFR 830-compliant.These deficiencies demonstrate that ASO and ANLdid not thoroughly review the SAR to validatecompliance with 10 CFR 830 when the regulation wasput into effect. Furthermore, ANL has not adequatelyperformed USQ screenings and determinations asrequired by 10 CFR 830.

Some nuclear safety requirements have notbeen fully implemented for ANL’s AGHCF and Gand K Wing Laboratories. The AGHCF and G andK Wing Laboratories did not implement all of the naturalphenomena hazard requirements of DOE Order420.1A, which requires that safety systems be capableof withstanding the effects of natural phenomena toensure life safety and confinement of hazardousmaterial. G and K Wing Laboratories did not implement

some of the cognizant system engineer programrequirements of DOE Order 420.1A, which requiresthat configuration management be applied to ensureconsistency among system requirements, performancecriteria, system documentation, and physicalconfiguration. In addition, required conditionassessment surveys are not conducted at the G and KWing Laboratories. The AGHCF is not fully compliantwith fire protection design requirements as specified inDOE Order 420.1A. Important elements ofmaintenance, testing, surveillance, and operations forAGHCF safety systems do not meet applicablerequirements. Several of the TSR controls formonitoring and surveillance testing of AGHCF safetystructures, systems, and/or components are incorrect,incomplete, or inadequate to provide the requiredassurance that they can perform their safety functions.Further, a significant number of surveillance and testingprocedures have incorrectly or inadequately translatedthe SAR and TSR requirements. In two cases,surveillances were not performed and documented ontime, resulting in TSR violations. Maintenanceprograms do not meet several important DOE Order433.1 requirements for formal control of replacementparts, a master equipment list, and review of outsideorganizations’ work procedures for the facility. A fewadequate operating procedures are in place, butoperating procedures have not been established for themajority of the safety-significant systems. Collectively,these deficiencies reduce the assurance that the safetysystems will perform their safety functions.

ANL has not established clearly definedfeedback and improvement programs at theinstitutional or divisional levels that areconsistently effective in identifying and analyzingsafety deficiencies, establishing appropriatecorrective and preventive actions, and identifyingand applying lessons learned to prevent injuries,operational events, and non-compliance withstandards . Self-assessment processes do not resultin proactively identified, planned, and scheduledassessments that are tailored to the organization’sactivities and conditions based on risk. Assessmentactivities and corrective action processes are ofteninsufficiently documented and are not rigorous inevaluating performance or in identifying causes andestablishing documented preventive actions that aretracked to completion. Some assessments required byOSHA, DOE standards, and ANL policy documentsare not being performed. ANL has not established adocumented, cohesive, and comprehensive correctiveaction program that effectively manages the

Front of Hot Cell

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documentation and resolution of safety process andperformance deficiencies for all Laboratoryorganizations. Weaknesses in processes andperformance for investigating operational incidents andsafety basis deficiencies may be impacting compliancewith DOE orders and safety regulations. Injury andillness investigations are poorly documented andtypically do not address the elements of ISM, reflectdetermination of causes, or address appropriatepreventive actions. ANL management has notestablished sufficient controls and monitoring/evaluationfor these programs to ensure their adequacy andeffective implementation.

ASO line management oversight has not beensufficiently rigorous to drive improvements inANL safety management. ASO operationalawareness activities are not always being conducted

with sufficient rigor and focus on observing work andANL feedback and improvement processes to preventrecurrence or drive continuous improvement in theLaboratory. ASO has not yet established sufficientsystems to provide feedback on the implementation andeffectiveness of ASO operational awareness activitiesto ensure that management expectations are being fullymet. In addition, ASO has not established andimplemented a fully effective issues management andcorrective action process that ensures that safetydeficiencies identified through ASO line managementoversight activities are appropriately documented andtracked to closure. Verification of closure andeffectiveness of corrective actions to previousdeficiencies has not always been sufficiently rigorousto prevent recurrence or drive continuous improvementof the contractor.

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Summary Assessment4.0

The following paragraphs provide a summaryassessment of the ASO and ANL activities thatwere evaluated by OA during this inspection.Additional details relevant to the evaluatedorganizations are included in the technicalappendices in Volume II of this report.

ISM Core Function Implementation

The first four core functions of ISM areimplemented with varying levels of effectivenessfor non-experimental work by the various lineorganizations reviewed. ANL personnel aretypically very experienced, and many workactivities are performed with a high regard forsafety. Some hazards are adequately analyzedand controlled. However, there are deficienciesin work planning and control in all organizationsreviewed. Further, there are deficiencies in someinstitutional safety requirements that impact theeffectiveness of ES&H programs at the facilityand activity level. As a result, in addition to thedeficiencies discussed below in individual ANLorganizations, some ES&H requirements have notbeen implemented, some medical surveillanceactivities have not been performed, and there aredeficiencies in some aspects of radiation protectionat the activities reviewed.

APS Work Planning and Control. APSoperational and maintenance activities aregenerally well defined, and most hazards are well

analyzed. The APS safety assessment documentand activity-level work documents define work tobe conducted, and the safety assessment documentfurther provides an extensive facility-level hazardsanalysis. Such mechanisms as the proceduredevelopment process, job safety analyses, andother work control processes provide appropriateanalyses of activity/task-level hazards in mostcases. However, in a few cases, individual activitiesor facility conditions have not been sufficientlyanalyzed to ensure that the appropriate controlscan be identified. Although APS has establishedmany of the appropriate engineering,administrative, and personal protective equipment(PPE) controls commensurate with the hazardspresent, in some cases engineering andadministrative controls have not been adequatelyimplemented. Instances were identified whereANL ES&H Manual and Waste HandlingProcedures Manual requirements were notincorporated into activity-level work documents.Although individual requirements were notfollowed in a few cases, the vast majority of workwas performed safely and in accordance withestablished controls.

WMO Work Planning and Control. Thescope of work for activities performed by WMOis generally clearly defined and sufficiently detailedto enable effective hazard identification. Severalmechanisms are used for hazards analysis, andrecent WMO efforts to tailor these tools to specificwork activities represent a continuing improvementand, with few exceptions, effective hazardsanalysis. The prevalence of radiological andchemical hazards associated with WMO workdictates significant use of administrative controlsand PPE to mitigate hazards. However,improvement is needed in the definition, application,implementation, and quality control of thesemechanisms to ensure effectiveness of controls.In addition, continuing deficiencies in fundamentalaspects of the site’s radiation protection programand line implementation of radiological requirementslimit the effectiveness of radiological controls anddefensibility of radiological data needed to ensurecompliance with regulatory requirements. Many

Aerial View of APS

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work activities in WMO were conducted safely and inaccordance with established controls. However, lackof attention to requirements and governing documentshas resulted in the failure to meet some nuclear facilityconduct of operations and quality assurancerequirements. Additional management attention isneeded to ensure that workers understand all procedurecompliance expectations, including the need to reviewand either follow or correct governing work controlmechanisms before completing their tasks.

PFS Construction Section, ConstructionCrafts, and Building Maintenance. In many cases,the PFS groups that OA reviewed have adequatelyimplemented the first four core functions of ISM. TheConstruction Section has established a rigorous processfor definition of work. PFS personnel were well trainedand knowledgeable. The work activities observed byOA were generally performed safely. In most cases,standard industrial hazards encountered by BuildingMaintenance mechanics and the Construction Craftsgroup are adequately addressed by job hazardquestionnaires, job hazards analyses, and taskevaluation processes, and construction project hazardswere generally well analyzed because of the formalrequirements placed in subcontractor contracts and theinvolvement of construction field representatives andsafety personnel in work planning. Although PFS hasshown improvement in implementation of ISM sincethe 2002 OA inspection, some deficiencies still exist.The formal work order process for Construction Craftsand Building Maintenance sometimes results in adefinition of work that may not be sufficient in detail toadequately analyze all potential hazards. PFS hazardcontrols are implemented through various mechanisms;however, the informality and/or lack of administrativedirection for some of these mechanisms have resultedin deficiencies in implementation of controls. In somePFS groups, corrective actions from the 2002 OAinspection have not been fully effective, as evidencedby recent events that resulted in injuries to PFS workers.Overall, the PFS work hazards analysis and controlprocesses as implemented rely too much on individualwork experience and informal communication betweensupervisors and workers.

Safety System Functionality and SafetySystem Oversight

The AGHCF managers and operators wereknowledgeable of the operations and controls of thesafety-significant AGHCF systems. Some progresshas been made to enhance nuclear safety systems in a

few areas, such as efforts to establish configurationmanagement and a systems engineer program.However, AGHCF safety systems and the SAR didnot fully comply with 10 CFR 830 requirements, andthe systems were not adequately designed and analyzedto ensure that they could perform their safety functionsunder design basis accident conditions. DSAs for theevaluated facilities contain omissions, inconsistencies,and non-conservative statements. Additionally, therewas no documentation to support the analyticalinformation presented in the AGHCF SAR. TheAGHCF fire protection system was determined to beinoperable. ANL did not adequately evaluate andimplement many of the requirements of DOE Order420.1A. ANL has not instituted a functionalconfiguration management program, the USQprocedure does not reflect the requirements of 10 CFR830, and many AGHCF USQ screenings anddeterminations were inadequately supported orincorrect. Several important aspects of maintenanceprocedures, testing and surveillance practices, andoperating procedures were inadequate. Some of thediscrepancies that were identified have been attributedto insufficient nuclear safety system oversight by ASO,weaknesses in the ANL feedback and improvementand cognizant system engineer programs, and the needfor an expanded nuclear safety infrastructure.

Implementation of DOE Order 450.1,Environmental Protection Program

ASO provides effective direction to and oversightof ANL for the development and implementation of anEMS, and ASO has driven enhanced performance byANL in achieving EMS milestones by usingperformance measures specific to these milestones.

APS Boosters Synchrotron

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ANL has developed an EMS within the ISM descriptiondocument; however, the EMS implementation actions arestill being developed, and additional efforts are needed todevelop detailed planning documents. Despite thesechallenges, the EMS is on schedule to be implementedand verified in accordance with DOE Order 450.1. ANLcontinues to implement a pollution prevention programand, with ASO performance measure incentives, is takingactions to reinvigorate the program following changes inwaste management funding.

Hoisting and Rigging

The PFS hoisting and rigging program is being updatedto remain current with changing DOE regulations.Equipment operators are current in their training and havecurrent licenses, and hoisting and rigging equipment isadequately inspected on an annual basis. However, in anumber of cases, pre-use and monthly inspections arenot being performed as required, and some equipmentwas defective. In addition, ANL hoisting and riggingrequirements have not been adequately incorporated insome ANL construction subcontractor’s contracts, ES&Hplans, or job safety analyses.

Chronic Beryllium Disease PreventionProgram

There are currently no active beryllium activities atANL, although beryllium has been used in past ANLoperations. Beryllium characterization of the ANL sitefacilities is complete, but only half of the beryllium-contaminated areas identified during the characterizationcampaign have been remediated. There have been noconfirmed cases of beryllium sensitization or chronicberyllium disease reported to date. The medical data oncurrent and former employees is robust; however, anumber of workers in the current beryllium database havenot been offered medical surveillance or been evaluatedby Medical, as required by the ES&H Manual and 10CFR 850. Furthermore, recent ASO oversight of theANL beryllium program has been minimal, and no formalassessments of the beryllium program have beenconducted by either ANL or ASO.

ANL Feedback and Improvement

A variety of feedback and improvement activities areconducted at ANL, and some ANL organizations havemade improvements in feedback and improvementprocesses. However, the process and implementationdeficiencies identified in the 2002 OA inspection continue

to exist. ANL conducts various assessments andmanagement walkdowns, identifies and correctsdeficiencies, and shares lessons learned. In many cases,however, these activities are not proactively planned andscheduled, and the resolution of deficiencies is ofteninformal. Little trend analysis of safety issues isperformed, and some mandatory assessments are notbeing performed. Weaknesses were identified in the rigorapplied to documenting the investigation of occupationalinjuries and exposures and the identification andimplementation of preventive actions. Most lineorganization corrective action processes are fragmented,informal, and insufficiently defined, and collectively donot constitute an effective management system forrigorous and consistent identification, evaluation, andresolution of Laboratory safety issues. Institutional policies,expectations, and procedures inadequately define the roles,responsibilities, authorities, and requirements for feedbackand improvement. A number of cases of failure to complyor inconsistent compliance with specific institutionalrequirements were identified. ANL management has notensured that sound feedback and improvement programshave been developed and effectively implemented.Management has not set sufficiently rigorous thresholdsfor acceptable ISM processes and performance.

SC/ASO Oversight

SC Headquarters has been more active and involvedin safety at its laboratories in the past several years. SChas established processes for developing performanceindicators, setting goals, and monitoring performancemeasures across SC laboratories. This management focushas contributed to a generally improving trend inperformance indicators at SC laboratories. ASO hasestablished processes for conducting operationalawareness activities and evaluation of contractor ES&Hperformance, and has made some improvements in itsfeedback and improvement processes. In addition, ASOis making effective use of the ANL contractual mechanismfor driving improvements in worker safety and inperformance in achieving EMS milestones. Although someaspects of the ASO oversight are effective, there are anumber of weaknesses in ASO assessment activitieslimiting the effectiveness of ASO oversight of ANLperformance. In addition, ASO has not established andimplemented a fully effective issues management andcorrective action process, and verification of closure andeffectiveness of corrective actions has not always beensufficiently rigorous to prevent recurrence and drivecontinuous improvement of the contractor.

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Conclusions5.0

SC, ASO, and ANL have made improvementsin a number of ISM elements. The ANL ES&HManual effectively identifies applicable site-specific requirements and regulatoryrequirements. Several ANL organizations havemade improvements in various aspects of workplanning and control processes. ASO provideseffective direction to and oversight of ANL forthe development and implementation of an EMS,and ANL has made considerable progress inimplementing the EMS. SC has also increasedits focus on communicating lessons learned,including EH safety and health alerts, to SC siteoffices and laboratories. These activities havecontributed to generally improving trends incertain worker safety performance measures.

ANL ES&H requirements are implementedwith varying levels of effectiveness by linemanagement in the various line organizations.ANL personnel are typically very experienced,and many work activities are performed with ahigh regard for safety. Some hazards areadequately analyzed and controlled. However,there are deficiencies in work planning and controlfor non-experimental work in all organizationsreviewed. In addition, there are deficiencies inimplementation of some institutional safetyrequirements, institutional radiation protectionprograms, and medical surveillance. Thedeficiencies in the institutional programs havecontributed to implementation deficiencies at theactivities reviewed on this OA inspection and mayimpact other ANL facilities and activities. In thearea of safety systems, progress has been madein a few areas, but the evaluated safety systemsand DSAs did not fully comply with 10 CFR 830and were not adequately designed and analyzedto perform their safety functions under designbasis conditions. The AGHCF fire suppressionsystem is inoperable and ANL and ASO need totake timely compensatory actions.

While some enhancements have been madein ASO and ANL feedback and improvementprocesses, many process and performanceweaknesses remain in assessments, issues

management, lessons learned, and injury andillness reporting. ASO and ANL have made onlylimited progress in correcting a number oflongstanding and systemic deficiencies identifiedby various internal and external assessments.Because of weaknesses in developing andverifying corrective actions, many findings havebeen closed before the effectiveness of thecorrective actions was validated and verified.Improvements in feedback and improvementprocesses are key to achieving the neededimprovements in safety management across ANLactivities and safety systems.

Some of the areas that warrant increasedANL management attention include:

• Enhancing worker safety and health andenvironmental protection through morerigorous hazards analysis and implementationof controls for industrial hazards andhazardous substances.

• Ensuring compliance with ES&Hrequirements, and full and effectiveimplementation of existing processes, toinclude clearly assigning responsibility forimplementation of ES&H requirements andholding managers accountable.

• Ensuring timely actions to addressfundamental weaknesses in the ANLradiation protection program throughadherence to the applicable portions of theDOE Order 441.1 series of implementationguides and the DOE radiological controlstandard.

• Ensuring timely actions to address theinoperable AGHCF fire suppression systemand prevent recurrences of TSR violations.

• Developing resource-loaded plans withmilestones to revise DSAs, TSRs, and USQprograms to meet current DOE andregulatory requirements.

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• Enhancing ANL feedback and improvementprocesses, particularly in issues management, inthe rigor and quality of assessments, and in thedisciplined and effective implementation of thecontractor assurance system.

• Strengthening the nuclear safety program andenhancing the nuclear safety infrastructure.

SC and ASO line management need to focus onANL efforts in the above areas and addressweaknesses in its line management oversight processesin the areas of assessments, issues management, andverification of corrective actions.

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6.0 Ratings

The ratings reflect the current status of the reviewed elements of the ANL ISM program.

Implementation of Core Functions #1-4 for Selected Work Activities

APS

WMO

PFS

Core Function #1 –Define the Scopeof Work

Effective Performance

Effective Performance

Effective Performance

Core Function #2 –Analyze theHazards

Effective Performance

Effective Performance

Needs Improvement

Core Function #3 –Identify andImplement Controls

Needs Improvement

Needs Improvement

Needs Improvement

Core Function #4 –Perform WorkWithin Controls

Effective Performance

Needs Improvement

Effective Performance

ANLACTIVITY

CORE FUNCTION RATINGS

Feedback and Improvement - Core Function #5

ASO and ANL Feedback and Continuous Improvement Processes ...........SIGNIFICANT WEAKNESS

Essential System Functionality (for selected safety systems at the AGHCF and G and K WingLaboratories)

Engineering Design and Compliance with DOE Order 420.1A ..................SIGNIFICANT WEAKNESSConfiguration Management ....................................................................SIGNIFICANT WEAKNESSSurveillance and Testing .........................................................................SIGNIFICANT WEAKNESSMaintenance .............................................................................................NEEDS IMPROVEMENTOperations ................................................................................................NEEDS IMPROVEMENT

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APPENDIX ASUPPLEMENTAL INFORMATION

A.1 Dates of Review

Planning Visit April 12 – 14, 2005Onsite Inspection April 25 – May 5, 2005Report Validation and Closeout May 18 – 20, 2005

A.2 Review Team Composition

A.2.1 Management

Glenn S. Podonsky, Director, Office of Security and Safety Performance AssuranceMichael A. Kilpatrick, Director, Office of Independent Oversight and Performance AssurancePatricia Worthington, Director, Office of Environment, Safety and Health EvaluationsThomas Staker, Deputy Director, Office of Environment, Safety and Health Evaluations

A.2.2 Quality Review Board

Michael Kilpatrick Patricia WorthingtonDean Hickman Robert Nelson

A.2.3 Review Team

Patricia Worthington, Team LeaderVic Crawford Robert Freeman Michael Gilroy Bill MillerBob Compton Joe Lischinsky Jim Lockridge Joe PanchisonDon Prevatte Michael Shlyamberg Ed Stafford Mario Vigliani

A.2.4 Administrative Support

MaryAnne Sirk Tom DavisShirley Cunningham Latonya Parker Kim Zollinger

A.3 Ratings

The Office of Independent Oversight and Performance Assurance uses a three-level rating system to provide linemanagement with a tool for determining where resources might be applied toward improving environment, safety, andhealth. It is not intended to provide a relative rating between specific facilities or programs at different sites becauseof the many differences in missions, hazards, and facility life cycles, and the fact that these reviews use a samplingtechnique to evaluate management systems and programs. The three ratings and the associated management responsesare:• Effective performance, which indicates that management should address any identified weakness• Needs improvement, which indicates a need for significantly increased management attention• Significant weakness, which indicates a need for immediate management attention, focus, and action.

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APPENDIX BSITE-SPECIFIC FINDINGS

FINDING STATEMENTS

Table B-1. Site-Specific Findings Requiring Corrective Action

1. ANL has not established adequate processes for ensuring that all applicable requirements are identified,responsibilities for implementation are assigned, appropriate implementing documents/procedures are developed,and effective implementation is verified by management.

2. The ANL institutional radiation protection program does not meet minimum DOE expectations in such areasas organization and administration, implementing procedures, radiation control technician training andqualifications, and technical basis documentation as needed to ensure effective sitewide radiation protectionperformance and compliance with 10 CFR 830 and 10 CFR 835 requirements.

3. Medical surveillances for a number of workers at ANL are not being implemented for beryllium, lead, andrespiratory protection as required by DOE orders, OSHA standards, and ANL procedures.

4. For some APS activities, hazards and hazard controls (including exposure assessments and the resultantrequisite controls) have not been sufficiently documented at the activity level in procedures or other workdocuments to ensure that risks to workers and the environment have been adequately identified, analyzed, andcontrolled.

5. APS line management has not ensured that all applicable requirements in the ANL ES&H Manual and theWaste Handling Procedures Manual flow down to activity-level work control documentation.

6. The definition, rigor, and quality assurance associated with preparation of some WMO work planning andcontrol documents are not sufficient to ensure consistent and effective implementation of controls.

7. Some radiological control requirements in WMO, including posting and labeling, radiological surveys andmonitoring, radiological recordkeeping, air sampling, and radiation work permits, are not being effectivelyimplemented in accordance with institutional and/or regulatory requirements.

8. WMO workers are not always meeting facility procedure compliance expectations outlined in the WMOConduct of Operations Manual.

9. Requirements for hazards analysis methods presented in the ES&H Manual and the PFS Supervisory Handbookdo not provide sufficient performance criteria and descriptions to ensure that all hazards are adequatelyanalyzed and that appropriate controls are identified.

10. ASO has not implemented a fully effective program of operational awareness and assessment activities withsufficient scope and rigor to ensure that contractor ES&H performance at all levels and in all organizations issufficiently and accurately evaluated, as specified in DOE Policy 450.5.

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FINDING STATEMENTS

Table B-1. Site-Specific Findings Requiring Corrective Action (continued)

11. ASO has not established and implemented a fully effective issues management and corrective action processthat ensures that safety deficiencies identified through ASO line management oversight activities areappropriately documented and tracked to closure, as required by DOE Order 414.1B.

12. ASO has not always conducted or required the contractor to conduct sufficient reviews of contractor correctiveactions to verify closure and effectiveness in ensuring resolution of internal and external findings and preventingrecurrence, as required by DOE Order 414.1B and DOE Order 470.2B.

13. ANL has not established and implemented a fully effective program of assessment activities with sufficientscope and rigor to ensure that ES&H performance at all levels and in all organizations is consistently andaccurately evaluated.

14. ANL has not established an effective corrective actions program that ensures that safety deficiencies areappropriately documented and rigorously categorized and evaluated in a timely manner, with root causes andextent of condition accurately identified, and appropriate recurrence controls identified.

15. The ANL injury and illness program lacks sufficient rigor to ensure that incidents are reported and sufficientlydocumented, causes are identified, and appropriate, effective corrective and preventive actions are identified,documented, and implemented.

16. ANL has not established a sufficiently rigorous lessons-learned program that ensures that applicable lessonslearned are identified and that actions to apply the lessons are taken to improve safety performance andprevent adverse events or non-compliance with regulations.

17. ANL has not fully implemented the requirements of DOE Order 420.1A for the natural phenomena hazards,cognizant system engineer, and fire protection programs.

18. The safety-significant AGHCF fire suppression system is inoperable, and therefore a fire outside a hot cellcould compromise cell confinement and shielding and could result in greater worker exposure than is currentlyanalyzed.

19. The AGHCF safety analysis report (Chapter 4, “Safety SSC,” Chapter 3, “Hazard and Accident Analysis,”and Chapter 5, “Derivation of TSR Requirements”), the G and K Wing Laboratories DSA, the technical safetyrequirements document, and supporting records contain numerous omissions, inconsistencies, and non-conservative statements and do not fully meet the requirements of 10 CFR 830.

20. Contrary to the requirements of 10 CFR 830, ANL has not instituted a functional configuration managementand USQ process for its nuclear facilities, has not established an adequate USQ procedure, and has notadequately performed USQ screenings and determinations.

21. Many surveillance, testing, maintenance, and operating procedures and practices in the AGHCF are not adequateto ensure that safety structures, systems, and/or components remain within the limits and capabilities requiredby the SAR and the TSRs and comply with the requirements of applicable regulations, rules, orders, codes, andstandards.

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FINDING STATEMENTS

Table B-1. Site-Specific Findings Requiring Corrective Action (continued)

22. ANL failed to perform a TSR-required monthly test of the backup power system automatic start functionwithin the maximum allowed interval at AGHCF and a TSR-required monthly validation of the materialinventory in the facility at the G and K Wing Laboratories.

23. SC and ASO have not provided effective line management oversight of the ANL nuclear facility safetysystems.

24. ANL feedback and improvement systems (such as self-assessments and the Nuclear Safety ReviewCommittee) and nuclear safety organization are not adequate to ensure that ANL nuclear facilities and safetysystems comply with 10 CFR 830 requirements and DOE expectations for operation of a Category 2 nuclearfacility.

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