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DoE Handbook: Guidance on Identifying, Reporting a
GUIDANCE
NOT MEASUREMENT SENSITIVE
DOE-HDBK-1089-95
JULY 1995
DOE HANDBOOK
GUIDANCE FOR IDENTIFYING, REPORTING AND
TRACKING NUCLEAR SAFETY NONCOMPLIANCES
U.S. Department of Energy
Washington, D.C. 20585 AREA SAFETY
DISTRIBUTION STATEMENT A. Approved for public release;
distribution is unlimited.
------------------------------------------------------------------------
This document has been reproduced directly from the best available
copy.
Available to DOE and DOE contractors from the Office of
Scientific and Technical Information, P.O. Box 62, Oak Ridge, TN
37831; (615) 576-8401.
Available to the public from the U.S. Department of Commerce,
Technology Administration, National Technical Information
Service, Springfield, VA 22161; (703) 487-4650.
------------------------------------------------------------------------
FOREWORD
This document provides Department of Energy (DOE) contractors,
subcontractors and suppliers with guidance in the effective use of
DOE's Price-Anderson nuclear safety Noncompliance Tracking
System (NTS).
Prompt contractor identification, reporting to DOE, and correction
of nuclear safety noncompliances provides DOE with a basis to
exercise enforcement discretion to mitigate civil penalties, and
suspend the issuance of Notices of Violation for certain violations.
Use of this reporting methodology is elective by contractors;
however, this methodology is intended to reflect DOE's philosophy
on effective identification and reporting of nuclear safety
noncompliances. To the extent that these expectations are met for
particular noncompliances, DOE intends to appropriately exercise
its enforcement discretion in considering whether, and to what
extent, to undertake enforcement action.
------------------------------------------------------------------------
GUIDANCE FOR IDENTIFYING, REPORTING, AND
TRACKING NUCLEAR SAFETY NONCOMPLIANCES
FOREWORD
1. INTRODUCTION
A. DEPARTMENT OF ENERGY ENFORCEMENT
AUTHORITY
B. SUMMARY OF DEPARTMENT OF ENERGY GENERAL
ENFORCEMENT POLICY
C. POLICY FOR CIVIL PENALTIES
D. POLICY FOR POSITIVE INCENTIVES
(1) Timely Identification and Reporting
a. Prompt Identification
b. Prompt Reporting
(2) Prompt and Comprehensive Corrective Actions
E. APPLICABILITY OF DOE ENFORCEMENT POLICY F
F. DEFINITIONS
(1) Contractor
(2) Radiological Activities
(3) Nuclear Facilities
(4) Noncompliance
(5) Enforcement Action
2. NONCOMPLIANCE IDENTIFICATION
A. REPORTS OCCURRENCES UNDER DOE ORDER 232.1,
OCCURRENCE REPORTING AND PROCESSING OF
OPERATIONS INFORMATION
B. CONTRACTOR INTERNAL REVIEWS
C. EXTERNAL REVIEWS
D. OTHER
3. THRESHOLDS FOR SIGNIFICANT NONCOMPLIANCES
A. PROGRAMMATIC OR MANAGEMENT DEFICIENCIES
(1) Repetitive or Recurring
(2) Programmatic Breakdown
(3) Intentional Violation of Nuclear Safety Requirement
(4) Significant Management Failure
(5) Misrepresentation
B. RELATIONSHIP OF DOE ORDER 232.1 SIGNIFICANT
OCCURRENCES TO THRESHOLD REPORTING
C. FAILURE OF ADMINISTRATIVE ACTIONS
D. MINOR NONCOMPLIANCES
E. TABLES LISTING THE MINIMUM SIGNIFICANT
NONCOMPLIANCE REPORTING CRITERIA
Table 3-1, PROGRAMMATIC OR MANAGEMENT
DEFICIENCIES
Table 3-2, DOE ORDER 232.1 SIGNIFICANT OCCURRENCES
Table 3-3, TABLES LISTING THE MINIMUM SIGNIFICANT
NONCOMPLIANCE REPORTING CRITERIA
4. NOTIFICATION METHODS
A. METHODS TO NOTIFY DOE
(1) Report Nuclear Safety Noncompliances to the Noncompliance
Tracking System (NTS)
(2) Report Minor Noncompliances to Contractor Self-Tracking
System
B. INITIAL REPORTS
5. NONCOMPLIANCE TRACKING SYSTEM
A. DESCRIPTION OF NONCOMPLIANCE B. CORRECTIVE
ACTIONS C. CONTRACTOR PAAA COORDINATOR D.
ORIGINATOR
6. CONTRACTOR TRACKING SYSTEM
7. SUMMARY OF DOE'S PHILOSOPHY
ADDENDUM - NONCOMPLIANCE TRACKING SYSTEM
USERS MANUAL
------------------------------------------------------------------------
1. INTRODUCTION
A. DEPARTMENT OF ENERGY ENFORCEMENT
AUTHORITY
The Price-Anderson Act provides indemnification to DOE
contractors who manage and operate nuclear facilities in the DOE
complex. In 1988, the Price-Anderson Amendments Act (PAAA)
was signed into law to continue this indemnification. The PAAA
subjects DOE indemnified contractors, subcontractors and
suppliers to potential civil and criminal penalties for violations of
DOE rules, regulations, and compliance orders relating to nuclear
safety requirements. As part of its agreement to continue the
indemnification coverage, Congress mandated that DOE enforce
nuclear safety requirements to minimize the risk to workers and the
public. The Enforcement and Investigation Staff, a DOE
organization, has the responsibility to carry out the statutory
enforcement authority provided to DOE in the PAAA. On August
17, 1993, DOE published its enforcement procedural rules and its
enforcement policy (Appendix A to Part 820, "General Statement of
Enforcement Policy). DOE's enforcement policy sets forth DOE's
strategy for ensuring contractor compliance with nuclear safety
requirements.
B. SUMMARY OF DEPARTMENT OF ENERGY GENERAL
ENFORCEMENT POLICY
The goal of the DOE enforcement policy is to enhance and protect
the radiological health and safety of the public and worker at DOE
facilities through a process that encourages timely identification
and open and prompt reporting and comprehensive correction of
noncompliance conditions. The cornerstone of the DOE
enforcement policy is voluntary compliance through contractor
initiatives to effectively understand and implement nuclear safety
requirements, critically self assess activities and promptly identify,
report and correct noncompliance conditions.
The following is a quote from 10 CFR 820, Appendix A:
"The single most important goal of the DOE enforcement program
is to encourage early identification and reporting of nuclear safety
deficiencies and violations of DOE Nuclear Safety Requirements
by the DOE contractors themselves rather than by DOE, and the
prompt correction of any deficiencies and violations so identified.
DOE believes that the contractors are in the best position to
identify and promptly correct noncompliances with DOE Nuclear
Safety Requirements.
"... it should be emphasized that if the DOE contractor is or should
have been aware of a violation and has not reported it to DOE and
taken appropriate corrective action despite an opportunity to do so,
each day the condition existed may be considered as a separate
violation and, as such, subject to a separate civil penalty."
The enforcement policy sets forth base civil penalties which are
determined by the Severity Level of a violation (Severity Level I, II,
or III) and the categorization of a facility as described in Table 1A
of the enforcement policy. DOE will apply a number of factors in
assessing each potential enforcement situation. In determining
whether a potential civil penalty will be mitigated, DOE will
consider, among other things, the opportunity available to discover
the violation, the ease of discovery, and the promptness and
completeness of the notification report to DOE and the corrective
actions. DOE will also consider other factors such as safety
significance, or administrative, management or programmatic
weaknesses in considering whether to mitigate a potential civil
penalty. No consideration will be given to a reduction in penalty if
the contractor does not identify the noncompliance in a timely
manner or does not take prompt action to report the problem to
DOE upon discovery and initiate appropriate corrective actions.
A report of a potential noncompliance in either the DOE
Noncompliance Tracking System (NTS) centralized data base or
the contractor's data base will not automatically initiate
enforcement action by DOE. Rather, DOE will review and evaluate
all available information prior to determining whether the potential
noncompliance has the requisite safety significance to warrant
commencing the formal enforcement process including initiating a
full investigation.
While it is preferable, a specific noncompliance issue does not have
to be submitted to DOE by the contractor before an enforcement
evaluation is initiated. A noncompliance issue may be brought
directly to the attention of the Enforcement and Investigation Staff
by external sources. If a formal enforcement investigation is to be
initiated as a result of information received from an external source,
the contractor will be promptly informed unless the nature of the
violation is such that this notification would compromise the
ability of DOE to properly complete the investigation. This
circumstance is expected to be a rare occurrence and normally
based on an egregious issue (such as intentional violation,
concealment or misrepresentation of information), or an allegation
raised by a confidential source. In any case, a noncompliance will
be reported to the contractor immediately by DOE if, left
uncorrected, it constitutes an immediate threat to the public or
worker health and safety.
DOE fully expects to rely on the accuracy and completeness of
information provided by its contractors. 10 CFR, Part 820.11
(Information Requirements) requires that any information
pertaining to a potential noncompliance provided to or maintained
for DOE by the contractor shall be complete and accurate in all
material respects. No person involved in a DOE nuclear activity
shall deliberately falsify conceal or destroy any information
concerning a noncompliance.
C. POLICY FOR CIVIL PENALTIES
Civil penalties are normally proposed for Severity Level I or II
violations, and for Severity Level III violations which are similar to
previous violations for which effective corrective actions were not
taken. If voluntary compliance activities are not effective and
violations of nuclear safety requirements occur, DOE is empowered
to initiate enforcement actions consistent with the procedural
requirements of 10 CFR, Part 820. The safety significance of the
violation, coupled with contractor performance in identification
and response, will play a major role in the enforcement process in
determining whether a Notice of Violation with or without a civil
penalty will be assessed.
Minor noncompliances of nuclear safety requirements will not be
subject to formal enforcement action. However, these minor
noncompliances should be evaluated by the contractors to assure
appropriate corrective action is taken to prevent recurrence, and to
determine if an aggregate of related minor noncompliances is
indicative of a programmatic breakdown warranting reporting as a
potentially significant noncompliance.
D. POLICY FOR POSITIVE INCENTIVES
As part of its enforcement policy, DOE has established positive
incentives through the application of adjustment factors to potential
civil penalties and through the exercise of discretion in not issuing
a Notice of Violation in some instances, for its contractors to do
the following:
Identify nuclear safety noncompliances in a timely manner;
Report thoroughly those noncompliances to DOE;
Conduct a root cause analysis of noncompliances; and
Promptly and comprehensively correct nuclear safety
noncompliances in a manner which precludes recurrence.
The application of the adjustment factors may result in substantial
reduction up to no civil penalty being assessed to a contractor for a
violation that is identified and reported in a timely manner, and
promptly and effectively corrected.
(1) Timely Identification and Reporting
Reduction of up to 50% of the base civil penalty may be given
when a DOE contractor promptly identifies the violation and
reports it to the DOE. In some instances DOE may conclude that
issuing even a Notice of Violation is not warranted if the above
criteria have been met. In weighing this factor, DOE will give
consideration to the opportunity available to the contractor to
discover the violation, the ease of discovery and the promptness
and completeness of the notification to DOE. Conversely, DOE
will not mitigate the base civil penalty if the contractor does not
promptly identify and report the violation.
a. Prompt Identification
DOE has not defined "prompt identification" in terms of hours or
days, since the facts of potential noncompliances will be evaluated
on a case by case basis. However, the following examples illustrate
how DOE will analyze various potential noncompliance situations.
Example 1. An event driven noncompliance, such as that related to
an unusual or emergency DOE Order 232.1 (Occurrence Reporting
and Processing of Operations Information), occurrence is reported.
Concurrently with this reporting, the contractor initiated an
evaluation without delay to determine if a potential noncompliance
condition exists and completes an evaluation promptly. Event is
determined to be a significant noncompliance. The time from the
event to the completion of the evaluation was about 15 days. DOE
would consider mitigation for such a case.
Example 2. An internal contractor audit, inspection, or surveillance
is completed and the findings suggest the existence of a
noncompliance condition. The contractor evaluates the information
to determine whether a potential noncompliance condition exists
and if so, how long the noncompliance condition existed without
being detected. This evaluation is completed within about 15 days,
and the condition was found to exist for only a few weeks. DOE
would consider mitigation for such a case.
Example 3. The contractor receives notification of a potential
noncompliance from an external source such as a state agency, the
Defense Nuclear Facilities Safety Board, or onsite DOE personnel.
DOE expects that the contractor will complete an evaluation
without delay to determine if a potential noncompliance condition
exists. However, mitigation will likely not be appropriate because
the problem was not identified by the contractor.
Example 4. An internal audit is completed at a facility. The scope
of the audit is inadequate, or it was conducted improperly. Six
months later a noncompliance, which should have been uncovered
during the audit, is identified. Alternatively, a violation of a
technical safety requirement is identified. Investigation established
that the technical specification violation had existed for 30 days
because required surveillances were not performed. In either case
DOE would likely not consider reducing a civil penalty, as the facts
do not indicate that identification of the noncompliance was
prompt.
b. Prompt Reporting
For enforcement purposes, prompt reporting is generally that done
within 20 calendar days after determining that a potential
noncompliance condition exists. Example 1: A Facility Manager
completes a walk-down of a facility. During the preparation of the
written report, a potential noncompliance was noted. He assigns an
area supervisor to review the situation. The supervisor takes five
days to determine that a potential noncompliance existed. The
noncompliance report was lengthy and required a review by a
subject matter expert. As a result, the noncompliance was not
reported to DOE until 15 days after the noncompliance was
identified. This example is still timely, considering the
circumstances. DOE would consider mitigation for such a case.
(2) Prompt and Comprehensive Corrective Actions
The promptness of and extent to which the contractor takes
corrective actions may result in a 50% decrease in a base civil
penalty. It is believed that most investigations and causal analysis
should be completed within 45 days of determining that a potential
noncompliance exists. Only those corrective actions that are
sufficiently comprehensive to prevent recurrence will warrant
mitigation considerations of civil penalties. DOE anticipates that
corrective actions and implementation plans will be identified
during this time period as well.
E. APPLICABILITY OF DOE ENFORCEMENT POLICY
The enforcement policy applies to all indemnified DOE
contractors, subcontractors and other suppliers who are responsible
for performing activities or supplying services or products that are
subject to DOE nuclear safety requirements. For purposes of
assessment of civil penalties or issuance of Notices of Violation,
DOE nuclear safety requirements are defined in 10 CFR, Part
820.20 (b), as the following:
DOE nuclear safety rules set forth in the CFR;
Compliance Orders issued pursuant to 10 CFR Part 820 Subpart
C; and
Any DOE approved program (including any commitment therein),
plan, or other provision required to implement any nuclear safety
requirement or Compliance Order identified above.
The substantive nuclear safety rules which have been published in
their final form, or are scheduled to be published include the
following:
10 CFR, Part 820.11 Information Requirements
10 CFR, Part 830.110 Safety Analysis Reports
10 CFR, Part 830.112 Unreviewed Safety Questions
10 CFR, Part 830.120 Quality Assurance
10 CFR, Part 830.122 Defect Identification and Reporting
10 CFR, Part 830.310 Conduct of Operations
10 CFR, Part 830.320 Technical Safety Requirements
10 CFR, Part 830.330 Training and Certification
10 CFR, Part 830.340 Maintenance Management
10 CFR, Part 830.350 Categorization, Notification, Reporting,
and Processing of Operational Occurrences
10 CFR, Part 834 Radiation Protection for the Public and the
Environment
10 CFR, Part 835 Occupational Radiation Protection
10 CFR, Part 708 Contractor Employee Protection
F. DEFINITIONS
(1) Contractor
The term contractor includes the Management and Operations
contractor as well as its subcontractors and suppliers.
(2) Radiological Activities
The rules in 10 CFR, Part 835, are applicable to all DOE activities
involving occupational exposure to ionizing radiation of DOE
employees and/or DOE contractor or subcontractor employees,
except for an activity specifically excluded under Part 835.1(b).
(3) Nuclear Facilities
The requirements in 10 CFR, Part 830, are applicable to DOE
nuclear facilities only, unless otherwise excluded specifically in a
particular rule. Nuclear facilities are defined in 10 CFR 830.3
(Definitions).
(4) Noncompliance
The term noncompliance and violation are essentially
interchangeable in that both terms connote a failure to comply with
an applicable nuclear safety requirement. Noncompliances
(violations) having the requisite safety significance will be subject
to Notices of Violation and if appropriate, civil penalties. Isolated
minor noncompliances involving minimal or low safety significance
will normally not be subject to enforcement action unless they are
repetitive or have multiple examples indicative of a larger
programmatic breakdown.
(5) Enforcement Action
The issuance of a Notice of Violation with or without a civil
penalty.
------------------------------------------------------------------------
2. NONCOMPLIANCE IDENTIFICATION
Each contractor should identify potential noncompliances that
occur at its respective nuclear facility(s) or nuclear activities. To the
extent practical, contractors should use existing programs to
promptly identify potential noncompliances with DOE nuclear
safety requirements and to implement appropriate corrective
actions. DOE expects that a review for potential noncompliances
will be an integral part of facility operations via the various
methods of assessment or oversight activities. The following are
examples of methods for or sources of identifying potential
noncompliances by DOE's contractors.
A. REPORTS OCCURRENCES UNDER DOE ORDER 232.1,
OCCURRENCE REPORTING AND PROCESSING OF
OPERATIONS INFORMATION
Analysis of occurrence reports prepared in accordance with DOE
Order 232.1 will be a significant opportunity for contractors to
identify potential noncompliance conditions. Any occurrence report
that involves a nuclear facility or radiological activity should be
reviewed to determine if the event resulted from or caused a
noncompliance.
B. CONTRACTOR INTERNAL REVIEWS
Another source to identify potential noncompliance conditions will
be contractor internal audits, assessments, surveillances, design
reviews, walk-downs and inspections. These reviews are conducted
by the contractor in accordance with existing DOE orders and
requirements, and should include a review of the findings for
potential nuclear safety noncompliance issues.
C. EXTERNAL REVIEWS
A third source of potential noncompliance identification is external
audits, assessments, surveillances, inspections, and visits
conducted by the DOE Headquarters Oversight, Field, Site, or
Operations Office, Defense Nuclear Facility Safety Board, or the
other agencies from the state or Federal government such as EPA,
DOT, or OSHA. The potential noncompliance should be identified
to the contractor. If the contractor has an effective self
audit/surveillance program, there should be a minimal number of
noncompliances identified through this mechanism.
Depending on safety significance or other factors, these
noncompliances may be candidates for enforcement action because
they were not identified by the contractor. However, DOE may
refrain from issuing a civil penalty for a violation if the contractor
requested assistance from DOE or another government agency in
resolving problems and the noncompliance was discovered by the
outside agency while giving assistance. These noncompliances,
once identified to the facility management, should be evaluated for
safety significance and reporting in accordance with the criteria set
forth in this Handbook.
D. OTHER
The fourth source of potential noncompliance identification will be
from management oversight and worker involvement in the facility
operation. Sources may be allegations or concerns from the
whistleblower program or local or external "Hot Line Operations,"
media reports, congressional inquiries, and issues that are brought
to the attention of management.
------------------------------------------------------------------------
3. THRESHOLDS FOR SIGNIFICANT NONCOMPLIANCES
The first threshold to be met is whether the occurrence or condition
is a potential noncompliance with a nuclear safety requirement
based on a PAAA Rule or a DOE approved Implementation Plan.
Once it is established that the occurrence or condition in question
is indeed a potential noncompliance with a nuclear safety
requirement, then it should be appropriately documented and
corrected. Significant safety noncompliances should be reported to
DOE through the NTS. Other noncompliances should be reported
through contractor self tracking processes. Thus identifying and
reporting these noncompliances enable DOE to consider mitigation
of any civil penalties that may arise. Criteria for determining
whether a noncompliance is "significant" have been developed by
DOE to aid the contractor in flagging those noncompliances that
should be reported in the NTS. These threshold criteria aid in the
identification of those significant noncompliances which, because
of their potential or actual adverse impact to the environment or the
health and safety of workers or the public, merit additional
management evaluation by both the contractor and DOE.
The Enforcement and Investigation Staff, in coordination with
appropriate DOE field elements, will review those potential
noncompliances reported by the contractor as meeting a safety
significant threshold criterion. The contractor will be notified
through the onsite DOE PAAA Coordinator of those reported
noncompliance issues which have been determined to be more
appropriately resolved through the existing processes, rather than
through the formal enforcement process.
The three sections in Table 3 may assist the contractor in
determining if the noncompliance is significant or minor. All three
sets of criteria should be reviewed in order to make this conclusion.
The following describes the three sections of the Table:
3-1 Programmatic or Management Deficiencies:
This set of criteria, described in Table 3-1, considers failure of
management or programmatic impacts surrounding the
noncompliance.
3-2 Minimum Criteria based on DOE Order 232.1:
A significant noncompliance may fit certain well-defined minimum
criteria easily recognizable by the contractor. These types of
noncompliances are based on the Nature of Occurrence subgroup,
and Occurrence Category as defined in DOE Order 232.1
Occurrence Reporting and Processing of Operations Information,
and are listed in Table 3-2.
3-3 Failure of Administrative Actions:
This set of criteria, based on failure of administrative actions, are
described in Table 3-3.
Where there is legitimate disagreement between the contractor and
DOE whether a potential noncompliance should be reported in the
NTS, it is recommended that the disagreement be addressed at the
appropriate level between DOE and contractor management. If
agreement cannot be reached, the contractor is encouraged to report
the potential noncompliance. The contractor may note its
disagreement with DOE in the NTS.
A. PROGRAMMATIC OR MANAGEMENT DEFICIENCIES
Programmatic or management deficiencies require more judgement
than the application of the criteria noted in Table 3-2 and are
indicative of programmatic, management or conduct of operations
deficiencies that aggravate the situation. These deficiencies might
be identified while performing trending and analysis of the minor
noncompliances data. Other issues might be uncovered during the
investigation and causal analysis of minor noncompliances.
Identification of any of these can be viewed as a potential
"significant" noncompliance to be reported into the NTS. Examples
of these programmatic or management deficiencies follow. These
noncompliances should be treated as significant, even though they
might be otherwise below the significant noncompliance threshold
level of Table 3-2.
(1) Repetitive or Recurring
The same noncompliance or a closely similar noncompliance has
continued to occur, indicating the corrective action, including root
cause determination, has not been effective.
Example 1: A component in a critical safety system required to be
operable by TSR requirements was found to be inoperable, but did
not fit the Unusual Occurrence for subgroup C of Facility
Condition, since a redundant train was functional and the safety
function could thus still be performed. The condition was also
within the design basis for the facility and did not violate a TSR.
Root cause evaluation concluded that normal system wear had led
to the problem and that preventive maintenance (PM) was required
to preclude similar recurrence. Corrective actions to restore the
system to operable status and changes to PM procedures were
performed. Subsequently, a similar failure in the other train
occurred, and was attributed to the same causes. Failure to
implement remedial actions on the other train, when the deficiency
in the PM procedures was previously identified, was determined to
have led to the additional critical safety system degradation.
Inadequate implementation of the corrective action led to the
recurrence. Once it was established that this failure was repetitive,
indicating the previous corrective action had not been effective, the
noncompliance was determined to be significant and reported
through NTS.
(2) Programmatic Breakdown
Several minor, related but not identical noncompliances have
occurred, indicating a common breakdown in a program or area of a
program. A total collapse of the program does not have to occur
before the event is categorized as a "Programmatic Breakdown".
Rather, it might involve a common cause of related noncompliances
indicating a weakness in the program which allowed or contributed
to the noncompliances occurring. A programmatic breakdown
generally involves some weakness in administrative or management
controls (or implementation of these) to such a degree that
systematic problems, including noncompliances, occur. This
weakness might be identified as part of the root cause
determination for a single event. Or it might be identified by the
presence of multiple control failures within the boundaries of a
single occurrence, failures which indicate a common breakdown in
a program or area of a program.
Example 2: While disposing of radiologically contaminated
equipment, personnel did not follow work package instructions to
notify radiological control technicians for survey of the equipment
before beginning work. Therefore, the workers did not know the
exact contamination or radiations levels with which they were
dealing. In addition, the work was done under a radiation work
permit that did not cover the scope of work to be performed. The
bag holding the contaminated equipment was inadvertently cut
during disposal work, and was repaired by taping over the cut,
rather than by overbagging. The repair method was inadequate to
prevent contamination of the exterior of the bag, and of the floor
beneath the bag. These multiple instances of failure to follow
approved procedures during the occurrence led to the determination
that there had been a reportable breakdown within the boundaries
of the occurrence.
Example 3: A fire occurred in an area that contained critical safety
equipment, but did not threaten the equipment before manual
suppression systems extinguished the fire. The fire did not activate
a fire suppression system. The fire event was determined to be an
Off-Normal Occurrence under the Fire/Explosion category.
Investigation of the fire established that personnel performing a
welding repair activity inappropriately introduced some
combustible material into the area without providing adequate
protection. This action was not in accordance with administrative
procedures for control of welding activities. Further review found
that these personnel had not received their required training in
these administrative procedures. Similar occurrences of personnel
not receiving required training had been identified in other events,
some of which were not noncompliances. Because of these similar
programmatic breakdowns in the area of training, this latter
determination of lack of adequate training was determined to be a
programmatic breakdown.
(3) Intentional Violation of Nuclear Safety Requirement
Example 4: An individual intentionally violated a nuclear safety
requirement. The contractor later determined that the individual's
actions were willful, although this aspect was not known
immediately. This finding, however, should flag the contractor to
notify DOE, including through the NTS, without delay once the
noncompliance was found to involve some willful aspects.
Example 5: A facility supervisor directs a radiological control
technician not to perform scheduled contamination surveys to avoid
paying overtime. The survey records were then falsified to indicate
that the surveys were performed when, in fact, they were not. Even
though not meeting any of the criteria of Table 3-2, this potential
noncompliance should be considered significant since it involved a
willful violation.
(4) Significant Management Failure
This criteria involves a significant breakdown in management
processes or actions.
Example 6: A contractor supervisor decides to allow a schedule
date in an approved Rule Implementation Plan to be missed, due to
pressing demands to complete some repair activities to critical
Safety Class equipment. The supervisor had the opportunity to
request a schedule change to the Implementation Plan or notify
DOE that the schedule date would be missed; he did not do so. The
supervisor was aware that his actions would represent a
noncompliance, but judged that since it was below the Table 3-2
minimum criteria, the noncompliance was not significant. Once the
contractor PAAA Coordinator became aware of the occurrence, he
concluded that it was potentially a significant management issue
even though it was otherwise below the Minimum Criteria in Table
3.2. Therefore he reported it through the NTS for evaluation.
Example 7: Radioactive contamination was found on an individual
who had not been working in a facility controlled area. Since the
contamination level was low, the event was classified as an Off-
Normal occurrence under the Personnel Contamination category.
Management initially determined that the investigation of the
occurrence was a low priority. Shortly thereafter, several additional
cases of contamination on personnel occurred, where personnel had
also not been working in facility controlled areas. Some of these
cases required off-site medical assistance. These cases constitute a
significant safety issue, and were determined to be above the
Minimum Criteria of Table 3-2 and thus reported. Additionally,
since the potential significance of the first issue was not
appropriately recognized by management, it was subsequently
determined to be significant and reported through the NTS.
(5) Misrepresentation
Misrepresentation includes the following: intentional concealing of
facts to avoid identifying the occurrence as a nuclear safety
noncompliance; falsification of records or reports; or intentional
reporting of inaccurate or incomplete information to the internal
self-tracking system.
Example 8: A supervisor found that a surveillance required to be
performed on a piece of critical Safety Class equipment had been
performed incorrectly by one of his staff, and that if re-performed
would be outside the required frequency for the surveillance. The
supervisor decided not to raise the issue of the incorrectly
performed maintenance. Subsequently, an employee aware of the
situation raised the concern to senior management. Once the
concern was validated, management decided that the occurrence
represented a noncompliance, which was below the Minimum
Criteria of Table 3-2 (i.e., it was an Unusual Occurrence for
Subgroup 1.F), but should be reported through NTS since it
involved misrepresentation of information.
If the noncompliance does not meet the Table 3-1 criteria, it should
be reviewed against the criteria of Tables 3-2 and 3-3 as described
in the following.
B. RELATIONSHIP OF DOE ORDER 232.1 SIGNIFICANT
OCCURRENCES TO THRESHOLD REPORTING
To obtain consideration for mitigation of civil penalties, any
noncompliance that meets the criteria in Table 3-2 should be
reported to the NTS as a potential safety significant
noncompliance. These criteria are based on the Nature of
Occurrence and Occurrence Category in DOE Order 232.1.
C. FAILURE OF ADMINISTRATIVE ACTIONS
Certain failures of administrative actions should be reported as
significant noncompliances, even if the criteria of Tables 3-1 and 3-
2 are not met. The criteria are listed in Table 3-3, Failure of
Administrative Actions.
D. MINOR NONCOMPLIANCES
Noncompliances that do not meet the criteria of Tables 3-1, 3-2 or
3-3 are tracked by a contractor's existing internal tracking process.
E. TABLES LISTING THE MINIMUM SIGNIFICANT
NONCOMPLIANCE REPORTING CRITERIA
Table 3-1, PROGRAMMATIC OR MANAGEMENT
DEFICIENCIES
Repetitive Programmatic Breakdown Intentional Violation
Significant Management Failure Misrepresentation
Table 3-2, DOE ORDER 232.1 SIGNIFICANT OCCURRENCES
NATURE OF OCCURRENCE
SUBGROUP
OCCURRENCE CATEGORY
1. Facility Condition A. Nuclear Criticality Safety Unusual B.
Fires/Explosions Unusual C. Safety Status Degradation Unusual D.
Loss of Control of Radioactive Material/Spread of Contamination
Unusual E. Vital/System Component Degradation Unusual F.
Violation/Inadequate Procedures Unusual G. Unsatisfactory
Surveillance/Inspections Unusual H. Operations Unusual 2.
Environmental A. Radionuclide Releases Unusual C. Hazardous
Material Contamination Unusual 4. Personnel Radiation Exposure
A. Personnel Radiation Exposure Unusual B. Personnel
Contamination Unsual
Table 3-3, FAILURE OF ADMINISTRATIVE ACTIONS Failure
to activate the site emergency plan as required as a result of a
noncompliance issue. Failure to complete a significant action as
identified in a DOE-Approved PAAA Implementation Plan. Failure
to meet a DOE PAAA Compliance Order. Failure to identify and/or
report to DOE an Unreviewed Safety Question.
------------------------------------------------------------------------
4. NOTIFICATION METHODS
A. METHODS TO NOTIFY DOE
Discussed below is the method by which potential noncompliances
of nuclear safety requirements can be reported to DOE.
1.Report Nuclear Safety Noncompliances to the Noncompliance
Tracking System (NTS)
To obtain consideration for mitigation of civil penalties based on
prompt identification and reporting, the contractor should report
potential noncompliances to the DOE-sponsored centralized data
base referred to as the Noncompliance Tracking System (NTS) for
those violations meeting the threshold criteria in Tables 3-1, 3-2 or
3-3. The use of the NTS is discussed in detail in Section 5,
Noncompliance Tracking System.
2.Report Minor Noncompliances to Contractor Self-Tracking
System
The contractor would use the NTS to report significant potential
noncompliances to DOE and would maintain its own systems for
reporting and tracking the minor potential noncompliances.
(Generally any potential noncompliance that does not fall within
the criteria of Table 3.1, 3.2, or 3.3 would be tracked by the
contractor in its existing local self-tracking system.) Should one of
these noncompliances be reviewed subsequently by DOE and
considered for enforcement action, the contractor's recording and
self-tracking of the noncompliance, will be considered to be
contractor identified and reported for purposes of consideration for
mitigation under the enforcement policy.
However, a significant mis-characterization of the facts or safety
significance surrounding the circumstances of the noncompliance
has the potential to negate any consideration for mitigation.
B. INITIAL REPORTS
DOE understands and accepts that the initial description of the
potential noncompliance provided by the contractor may be limited.
Full investigation into the noncompliance and a causal analysis by
the contractor is not required before the potential noncompliance is
reported to DOE. Because full investigation is not required for the
initial report, DOE will not pursue an enforcement action based
solely upon the initial description of a potential violation provided
by the contractor. In other words, a report of a potential
noncompliance in either the centralized NTS data base or the
contractor's data base will not be taken as a conclusion that a
significant noncompliance actually exists. Rather, DOE will review
and evaluate all available information prior to determining whether
the potential noncompliance has the requisite safety significance to
warrant commencing the formal enforcement process.
------------------------------------------------------------------------
5. NONCOMPLIANCE TRACKING SYSTEM
A centralized data base allows contractors to promptly report
significant potential noncompliances and take advantage of the
mitigation provision of the enforcement policy. This data base,
called the Noncompliance Tracking System (NTS), will be linked
to the PC ORPS and automatically copy pertinent data from certain
ORPS fields into the corresponding centralized data base fields,
thereby reducing data entry.
DOE prefers that significant potential noncompliances, as defined
in Section 3, Thresholds for Significant Noncompliances, be
reported in the NTS and that the minor noncompliances be reported
in the contractor's tracking system.
Reporting of a potential minor noncompliance in the contractor's
tracking system constitutes formal reporting to DOE for PAAA
enforcement purposes.
The system requirements for accessing and use of the NTS are
included in the appended NTS Users Manual. However, additional
guidance for input of information into several of the fields is
provided below.
A. DESCRIPTION OF NONCOMPLIANCE
This field should contain a clear, concise, factual, and objective
description of the noncompliance to include any impact on the
environment, safety, and health.
If the information in this field is not clear or if more information is
deemed necessary, a DOE representative might contact the
contractor for additional information. As stated earlier, DOE will
not take enforcement action based solely upon information in the
NTS.
B. CORRECTIVE ACTIONS
The three fields pertaining to corrective actions include the target
and actual completion dates for corrective actions as well as a brief
summary addressing the root cause and the corrective action. The
contractor is expected to take as many corrective actions as needed
to prevent the noncompliance from recurring. The contractor need
not list every corrective action used to prevent recurrence, but
should list the significant corrective actions.
The noncompliance condition should be corrected for the nuclear
facility at which the noncompliance occurred as well as any other
nuclear facilities under the management of the respective M&O or
not-for-profit contractor. These corrective actions are not required
to be approved by the DOE, however, the DOE may be involved in
the selection of the corrective action if there will be a significant
commitment of funds or a request for additional funds to correct
the noncompliance.
Once the corrective actions have been completed and entered into
the NTS, the contractor has the option of closing the report at that
time or leaving it open for an additional 45 days. The NTS will not
allow a noncompliance report to be closed until all reported
corrective actions have been completed. The NTS computer system
will automatically close the report 45 days after the last corrective
action has been entered. This option allows the contractor to add
corrective actions, if appropriate, within the 45 day window after
completion of the last corrective action.
Corrective actions as described in the NTS are primarily for
tracking and closure purposes; it is not a forum to argue the
comprehensiveness of corrective actions. If an enforcement action
is contemplated, the contractor will have the opportunity to discuss
corrective actions during the enforcement review process. As noted
earlier, the contractor will have ample opportunity to update,
provide more detail or add more corrective actions to a
noncompliance report in the event it is being considered for
enforcement action by DOE.
C. CONTRACTOR PAAA COORDINATOR
The NTS will enter the name and phone number of the person
transmitting this report to the NTS system based on the
authorization password.
D. ORIGINATOR
The fields associated with the originator will show the name, phone
number, and organizational title of the person most knowledgeable
about the noncompliance. The Enforcement and Investigation staff
will initially contact this person for additional information, if
necessary. The contractor may designate other personnel as points
of contact to work with the DOE Investigator.
------------------------------------------------------------------------
6. CONTRACTOR TRACKING SYSTEM
The contractor can record minor noncompliances in its existing
local tracking system at each facility or site as appropriate. The use
of a local tracking system will serve as the official notification to
DOE of any minor noncompliance of nuclear safety requirements as
well as an audit trail for corrective actions. DOE does not require,
nor will it provide, any new funding for developing and maintaining
a special tracking system for PAAA purposes.
------------------------------------------------------------------------
7. SUMMARY OF DOE'S PHILOSOPHY
The following is a summary of DOE's philosophy for meeting the
spirit and intent of the noncompliance reporting program. An
implementation plan is not required in support of this Handbook.
a. Events or conditions are reviewed for potential noncompliance
with a DOE Nuclear Safety Requirement,
b. Each potential noncompliance is categorized as either significant
or minor,
c. The noncompliance report is prepared, reviewed and coordinated
internally as required and transmitted to the NTS or contractor
tracking system,
d. Minor noncompliances reported in the contractor's tracking
system are periodically reviewed for trends. Significant trends are
reported to the NTS as appropriate.
e. Noncompliances are appropriately corrected.
f. Complete files for PAAA purposes are to be maintained for a
period of two years. However, files may need to be maintained for
an additional time period in accordance with contractual,
procedural, or Federal requirements,
g. Only designated contractor personnel are authorized to transmit
reports to the NTS (Term Enforcement Coordinator is used on the
NTS),
Note: The number of personnel designated to transmit the initial
report and to update corrective actions should be limited to ensure
that incorrect information is not put on the system.
h. Designate a point of contact for each significant potential
noncompliance (The term Originator is used in the NTS report.)
Note: This person should be knowledgeable about the
noncompliance. He/she should be able to answer any technical
questions about the noncompliance or identify individuals with the
best knowledge to discuss the issue and be able to assist the DOE
during any initial inquiries about the potential noncompliance.
Details on use of the NTS are provided in an appended document,
NTS Users Manual.
------------------------------------------------------------------------
CONCLUDING MATERIAL
Review Activity:Preparing Activity:DOEDOE-EH-3
EH
Project Number:
SAFTOO46
National Laboratories
ANL (West)
LLNL
LANL
Sandia
Contractors
Martin Marietta Speciality Components
Westinghouse - SR
Westinghouse Hanford
West Valley Nuclear Services
Martin Marietta - OR
Westinghouse WIPP
FERMCO
EG&G Mound
EG&G - RF
REEC - NV
INEL
United States Department of Energy
Office of Scientific and Technical Information
Post Office Box 62
Oak Ridge, Tennessee 37831
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