The Health and Safety Executive (HSE) has today made available a previously unpublished memorandum containing observations written last year by a member of HSE's Nuclear Installations Inspectorate (NII). The memorandum concerns the Fuel Cycle Area (FCA) at the United Kingdom Atomic Energy Authority's (UKAEA's) Dounreay plant in Caithness, Scotland. (The FCA was built to reprocess spent, irradiated, nuclear fuel to recover usable products and to process unirradiated nuclear materials for a variety of purposes).

  Reference was made to the memorandum in the Site Inspector's quarterly report for the period July to September 1997 published in October 1997. There have been a number of requests for release of the memorandum recently including parliamentary questions from MPs, and a request for sight of it from the House of Commons Select Committee on Trade and Industry.

  It has not been possible to publish it hitherto for legal reasons to do with its potential impact on matters which the UKAEA regarded as commercially confidential. However the announcement on 5 June that commercial reprocessing would cease at Dounreay removed the barrier to publication. The UKAEA has agreed to publication of the document. A copy is attached.

  Commenting today David Eves, Deputy Director General of HSE, said:

"Dounreay is an old site which has recently gone through substantial management change. Last summer NII's site inspector expressed a number of concerns about the FCA. These have led to a programme of improvements. HSE is currently conducting an audit which, inter alia, will establish what has so far been achieved and what remains to be done.

"The site inspector's memorandum was written in order to trigger a dialogue with the management and a programme of safety improvements in the FCA—which it did. For that reason it was written in blunt terms. Its status is not that of a considered HSE/NII report prepared for publication. It is an example of a vigorous communication of a kind that inspectors use from time to time as part of the regulatory dialogue.

"We are publishing at the same time a summary of the memorandum which is intended to help public understanding of a communication which was part of the regulatory process. These observations and the response by UKAEA to them will be taken into account by the NII/Scottish Environment Protection Agency team which is currently carrying out an audit of the management of safety at Dounreay.

"At the present time the issues are being actively considered by the UKAEA. It is HSE's opinion that currently the site is not unsafe."

NOTES TO THE EDITORS

  1.  The House of Commons Select Committee on Trade and Industry is conducting an inquiry into the shipment of nuclear fuel which took place in April from Georgia to Dounreay. The Committee is holding a public session at Thurso, near Dounreay, today, and Mr Eves will answer questions on behalf of HSE. HSE was consulted about the movement of the Georgian fuel to Dounreay, and its storage there, and was satisfied that this could be done safely.

  2.  Currently the Fuel Cycle Area is closed following a Direction issued by the NII after an incident on7 May in which electrical supply to the FCA was interrupted. HSE and SEPA also brought forward a planned audit of the management of safety at the Dounreay site which had been scheduled for later in the year.

15 June 1998

INTRODUCTION

  1.  This is a summary of the findings of a series of inspections which were made between September 1996 and February 1997 in the Fuel Cycle Area (FCA) at Dounreay. It is based upon the internal NII report referred to in the NII Quarterly report to the Dounreay Local Liaison Committee covering the period 1 July-30 September 1997.

  2.  This summary addresses:

(a)  the scope of the inspection findings, and

(b)  the key general issues raised by the inspection findings.

SCOPE OF INSPECTION FINDINGS

  3.  The inspections covered both the design and engineering condition of all the main safety-related plants in the FCA. Thus the inspection findings addressed deficiencies associated with the reprocessing plants, the waste management plants, the waste storage plants, the fuel manufacture and storage facilities and the laboratories. The inspections and the resultant findings also extended to plants that were declared by UKAEA to be in a "care and maintenance" regime or which were undergoing "post operational clean out" (POCO). Some minor plants were not inspected because of resource constraints. The observations upon which the findings are based were acknowledged to be incomplete, but they gave a good indication of both the nature and extent of the problems facing UKAEA in the light of modern standards.

  4.  The inspection observations were grouped into various general categories which were then described in notes and with examples to clarify the general issues which each category raised. The inspections and their findings also extended to a general consideration of UKAEA procedures, resourcing in the FCA and contractors. Plant safety management practices such as operating procedures, safety cases, criticality safety, maintenance, safety working parties and training were considered, as were project management practices including project safety categorisation.

  5.  The report was sent to UKAEA in June 1997. The UKAEA was requested to inform NII of their plans to identify any similar deficiencies elsewhere and to then remedy them all once an agreed way forward had been established.

KEY GENERAL ISSUES RAISED BY INSPECTION FINDINGS

  6.   Reasonably practicable engineering improvements to both plant design and condition, in the light of modern standards: There were instances of poor plant design and engineering condition which would benefit from improvements that are reasonably practicable. Many of the plants are old now and the deficiencies covered a range of fundamental aspects of plant design such as containment, ventilation, shielding and instrumentation. There were instances where known problems had not been dealt with. The findings also pointed to instances of long-standing, temporary radiological shielding and/or temporary health physics barriers. These had been erected in locations either where spillages or accidents had occurred in the past or where poor plant design had in practice been unable to meets its intended duty of containment or shielding.

  7.   Waste management practices and strategies: The findings pointed both to deficient current practices and strategies for waste management that were either short term or absent. The strategies did not address the receipt, processing and storage in the long term of decommissioning wastes. Drummed waste in increasing quantities and redundant equipment including many flasks was being accumulated in operating areas in some plants. ISO containers were being used in some areas for temporary storage.

  8.  Shielded cave facilities that were once used for active handling work were being used to store both waste that had been generated at the time the plant was operating, and spent fuel. In one case, spent fuel was being stored in a plant that had been declared to be in a "care and maintenance" regime and was being operated by a contractor.

  9.  The FCA waste management operational strategy had been halted by an instrument failure associated with the one plant that was central to the continuing process of waste sorting and sentencing. This had caused a build up of waste to occur elsewhere and within the facility itself, which was designed to take normal operational, rather than POCO and decommissioning wastes. The use of the wet silo for the storage of intermediate level waste continued.

  10.   POCO and "care and maintenance": POCO was outstanding for a number of facilities, with two particularly poor examples. Some facilities had been re-categorised as being under a "care and maintenance" regime when POCO had not yet taken place. The availability of suitably qualified and experienced operational staff who would have known the plant in detail and been able to undertake this activity had been prejudiced in some instances either by them being offered early retirement or by the divestment of either AEA(T) or Johnson Controls.

  11.   Safety cases: In the sample examined the content, approach to, and use of, plant safety cases was found to be deficient; as was the Safety Working Party system itself. This was in relation to the assessment of both plant design and condition in the light of modern standards, operating directives, operating rules, maintenance schedules, and safety mechanisms. Criticality safety assessment was not an integral part of the safety case but a parallel activity. UKAEA's own expertise in the subject of criticality was deficient because of the divestment of that expertise to AEA(T). Consequently AEA(T) was then providing a service back to the site that was being less than adequately controlled and monitored by UKAEA.

  12.   Safety categorisation of projects and plant modifications: The under categorisation of some new projects and some plant modifications was found to be taking place. The sub-division of the projects and modifications into a number of smaller parcels of work, thereby attracting lower categorisations, was also found to be taking place. The operation of the system was thus deficient. There were instances where the safety significance of work associated with fissile material was under-categorised and the basis for the approach to categorisation was found to be deficient.

  13.   Safety instructions, operating instructions, and maintenance procedures: The centrally-run UKAEA Corporate Safety Instructions (CSIs) appeared to be less than helpful to the Dounreay site infrastructure with its Director and its (then) Dounreay Management Team comprising of UKAEA and the consortium of contractors working in accordance with the Management Support Contract. The linkage between the requirements of the Conditions attached to the Nuclear Site Licence for Dounreay and the CSIs was less than clear.

  14.  Plant operating instructions were found to need improvement in a number of instances. Contractors had been brought in to revise the operating instructions for one particular plant and the need for a complete set of maintenance procedures covering safety related equipment was not seen as being an issue in the proposed divestment of the FCA's Engineering Services Group (ESG).

  15.   Training and Suitably Qualified and Experienced Persons (SQEPs): In the sample examined, there were deficiencies found in training records, instructions and in the ability of some staff to demonstrate an adequate knowledge of their plant. Resources for plant support were in short supply and plant managers were hard pressed to fulfil their responsibilities. There was an apparent vacuum between the plant managers and the remainder of their line management which was reinforced by the renewal process for the plant manager's Authority To Operate (ATO).

INTRODUCTION AND SUMMARY

  1.  The attached set of observations were made between September 1996 and February 1997 during a series of inspections in the FCA. The observations have been grouped into categories that are listed over leaf and then individually described with brief notes and examples where appropriate, to clarify the general issues they raise. General conclusions are drawn.

  2.  It should be noted that the attached set of observations are incomplete and it would be incorrect to assume otherwise. The inspections were no more than a series of brief visits to some of the more major plants in the FCA—in effect, no more than a "quick look round". This means that the inspections would not have revealed all deficiencies and moreover, there are some plants/buildings that have still not been visited.

  3.  The sample size and range of plants inspected strongly suggests that similar deficiencies are to be found elsewhere in the FCA and also perhaps elsewhere on the Dounreay site at PFR, DFR or the MTR. Significantly, the deficiencies are not all associated with just plant and equipment. Many are also associated with the softer issues of management of safety and safety culture. Some also relate to the management of change, resources and the structure of the organisation itself.

THE WAY FORWARD

  4.  A July meeting has been arranged with UKAEA to discuss with them the general and specific issues that arise from the categorised observations. The meeting has been arranged with a view to helping UKAEA commence the process of dealing with the specific problems to agreed timescales. in the mean time, this summary of observations has been sent to the site with a request that UKAEA gives them considerationwith a view to informing us of their plans to identify any similar deficiencies elsewhere and to then remedy them all.

CATEGORISATION OF MAJOR DEFICIENCIES

  5.  The attached observations have been grouped into the following categories which themselves give a very good indication of the sheer extent of the problems facing the UKAEA at Dounreay:

—  plant design and engineering condition, both in the light of modern standards:

—  containment


—  ventilation


—  shielding


—  instrumentation

—  long-standing "temporary" shielding and/or barriers in lieu of clean up/redesign/refurbishment

—  waste management strategy: wet silo/in-cave storage of fuel/waste posting cell

—  POCO outstanding for a number of facilities, including some already in "care and maintenance"

—  lab 33: simply unacceptable

—  operating plant in so-called "care and maintenance"

—  safety cases

—  plant design and engineering condition, both in the light of modern standards


—  operating directives, operating rules, maintenance schedules (EMITS), safety mechanisms (Key Safety Related Equipment?)


—  Nuclear safety assessments (criticality assessments), conditions and limits


—  SWP involvement

—  project categorisation and sub-division

—  maintenance procedures and equipment lists

—  SQEPs, DAPs and training

—  ATOs, ATO-holders, bureaucracy and SWPs

—  nuclear site licence conditions and CSIs

—  conflict between POG operations and DMT/loss of control/timescales:

    "us and them" attitudes and interface management

  6.  It should be noted that a particular observation may be representative of more than one of the above categories. Significantly, management of safety issues lie at the root of many of them.

PLANT DESIGN AND ENGINEERING CONDITION, BOTH IN THE LIGHT OF MODERN STANDARDS

  7.  Many of the plants are very old and generally these old plants have not kept pace with modern standards. There are instances where problems have been known to exist, for the problems simply to have been tolerated, resulting in important refurbishment work never taking place (eg D1204, D1206, D1208). The problem of the shortfall in standards is compounded by a complacent and understated consideration of the condition of the plant in the safety case (eg lab 33, D1204, D1206, D1208). There are many instances of shortcomings in the following fundamental areas:

containment

  eg lab 33, some D1200 facilities, D1203 "amber area", D1204 pond, D1206, D1208 floc tank 1, D1208 sump liquor.

ventilation

  eg lab 33, poor/inappropriate segregation in D1200, no hepa filtration of building green extract anywhere, D1203 "amber area", D1208 depressions, and ventilation plant.

shielding

  temporary lead augmenting existing shielding, eg D1200, D1206, D1204, D1208, D2670.

  "temporary" lead covering leaks/fixed contam., eg D1206, D1200, D1217, D2001, D2670.

  permanent "temporary" HP barriers, eg D1217, D2001, D2670, D1200.

instrumentation

  eg D1204, D1206, CIDAS in D1202/3/7.

LONG-STANDING "TEMPORARY" SHIELDING AND/OR BARRIERS IN LIEU OF CLEAN-UP /REDESIGN/REFURBISHMENT

8.  Plant design deficiencies, "accidents" leading to loss of containment and activity finding its way into places that were never designed to see it. Where this has occurred, lead sheets and/or HP barriers have had to be installed. Poor safety culture and management of safety have apparently allowed a tolerance to develop towards such short term mitigation measures becoming long term solutions, eg permanent "temporary" HP barriers such as D2001, D1217, D2670.