Recent issues and managerial responses indicate potentially elevated safety risks at SRS facilities handling nuclear materials due to increased human error.  This is of public health and safety concern given potential negative impacts to workers, the public, and SRS missions in the event of an accident.

by Don Moniak
March 14, 2025

Six months ago, an official from the Savannah River Site’s (SRS) primary operating and management contractor—Savannah River Nuclear Solutions (SRNS)—presented material (2:04:00 of meeting) pertaining to SRS Conduct of Operations (ConOps) to the SRS Citizens Advisory Board (SRS-CAB).  Board members were informed of the obvious, though still comforting, fact that SRS operations require executing tasks in a “deliberate and structured manner.” 

But at SRS, the term “deliberate” has two meanings. There is work conducted in a deliberate fashion, and there is a “deliberate operations” status. Minimizing the likelihood of a high consequence accident resulting from human and/or system failures can require an additional administrative safety layer known as a deliberate ConOps status. In such an operational status, the pace of site activities is lessened, there is a heightened reliance on management oversight, and only essential and approved activities are ongoing. 

The deliberate operations status results when violations of “technical safety requirements” (TSR) have become too common to justify the status quo of normal conduct of operations to continue.

The Defense Nuclear Facilities Safety Board (DNFSB) has described TSRs as “necessary to ensure the safe operation of nuclear facilities, and to reduce the potential risk to the public and workers from uncontrolled releases of radioactive materials or from radiation exposures due to inadvertent criticality.” In its “Implementation Guide for Use in Developing Technical Safety Requirements,” DOE describes TSRs as defining the limitations of its nuclear facilities, as well as constituting the “nuclear safety basis and facility authorization from DOE to the contractor to operate (nuclear) facilities.”

In short, entering into an administrative operations mode known as “deliberate operations” means that all is not as well as SRS officials like to proclaim in public relations announcements–although at the same time it does indicate that senior officials have recognized that additional steps to maintain the site’s safety envelope are necessary and are being taken.

In the past two years, various SRS facilities have been placed in a “deliberate operations” status due to excessive TSR violations; as well as generally inadequate conduct of operations that do not rise to the level of TSR violations.

In September 2023, the Defense Waste Processing Facility (DWPF) entered into a “period of deliberate operations with 24/7 Senior Supervisory Watch…due to the series of conduct of operations (ConOps) issues since February. Most recently, a control room operator (CRO) failed to perform multiple procedure steps including valve alignment when attempting to transfer waste chemicals” from one processing tank to another.  

Incidents prior to that included the premature and inadvertent pouring of 57 pounds of molten radioactive glass into a canister in August 2023; the dropping of an 1100 pound drum in September 2023, inconsistent reading of procedure notes associated with technical safety requirement implementation steps, and a failure to conduct appropriate surveillance of key safety systems.

During the same inspection period in September 2023, Defense Nuclear Facility Safety Board Resident Inspectors observed “varying degrees of other shortcomings, such as improperly reading analog gauges (i.e., from an angle) and failing to confirm which component they were reading prior to recording a TSR surveillance.” 

The slower, even more methodical, and heavily supervised deliberate operations status at DWPF continued for one year, finally ending in October 2024; it took one year to improve conduct of operations to an acceptable level. 

More recently, in November 2024, SRNS “placed all their facilities into deliberate operations,” meaning only “essential and approved activities” would be performed, and only then with “additional management oversight.” The already slow and deliberate process of handling tritium gas, plutonium, and other nuclear hazards will become even more deliberate and slower; perhaps better resembling prolonged training exercises than normal production. (Figure 1, above).

 In addition, personnel from an “independent evaluation board” has been tasked with conducting “additional oversight and evaluation of personnel performance at SRNS facilities and initiated a common cause analysis focused on the TSR violations across the site,” including operations of the liquid radioactive waste stabilization contractor (which includes DWPF) and the Savannah River National Laboratory. 

The incidents of technical safety requirements violations or inadequate conduct of operations that preceded this latest extraordinary management decision included “multiple operations errors” at the tritium processing facilities such as the improper opening of a gas transfer valve; blowing a “protective rupture disk” while operating other valves outside of the approved procedure; and a construction worker “stepping on and breaking a process pipe during glovebox maintenance.” 

At the K-Area plutonium processing site, another TSR violation involved workers exceeding allowable plutonium levels in one work module. At H-Canyon, a failure to meet adequate worker staffing constituted another violation. At the Savannah River National Laboratory, an inventory system tracking special nuclear materials was found to have underreported the amount of plutonium in one facility, leading to the discovery that the amount of material at risk was well above the TSR inventory limit.

One contributing cause* for the unusual step of entering into a deliberate operations status could be reduced workforce experience. During the SRNS presentation to the CAB, the change in age and experience in the past decade was highlighted (Figure 2 below). SRS now essentially has a new generation of workers, one that is inherently less experienced and knowledgeable about site facilities. This alone does not equate to a less safe workforce, but it does indicate reduced institutional knowledge, and fewer subject matter experts.

In fact, in early February, the DNFSB reported that a review of 81 work packages in the radioactive liquid waste stabilization program revealed that only half of the “assisted hazards analysis (AHA) had evidence of adequate planner, subject matter expert (SME), and worker walkdown….The review found that the current program relies on experienced work planners and SMEs. However, most of the personnel interviewed had less than five years of experience.”

Footnote:

* SRS contractors have had other spells when consistent compliance with technical safety rules was an issue, most notably in the 2014-2018 time period when workforce experience was higher. During that period the two main SRS contractors reported a collective average of 8 TSR violations per year across 14 nuclear facilities.

According to Technical Safety Requirements Implementation at the Savannah River Site, the causal analysis at that time found only “common themes of less-than-adequate knowledge of TSR controls and their bases, and less-than-adequate rigor with implementation of TSR controls;” while the underlying reasons were diverse enough to complicate the resolution of safety issues. In total, eleven corrective actions were undertaken, and four long-term measures were implemented.