Energy Facility Contractors Group (EFCOG) Safety
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Energy Facility Contractors Group (EFCOG) Safety Working Group Regulatory Reporting Technical Subgroup Enforcement Letter: Suspect Documentation October 21, 2015 Alan Duncan Enforcement Coordination Consolidated Nuclear Security, LLC
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01
Energy Facility Contractors Group (EFCOG)
Safety Working Group
Regulatory & Reporting Technical Subgroup
Enforcement Letter: Suspect Documentation
October 21, 2015 Alan Duncan Enforcement Coordination
Consolidated Nuclear Security, LLC Alan.Duncan@cns.doe.gov<br>
Safety Working Group
Regulatory & Reporting Technical Subgroup
Enforcement Letter: Suspect Documentation
October 21, 2015 Alan Duncan Enforcement Coordination
Consolidated Nuclear Security, LLC Alan.Duncan@cns.doe.gov<br>
02
Event Reporting ORPS NA- -PS-BWP-PANTEX-2014-0036, Discovery of Suspect Supplier Documentation
On May 14, 2014 in support of evaluation of a specific container for off-site shipment of components, the Packaging Engineer determined that reports received from the manufacturer were inconsistent and suspect. Subsequent investigation by the Supplier Quality organization determined that inadequate quality controls were in place with regard to the quality assurance documentation system and in particular that the questioned record included a signature from an individual no longer in the employ of the manufacturer. One of several issues raised with the manufacturer was lack of date associated with the signature and inadequate change control practices with regard to the certifications.
4C(2) – Discovery of any other suspect or counterfeit item or material (i.e., not found in a Safety Class or Safety Significant Structure, System, or Component) that is found in any application whose failure could result in a loss of safety function, or present a hazard to public or worker health and safety.
NTS-NPO—CNS-Pantex-2014-0009 submitted October 2, 2014 2<br>
On May 14, 2014 in support of evaluation of a specific container for off-site shipment of components, the Packaging Engineer determined that reports received from the manufacturer were inconsistent and suspect. Subsequent investigation by the Supplier Quality organization determined that inadequate quality controls were in place with regard to the quality assurance documentation system and in particular that the questioned record included a signature from an individual no longer in the employ of the manufacturer. One of several issues raised with the manufacturer was lack of date associated with the signature and inadequate change control practices with regard to the certifications.
4C(2) – Discovery of any other suspect or counterfeit item or material (i.e., not found in a Safety Class or Safety Significant Structure, System, or Component) that is found in any application whose failure could result in a loss of safety function, or present a hazard to public or worker health and safety.
NTS-NPO—CNS-Pantex-2014-0009 submitted October 2, 2014 2<br>
03
Event Reporting ORPS NA- -NPO-CNS-PANTEX-2014-0027, Discovery of Noncompliant Containers
As a part of an extent of condition review for the May 2014 noncompliance, certification documentation was reviewed and the review determined that documentation described differing testing conditions between lots. When the requirements were investigated it was determined that some testing results were not in conformance to DOT requirements.
4C(3) – Discovery of any defective item or material, other than a suspect/counterfeit item or material, in any application whose failure could result in a loss of safety function, or present a hazard to public, or worker health and safety.
Additional information added to NTS-NPO- -CNS-Pantex-2014-0009. 3<br>
As a part of an extent of condition review for the May 2014 noncompliance, certification documentation was reviewed and the review determined that documentation described differing testing conditions between lots. When the requirements were investigated it was determined that some testing results were not in conformance to DOT requirements.
4C(3) – Discovery of any defective item or material, other than a suspect/counterfeit item or material, in any application whose failure could result in a loss of safety function, or present a hazard to public, or worker health and safety.
Additional information added to NTS-NPO- -CNS-Pantex-2014-0009. 3<br>
04
Significance of Conditions The Office of Enforcement guidelines considered the false record created by the vendor a willful act and were reluctant to believe it was isolated.
The Office of Enforcement assigns greater significance to the actions of managers and supervisors. The occurrence report identifies the Quality Manager as the individual responsible for the false record.
The vendor provides numerous containers in support of the NNSA mission. Customers include Pantex, Los Alamos, Sandia, Y-12, Brookhaven, and Oak Ridge National Lab.
Joint investigation of record-keeping revealed that the wrong calculation had been used in support of United Nations stack weight certifications.
Use of many containers was suspended pending recertification affecting shipments complex-wide.
On May 30, 2014, the Pantex PAAA Department tracked the issue pending outcomes of the initial investigations, but facts in the initial occurrence report reveal a reportable condition, a willful act. Discussions with the Office of Enforcement began in July. A Noncompliance Tracking System report was submitted October 2, 2014. A delay in reporting may have been part of the Office of Enforcement considerations. 4<br>
The Office of Enforcement assigns greater significance to the actions of managers and supervisors. The occurrence report identifies the Quality Manager as the individual responsible for the false record.
The vendor provides numerous containers in support of the NNSA mission. Customers include Pantex, Los Alamos, Sandia, Y-12, Brookhaven, and Oak Ridge National Lab.
Joint investigation of record-keeping revealed that the wrong calculation had been used in support of United Nations stack weight certifications.
Use of many containers was suspended pending recertification affecting shipments complex-wide.
On May 30, 2014, the Pantex PAAA Department tracked the issue pending outcomes of the initial investigations, but facts in the initial occurrence report reveal a reportable condition, a willful act. Discussions with the Office of Enforcement began in July. A Noncompliance Tracking System report was submitted October 2, 2014. A delay in reporting may have been part of the Office of Enforcement considerations. 4<br>
05
Timeline 2007 order containers
June 2007 receive containers
At some point after receipt of the containers the related project was removed from the schedule.
April – May 2014 Packaging Engineer begins evaluation of containers in preparation for the rescheduled project.
May 14, 2014 Packaging Engineer notifies Supplier Quality of suspect documentation.
May 15, 2014 Shipments involving this container type were suspended.
May 21, 2014 Site Investigation of Vendor
May 29, 2014 Site Investigation of Vendor Published
May 30, 2014 PAAA initial screening was to locally-track and monitor the PER for developments pending receipt of the site investigation.
July 1, 2014 Transition to M&O Contractor Consolidated Nuclear Security is complete.
July 1, 2014 CNS sustains the suspension of shipments.
July 2014 PAAA revisits screening determination and recommends reporting to management.
July – August 2014 discussions with management regarding reporting an issue for a previous M&O. 5<br>
June 2007 receive containers
At some point after receipt of the containers the related project was removed from the schedule.
April – May 2014 Packaging Engineer begins evaluation of containers in preparation for the rescheduled project.
May 14, 2014 Packaging Engineer notifies Supplier Quality of suspect documentation.
May 15, 2014 Shipments involving this container type were suspended.
May 21, 2014 Site Investigation of Vendor
May 29, 2014 Site Investigation of Vendor Published
May 30, 2014 PAAA initial screening was to locally-track and monitor the PER for developments pending receipt of the site investigation.
July 1, 2014 Transition to M&O Contractor Consolidated Nuclear Security is complete.
July 1, 2014 CNS sustains the suspension of shipments.
July 2014 PAAA revisits screening determination and recommends reporting to management.
July – August 2014 discussions with management regarding reporting an issue for a previous M&O. 5<br>
06
Timeline August 20, 2014 contact with the Office of Enforcement regarding reporting an issue for a previous M&O.
August 21, 2014, following review of the Occurrence Report, Office of Enforcement requests additional information regarding the screening and reporting determinations. Questions directed at how a determination of “not willful” was made.
August 22, 2014 provide additional information and receive request for the Investigation Report.
Begin coordinating draft NTS report.
September 2, 2014 provided Investigation Summary to the Office of Nuclear Safety Enforcement.
October 2, 2014 submit NTS report.
October 6, 2014 visit to contractor to discuss the Office of Enforcement interest and path forward.
October 8, 2014 requests copies of causal analyses and corrective action plans from the M&O and vendor.
October 29, 2014 Office of Nuclear Safety Enforcement requests a visit so that an open discussion may occur regarding potential container contents and hazards.
November 12, 2014 occurrence report regarding testing methods.
December 5, 2014 provided documents to the Office of Nuclear Safety Enforcement:
Characterization of container content for containers provided by this vendor,
Initial Causal Analysis, and
Formal Causal Analysis and Corrective Action Plan 6<br>
August 21, 2014, following review of the Occurrence Report, Office of Enforcement requests additional information regarding the screening and reporting determinations. Questions directed at how a determination of “not willful” was made.
August 22, 2014 provide additional information and receive request for the Investigation Report.
Begin coordinating draft NTS report.
September 2, 2014 provided Investigation Summary to the Office of Nuclear Safety Enforcement.
October 2, 2014 submit NTS report.
October 6, 2014 visit to contractor to discuss the Office of Enforcement interest and path forward.
October 8, 2014 requests copies of causal analyses and corrective action plans from the M&O and vendor.
October 29, 2014 Office of Nuclear Safety Enforcement requests a visit so that an open discussion may occur regarding potential container contents and hazards.
November 12, 2014 occurrence report regarding testing methods.
December 5, 2014 provided documents to the Office of Nuclear Safety Enforcement:
Characterization of container content for containers provided by this vendor,
Initial Causal Analysis, and
Formal Causal Analysis and Corrective Action Plan 6<br>
07
Pre-Visit Activities Obtained information regarding the Office of Nuclear Safety’s Areas of Interest.
Use and potential use of the containers.
Vendor recognition of significance
Met with the Site Manager and Issue Owner to discuss the scope of interest.
Worked through Procurement to notify the vendor and requested their participation.
Identified Site Participants.
Arranged a facility tour.
Took the opportunity to provide Rich and Kevin with contextual information about Pantex including a site tour and meetings with personnel key to assuring Nuclear Safety at the Site. 7<br>
Use and potential use of the containers.
Vendor recognition of significance
Met with the Site Manager and Issue Owner to discuss the scope of interest.
Worked through Procurement to notify the vendor and requested their participation.
Identified Site Participants.
Arranged a facility tour.
Took the opportunity to provide Rich and Kevin with contextual information about Pantex including a site tour and meetings with personnel key to assuring Nuclear Safety at the Site. 7<br>
08
Pre-Visit Activities Prepared a list of anticipated questions and gathered responses.
Coordinated the responses to assure accuracy.
Distributed the questions and responses to participants.
Conducted a Dry Run.
Dealt with last minute resolution of vendor concern regarding acceptance of their corrective action plan. 8<br>
Coordinated the responses to assure accuracy.
Distributed the questions and responses to participants.
Conducted a Dry Run.
Dealt with last minute resolution of vendor concern regarding acceptance of their corrective action plan. 8<br>
09
Conduct of Fact Finding Visit Discussions Office of Nuclear Safety Enforcement Participants
Rich Day
Kevin Mattern
Site Participants
NPO Enforcement Coordinator
Representatives of Supplier Quality
Representatives of Packaging Engineering
Representatives of Transportation Logistics (responsible for DOT Compliance)
Representatives of Contractor Enforcement Coordination
Manager, Mission Assurance
Pantex Site Manager (Welcome and Out Brief)
CNS CEO (Out Brief)
Legal
Vendor Participants
Owner
Second in Command 9<br>
Rich Day
Kevin Mattern
Site Participants
NPO Enforcement Coordinator
Representatives of Supplier Quality
Representatives of Packaging Engineering
Representatives of Transportation Logistics (responsible for DOT Compliance)
Representatives of Contractor Enforcement Coordination
Manager, Mission Assurance
Pantex Site Manager (Welcome and Out Brief)
CNS CEO (Out Brief)
Legal
Vendor Participants
Owner
Second in Command 9<br>
10
Conduct of Fact Finding Visit Discussions Office of Enforcement provided a brief introduction.
Introductions of Participants
Summarized the timeline of discoveries
Discussed the compensatory and corrective actions.
Allowed a designated time for conversation between the Office of Nuclear Safety Enforcement and the Vendor. (Enforcement Coordinator and NPO Enforcement Coordinator were present)
Discussion was free flowing with the Office of Enforcement asking questions throughout the discussion.
Maintained focus of noncompliant conditions and their effect on safety.
Very prepared and very professional. 10<br>
Introductions of Participants
Summarized the timeline of discoveries
Discussed the compensatory and corrective actions.
Allowed a designated time for conversation between the Office of Nuclear Safety Enforcement and the Vendor. (Enforcement Coordinator and NPO Enforcement Coordinator were present)
Discussion was free flowing with the Office of Enforcement asking questions throughout the discussion.
Maintained focus of noncompliant conditions and their effect on safety.
Very prepared and very professional. 10<br>
11
Enforcement Process Timeline May 14, 2014 – Identify potential concern regarding paperwork
May 21, 2014 – Submit Occurrence Report
May 30, 2014 – Initial screening as locally-tracked, monitoring
August 20, 2014 – Initial Contact with Office of Enforcement
September 2, 2014 – Provided the M&O’s Vendor Investigation Report
October 2, 2014 – Submit NTS report
October 30, 2014 – Request for Visit
December 5, 2014 – Provide Causal Analysis and Corrective Action Plan
December 15-16, 2014 – Site Visit
March 2, 2015 – Provided draft Enforcement Letter for review
April 6, 2015 - Enforcement letters to vendor and to CNS/B&W Pantex 11<br>
May 21, 2014 – Submit Occurrence Report
May 30, 2014 – Initial screening as locally-tracked, monitoring
August 20, 2014 – Initial Contact with Office of Enforcement
September 2, 2014 – Provided the M&O’s Vendor Investigation Report
October 2, 2014 – Submit NTS report
October 30, 2014 – Request for Visit
December 5, 2014 – Provide Causal Analysis and Corrective Action Plan
December 15-16, 2014 – Site Visit
March 2, 2015 – Provided draft Enforcement Letter for review
April 6, 2015 - Enforcement letters to vendor and to CNS/B&W Pantex 11<br>
12
Enforcement Letter Enforcement Letter to CNS commends
actions taken by CNS and B&W Pantex to identify the issues,
questioning attitude
compensatory measures
communication with other contractors using the vendor
effective communication with the Office of Enforcement
Intended and received as a “positive enforcement letter.”
NPO counterpart encouraged the preparation of the letter to note the actions taken by B&W Pantex and CNS.
The unique condition of a “positive enforcement letter” resulted in the opportunity for the M&O to review the draft. 12<br>
actions taken by CNS and B&W Pantex to identify the issues,
questioning attitude
compensatory measures
communication with other contractors using the vendor
effective communication with the Office of Enforcement
Intended and received as a “positive enforcement letter.”
NPO counterpart encouraged the preparation of the letter to note the actions taken by B&W Pantex and CNS.
The unique condition of a “positive enforcement letter” resulted in the opportunity for the M&O to review the draft. 12<br>
13
Lessons Learned Initial responses by the issue owner are the primary focus of the commendation from the Office of Enforcement. Most of these actions took place before screening and reporting determination.
We should have monitored the development of information more effectively and been more timely in reporting.
Report for the previous M&O contractor, especially if the new M&O contractor will be responsible for implementing any portion of the corrective actions.
Phone calls to the Office of Nuclear Safety Enforcement to request advice were very revealing regarding perceived significance and helpful in making the reporting determination. 13<br>
We should have monitored the development of information more effectively and been more timely in reporting.
Report for the previous M&O contractor, especially if the new M&O contractor will be responsible for implementing any portion of the corrective actions.
Phone calls to the Office of Nuclear Safety Enforcement to request advice were very revealing regarding perceived significance and helpful in making the reporting determination. 13<br>