DNFSB Reveals More Details on SRS Puncture Incident Investigation
NS&D Monitor
4/10/2015
A puncture incident earlier this year at the Savannah River Site’s Tritium Facilities occurred because the site’s managing contractor, Savannah River Nuclear Solutions, lacked a tool control/sharps program, didn’t completely analyze hazards, and was noncompliant in operations, including “weaknesses with procedure compliance, pre-job briefings, complacent reliance upon skill of the craft, and execution of the immediate procedure change (IPC) process,” the Defense Nuclear Facilities Safety Board said in a recently released memo outlining the conclusions of a SRNS independent investigation team.
An employee received a puncture wound to their hand after a glovebox slip-up in January but bioassay results revealed the dose the worker received was below regulatory and SRNS radiation exposure guidelines. The worker was using a slender metal stylus shaped like a dental pick to remove a degraded O-ring gasket from a metal process component when the employee’s hand slipped, causing the tool to puncture the employee’s protective gloves and skin.
The investigation team recommended creating a tool control/sharps program, conducting training on the site’s assistant hazard analysis program, and improving IPC process, procedure validation, procedure compliance and understanding, and pre-job briefings. The DNFSB also said SRNS had tasked a board of senior managers to analyze how a shift operations management team would “plan and execute a hypothetical high-risk task.”
