DOE-HDBK-7502-95 Volume II, Implementing U.S. Department of Energy Lessons Learned Programs, Volume II

boos NOT MEASUREMENT SENSITIVE DOE-HDBK-7502-95 August 1995 DOE HANDBOOK IMPLEMENTING U.S. DEPARTMENT OF ENERGY LESSONS LEARNED PROGRAMS Volume Il U.S. Department of Energy - FSC 6910 Washington, D.C. 20585 ~~ 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. Order No. DE95017323 ee — Lessons Learned Handbook DOE-HDBK-7502-95 Table of Contents FOTEWOId i aaeasacnesesnenececececcececetsccecscucssnsstsncucsesnsntsescsssessesesesesseneseseeasscecseseeceasessesese iil Appendix |: ProGraM DeSCTIPTION............cecsececesesscsesesesseseseesesesesesssecseenssenesenennsens I-1 Appendix II: Project Inputs, Activities, and OUtpUTS........... eee eseeeeeeeenenees {I-1 Appendix Il: Management Requirements and Procedufes.............:.cseeseseees Iil-1 Appendix IV: Communications Material... ssccccceceseseeeeesessseseenseesseeeenenens V-1 Appendix V: Air Force Lessons Learned Validator’s Guide............-...eeeeeeeeeeesseees V-1 Appendix VI: FUNCtIONAal Cate GOTIeS.............eccecssssesesececeeceeecececeeeetsceesseseseseseseesees VI-I Appendix Vil: Examples of Electronically Shared Lessons Learned..................... VIl-1 Appendix VIII: Lessons Learned Transmittal DOCUMENTS..............-.ceseeeeeeeeeeeeeees VIII-1 Appendix Ix: Corrective ACtions Tracking.............cccecesesesecesececeseceseneneeeeesteeeeees IX-1 Appendix x: Lessons Learned Program REVICW.............--csceeeeseseseeseseeseeseetenenens X-1 Appendix XI: Index of Professional and Industry Sources of LESSONS LEAINEC..........cesesseceseseseseeeseeeseecececsesesesesesceeseeeeseeeseenesseeses XI-1 Appendix XII: Applicable Training DOCUMENIS................cecsseseeeeeeeteeteteeeeteseneeneens XII-1 Appendix XIll: Frequently Asked Questions About the DOE Lessons Learned List SCrViCC................cccccceececssesscsesecsesscessensseeeesseeeeseeenees XIII-1 Page | Lessons Learned Handbook DOE-HDBK-7502-95 Page il This page intentionally left blank. Lessons Learned Handbook DOE-HDBK-7502-95 Foreword The Department of Energy (DOE) Lessons Learned Handbook is a two-volume publication developed to supplement the DOE Lessons Learned Standard (DOE Standard: Development of Lessons Learned Programs (DOE-STD-7501-95)) with information that will assist organizations in developing or improving their lessons learned programs. Volume | of the Handbook includes greater detail than the Standard in areas such as identification and documentation of lessons learned. Volume | also contains sections on specific processes such as training and performance measurement. Volume II of the Handbook (this document) contains examples of program documents developed by existing lessons learned programs as well as communications material, functional categories, transmittal documents, sources of professional and Industry lessons learned, and frequently asked questions about the Lessons Learned List Service. The Lessons Learned Handbook is a living document that will be updated as new information and examples become available, Page ill Appendix I Program Description

Lessons Learned Handbook: DOE-HDBK-7502-95 Appendix I Program Description Appendix | provides two examples of Lessons Learned Program Descriptions and one Program Management Plan. The Program Description may be combined with Lessons Learned Management Requirement and Procedures document (see Appendix II!) or be provided separately. The examples provided Include the following: © Savannah River Lessons Learned Program, Semi-Annual Review of the Site Lessons Learned Program, July 1-December 31, 1994: Attachment I, Site Lessons Learned Program Description and Attachment Il, Site Lessons Learned Program History oO DOE Richland Operations Office Lessons Learned Program, Draft Program Description, June 1995. DOE Richland Operations Office Lessons Learned Program, Draft Program Management Plan, June 1995. Lessons Learned Handbook: DOE-HDBK-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 Appendix I-A Savannah River Lessons Learned Program Program Description Lessons Learned Handbook: DOE-HDBKE-7502-95 This page intentionally left blank. 1-4 Lessons Learned Handbook: DOE-HDBKE-7502-95 ATTACHMENT I SITE LESSONS LEARNED PROGRAM DESCRIPTION The Site Lessons Learned Program implements a systematic review of the operating experiences at Savannah River Site facilities, similar DOE complex facilities, and commercial nuclear industry facilities for the purpose of applying the lessons learned from those experiences. The program is defined by WSRC Policy Manual 1-01, MP 4.19, Revision 1, Lessons Learned Program, and is the responsibility of the Facility Safety Evaluation Section (FSES) in ESH&QA. Further clarification for implementation of this program is provided in Management Requirements and Procedures Manual 1B, MRP 4.14, Revision 0, Lessons Learned Program. The program is administered by the Site Lessons Learned Coordinator, who is appointed by the ESH&QA Division Vice President. A staff of technical reviewers assist the Site Coordinator with the screening and dissemination of lessons learned information. Division Lessons Learned Coordinators are appointed by their respective Division Vice Presidents and are matrixed to the Site Coordinator. The Division Coordinators are responsible for implementing and directing their own Division Lessons Learned Program which includes interacting with Division Safety Committees on lessons learned issues. These programs will effectively evaluate issues disseminated by the Site Coordinator and will implement appropriate corrective actions. The Site Coordinator tracks the evaluations and corrective action implementations, and provides oversight of all Division Lessons Learned Programs. The technical reviewers are appropriately qualified members of the Facility Safety Evaluation Section. FSES obtains and screens for applicability approximately 7000 documents per year which includes sources from the Institute of Nuclear Power Operations, the Nuclear Regulatory Commission, and the Department of Energy complex including Savannah River Site (SRS). Items with potential lessons learned value to SRS facilities are forwarded to the appropriate Division Lessons Learned Coordinators for evaluation of the information and development of appropriate corrective actions.

The Division Lessons Learned Coordinators determine which departments in their divisions may need to take action on the lessons learned documents they receive from the FSES reviewers. They monitor progress of the evaluation, corrective actions, and report the status to the Site Lessons Learned Coordinator. In addition, these coordinators screen their division occurrences for lessons learned that may apply to other divisions and report their results to the Site Coordinator. The Site Lessons Learned Coordinator administers the program and tracks the progress of required corrective actions from Lessons Learned items. The more significant lessons learned items are discussed by the Site Lessons Learned Committee which is chaired by the Site Coordinator, and whose members are all FSES reviewers and Division Coordinators. From this meeting, decisions are reached on whether the issue should be brought to the attention of the Site Safety Review Committee for possible further action. A hierarchy of lessons learned documents has been established and facilitates the dissemination of lessons learned so as to process the most urgent first and require Division responses only from the more significant items. The following are the six (6) transmittals FSES utilizes to notify Divisions and Management of Lessons Learned. They are listed in order of highest to lowest priority, with the lowest requiring no action. 1-5 Lessons Learned Handbook: DOE-HDBK-7502-95 Site Lessons Learned Directive This is the highest level of concern and indicates a generic sitewide problem which must be corrected. It will have specific instructions for corrective actions as well as an identified time table for closure. The Directive comes from the WSRC President's office. The QA Department within ESH&QA will independently verify completion of corrective actions associated with directives. Directives are sent to appropriate Division Vice Presidents for action and Division Coordinators for information only. The Division Vice Presidents or their designee are responsible for reporting the results of their evaluation to FSES. FSES is responsible for tracking Directives through closure. SRS Lessons Learned Bulletin The Bulletin is generally used for recurring sitewide events which have not been adequately addressed or for high significance degradations at SRS. Division Coordinators are requested to evaluate and correct recurring or high significance degradations and report the results of the evaluation to FSES. Bulletins are sent to Division Lessons Learned Coordinators for evaluation and WSRC Level 5 and above managers for information. All DOE-SR management, Branch Chiefs and above, are also sent the Bulletins for information only. Site Lessons Learned Notification The Notification is used to identify significant issues which may affect one or more Divisions. The Notification is sent to appropriate Division Coordinators for evaluation. The Division Coordinators are required to report the results of their evaluations and corrective action implementation to FSES. Site Lessons Learned Program Special Information Notice The Special Information Notice is used to provide helpful information sources for selected activities. This information is sent to Division Coordinators for dissemination. Division Reviewers evaluate the need for corrective actions. Response to FSES is not required. , SRS Lessons Learned Digest

The Digest is used to disseminate SRS lessons learned information which is not considered significant enough to warrant a formal request for evaluation, but does have value as a possible training resource. 'ne Digest is distributed to the Division Coordinators and all WSRC Level 5 and above managers. Division Reviewers evaluate the need for corrective actions. All DOE SR Management, Branch Chiefs and above, are also sent the Digests for information only. FSES Weekly Newsletter The Newsletter is used to disseminate commercial industry and DOE complex information relevant to SRS personnel. Its primary purpose is to keep SRS abreast of outside industry and DOE issues and expectations. The newsletter requires no action or response and is distributed to the Division Coordinators and an identified mailing list. Lessons Learned Handbook: DOE-HDBKE-7502-95 To further encourage the input of lessons learned information to FSES from individual employees, a telephone hotline has been established to capture other lessons learned information which is not available through normal document reviews. Lessons Learned Handbook: DOE-HDBK-7502-95. This page intentionally left blank. 1-8 Lessons Learned Handbook: DOE-HDBE-7502-95 ATTACHMENT I SITE LESSONS LEARNED PROGRAM HISTORY Use of lessons learned information from operating experiences has long been considered a significant contribution in a facility's effort for continuous improvement. At Savannah River Site, two separate lessons learned programs, one for the nuclear reactors and one for the non-reactor nuclear facilities, were developed in 1990. These two programs were merged and strengthened in March 1992, concurrent with the merging of the former Reactor Safety Evaluation (RSES) Section into the Facility Safety Evaluation Section (FSES). In May 1992, Management Policy 4.19 Revision 0, Operating Experience Review, was approved which formalized this process and combined the efforts of the two programs. In June 1992, the former RSES group, which handled Reactor Operating Experience Reviews took responsibility for the newly combined sitewide program. A dedicated staff was assigned the responsibility of reviewing operational experiences from WSRC, other DOE complex facilities, and nuclear industry for potential lessons learned information for all reactor and non-reactor facilities and processes at SRS, with the goal of improving safety and reliability. FSES forwarded applicable lessons learned information items to several lessons learned coordinators in various departments across the site for evaluation and correction of identified problems. The program was effective in getting lessons learned information distributed to departmental coordinators; however, it was determined that useful information from onsite operational experiences was often slow in being disseminated to FSES for evaluation of potential lessons learned. In addition, the lessons learned information disseminated by FSES was not always being evaluated by all applicable divisions; furthermore, no formalized tracking system existed to ensure the necessary accountability in the system.

On February 8, 1993, the WSRC President directed in a letter to his Senior Staff that lessons learned program enhancements were to be implemented to ensure rapid dissemination of lessons learned information at SRS. The directive mandated activities that would improve all aspects of the Site Lessons Learned Program. Division involvement was increased by assignment of twelve Division Lessons Learned Coordinators (DLLCS) by March 1, 1993. The DLLCs are responsible for disseminating the lessons learned information sent to them from the Site Lessons Learned Coordinator to applicable personnel in their division, and for rapidly communicating lessons learned information generated within their division to the Site Lessons Learned Coordinator. Also in March 1993, the Site Lessons Learned Committee was formed. This committee is comprised of all Division Coordinators, FSES lessons learned screeners, and the Site Coordinator. Its purpose is to provide input to the Site Coordinator for issues which may require briefing to the Site Safety Review Committee due to significance. In addition, FSES was reorganized to provide specific oversight of the lessons learned program and to ensure accountability through detailed tracking of the status of items disseminated to the DLLCS. Briefings on the new Lessons Learned Program changes were given to all existing WSRC Safety Review Committees during March 1993. In May 1993 changes delegated by the February 8 letter from the WSRC President were incorporated and approved in Revision 1 of Management Policy 4.19 now called, Lessons Learned Program. After approval of this policy, a Management Requirements and Procedures MRP 4.14, Revision 0, Lessons Learned Program, was generated which gives more detail on program requirements. This MRP was approved and implemented on August 27, 1993. Lessons Learned Handbook: DOE-HDBKE-7502-95 This page intentionally left blank. I-10 Lessons Learned Handbook: DOE-HDBK-7502-95 Appendix I-B Richland Operations Office Lessons Learned Program Program Description I-11 Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. I-12 Lessons Learned Handbook: DOE-HDBE-7502-95 Draft DOE Richland Operations Lessons Learned Program Program Description Introduction The Department of Energy (DOE) Lessons Learned Program was developed as a formal program for disseminating lessons learned across DOE. Lessons learned provide valuable information learned from things that went wrong, and information learned from good practices which would pay off if they were widely known. This Program will consolidate other similar programs which already exist at DOE, providing a wide base from which to draw information. All lessons learned will be available to all of DOE from a single source, in a single format. Each DOE site will operate its own Lessons Learned Program, contributing individual lessons learned to the DOE-wide program. Objective The Richland prograin will coordinate and centralize the collection and dissemination of Lessons Learned at Hanford. Both material developed at Hanford and material from other DOE sites will be available to personnel at Hanford. Scope The Program includes all operations at Hanford, Washington, including DOE, its contractors, and its subcontractors. Lessons learned will be collected from all available sources, including DOE, other government agencies, and private industry. General Description of the Program

Each contractor has a Lessons Learned Program (a contractor could have more than one) which collects, reviews, and categorizes lessons learned. Lessons learned are submitted to a central coordinator at WHC where it is entered into a system on the Internet and made available throughout DOE. Each Lessons Learned Program has access, through Internet, to all lessons learned from the DOE complex. Material will be distributed throughout each contractor organization according to subject. 1-13 Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. 1-14 Lessons Learned Handbook: DOE-HDBE-7502-95 _ Appendix I-C Richland Operations Office Lessons Learned Program Program Management Plan 1-15 Lessons Learned Handbook: DOE-HDBK-7502-95 This page intentionally left blank. I-16 Lessons Learned Handbook: DOE-HDBKE-7502-95 Draft Lessons Learned Program Management Plan DOE-RL Brief Program Description This Management Plan outlines a plan of action to get the Lessons Learned Program at Hanford started. At Hanford, each contractor has one or more Lessons Learned Program, each with a program coordinator. Lessons learned will be compiled and reviewed by each program coordinator, then sent to a central coordinator who will enter them into the DOE-wide database on the Internet. A coordinator at RL will'monitor the entire process at Hanford. This Program depends on endorsement by management, both senior contractor management and management of the organization sponsoring the Lessons Learned Program. This program is intended to be integrated into day-to-day work. Lessons Learned Program Staff and Responsibilities Each Lessons Learned Program at Hanford will designate a program coordinator who will either serve as point-of-contact or designate a point-of-contact for that Program. Each program coordinator is responsible for assuring that lessons learned are collected, reviewed, categorized, and made available to the DOE Lessons Learned Program in a format compatible with the DOE Standard. DOE-RL will designate a program coordinator, whose primary responsibility is to monitor and coordinate the Lessons Learned Programs at Hanford. The RL program coordinator may also contribute lessons learned to the DOE-wide Program, operating through the same channels the other program coordinators at Hanford use. The RL program coordinator will establish connections within RL to collect and disseminate lessons learned. Training Program coordinators shall be trained, through self-study or other means, so that they are thoroughly familiar with the DOE Lessons Learned Program and can operate competently within the DOE standard for this program. 1-17 Lessons Learned Handbook: DOE-HDBKE-7502-95 Implementation Plan Each contractor will participate in the DOE Lessons Learned Program, either by operating its own program or by participating in another organization's program. Organizations within a contractor may operate separate programs, if necessary. Each Program must designate a Program Coordinator. Each Program Coordinator should write a Program Description for that program, or adopt a Program Description from another Program. The Program Description should describe how lessons learned will be used in training, engineering, operations, maintenance, RadCon, and all other aspects of the organization's work. Each Program Coordinator must write a Management Plan, with enough detail to get the program started and keep it consistent with other DOE Lessons Learned programs.

Each Program Coordinator must develop a system for collecting, writing, reviewing, and categorizing lessons learned. Lessons learned will be submitted to a central Coordinator, who will enter them into the DOE Lessons Learned database on the Internet. Each Program Coordinator must develop a system for disseminating lessons learned to the appropriate people. The Program Coordinators, together, will develop promotional material for distribution throughout Hanford. The promotional material will let Hanford personnel know that material is available for their use. The Program Coordinators and their managers shall develop general employee training material. Eventually, after the Program is operating, the Program Coordinators shall develop means of assessing the effectiveness of the program. 1-18 Appendix II Project Inputs, Activities and Outputs Lessons Learned Handbook: DOE-HDBE-7502-95 r This page intentionally left blank. Lessons Learned Handbook: DOE-HDBK-7502-95 Appendix II Project Inputs, Activities and Outputs Lessons learned programs generally include two basic types of processes: a development process that Includes identification, documentation, validation, and dissemination of a lesson learned; and an Incorporation process that Includes identification of applicable lessons learned, distribution to appropriate personnel, and follow-up to ensure that appropriate actions were taken. This appendix provides an example of a flow chart that depicts the flow of lessons learned information (inputs, activities and outputs) in the Office of Nuclear Safety, Model Lessons Learned Program, dated July 1994. This chart can be used as a guide for developing or evaluating your own lessons learned information flows. II-1 Lessons Learned Handbook: DOE-HDBK-7502-95 This page intentionally left blank. T-2 Lessons Learned Handbook: DOE-HDBE-7502-95 Office of Nuclear Safety, Model Lessons Learned Program oe eo e e Project Activities INPUTS ACTIVITIES QUTPUTS DOE daily office reports Commercial wire service > i Dally review > Daily OE updates ORPS database . NRC dally events reports + | Analysis of » Monthly OE updates > NS-40 site residents ponneveeeee ft | Short-term events A DOE facifty reps Lead facility engineers Pe | Technical and Site visits > Analysis of > engineering analysis M&O contractors > long-term events reports* DOE program offices DOE field offices Chemical Industry , Event Be! Assessment reports > assessments DOE assessment reports . + —— | Feedback NRC documents’ Scheduled Be | communications* « Information notices —< assessments Bulletins Weekly summary « Generic letters > Safety notices ar Safety bulletins INPO documents* pee | Identification and NS yeu letters ¢ SERs > development of Event reports * SOERs generic issues EPRI reports* Vendor reports’ povnwroveconnneveree—-> | ~— Component- ] failure reporting > Equipment failure Config. management data > system reports* Equipment failure data Oral history $pe-| Oral history reports* Oral history data ferences gee | Erggram ry ree Key Periodic ——>Ra»- Ongoing ——}- Future J * Denotes Inputs Into OE database II-3 ae Eve Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. I]-4 Appendix III Management Requirements and Procedures Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBK-7502-95 Appendix III Management Requirements and Procedures

In order to define how a lessons learned program will be implemented and administered, an organization needs approved requirements and procedures. This appendix provides three examples which may be used as guidance for developing lessons learned requirements and/or procedures. O Martin Marietta Energy Systems, Inc. Procedure Lesson Learned and Alerts Program, Revision 2, QA-16.3, dated October 10, 1994. oO Westinghouse Savannah River Company, Operations Oversight and Compliance, Administrative Procedure Manual, Procedure No. OOCD-OCI-1.0, Rev. 0, dated January 31, 1995. oO Air Force Directorate of Support Equipment and Lessons Learned Acquisition Logistics Division, Lessons Learned Writing Guide, dated February 15, 1991. Lessons Learned Handbook: DOE-HDBE-7502-95 TH-2 Lessons Learned Handbook: DOE-HDBE-7502-95 Martin Marietta Energy Systems Proceduré Lessons Learned and Alérts Program Revision 2 Til-3 Lessons Learned Handbook: DOE-HDBK-7502-95 IlI-4 Lessons Learned Handbook: DOE-HDBK-7502-95 x ‘ UC CEST SS wde ku UNCGETSS 25 wupy MARTIN MARIETTA ENERGY SYSTEMS, INC. PROCEDURE LESSONS LEARNED AND ALERTS PROGRAM QA~16.3 Revision 2 PURPOSE APPLIES TO OTHER DOCUMENTS NEEDED WHAT TO DO Quality Managers Division Managers Page 1 of 15 This procedure defines the Energy Systems program for identifying and disseminating positive and negative operating experience (Lessons Learned and Alerts), which may be applicable to other organizations. It also specifies the recommended and mandatory actions to be taken in response to Red, Yellow, and Green Alerts. This procedure applies to all Energy Systems Sites and Central Organizations. This procedure is written to allow for direct implementation across Energy Systems. o QA-16.1, “Corrective Action Program" ° I0-101, “Records Management" Assignment of Responsibilities 1. Assign an individual to be the Lessons Learned Program Manager. 2. Assure Lessons Learned and Alerts are validated. 3. Designate individual(s) to coordinate organizational alert responses, as needed. 4. Maintain awareness of operational incidents external to Energy Systems by monitoring bulletins and publications and develop Lessons Learned on experiences potentially applicable to Energy Systems operations. YOR INTERNAL USE ONLY TYI-5 ve aa Lessons Learned Handbook: Sot ee ee eee ae DOE-HDBE-7502-95 HRN SUPA AL, OO AAs UGA ft OOP QA~16.3 LESSONS LEARNED AND ALERTS PROGRAM Page 2 of 15 Division Managers All Employees Originator Revision 2 Originating Lessons Learned and Alerts NOTE: Refer to Appendix A, "Lessons Learned and 1. Alerts Flow Diagram". Ensure that employees, originate Lessons Learned and/or Alerts from the Occurrence Reporting System, the Maintenance Program, the Conduct of Operations Program, the Corrective Action Program, trend analysis activities, the review of external operating experience and other sources. Identify and originate Lessons Learned from positive and negative experiences encountered during operations or during review of industry experience which are potentially applicable to Energy Systems organizations. Initiate a draft on either a hard-copy input sheet or electronic input sheet. See Appendix C, "Lessons Learned and Alerts Input Sheet Instructions". Ensure that the draft contains no classified information. IF there is any question as to whether the draft contains classified information, THEN a. Consult an Authorized Derivative Classifier (ADC).

b. Ensure that classified information is removed from the draft. c. Record the name of the ADC on the Lessons Learned/Alert Input Sheet. IF the draft Lessons Learned includes reference to a manufacturer, THEN follow the guidelines in Appendix D, “Guidelines for Use of A Manufacturer’s Name in the Lessons Learned System". Forward the draft Lessons Learned or Alert toa Validator who has technical expertise in the subject matter of the draft. FOR INTERNAL USE OMEY III-6 Lessons Learned Handbook: DOE-HDBE-7502-95 o~ arr ma i zn ~ 9 UNE TE CELE ry} age LESSONS LEARNED AND ALERTS PROGRAM QA-16.3 Revision 2 Page 3 of 15 B. Originating Lessons Learned and Alerts (cont.) Validator 7. Ensure that the subject matter of the Lesson/Alert falls within your area of expertise. IF NOT, THEN consult a qualified Subject Matter Expert to assist in the validation. 8. Validate the draft Lessons Learned to ensure that the experience, example, observation, insight, or generic problem is potentially applicable to other Energy Systems organizations or personnel. 9. Review the draft for technical accuracy and pre-existing Lessons/Alerts on similar experiences. 10. Coordinate any required changes with the originator. 11. IF the Lessons Learned or Alert is valid, THEN forward the draft to the Site Lessons Learned Program Manager. IF NOT, THEN return the draft to the originator with an explanation as to why the Lessons Learned or Alert is NOT valid. Lessons 12. Review the draft Lessons Learned or Alert Learned received from the Validator. Program Managers 13. IF the draft is an Alert, THEN determine or verify the Alert classification (Red, Yellow, Green). 14. Coordinate any required changes with the Originator, the Validator, and/or the ADC. 1S. IF the draft is an Alert, THEN obtain approval of the draft from the Quality Manager or designee. 16. Forward the draft to the Energy Systems Lessons Learned Program Manager. FOR INTERNAL USE ONLY IlI-7 ‘Lessons Learned Handbook: DOE-HDBE-7502-95 : a} Pr Te Ne pee aa ! wet peo iosad UNGE:. ig fepy QA-16.3 LESSONS LEARNED AND ALERTS PROGRAM Page 4 of 15 : Revision 2 B. Originating Lessons Learned and Alerts (cont. ) Energy Systems 17. IF the draft is an Alert, THEN Lessons Learned a. Obtain independent validation of the draft Program as a Red, Yellow, or Green Alert. Manager b. Coordinate any required changes with other Lessons Learned Program Manager, ADC, Validator, or Originator. 18. IF the draft is a Lessons Learned, THEN issue the Lessons Learned by entering it into the Energy Systems Lessons Learned Information Systen. 19. IF the draft is an Alert, THEN precess it in accordance with Section c of this procedure. c. Issuing Red, Yellow, and Green Alerts Lessons 1. Distribute Green Alerts to Energy Systems Learned organizations. Progran Managers Division 2. Review Green Alerts for applicability to their Managers organization. 3. Incorporate the information in the Alert into applicable programs or processes, aS appropriate. Lessons 4. Distribute and direct that the Yellow Alert be Learned reviewed for applicability to organizations. Progran Managers a. Indicate in the distribution whether a documented response is required AND b. Time frame for response. 5, IF the Yellow alert requires a documented response, THEN process in accc. jance with Section D of this procedure. FOR INTERNAL USE ONLY IiI-8 Lessons Learned Handbook: DOE-HDBK-7502-95 1 epira ect me - cv, Jee 7 “apy

LESSONS LEARNED AND ALERTS PROGRAM QAan-16.3 Revision 2 Energy Systems Lessons Learned Program Manager Division Managers Lessons Learned Program Managers Page 5 of 15 Cc. Issuing Red, Yellow, and Green Alerts (cont.) 6. 10. Obtain the approval, for Red Alerts, of the Energy Systems Vice President for Compliance, Evaluation, and Policy. IF the alert is not approved as a Red Alert, THEN reevaluate the alert as a Yellow Alert. Enter the Red Alert information into the Energy Systems Action Management System (ESAMS). Distribute the Red Alert specifying the time frame for a response, which is normally 30 days. Enter the Red, Yellow, or Green Alert in the Energy Systems Lessons Learned Information Systen. D. Responses to Alerts 1. 2. Ensure review of the Alert for organizational applicability as requested. IF the alert is applicable, THEN process corrective actions to be taken, in accordance with the requirements of QA-16.1, "Corrective Action Program". Provide documented response to the Lessons Learned Program Manager indicating whether the Alert is applicable, and any actions to be performed. Compile the division/program responses into a Site or Organization response. Obtain the Site or Organization Managers approval. Forward the response to the Red and applicable Yellow alerts to the Energy Systems Vice President for Compliance, Evaluation, and Policy. FOR INTERNAL USE ONLY I-9 Lessons Learned Handbook: DOE-HDBE-7502-95 UNE? 53 gOPY QA-1i6.3 LESSONS LEARNED AND ALERTS PROGRAM Page 6 of 15 Revision 2 E. Applying Lessons Learned NOTE: The Energy Systems Lessons Learned System is accessed by selecting it from the Videotex (VTX) Menu on Energy Systems computer networks. All Employees 1. Conduct word searches of the Lessons Learned Information System to identify applicable Lessons Learned o When developing new programs or procedures o Proposing new corrective actions © Addressing adverse program trends to identify methods previously proven effective in addressing similar situations. RECORDS Records shall be maintained in accordance with approved records inventory and disposition schedules as specified in I0-101, "Records Management". Records supporting Corrective Actions developed in response to Red and Yellow Alerts are maintained in accordance with QA-1i6.1, "Corrective Action Progran". Lessons 1. Maintain records of organizational reviews of Learned Red and Yellow Alerts for applicability. Progran Managers 2. Maintain records of Site or Organizational responses to Red and/or Yellow Alerts. FOR INTERNAL USE ONLY . I-10 yee TEE . FADY UNGiai colle “uP? LESSONS LEARNED AND ALERTS PROGRAM Revision 2 APPENDIXES Appendix A. Appendix B. Appendix C. Appendix D. Prepared by: Ll. Ted Haye Lessons Learned Handbook: DOE-HDBE-7502-95 ; QAW16.3 Page 7 of 15 Lessons Léarned and Alerts Flow Diagran , Definitions bessons Learned and Alerts Input Sheet Instructions Guidelines for Use of A Mantfacturer’s Name in the Léssons Learned System Corrective Action Support Staff Approved by: WV. /} & Fred R. Mynatt, Vice President Compliance, Evaluation, and Policy FOR INTERNAL USE ONLY I-11 Lessons Learned Handbook: DOE-HDBK-7502-95 QA-16.3 Page 8 of 15 LESSONS LEARNED AND ALERTS PROGRAM APPENDIX A Page lo £1 Revision 2 LESSONS LEARNED AND ALERTS FLOW DIAGRAM Occurrence Maintenance Conduct of DOE Corrective Action Other Reporting Program Program Operations Experience Program Sources L T 1 T T T Oriainator Oratt Lessons Learned or Alert

j 1 Authorized Oerivative Classifier Perform Classification Review ! Validator Validate LL/Alert a Yes LL Proaram Manaaer Coordinate Needed Changes With Originator, Vatidator. and Classifier Green & Yellow Lessons Learned { ES LL Proaram Manaaer ES LL Program Manager ES LL Proaram Manaaer Distribute Green & Yellow Alerts for Review & Response Obtain Approval of CEP Vice President, Distribute Red Alert Enter LL Into Lessons Learned Information System (LLIS) Database { J ! Oraanizations Review Alert, ID Corrective Actions, Respond to LL Program Manager Y ES LL Proaram Manaaer Enter Alert into Lessons Learned Information System (LLIS) Database FOR INTERNAL USE ONLY I-12 { Alt Emplovees Monitor LLIS, Incorporate Applicable Lessons into Program Lessons Learned Handbook: DOE-HDBE-7502-95 ti? ‘ toes Ubud. co iis LESSONS LEARNED AND ALERTS PROGRAM QA-16.3 Revision 2 Page 9 of 15 APPENDIX B Page 1 of 1 DEFINITIONS Division Manager - Division Manager, Division Director, Program Manager, Organization Manager, i.e., a division-level manager of a program or organization. Green Alert - information derived from a positive Lessons Learned that has the potential to be the basis of significant improvement in other organizations. Lessons Learned ~ an experience, example, observation, or positive insight that constitutes a "good work practice" or defines and identifies the solution to a problem which could be of benefit to other Sites or Energy Systems organizations. Lessons Learned Program Manager - the administrator for the Lessons Learned and Alerts Program for Energy Systems or for a Site. Originator - the individual who identifies and documents a proposed Lessons Learned or Alert. Other Sources - refers to sources of Lessons Learned external to Energy Systems such as the DOE Weekly Operating Experience Summary or trade or industry publications. Red Alert - information that describes an issue or experience that potentially has major environmental, safety, health, or quality implications and requires a documented review for applicability, and if applicable, a formal corrective action response. Validator - a qualified subject matter expert assigned responsibility for reviewing draft Lessons Learned and Alerts for technical accuracy, classified information, validity, and potential applicability. Yellow Alert - information concerning a situation posing sufficient risk to require review and possibly corrective or preventive action by other organizations. FOR INTERNAL USE ONLY I-13 Lessons Learned Handbook: DOE-HDBE-7502-95, QA-16.3 Page 10 of 15 LESSONS LEARNED AND ALERTS PROGRAM Revision 2 APPENDIX C Page 1 of 5 LESSONS LEARNED AND ALERTS INPUT SHEET INSTRUCTIONS The following instructions explain how to complete the on-line Lessons Learned Input Forn. The on- line input form may be accessed by typing "A1FORMS" from any ALL-IN-1 Menu, then typing "LL" and pressing <RETURN>. 1. TITLE 2. VALIDATORS MAILNAME 3. CATEGORY 4. DATE SUBMITTED 5. SUBCATEGORY 6. DATE VALIDATED Enter a brief description of the subject and press <RETURN>. For example, for a lesson regarding a potential leakage problem in forklift fuel pumps, the title might be "Fuel Pump Leakage in Forklifts." This will appear as the Lessons Learned title in VTX and will be automatically inserted on the forn. Enter your validator’s mailname on the "Edit Message Header" screen and press GOLD F. The Lessons Learned Template will be displayed on your screen.

Enter the category that best indicates the general subject area of the text of the Lessons Learned. See Appendix D, Section B, for instructions on finding the appropriate category. NOTE: The "Other" category will be evaluated periodically to determine whether any one subject has received sufficient input to justify a new category. This is the date you submit the completed draft to the Validator. The date should take the form mn/dd/yy; ensure that the month designation is two digits, e.g., 05/12/94. Subcategories further define the subject area. Enter the subcategory which best aligns with the material contained in the Lesson. If none are appropriate, propose a new subcategory. The Lessons Learned Validator receives the draft and first ensures that it falls within his/her area of technical expertise. The validator then reviews the Lesson for technical accuracy and pre-existing lessons in the system containing similar information. Following the Validation review, the Validator completes this field using the format mm/dd/yy. FOR INTERNAL USE ONLY IlI-14 Lessons Learned Handbook: DOE-HDBK-7502-95 AL Pee em es WAG ET sapy LESSONS LEARNED AND ALERTS PROGRAM QAn-16.3 Revision 2 7. SITE 8. DIVISION 9. ORIGINATOR 10. VALIDATOR 11. LESSON LEARNED 12. PROBLEM/ ISSUE Page i1 of 15 APPENDIX C Page 2 of 5 The correct entry for this field is one of the following: K-25, Paducah, Portsmouth, X-10, Y-12. Central organizations may put their group’s name in this field if the Lesson originated there. The proper format is Centr. (space) (e.g., Centr. Quality). The name of the division which originated the Lesson Learned. The name of the person composing the text of the Lesson. The name should be in the following format: (initial].{initial]. (space) (last namej; e.g., J.D. Doe. The name of the authorized Lessons Learned Validator who reviewed the Lesson for the issues specified under item 6 of this appendix. Use the format (initial].{initial]. (space) [last name]. Enter a one= or two-sentence summary of the content of the Lesson. The summary should state what positive outcome could come from the use of the information contained in the lesson. For example, if the example begun in item 1, of this appendix, is continued, this field might state: “Downtime to forklifts may be minimized with preventive maintenance for possible fuel pump leakage." A brief description of the issue which precipitated the Lesson. Continuing the example above, this section might read as follows: "Forklifts have been failing at an unacceptably high rate for the last three months. Analysis of the failure indicates that the fuel pumps are the cause of the failures. Further investigation reveals pinholes in the fuel gaskets which causes leakage; degrading the performance of the pump and eventually causing complete pump failure." FOR INTERNAL USE ONLY I-15 ae ek Lessons Learned Handbook: DOE-HDBE-7502-95 QA-16.3 Page 12 of 15 13. DISCUSSION 14. RESOLUTION 15. REFERENCES 16. KEYWORDS 17. CONTAINS NO CLASSIFIED DATA eens GHCCET UD appy Me ce ee . ~w ARGS LESSONS LEARNED AND ALERTS PROGRAM Revision 2 APPENDIX C Page 3 of 5 This section contains information on actions taken in the investigation or background information pertinent to the Lesson. For example; "The manufacturer was contacted on 05/12/94 and reported that several other customers have reported similar problems. They have contacted the supplier for the gaskets and have learned that a new formulation of gasket material was tried approximately 18 months ago. The new material apparently degrades at a higher rate than the material previously used. The forklift manufacturer is in the process of identifying the forklifts containing the suspect material and will initiate remedial action when this information is available."

A description of what actions were taken to successfully resolve the Issue/Problem as stated in item 11 above. To continue the example; "The fuel pump gaskets have been removed and replaced with improved materials. The material was provided by the manufacturer, and the labor costs to perform the changeout have been billed to the forklift supplier." NOTE: If the Lesson arises from a positive experience, you may elect to place the words "Not Applicable -- This is a Positive Lesson" in this field. This field lists any documents used in the investigation or resolution of the problem or issue. If an Occurrence Report was generated regarding the problem, the Energy Systems occurrence report number must be entered in this field. The VTX word search searches every word in each Lesson, not simply the keywords. Keywords are eptional and may be used to convey related concepts not explicitly stated in the Lesson. This is an optional field to be used by the Validator. If, during review of the draft Lesson, there is any question about whether classified material is contained in the Lesson, the Validator must obtain a review by an Authorized Derivative Classifier (ADC) to ensure that no classified material is entered in the system. If the ADC is consulted, his/her name must be entered here. POR INTERNAL USE ONLY Iil-16 Lessons Learned Handbook: DOE-HDBE-7502-95 ou ey LESSONS LEARNED AND ALERTS PROGRAM QA-16.3 Page 13 of 15 Revision 2 APPENDIX C Dage 4 of 5 18. OBSOLESCENCE If the information in the Lesson is subject to OF DATA obsolescence, this must be noted here. Either the Originator or the Validator completes this section, noting the time interval after which the Lesson should be reviewed for continued validity. FOR INTERNAL USE ONLY Ill-17 Lessons Learned Handbook: DOE-HDBE-7502-95 UG : a QA-16.3 LESSONS LEARNED AND ALERTS PROGRAM Page 14 of 15 Revision 2 APPENDIX C Page S of 5 OFFICIAL USE ONLY LESSONS LEARNED TEMPLATE Title: Category: Date Submitted: Subcategory: Date Validated: Site: Division: Originator: Validator: Program Mor: Lesson Learned: Problem/tssue: Discussion: Resolution: References: Keywords: Contains NO Classified Data Authorized Derivative Classifier Should this Lesson Learned b-: reviewed periodically for obsolescence of data? Yes No if YES, what should be the review intervai? FOR INTERNAL USE ONLY I-18 Lessons Learned Handbook: DOE-HDBE-7502-95 HERING sm Noman JG. 7 LESSONS LEARNED AND ALERTS PROGRAM QA-16.3 Revision 2 Page 15 of 15 APPENDIX D Page 1 of 1 GUIDELINES FOR USE OF A MANUFACTURER’S NAME IN THE LESSONS LEARNED SYSTEM PURPOSE: To avoid the possible appearance of slander of goods or commercial disparagement, care must be taken when information about manufactured goods or products is distributed on the lessons leaned system (the "System"). The following guidelines are intended to advise System originators, coordinators and validators about the appropriate use of a manufacturer’s name on the Systen. USE OF MANUFACTURER’S NAME: Certain situations may warrant inclusion of a manufacturer’s name whens: 1. Worker safety an health could be affected; 2. A potential for property damage exists; 3. There is a demonstrated need to track the failure rate or trending of problems associated with a particular type of goods or products; or, 4. The manufacturer’s name is essential for utilizing the actual lessons learned. GUIDELINES: .

When it has been determined that a manufacturer’s name should be referenced or included in a Lessons Learned, the following guidelines should be followed: 1. State facts only and not opinions. Lo 2. Draw NO CONCLUSIONS from the facts. 3. Deseribe the circumstances of the failure or shortcoming of the goods or products in the Problem/Issue sectior. 4. Discuss the extent of the problem in the Discussion section. 5. Notify the manufacturer and relate the problem. If the manufacturer undertakes corrective action (such as issuing replacement parts), include a statement of that fact in the Resolution section. Also, notify the appropriate department personnel about the problem, i.e., quality assurance, procurement or safety and health personnel. If appropriate, include a contact’s name and telephone number in the References section. 6. Document discussion with manufacturer. POR INTERNAL USE ONLY I-19 Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. IiI-20 Lessons Learned Handbook: DOE-HDBE-7502-95 Westinghouse Savannah River Site Operations Oversight and Compliance Department Administrative Procedure Manual Site Lessons Learned Program January 31, 1995 TJ-21 Lessons Learned Handbook: DOE-HDBE-7502-95 Opcrations Oversight and Compliance Manual: Ql Department Procedure: OOCD-OCI-1.0, Rev. 0 Administrative Procedure Manual Effective: 1/31/95 Page: 1 of 23 SITE LESSONS LEARNED PROGRAM (U) Approved by: Manager, OOCD 1.0 PURPOSE This procedure provides guidelines for systematically reviewing operating experiences of the Westinghouse Savannah River Company (WSRC), the Department of Energy (DOE) complex, and commercial nuclear industry facilities and processes for the purpose of applying lessons learned from those experiences. This procedure also ensures that screened operating experiences that identify areas of concem are tracked for corrective actions with the goal of improving safety and reliability at WSRC. 2.0 SCOPE The requirements of this procedure apply to the screening, evaluation, and corrective action tracking for the types of information sources identified in Attachment 1 for possible applicability to WSRC facilities in the areas of process safety, personnel safety and health. Process safety not only includes conditions causing degradation of operations, but also those conditions capable of negative impact on the environment and public confidence. The lessons learned from such reviews will be applied to promote the safe, effective operation of WSRC facilities and enhance the safety and health of WSRC employees and the public. 3.0 TERMS/DEFINITIONS 3.1 Acronyms ASLLC - Assistant Site Lessons Learned-Coordinator DLLC - Division Lessons Leamed Coordinator DOE - United States Department of Energy ESH&QA - Environment, Saféty, Health and Quality Assurance OCIS - Oversight Compliance Integration Section GOCO - Government Owned Contractor Operated INPO - Institute of Nuclear Power Operations DOES NOT CONTAIN UNCLASSIFIED CONTROLLED NUCLEAR INFORMATION Reviewing Official:, Date: (Name and Title) Tl-23 Lessons Learned Handbook: DOE-HDBE-7502-95 Operations Oversight and Compliance Manual: Qli t Procedure: OOCD-CCI-L.O, Rev. 6 Administrative Procedure Manual Page: 2 of 23 4.0 3.2 NRC - Nuclear Regulatory Commission ORPS - Occurrence Reporting and Processing System LLG - Lessons Learned Group SLLC - Site Lessons Learned Coordinator SRS - Savannah River Site SSRC - Site Safety Review Committee

WSRC - Westinghouse Savannah River Company Definitions Document Reviewer - For the purpose of this procedure, the individual assigned the responsibility of screening the documents given in Attachment 1 for possible applicability to WSRC facilities. Lessons Learned - Positive or negative impacts, their resolutions, and implementation for operating experiences that affect process safety, personnel safety and health of WSRC employees and the public. Offsite - Refers to events or operating experiences that occur outside the WSRC facilities which includes sources from the INPO Nuclear Network, the Nuclear Regulatory Commission, and the DOE complex Unusual and Emergency ces. Onsite -"Refers to events or operating experiences which occur within the WSRC facilities as reported through the DOE Occurrence Reporting Processing System. Operating Experience - Documented accounts of events or occurrences, Screening - The process of evaluating the applicability of documents and the probable effect of the event on WSRC facilities. Site Safety Review Committee - A committee whose membership is comprised of experienced WSRC managers. For the Lessons Learned Program, their responsibility is to ensure appropriate corrective action on significant lessons learned issues is addressed. Significant lessons leamed issues are forwarded to the SSRC by the SLLC, Suspect Part - An item whose characteristic or identity does not appear to be authentic. RESPONSIBILITIES 4.1 4.2 4.3 The Vice President and General Manager of ESH&OA, Westinghouse Savannah River Company is responsible for designating the Site Coordinator for the Lessons Learned Program as required by References 7.1 and 7.6. The Division Vice Presidents, Westinghouse Savannah River Company are responsible for designating Division Lessons Learned Coordinators who are matrixed to the Site Lessons Leamed Coordinator as required by References 7.1 and 76. The Manager, Quality Assurance Department of ESH&QA, is responsible for ” Ti-24 Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance Manual: Qui Department Procedure: OOCD-OCI-1L.0, Rev. 6 Administrative Procedure Manual Page: 3o0f 23 verifying completion of all Directives for cach Division and notification of results to the Site Lessons Learned Coordinator as required by Reference 7.9. 4.4 The Manager, Oversight Compliance Integration Section (OCIS), is responsible for: 4.4.1 Overall implementation of the Site Lessons Leamed Program as defined by MP 4.19, "Lessons Learned Program,” MRP 4.14, “Lessons Learned Program,” (References 7.1 and 7.6) and this procedure 4.4.2 Providing staffing and procedures for the administration of the site level functions of this program 4.4.3. Ensuring OCIS provides guidance to and oversight of WSRC Division Lessons Learned Programs and procedures. 4.5 The Site Lessons Leamed Coonlinator (SLUC) is responsible for: 4.5.1 Reviewing or assigning for review, the various documents listed in Attachment I 4.5.2 Assigning preparation of and approving Site Lessons Learned Directives, SRS Lessons Learned Bulletins, Site Lessons Learned Notifications, Site Lessons Learned Program Special Information Notices, SRS Lessons Leamed Digest, and the Lessons Learned Newsletter 4.5.3 Concurring on any items deemed potentially applicable, and any recommendations which are generated by the document reviewers during the review process. The SLLC has the final authority for dissemination of

lessons learned material 4.5.4 Chairing the Site Lessons Learned Committee 4.5.5 Disseminating transmittal letters generated by this procedure ta the appropriate WSRC Divisions 4.5.6 Assuring the overall Lessons Leamed Program is conducted effectively per the intent of MP 4.19 and MRP 4.14 4.5.7 Notifying informally the Site Safety Review Committee of potential significant lessons leamed items, and requesting them formally to review items determined by the SLLC to be significant and candidates for uniform sitewide corrective actions 4.5.8 Providing direction to and oversight of the Division Lessons Learned Coordinators. The SLLC ensures that the Division Lessons Learned Programs adequately support the Site Lessons Learned Program. 4.6 The Assistant Site Lessons Learned Coordinator (ASLLC) is responsible for: 4.6.1 Serving as administrator for alt routine Site Lessons Learned Program activities TH-25 Lessons Learned Handbook: - DOE-HDBE-7502-95 Operations Oversight and Compliance Manual: Qu Department Procedure: OOCD-OCI-L0, Rev. 0 Administrative Procedure Manual Page: 4 of 23 4.7 4.8 4.6.2 Developing and maintaining OCIS's Lessons Learned Program Procedures 4.6.3 Coordinating receipt of the documents listed in Attachment 1 and assigning their distribution for screening 4.6.4 Ensuring proper distribution of lessons leamed transmittals per Section 5.5 4.6.5 Tracking the status of lessons leamed items transmitted for evaluation to the Division Lessons Learned Coordinators. Ensuring items requiring a response are entered into the “Lessons Learned Open Items Tracking System", and that tracking continues until all identified actions have been completed. (See Attachments 5 and 6 for examples) 4.6.6 Interacting with all Division Lessons Learned Coordinators as appropriate to discuss possible improvements to the efficiency and effectiveness of the lessons learned effort, and to resolve any problems 4.6.7 Serving as a member of the Site Lessons Learned Committee and is the Alternate Chairperson when the SLLC is not in attendance. The OCIS Document Reviewers are responsible for: 4.7.1 Screening in a timely manner all assigned onsite and offsite documents for possible applicability to WSRC facilities 4.7.2 Reviewing documents from the oversight activities within OCIS for applicability to WSRC facilities and submitting them into the Lessons Learned Program 4.7.3 Documenting the screening results using the form represented by Attachment 2 when required 4.7.4 Serving as members of the Site Lessons Leamed Committee 4,7.5 Preparing appropriate lessons learned transmittals for review by the SLLC 4.7.6 Reviewing the daily log of the Technical Operations Center and notifying te SLLC of events which have potential sitewide significance 4.7.7 Tracking, and maintaining computer databases as directed by the SLLC, WSRC Division Lessons Learned Coordinators (DLLCs) are responsible for: 4.8.1 Daily review of their respective Division Occurrence Reports for potential applicability to other WSRC Divisions, and transmitting lessons learned to the ASLLC for final determination and possible dissemination. 4.8.2 Serving as members of the Site Lessons Leamed Committee 4.8.3 Serving as designated points of contact for their Division for lessons learned information formally transmitted for evaluation by the SLLC T-26 Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance Manual: Qll Deparment Procedure: OOCD-OCI-1L.0, Rev. 6

Administrative Procedure Manual Page: Sof 23 4.9 4.10 4,14 4,12 4.8.4 Determining which departments in their Divisions need to evaluate and respond to transmittals from the SLLC 4.8.5 Tracking Division responses to transmittals from the SLLC 4.8.6 Reporting to the SLLC on a matrix basis 4.8.7 Submitting periodic reports to the SLLC on the status of lessons learned items in their Division 4.8.8 Serving as members of the Division Independent Safety Review Committees 4.8.9 Serving as liaison between the Site Lessons Learned Program and the Facility Operations Safety Committees as required by References 7.1 and 7.6. The Site Lessons Leamed Committee is responsible for: 4.9.1 Identifying unfavorable SRS trends in the areas of operational safety, personnel safety and health 4.9.2 Identifying significant lessons learned issues and notifying the SLLC for possible dissemination to the Site Safety Review Committee for their review and possible further corrective action as required by References 7.1 and 7.6. The Site Safety Review Committee (SSRC) is responsible for: 4,10,1 Reviewing significant lessons learned items sent to them by the SLLC 4,10.2 Reporting the results of their reviews to the SLLC so that any additional corrective actions can be tracked. Significant lessons learned. items are submitted to the SSRC utilizing the form shown in Attachment 3 4.10.3 Keeping WSRC senior management (Division Managers and above) informed on sitewide issues which are considered significant and are generated from this program 4.10.4 Periodically reviewing the performance and effectiveness of the Site Lessons Leamed Program as required by References 7.1 and-7.6. The Systems Engineering Suspect Parts Program Manager is responsible for: 4.11.1 Evaluating suspect/counterfeit items transmitted by the SLLC for site applicability, and recommending actions for appropriate items 4.11.2 Reporting the results of the evaluation to the SLLC as required by Reference 7.10. . The Lessons Leamed Group (LLG) Secretary is responsible for: 4.12.1 Maintaining a computer log of all documents screened per Attachment 2 I-27 Lessons Learned Handbook: DOE-HDBE-7502-95 Operations Oversight and Compliance Manual: Qil Department Procedure: OOCD-OCI-1.0, Rev. 0 Administrative Procedure Manual Page: 6 of 23 4.12.2 Maintaining a file of all material screened and the documented results of the screening. 5.0 PROCEDURE 5.1 Overview of the Site Lessons Learned Program The Site Lessons Learned Program implements a systematic review of the operating experiences at Savannah River Site facilities, similar DOE complex facilities, and commercial nuclear industry facilities for the purpose of applying the lessons learned from those experiences. The program has also been referred to as the Operating Experience Review Program in the past. The program is defined by WSRC Management Policies, Manual 1-01, MP 4.19, A and WSRC Management Requirements and Procedures, Manual IB, MRP 4.14, Lessons Leamed Program, and is the responsibility of the Oversight Compliance Integration Section (OCIS) in ESH&QA. The program is administered by the Site Lessons Learned Coordinator. A staff of technical reviewers assist the Site Coordinator with the screening and dissemination of lessons leamed information. Lessons Learned Coordinators from each Division, matrixed to the Site Coordinator, have the responsibility for implementing and directing their own Division Lessons Learned Program. These programs will effectively evaluate issues disseminated by the Site Coordinator and will implement appropriate corrective actions. The Site Coordinator tracks the evaluations and corrective action implementations, and provides oversight of all Division Lessons Learned Programs.

The OCIS technical reviewers, who report to the Site Lessons Learned Coordinator, are appropriately trained. OCIS obtains and screens for applicability approximately 7000 documents per year which includes sources from the Institute of Nuclear Power Operations, the Nuclear Regulatory Commission, and the Department of Energy complex. Items with potential lessons leamed value to SRS facilities are forwarded to the appropriate Division Lessons Learned Coordinators for evaluation or information, based on screening criteria. The Division Lessons Learned Coordinators, appointed by the Division Vice Presidents, determine which departments in their divisions may nced to take action on the lessons learned documents they receive from the OCIS. They monitor progress of the evaluation, corrective actions, and report the status to the Site Lessons Learned Coordinator. In addition, these coordinators screen their division occurrences for lessons learned that may apply to other WSRC Divisions and report their results to OCIS. WSRC Divisions participating in the Site Lessons Learned Program are shown in Attachment 4. The Site Lessons Learned Coordinator administers the program and tracks the progress of required lessons learned item evaluations and corrective actions. The more significant lessons learned items are discussed by the Site Lessons Learaed Committec, whose members are all OCIS reviewers and Division coordinators, and decisions are reached on whether the issue should be brought to the attention of the Site Safety Review Committee. A hierarchy of lessons learned documents has been established to help identify the relative significance of the items and assist in the T-28 Lessons Learned Handbook: DOE-HDBE-7502-95 Operations Oversight and Compliance Manual: QU Department Procedure: OGCD-OCL-LO, Rev. 0 Administrative Procedure Manual Page: 7 of 23 development of appropriate corrective actions. Figure 1 presents an overview of information received and disseminated by OCIS. 5.2 Acquisition of Offsite and Onsite Information 5.2.1 The ASLLC shall be the point of contact for acquiring sources of information of the types listed on Attachment 1, as well as items submitted by the Division Lessons Learned Coordinator. 5.2.2 The ASLLC will ensure the assignment of the information to appropriate OCIS Document Reviewers for applicability assessment. 5.3 S¢reening for Applicability 5.3.1 The OCIS Document Reviewer determines the document applicability to WSRC facilities using the guidelines in Attachment 2. 5.3.2 Results of the review are documented on Attachment 2, for required items, and ultimately returned to the LLG secretary by the ASLLC for logging and filing. 5.3.3 If the document is determined to either be applicable, but uo corrective actions required, or not applicable to WSRC facilities, then the results are recorded as per Attachment 1 guidelines for documentation and forwarded to the ASLLC for filing. 5.3.4 Ifthe document meets the screening criteria for suspect parts as provided in Attachment 2, then, the OCIS Docament Reviewer will inform the SLLC. The SLLC will transmit the item to the Systems Engineering Suspect Parts Program Manager for evaluation. The results of this evaluation along with any recommendations will be sent to the SLLC. If dissemination is required, then the appropriate transmittal in Section 5.5 will be utilized.

5.3.5 If the document is determined to be applicable or potentially applicable to WSRC facilities and has potential for corrective actions, Attachment 2 is completed and sent to the SLLC, and the actions of Section 5.4 are taken if the SLLC agrees with the applicability determination. The SLLC has the final authority for dissemination of lessons leamed material. 5.3.6 Ifthe OCIS Document Reviewer believes that immediate attention is required, the SLLC shall be notified immediately. The SLLC will determine the appropriate method of transmitting the information, which could include telephone calls or person to person visitation. 5.4 Dissemination to WSRC Divisions and Management 5.4.1 Vf the SLLC concurs that a lessons learned item may require a uniform sitewide corrective action and has sufficient significance, the SLLC discusses the issue with the Site Safety Review Committee chairperson to determine if a Directive should be issued by the WSRC President (Section 5.5.1). If the chairperson concurs, the SLLC prepares form OSR 25-143, Staff Summary I-29 Lessons Learned Handbook: DOE-HDBKE-7502-95 Operations Oversight and Compliance Manual: Qil Department Procedure: OOCD-OCI-1.0, Rev. 0 Administrative Procedure Manual Page: 8 of 23 3.5 5.4.2 5.4.3 5.4.4 5.4.5 5.4.6 5.4.7 Sheet, in preparation for formal review by ESH&QA, SSRC, and the WSRC President after proper Division and SSRC approvals are obtained. The SSRC chairperson arranges for discussion of the issue with the WSRC President. Upon approval, the SLLC issues the Directive and begins tracking. After the item is closed out by all Divisions, the SLLC notifies the Manager of Quality Assurance to begin an independent verification that all Divisions have completed the required actions. If the SLLC concurs that a lessons leamed item has potential applicability and sufficient significance for any of the WSRC facilities, then the SLLC provides a letter, utilizing the transmittal hierarchy of Sections 5.5.1-3, requesting the appropriate Division to: ‘ 5.4.2.1 perform an applicability evaluation of the item for all Departments within the Division and, 5.4.2.2 determine any needed corrective actions and, 5.4.2.3 report the results of the evaluation to the SLLC per section 5.5. Normally these items are sent to all WSRC Division Coordinators, but responise is only required by those Divisions designated by the SLLC. fnformation potentially applicable or otherwise useful but deemed not to require formal evaluation, may be disseminated per the transmittals in Sections 5.5.4-6. Any screened information deemed to require immediate attention or notification, shall be transmitted by the SLLC using the fastest means available and the Site Safety Review Committee will also be notified. Itis the SSRCs responsibility to keep senior management (Division Managers and above) informed of the status of appropriate significant sitewide issues. For items evaluated to have a potential need for sitewide corrective actions and sufficient significance, the SLLC will complete Attachment 3 (OCIS portion) and transmit it to the SSRC chairperson. The chairperson will perform the SSRC review, initiate appropriate corrective actions, complete the form, and transmit the results back to the SLLC documenting closure of the item. : The SLLC will notify the SSRC informally (e.g. phone call, All-In-One) of lessons leamed items detected by the program which may develop into major issues. The SSRC may then initiate iis own investigation and inform senior management,

Section 5.5 details the wansmital process utilized for disseminating information. , Lessons Learned Transmittals ‘The following are the six transmittals utilized to notify Divisions and Senior TiI-30 Lessons Learned Handbook: DOE-HDBE-7502-95 Operations Oversight and Compliance Manual: Ql Department Procedure: OOCD-OCI-L6, Rev. 0 Administrative Procedure Manual Page: 9 of 23 Management of lessons learned. They are listed in order of highest to lowest Significance. Items transmitted via 5.5.1 - 5.5.3 require a formal response to the SLLC. §.5.1 Site Lessons Learned Directive - The highest level of concern which indicates a generic sitewide problem which must be corrected. It will have specific instructions for corrective actions as well as an identified time table for closure, The Directive, signed by the WSRC President, is addressed to Division Vice Presidents for action. The Division Vice Presidents or their designees are responsible for reporting the results of their cvaluation to the Site Lessons Learned Coordinator. The Site Lessons Learned Coordinator is responsible for tracking directives until closure. Before a Directive can be considered completed, closure must be independently verified by the Quality Assurance Department and results reported to the SLLC in writing. 5.5.2 SRS Lessons Learned Bulletin - The Bulletin is generally used for recurring sitewide events which have not been adequately addressed or high significance degradations at SRS. Division Coordinators are requested to evaluate and initiate appropriate corrective actions and report the results to the SLLC. Bulletins are sent to Division Lessons Learned Coordinators for evaluation and WSRC Level 5 and above managers for information. Bulletins are also sent to all! DOE-SR Managers and Directors for information. 5.5.3 Site Lessons Learned Notification - The Notification is used to identify significant issues which may affect one or more Divisions. The Notification is sent to Division Coordinators for evaluation and implementation of appropriate corrective actions. The Division Coordinators are required to report the results of the evaluation and corrective actions to OCIS. 5.5.4 Site Lessons Learned Program Special Information Notice - The Special Information Notice is used to disseminate informational sources for selected activities which may not require corrective action, but represent particularly useful training resources. This information is seat to Division Coordinators for further dissemination, Division reviewers evaluate the need for corrective actions. 5.5.5 SRS Lessons Learned Digest - The Digest is used to disseminate lessons learned information (SRS experience only) from documents or occurrences which are not considered significant enough to warrant a formal request for evaluation, but do have value as a possible training resource. The Digest is distributed to the Division Coordinators and all WSRC Level 5 and above managers. Division reviewers evaluate the need for corrective actions. The Digest is also sent to all DOE-SR Managers and Directors for information. 5.5.6 Lessons Learned Newsletter - The Newsletter is used to disseminate DOE complex and commercial nuclear industry information relevant to SRS personnel. Its primary purpose is to kecp SRS abreast of industry and DOE complex issues and expectations, The newsletter does not require a response and is distributed to the Division Coordinators and an identified mailing list. T-31

Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance Manual: QU Department ; Procedure: OOCD-OCTI-L0, Rev. 0 Administrative Procedure Manual Page: . 10 of 23 5.6 Dissemination to DOE-HQ All transmittals (excluding the Lessons Learned Newsletter} issued by the Site Lessons Learned Program are disseminated to the Defense Program Lessons Leamed Coordinator and the EH Lessons Learned Coordinator at DOE-HQ. All transmittals are sent through the required MRP 3.25 review (using OSR Form 14-357) before sending the items offsite. ; 5.7 Tracking All Directives, Bulletins, and Notifications are wacked by the Site Lessons Leamed Program. A computer database is utilized to track the status of these mansmittals for all divisions. Information tracked includes personnel evaluating the item, results of the evaluation, corrective actions developed, and completion dates for corrective actions. Division Coordinators must initially respond to the SLLC within thirty days of the issuance of the transmittal, Normally, because of the brevity of time, this initial response will not close the issue. Therefore, once each quarter (10th of January, April, July, and October) the Division Coordinator provides to the SLLC a comprehensive report of all transmittal items which have not been previously closed out. This tracking system enhances the effectiveness of the Lessons Learned Program ’through increased accountability in the site and division/department level activities. Each thirty day report and quarterly report submitted by the DLLCs will be reviewed for: 3.7.1 Determination of applicability to all of the division/department contacts, §.7.2 Adequate justification for non applicability for any division/department contacts, 5.7.3 Adequate corrective actions including expected completion dates, and 5.7.4 Adequate justification for no corrective actions being necessary. Tracking will begin with the transmission of the item to the selected Division Lessons Learned Coordinators. The system will be used to alert the Site Coordinator when 30-Day Reports are delinquent. All corrective actions reported by the Division Coordinators will be tracked through completion of the action. Completion will be reported in writing by the Division Coordinator in the Quarterly Report following completion of the corrective action. An item will be considered open at the site level until all Division Coordinators have reported it as being complete. The tracking system will be used to develop statisties for the Semi-Annual Lessons Learned Reports. Auachments 5 and 6 show examples of the statistics that will be maintained through the tracking system. 5.8 Review of Other Documents On occasion, items may be sent to OCIS for lessons learned evaluation (not part of Attachment 1) which may have potential applicability to WSRC facilities. These will Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance Manual: Qu Department Procedure: OOCD-OCTI-1.0, Rev. 0 Administrative Procedure Manual Page: ; H of 23 be screened and distributed to WSRC Divisions on a case-by-case basis at the discretion of the SLLC. 5.9 Lessons Leamed Personnel Qualifications OCIS Document Reviewers and Checkers shall have a bachelors degree in the physical sciences or engineering with a minimam of 5 years nuclear industry experience and shall be trained in the use of this procedure. Reference 7.7 lists training requirements that must also be met for Document Reviewers and Checkers.

5.10 Site Lessons Learned Committee Meetings are held periodically between the SLLC, DLLC, and the OCIS Document Reviewers to discuss the status of transmittals in Section 5.5.1 through 5.5.3 which helps the SLLC determine if any of these issues need to be reviewed by the SSRC. This meeting is designated as the Site Lessons Learned Committee Meeting. DLLCs also discuss any problems they are having and actions are formulated to resolve these problems. OCIS develops and mails the meeting agenda, chairs the meeting, and issues meeting minutes upon approval by the SLLC. 5.11 Site Safety Review Committee The SLLC attends the SSRC meetings, presents lessons learned issues to the committee for further review, and provides a periodic status of the Lessons Learned Program. Lessons learned items may be informally sent to the SSRC chairperson by the SLLC; however, items determined to require SSRC review are sent by the SLLC to the SSRC chairperson utilizing Attachment 3. The SSRC chairperson is responsible for evaluating items for sitewide applicability and need for corrective action. The chairperson completes the Attachment 3 form with the evaluation results and transmits it to the SLLC for final closure, If further action becomes necessary, then the SLLC works with the SSRC chairperson to complete the action. Additionally, Directives must be approved by the SSRC prior to submittal to the WSRC President. 5.12 Employee Input A telephone hotline, H-LINE, (644-5463) has been established and publicized to encourage all SRS employees to submit lessons learned items to OCIS for their review and possible dissemination. There are valuable lessons learned which have not been documented and it is the intent of this hotline to tap this resource. 5.13. OCIS Oversight OCIS will periodically monitor the Site Lessons Learned Program by reviewing Division procedures, evaluations, corrective action development and implementation, etc., for the purpose of improving program effectiveness and consistency. Results of the oversight effort will be documented in special reports or the Semi-Annual Lessons Leamed Reports. TH-33 Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance Manual: Qu Department Procedure: OCOCD-OCI-1.0, Rev. 0 Administrative Procedure Manual Page: 12 of 23 5.14 Effectiveness Reviews Independent effectiveness reviews of the Lessons Learmed Program are required to help ensure adequate implementation. The independent review of this program will be done triennially by WSRC organization chosen by the WSRC President. The review of the WSRC Division Lessons Learned Programs will be done as a part of the Annual Self Assessment Program. 6.0 RECORDS RETENTION 7.0 6.1 The Lessons Learned Package shall consist of the reviewed document, completed Attachment 2 (if required) and any other pertinent information used in the disposition of an item. A copy of the completed Attachment 2 form afong with the document reviewed and transmittals are retained in OCIS files for two years. 6.2 A computer database composed of logs, similar to the Attachment 2 form, summarizing each Lessons Learned document review is maintained by the LLG secretary. , 6.3 Theoriginal Attachment 2 form shall be retained by Site Central Files for the life of the plant. REFERENCES 7.1 WSRC Management Policies Manual, WSRC-1-01, MP 4.19, “Lessons Leamed Program” 7.2 DOE5480.19, "Conduct of Operations Requirements for DOE Facilities”

7.3 DOE5000.3B, "Occurrence Reporting and Processing System” 7.4 WSRC1Q,"WSRC Quality Assurance Manual” 7.5 WSRC Management Requirements and Procedure, Manual 1B, MRP 4.09, “Savannah River Site Issue Management” 7.6 | WSRC Management Requirements and Procedure, Manual 1B, MRP 4.14, “Lessons Leamed Program” 77 Letter ESH-FSE-930573, Dated 6/16/93, "SRTC/AL-TSA-92 Action Closure, SA- 9g" 7.8 | WSRC Management Requirements and Procedure, Manual 1B, MRP 3.25, “Release and Management of Scientific and Technical Information" 7.9 Letter from A. L. Schwallie to R. T. Begley, ET AL, WSR-93-0022, Dated 2/8/93, "Site Lessons Learned Program" TH-34 Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance Manual: Qi Department Procedure: OOCD-OCI-1.0, Rey. 0 Administrative Procedure Manual Page: 13 of 23 7.10 WSRC Engineering and Engincered Services Procedure, Manual 1E, "Suspect Parts Identification Program (SPIP)" 8.0 ATTACHMENTS Attachment 1 - Types of Information to be Screened. Attachment 2 - OCIS Lessons Learned Screening Form. Attachment 3 - Potential Lessons Leamed to be Reviewed by Site Safety Review Committee Screening Form Attachment 4 - Divisions Participating in the Lessons Leamed Program Attachment 5 - Sample Tracking Chart Site Lessons Leamed Corrective Actions Attachment 6 - Sample Tracking Chart Site Lessons Learned Program Statistics TABLES 8.7 Figure 1 - Flowchart of Transmittals from the Sitewide Lessons Learned Program pepo ge 90.9090 AU WI me I-35 Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance Manual: QUE Department Procedure: OOCD-OCI-1.0, Rev. 0 Administrative Procedure Manual Page: 14 of 23 ATTACHMENT I TYPES OF INFORMATION TO BE REVIEWED RESPONSIBLE - SCREENING SOURCE GROUP TTILE FORM USED DOE LLG Emergency and Unusual Occurence Reports = Note 1 (all DOE facilities} “SRS Div. Coord. All WSRC Occurrence Reports Note 2 (Off-Normal, Unusual, and Emergency) NRC LLG Bulletins At 2 LLG Information Notices Att 2 LLG * Selected NUREGs Att 2 LLG * Regulatory Guide changes Att 2 and additions LLG Generic Letters Att2 LLG * SECY Letters Att2 LLG * Policy Statements At2 INPO LLG Nuclear Network Information Items Note 1 LLG Significant Operating Experience Reports At2 LLG Significant Event Reports At2 LLG Significant.by Others Att2 OTHER LLG * Vendor Bulletins At2 LLG * Chemical Engineering Atr2 LLG _ * Chemical and Engineering News At2 LLG * Process Safety Progress Att2 + Only items that are potentially applicable to WSRC facilities are screened as determined by the Document Reviewers from title/synopsis screening. Those items determined to be not applicable are not entered into the Lessons Learmed Program. Note 1: These documents do not require a second check and will use Attachment 2 form only for potentially applicable items. Not Applicable items will be entered into the computer database. Note 2: Each Division is responsible for maintaining and filing their screening of WSRC occurrence reports. Only reports transmitted by OCIS will have a completed Attachment 2 form. T-36 eee aoe Lessons Learned Handbook: DOE-HDBKE-7502-95 Deena Oversight and Compliance Manual: Qu arument Procedure: GOCcD-OCI-1.0 Administrative Procedure Manual Page: © ts af 23 4 ATTACHMENT 2 . OCIS OPERATING EXPERIENCE REVIEW SCREENING ANO DATA COLLECTIONS EoD Oceurrance Flapent Patt Pant2 impacts ‘ Number: [Repod Number ] Bequence Humber | Number Ce Document The — (Tiia of Document

Grist Descnption: [Desergxion at Document including a pustficsina for zoplicsbday of nonapplicabity Date Discovered: [7] Tena Discavered (_- ] Cuero: {Type (Unesuat, HAC. FPO} Other, give [Keywords are anered hace , dascrigtion: teat teed TS OSA None Salety Significance: Type Violation: . taa-Salety Signiicance: LJ J none, mark None box. ° Othar violation description: puna sa cnet; RE Oe, Oa, OR, anion {ndial [teeme [races | [Ti2esa} [ries | ete3] & jy €.N 1e0y = ICO Ce oC CR tnterim iI ica oc cs Goes Fat [ IC OCT a sas oe Lenerto: [Filia # Letter ts Generated ] benerto: =f | Lener Numb . [FSES Letter Number 1 cotter ti ser { a) tener Date. [1172493 | LenerDate: (Cd Commants: {Transmetal Used @ Onectve, Suketn, Notdscation etc. Hf the semis apohcable, “x”, and requaas auction check this, box, # the dem ts apphicable, *y*. check this box, Hf the Cert ss not appticatte, 2", input the cause code nomber 1 sho fi hese 1s a Root Cause Regon Necessary? { | Yes { i No Was tha Root Causa Anatyss Acceptable? f Yes { j fo Note. f the OR is an Emergancy ar Unusual, arhas potenualor Was a Contact ade? C] Yes CI) to actuat significance of A-E, 2 soot cause report 1s Necessary. Commons. . ! ——_—_I I-37 wet sets Lessons Léeatned Handbook: DOE-HDBK:7502-95 Operations Oversight and Compliance Manual: Qil Department Procedure: OOCD-OCI-1.0, Rev. 0 Administrative Procedure Manual - Page: 16 of 23 The following guidelines will be used to help the document reviewer to determine whether any of the information contained in the document being screened is applicable to WSRC facilities: . . - Do WSRC facilities utilize the same cquipment (safety, production, monitoring, etc.) described in the document being screened? - Do WSRC facilities employ the same designs described in the document being screened? - Do WSRC facilities utilize a similar administrative or management control system described in the document being screened? - Do WSRC facilities use, store, or produce the same or similar chemicals/products described in the document being screened? . - Are the same activities or operations described in the document being screened present at any of the WSRC facilities? - Do WSRC facilities follow the same regulations/codes/standards described in the document being screened? - Is there the opportunity for a similar problem or situation to exist within any of the WSRC facilities? The following codes will be used for all items determined to be “not applicable" to WSRC Facilities: 1. NRC regulatory issue applicable only to licensees. No SRS facility safety potential, Systems, conditions and/or processes not applicable to SRS facilities. Failure of site specific administrative controls or systems. “~ fF YN Occurrence unique to a specific facility. 6. No lesson to be learned from this event. The following guidelines will be used to help the document reviewer to determine whether any of the information contained in the document being screened is a suspect part: 1 - Failure by the supplier to identify a refurbished or remanufactured pan as such - Counterfeiting or imitation of a part with the intent to deceive TI-38 Lessons Learned Handbook: DOE-HDBE-7502-95 Operations Oversight and Compliance Manual: Qui Department Procedure: OOCD-OCE-10, Rev. 0 Administrative Procedure Manual Page: . 17 of 23 Manufacturing defects that can ead to malfunctions of a part in an application for which i it was designed or specified

When material substimtion is made and not so documented. III-39 Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance Manual: , Qli t Procedure: OOCD-OCCI-1.0, Rev. 6 Administrative Procedure Manual Page: . 18 of 23 ATTACHMENT 3 POTENTIAL LESSONS LEARNED TO BE REVIEWED BY SSRC (Completed by OCIS) Item Number: Title/Issue: Recommended to SSRC: Date: Priority: Requested Action by SSRC: (Completed by SSRC Secretary) SSRC Response: Meeting Date: Committee Directed Action: Discussion/Follow up Actions: Closure: Date Closed/Memo: III-40 Lessons Learned Handbook: DOE-HDBK-7502-95 Operations Oversight and Compliance. Manual: Qli t Procedure: OOCD-OCI-LO, Rey. 0 Administrative Procedure Manual Page: 19 of 23 Instructi f leting Attact 13 OCIS SECTION: Item Number -- A sequential number starting with the year (i.¢. 93-1) Title -- Title of the potential issue Date -- Date sent to the SSRC chairperson Priority -- Defines whether an item can be deferred until the next meeting or action is required sooner Requested Action -- Defines the reason the committee is reviewing the item (Le. review for possible directive/bulletin, general review, etc.) SSRC SECTION: Meeting Date -- Date the issue was initially discussed Directed Action -- Defines what committee action is consistent with the Lessons Learned Program (Le., will be issued in a directive, bulletin, notification, or other means). Discussion/Follow-up Actions -- For those issues that cannot be resolved in one meeting, this will provide a space to define how they will be resolved. CLOSURE: Date Closed/Memo -- The date and letter number which closes the issue. TH-41 Lessons Learned Handbook: DOE-HDBE-7502-95 Operations Oversight and Compliance ‘ Manual: Ql Department Procedure: OOCD-OCI-1L0, Rev. 0 Administrative Procedure Manual Page: 2% of 23 ATTACHMENT 4 DIVISIONS PARTICIPATING IN THE LESSONS LEARNED PROGRAM 1. Administration and Logistics Division Chief Financial Officer Division Economic Development Division 2 3 4. Engineering and Construction Services Division 5. Environment, Safety, Health and Quality Assurance 6. High Level Waste Division 7. Human Resources Division 8. Internal Oversight Division 9. Nuclear Materials Processing Division 10. Operations Training and Assessment Division 11. Reactor Restart Division ° 12. Safeguards Security and Emergency Services 13. Savannah River Technology Center 14. Site Services Division 15. Solid Waste and Environmental Restoration T-42 Lessons Learried Handbook: DOE-HDBK:7502-95 Operations Oversight and Compliance Manual: Qli Department - Procedure: OOCD-OCI-LO, Rev. 0 Administrative Procedure Manual Page: 23 of 23 ATTACHMENT 5 ITEM # {TOPIC DIVISION CORRECTIVE ACTIONS DUE DATE N.94-05-1 [Heat Tracing Tepe Misapplication SSD {Reqoired Reading (CSWE) _ | COMPLETE RD {A walkdown will be performed lo ses if condition exists. (FS} IBID N-94-05-2 [Beta Smear Counter Calibration SSD {Inspected Planchets, no breaches found (ANALAB) COMPLETE N-94-06-1 [Hyster Lift Truck Retrofit Kit HLW {Two Hyster Lift Tracks Identified, retrofit kits on order 22895 SRTC {One Hyster Litt Truck identified, retrofit kiton order CINX) 272855 EPD Searched equipment, no such trucks found (Construction) COMPLETE N-94-08-4 [Sealed Tank Voltage Regulators ADMIN {Searched database, none found, none issued COMPLETE HLW _ |Search indicated that none exist in HLW COMPLETE RD |Search indicated thet cone existin RD COMPLETE N-94-08-5 [Square-D Instrument potential forme] ADMIN |Searched performed, one found, in good shape COMPLETE. SSD | Required Reading (CSWE) COMPLETE N-94-08-6 [Powell Flanged Gate Valves NMPD |Searched of databases and spare parts, 2 found and removed COMPLETE SWER | Determinoif any of the Powell valves eve made in China (SW) 872984 ADMIN |Search found 298 valves, walkdown showed none from Chine. COMPLETE ’ HLW {Perform MEL search ofp4 894-4 [Degraded System Support Poles ADMIN | Inspected inventory of support poles by CSWE (Stores) COMPLETE

HLW [H-Area completed pole inspection, results forwarded to Power Dept. | COMPLETE SSD __ {Required Reading (CSWE) COMPLETE SWER {Poles to be inspected (SW) 9R0D4 RD __ [Develop PM inspection schedsle to inspect poles 9094 SRTC |SRTC walkdown complete, defective poles located COMPLETE B-94-5 | Followup on Acid Line Failure SRTC [Identified system pipes, to establish NDE inspection (TNX) B/094 B-94-6 Hncorrect Breathing Air Piping RD [Perform walkdown and repair as necessary (FS) 8/5/94 SRTC {Completed review and walkdown of Breathing Air System (773) COMPLETE SSD _jRequired Reading (CSWE) COMPLETE NMPD {| Walkdown BA system and verify Verification Records _ (Sep) 916/94 NMPD {| Walkdown HP boltle stations and verify Verification «ecords (Trit) SRDS D-94-1 Polycarbonate Bowls ADMIN {Removed 63 bowls from stores COMPLETE HLW {Replaced 26 bowls with metal bowls COMPLETE _, EPD__ Removed it bow!s from service, mplaced 34 bowls with metal bowls COMPLETE SWER_ [Replaced 2 bowls with metal bowls | COMPLETE __NMPD [Removed | bowl! from service, replace (12 bowls with metal bowls SUSIE SSD__ [Replace 178 bowls with mew! bowls COMPLETE SSES |Compleiclyenclosc2bowls | nas RD __ [Removed 208 hows fram sernce, replace 103 bowls wth meut bowls | YAS SRTC [Removed I bowls from service, replace 102 bowls with mets! bowls {OBS TH-43 athe Boe Lessons Learned Handbook: DOE-HDBE-7502-95 Operations Oversight and Compliance Manual: Qui Department Procedure: OOCD-OCI-1.6, Rev. 0 Administrative Procedure Manual Page: 22 of 23 ATTACHMENT 6 DIVISION NMPD | SW&ER # af Items Transmitted to the DLLC . 45 43 Items not responded to by end of quarter 0 0 Ttrems under going evaluation by Division Contacts 20 9 Ttems Closed 25 (6%)} 34 (79%)] Items Determined Net Applicable by the DLLC 8 0 Items Closed by Division Contacts - 17 34 # of Items Transmitted to Division Contacts by end of the quarter 37 43 tems with No Corrective Actions determined by end of the quarter 21 32 Items with Corrective Actions determined by end of the quarter 16 it Items with Corrective Actions closed 2 9 Iterns with Corrective Actions averdue 0 0 DIVISION COORDINATOR NMPD | SWRER Required Reports Submitted on Division Daily Occurrences, % | 98% 93% Number of 30 Day Reports required 45 43 Number of 30 Day Reports submitted 45 43 Number of 30 Day Reports submitted more than 10 days late "0 0 Average 30-Day Report response time, days 30 31 Quarterly Reports submitted (2) VA YES 2nd YES | tn YES ad VES: Quarterly Reports (2) submitted on time, (<1 0 days late) In YES 2nd VES| lat YES 2nd YES Site Lessons Learned Committee Mecting Auendance, % . 100% 83% T-44 Lessons Learned Handbook DOE-HDBK-7502-95 Qu OOCD-OCI-LO, Rev. 0 Manual Operations Oversight and Compliance Procedure Pape 4 . t Administrative Procedure Manval 23 of 23 FIGURE f XAId WOO 30d ‘US-dod ‘OUSM O1 GALYNINSSSIC t Gayinoay SNOdS3Y ON gayinosay FaSNOdSaYy ON aauinoay SNOdBSaY ON SNOVEL *GHOOS Ald ‘SSNOdsay SHOVEL "dYOOS AIG ‘asNodssy SHOVEL Sass ‘3SNodsay 002 + SHOLYNIGHOOS 005% + SHOLYNIGHOOS SHOLYNIGUOOD SBOLVNIUOOD o0Sz + SHOLYNIGHODS SHOLYNIGUOOD + dA 9% 43 ow oz~ Oe 5” USLISISMSN = (9 isaola (¢ AOLLON OJNI ‘Whads ty NOLLVOILLON §(t NUSTING §(% BAWOSUIA « (h ROSY = NOLIUIEIST «EVEN «6©—- SROWLYOBTION SN3ISAH 9 ALSAVS “WNOLLVdNS50 SAIGVLHOd3Y O3NuV3I SNOSS31 NOISIAIO sus S190 LHDISYSAO S3as3 SHOLVNIOUCOD IANNOSY3d OQ3NYUYAI SNOSS31 SYS NOISIAIO LNSWSOVNYIN Nvauor a YyOINaS o ouss <€> SBHIMNDVA ™ on09 M (300'OdNI ‘OUN) S30uNnosS WNUSBLXS,

WVYSOudd GANYVA SNOSS31 AGIMaLIS WOdd STIVLLINSNVYL SHL T-45 Lessons Learned Handbook: DOE-HDBK-7502-95 TH-46 Lessons Learned Handbook: DOE-HDBE-7502-95 Air Force Lesson Learned Program Lessons Learned Writing Guide February 15, 1991 Iil-47 Lessons Learned Handbook: DOE-HDBE-7502-95 I-48 Lessons Learned Handbook: DOE-HDBKE-7502-95 THE AIR FORCE LESSONS LEARNED PROGRAM "FINGERTIP ACCESSIBILITY TO EXPERIENCE" Published By The Directorate of Support Equipment and Lessons Learned Acquisition Logistics Division (ALD) 15 FEBRUARY 1991 LESSONS LEARNED WRITING GUIDE ADDRESS INQUIRIES TO: ALD/LSE WRIGHT-PATTERSON AFB OHIO 45433-5000 DSN: 785-9698 COMMERCIAL: (513) 255-9689 I-49 Lessons Learned Handbook: DOE-HDBE-7502-95. I-50 Lessons Learned Handbook: DOE-HDBE-7502-95 GUIDE FOR WRITING POTENTIAL LESSONS (PLL) INTRODUCTION In order to establish control and ensure consistency in the Lessons Learned program, PLLs are submitted through ALD/LSE. The PLL must be structured into the proper format in accordance with this writing guide before receiving final approval. PLLs may be submitted on plain bond paper or on AF Form 1251, "Potential Lessons Learned Submittal Record" (Atch 1). This guide was prepared to give writers of potential lessons an insight into the proper format and instructions necessary for writing good lessons. The guide emphasizes the need to properly complete the AF Form 1251. The form included in this guide may be locally reproduced. Potential lessons may contain reference to programs, weapon systems or contractors associated with those programs/weapon systems. BACKGROUND A lesson learned is defined as "a recorded experience of proven value in conducting future programs or modifications." To realize this value, a lesson must be recorded and entered into the data base before it can be applied in any learning process. The sources of these lessons are numerous - program offices, labs, reports, product improvement efforts, and flightline, intermediate, and depot maintenance personnel, headquarters managers, etc. After PLLs are submitted to ALD/LSE, functional specialists (validators) analyze the experiences and provide the research necessary to document whether the lesson should be recorded in the data base. Validated lessons are entered into the data base where they can be retrieved electronically and applied in other programs. CRITERIA The first question that an individual writing a lesson must ask is "Can someone else learn from my experience?" Answering this question involves an analysis of the potential lesson based on the criteria.that a . potential lesson must be beneficial, valid, and applicable. Oo: To be beneficial, it must have a readily recognized impact within the Air Force, and it should provide a helpful reminder to the reader. In other words, there must be a reasonable possibility that a designer/manager will repeat the same mistake. However, a lesson does not necessarily have to be about a problem or a mistake. It can be a positive lesson concerning an innovative technique or a new design that can save money and man-hours, or improve supportability/reliability. To be valid, a potential lesson must be factually and logically correct. For example, it is valid to say that "significant cost savings have been realized through use of the impingement spray technique for final cleaning of precision piece parts." This statement is supportable because documentation was submitted with the lesson. However, a design or process that is merely thought to be superior but which has never been tested does not constitute a proven experience of value in conducting future programs.

Finally, a potential lesson must be applicable. It should not tell the manager/designer to "build a simulator system to the lowest life cycle cost." No one is going to consciously bring an insupportable system into the Air Force inventory. This unfortunate phenomenon usually results from a multitude of uninformed I-51 Lessons Learned Handbook: DOE-HDBE-7502-95 decisions during the acquisition process. For this reason, the lesson must identify a specific management or design decision which has a potential for reducing support costs. On the other hand, the lesson must not set forth an action which cannot be applied. For example, changes in a specific accounting or contracting technique may occasionally seem advantageous to the Air Force. However, if such a change is inconsistent with existing law or regulations, then it would not constitute an applicable lesson within the Air Force. A potential lesson that fails to meet any of the three foregoing criteria should not be submitted. T-52 Lessons Learned Handbook: DOE-HDBE-7502-95 INSTRUCTIONS FOR COMPLETING AF FORM 1251 TOPIC: Use a brief topic (one to two lines) that accurately describes the contents of the lesson. LESSON LEARNED: One or two sentences stating the single most important finding. This Statement must show a "cause and effect" relationship. PROBLEM: A concise, general statement (preferably no longer than one or two sentences) describing what went wrong. If writing a positive lesson, enter "none." DISCUSSION: Describe the situation, giving a complete, concise account of the findings as they relate to the specific situation, procedure or design. This account is usually one to three paragraphs in length. RECOMMENDED ACTION: This part of the lesson must provide the reader with a course of action and tell who should take the action (program manager, contracting officer, etc.), when the action should be taken (i.c., during what program phase (concept exploration & definition, engineering & manufacturing development, production & deployment, etc.) If it is an acquisition or logistics-related lesson). This statement should identify "what,who,when." **NOTES: If acronyms are used, be sure to spell them out the first time they are used. If additional space is needed for pertinent information, attach a Sheet to the AF Form 1251. TI-53 Léessdiis Learned Handbook: DOE-HDBK-7502-95 EXAMPLES Whien writing potential lessons, writers seeni to have the most difficulty writing the LESSON LEARNED and RECOMMENDED ACTION statements. The following are examples of both the correct and incorrect way to write thiosé portions of potential lessons. EXAMPLE OF A CORRECT LESSON LEARNED STATEMENT LESSON LEARNED: Inadequately designed heat removal systems and lack of status monitoring of critical equipment cooling can result in data errors and equipment failure or damage. (Shows a "cause and effect" relationship.) EXAMPLE OF AN INCORRECT LESSON LEARNED STATEMENT LESSON LEARNED: There should be one Quality Assurance organization for the entire project. (Statement is very vague and does not show a "cause and effect" relationship.) EXAMPLE OF A CORRECT RECOMMENDED ACTION STATEMENT RECOMMENDED ACTION: Prior to entering full scale development, the Deputy Program Manager for Logistics/Technical Order

Management Agency (DPML/TOMA) should prepare plans for the acquisition of technical orders. To accomplish this, the DPML/TOMA must draw upon knowledgeable, experienced personnel, both within and outside of thé program. The prime points of contact to assure proper consultation are HO USAF/LEYE, HO AFSC/PLLM or ALD/LSG. (Tells “when, who, what" should be done.) EXAMPLE OF AN INCORRECT RECOMMENDED ACTION STATEMENT RECOMMENDED ACTION: Implement a policy or letter of direction defining Aerospace COE standards for construction projects and allowing AFQA to "help" document the work being formed. Include this with the SOW for all high tech construction projects down to the subcontractor level. (Does not say who should implement policy or "when" it should be done. Also, the acronyms were not spelled out.) I-54 Appendix IV Communications Material Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBK-7502-95 APPENDIX IV COMMUNICATIONS MATERIAL Appendix IV provides an example of material that can be used to communicate information about a lessons learned program. The document provided is a Lessons Learned Program Guide used to communicate key points and contact information regarding the Martin Marietta Energy Systems (now Lockheed-Martin) Lessons Learned Program. Articles, flyers and other materials can be effectively used to inform staff about the program and to encourage participation. Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 Lessons Learned Sharing Experiences with Others For detailed requirements of the Lessons Learned and Alerts Program, refer fo QA-16.3 What are Lessons Learned? “Lessons Learned" are experiences, examples, observations, or positive insights that constitute a “good work practice" or define and identify the solution to an issue which could be of benefit to other Energy Systems organizations or DOE Sifes. What is an Alert? An “Alert’ is a Lessons Learned from a significant issue or experience that has environmental, safety, health, or quality implications, or which identifies a significant improvement area. An Alert may require management action and feedback to ensure that the problem or issue has been resolved, or that the improvement has been incorporated. Why do we issue Lessons Learned or Alerts? Lessons Leamed and Aleris are documented and issued to provide a method of sharing experienceswith othersto hopefully avoid repeating similar problems/ mistakes and to share proactive approaches to improve efficiency and avoid potential problems. Wide sharing of your problems or successes may help someone else avoid a similar situation in the future—and it may help reduce our operating costs. Who can generate a Lessons Learned? Anyone can and shoulal! lf you have found an approach to handling a situation which others may benefit from, have experienced a significant problem or been involved in a hazardous situation--or know of one which has occured, you can initiate a Lessons Learned using information contained in this guide or by contacting one of the Lessons Learned Program Managers. Lessons Learned Program Guide Lessons Learned Handbook: DOE-HDBE-7502-95 What are typical sources of Lessons Learned? - Daily activities and experiences - Occurrence and Incident Reporis - Within MMES ~ From other DOE Contractors - Assessment issues - Operational Readiness Reviews - Performance or process improvement initiatives - Goverment and Industry experiences - Technical periodicals and bulletins - Project completion evaluations

How do! submit a Lessons Learned? To submit a Lessons Learned. complete the Lessons Leamed form which can be _ obtained by either contacting a Lessons Leamed Program Manager or thru ALL-IN-1 by typing ‘ATFORMS*. After you have compiled the Information, it will be validated by a technical expert In the area to which the Lesson pertains prior to actual entry In the Lessons Learned Information System. Be sure to have it evaluated for classification PRIOR to entry on any computer system. Helpful tips for writing a Lesson - Be consise and brief in the descripiion of the Lesson and recommendations - Include examples which indicate scope of applicability - Identify sources for additional information or reference - Spell out acronyms - Include contact person for follow-up information - Obtain classification review prior fo entry on any computer system Refer to the Lessons Learned Form Instructions in VIX for additional details. Printing a Lessons Learned To print a Lesson Learned or any of the information contained in the Lessons Leamed Information System, enter a <GOLD S> followed by a <GOLD W> and the Lesson or Information you are currently viewing will be printed. See the VIX End User Help option on the main VIX menu for additional Information on printing from VIX. Lessons Learned Program Guide Lessons Learned Handbook: DOE-HDBK-7502-95 How do | find previously issued Lessons Learned? AllLessonsLearned and Alerts are entered intothe Lessons LeamediInformation System, which is available via VIX on MMES computer networks. These lessons may be helpful when developing new programs or procedures, proposing new corrective actions, or identifying methods previously proven effective for similar situations. To access historical lessons: - Logon to your MMES computer account - At the system $ prompt, type VIX ~ Select the Energy Systems Lessons Learned option fromthe VIX menu The Lessons Leamed Information System has several options you can choose from: . Lessons Learned Word Search provides the capability to locate lessons contalning a word you supply. Lessons Learned Category Search provides the capabllity to locate lessons from a predefined list of categories. . Last 30 Days Entries provides a listing of new Lessons Leamed. Lessons Leamed Program Contacts provides a current listing of the Lessons Learned Help contacts and divisional coordinators. Validators by Organization provides a listing of technical personnel who are approved fo valldate new Lessons Leamed. Lessons Leamed Input Form Instructions provides guidance on completing the Lessons Leamed Form fo submit a new lesson. Blank Lessons Leamed Input Form provides a form which can be printed to submit a new lesson. 8. Printing a Lessons Leamed provides instructions on how to print a hard-copy of a Lessons Leamed. 9. Help in Using the Lessons Learned System provides step-by-step Instructions: for using the Lessons Learned Systern. _ o 2 BY N ~ Need more information? if you need additional information regarding the Lessons Learned Program, or have an experience which you believe should be shared with others via a Lessons Learned, consult the Lessons Learned and Alerts Program Procedure, QA-16.3, or contact one of the Lessons Learned Program Managers: ERWM: R. K. Gupta (4-1057) Y-12 & MMES: J.C. Bell (6-8011) ORNL: A. L. Wachs (4-2343) Central Org: _—~P.. L. Johnson (4-9365) or send an e-mail to LESSONSLRND a Lessons Learned Program Guide Lessons Learned Handbook:

DOE-HDBE-7502-95 OFFICIAL USE ONLY LESSONS LEARNED FORM Title: Category: Date Submitted: Subcategory: Date Validated: Site: Division: Originator: Validator: Program Manager: Lesson Leamed: Problem/Issue: Discussion: Resolution: References: Keywords: Contains NO Classified Data Authorized Derivative Classifier Should this Lesson Leamed be reviewed periodically for obsolescence of data? Yes No If YES, what should be the review interval? Seles Lessons Learned Program Guide Appendix V. Air Force Lessons Learned Validator’s Guide Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 APPENDIX V AIR FORCE LESSONS LEARNED VALIDATOR'S GUIDE Appendix V provides an example of a lessons learned validation process that has been implemented as part of the Air Force Lessons Learned Program. The Afr force Validator’s Guide was prepared to provide validators with the proper format, instructions and samples for validating potential lessons learned. It also includes criterla for determining what is and what is not a valid lesson learned. * ' haem Lessons Learned Handbook: DOE-HDBKE-7502-95. This pase intentionally left blank. V-2° Léssons Learned Handbook: DOE-HDBK-7502-95 AIR FORCE LESSONS LEARNED PROGRAM "Fingertip Accessibility to Experience" (FATE) LESSONS LEARNED VALIDATOR'S GUIDE Published by THE AIR FORCE LESSONS LEARNED PROGRAM MAY 1993 ADDRESS INQUIRIES TO: ASC/CYN, BLDG 17 2060 MONAHAN WAY Wright-Patterson AFB, OH 45433-6503 DSN: 785-3454 COMMERCIAL: (513) 255-3454 We Lessons Learned Handbock: DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 INTRODUCTION In order to establish control and ensure consistency in the program, potential lessons learned (PLL) are submitted through ASC/CYM. PLLs may be submitted on plain bond paper, on AF Form IZ51 (available from ASC/CYM). Upon receipt, PLLs will be assigned by the Lessons Learned (LL) staff to the project (validation) office having primary functional responsibility for the area covered by the PLL. The project (validation) office will designate a functional specialist (validator) to analyze, validate and rewrite Gf necessary) the lesson. Also, we receive lessons that have been written and validated by offices with which we have established a Memorandum of Agreement/Letter of Agreement. These lessons require no further validation. The PLI must be structured into the proper lessons learned format (see page 7) in accordance with this guide before receiving final approval from senior level management (Col/GH-15). This guide was prepared to give validators the proper format, instructions and samples for validating potential lessons. The guide emphasizes the need to properly complete the AFLC Form 8015 (“Lessons Learned Worksheet"), the validation check list, and attach pertinent information as back-up material. The AFLC Form 8015 must contain a summary of all the information gathered by the validator in the process of researching the potential lesson to determine its validity. Samples of the three types of lessons (Lesson Learned, Rewrite and No Lesson Learned) are included in this guide. Lessons Learned Handbook: DOE-HDBK-7502-95, GUIDE FOR VALIDATING POTENTIAL LESSONS LEARNED BACKGROUND

A lesson learned is defined as "a recorded experience of proven value in conducting future programs and modifications." To realize this value, a lesson must be recorded, validated and entered into the data base before it can be applied in any learning process. The sources of lessons are numerous - program offices, labs, reports, product improvement efforts and flightline, intermediate and depot level maintenance personnel, etc. Functional specialists (validators) analyze these potential lessons and conduct the research necessary to document whether a lesson is valid. Validated lessons are entered into the data base where they can be retrieved electronically and applied to other programs. Potential lessons may contain references to programs, weapon systems or contractors associated with those programs/weapon systems. CRITERIA The first question an individual researching a potential lesson must ask is "Can someone else learn from this experience?" Answering this question involves an analysis of the potential lesson based-on the criteria that it must be beneficial, valid and applicable, To be beneficial, it must have a readily recognized impact within the Air Force. It should provide a helpful reminder to the reader. In other words, there must be a reasonable possibility that a designer or manager could repeat the same mistake. However, a lesson does not necessarily have to be about a problem or a mistake. It can be a positive lesson (Best Practice) concerning an innovative technique or a new design that can save money and man-hours or improve supportability/reliability. To be valid, a potential lesson must be factual and logical. For example, it is valid to say that "significant cost savings have been realized through the use of the impingement spray technique for final cleaning of precision piece parts." This statement is supportable because documentation was submitted with the lesson learned. However, a design or process that is merely thought to be superior, but which has never been tested, does not constitute a "proven experience of value in conducting future programs." Finally, a potential lesson must be applicable. It should not tell the manager/designer to “build a simulator system to the lowest life cycle cost." No one is going to consciously bring an insupportable system into the inventory. This unfortunate phenomenon usually results from a multitude of uninformed decisions during the acquisition process. For this reason, the lesson must identify a specific management or design decision which has a potential for reducing support costs. On the other hand, the lesson must not set forth an action which cannot be applied. For example, changes in a specific accounting or contracting technique may seem advantageous to the Department of Defense (DOD). However, if such a change is inconsistent with existing law or regulations, then it would not have applicability within the DOD. A potential lesson that fails to meet any of the three foregoing criteria should be treated as a "no lesson learned." If the lesson meets all the criteria and is not already documented in the data base, it should be validated as a "lesson learned." If the lesson is similar to one that is already contained in the data base, it may be added to the existing lesson as a "rewrite" to help substantiate it or added to the lesson folder as additional back-up information. A validation check list will be included with each PLL that is forwarded for validation. The validator will complete the check list and return it along with the completed AFLC Form 8015.

In the process of validating a potential lesson, the validator will determine the adequacy of policy/regulations covering the lesson learned content and ensure any inadequacies are corrected. fy Lessons Learned Handbook: DOE-HDBK-7502-95 INSTRUCTIONS. FOR COMPLETING AFLC FORM 3015 Fill in the appropriate blocks as follows: *NOTE: Blocks 1 and 8 are completed by ASC/CYM.. *1, LESSON NUMBER: (Assigned. by ASC/CYM). 2. STATUS: (Examples of the following types can be found in this guide). Lesson Learned - This block will be checked if the validator determines that this is a valid. lesson.. Lesson Rewrite - This block will be checked when the validator adds information from the potential lesson to a similar lesson found during a data base search. (The existing lesson will be included in the file). No Lesson Learned - This block will be checked when the potential lesson does not meet the criteria (is. not valid) or is a duplicate of a lesson already in the data base. 3. TOPIC: Use the topic shown on the PLL or change it to better reflect the content of the PLL. 4. IMPACT AREAS: Enter the impact area(s) and. impact area number(s) to which the lesson a 2 pertains. More than one area may be used on thie same lesson. The impact areas are listed on Atch 1. If - = the lesson is a "No Lesson Learned," leave this space blank. he 5. ENTER IN ACQUISITION MODEL YES _§ NO FUNCTIONAL AREA EM/PK/XR/EN/DO/AL: Mark appropriate block. If you feel it should be in the Air Force Acquisition Model circle the appropriate functional area(s). Those selected will be forwarded to the appropriate functional area for a final decision. 6. PROGRAM PHASE: Enter the phase of a program during which the lesson can best be applied. The five program phases are: Concept Exploration & Definition (includes Pre-conceptual), Demonstration & Validation, Engineering & Engineering & Manufacturing, Development, Production & Deployment and Operations & Support. If the lesson is a "No Lesson Learned" or is non-acquisition or non-logistics related, enter "N/A." 7. VALIDATOR: Enter your name, office symbol and telephone extension. When rewriting a lesson, include the name of the original validator, as well (if available). *8., SOURCE OF ORIGIN (of the potential lesson): This-refers to the original submitter of the PLL and is entered by ASC/CYM. 9. REFERENCES: List people contacted and documents used as sources of information during your research. Include full names, office symbols, addresses.and' DSN numbers. It is the validator's responsibility to seek out other functional experts within, as well as outside their organization to ensure the validity of the information in the potential lesson. Documents reviewed and persons contacted should be commented on in block 10-3 (Analysis Section). The lesson submitter should be contacted, whenever possible, to discuss the content of the PLL. You must also enter this information for a "No Lesson Learned" Lessons Learned Handbook: DOE-HDBE-7502-95 ‘ 10. ANALYSIS: List comments on the course of your research and analysis of the potential lesson. Complete the block as follows: A. The validator will search the data base to determine whether any similar lessons are on file. If no lessons-are found, write "NONE" in block 10-A. B. If an identical or similar lesson is found, list the number(s) and comment on the applicability of the lesson(s) in block- 10-B. Cc, Summary of the Analysis: (1) This will be used as historical back-up material when needed.

(2) A concise statement of any pertinent discussions of the subject with the lesson submitter, system program office, equipment specialist, system manager, item manager, engineer, deputy program manager for logistics, integrated logistics support manager, contracting specialist, etc. (3) Comment on any documents listed in Block 9 (References). When any document or excerpt from a document is included in the lesson folder as back-up material, it must be referred to as Atch 1, Atch 2, etc. (4) Comment on any lesson(s) found when the data base was searched. Decide at this point if your potential lesson is identical to an existing lesson or determined to be not valid (No Lesson Learned); to be combined with an existing lesson (Rewrite); or accepted as a valid Lesson Learned (see Block 2, Status). NOTE: A copy of the completed AFLC 8015 (showing the validator's name) will be provided to the submitter of the lesson when he/she is notified of the disposition of the submitted potential lesson. 11, Signature of Project Officer/Validator: Validator will sign this block. 12. Date: Date validator completes the form. 13. Director/Project Office Coordination: Signature of validator's supervisor (no lower than directorate level). Signature verifies supervisor's approval. 14. Date: Date supervisor signs the form. 15. Senior Level Management Approval (Col/GM-15). Signature verifies approval. 16. Date. Date Senior Level Manager approves validator's analysis. 17-19. Used by project office to inform ASC/CYM that the potential lesson should be rerouted to another organization for validation, and-where it should be rerouted to. te eee - = a wo ee wp Tt eee - moc - we IMPACT AREAS IMPACT AREAS (ALPHA LISTING) AS OF 1 MAY 1993 AUTOMATED INFORMATION SYSTEMS AVIONICS BLUE TWO VISITS COMPOSITES COMPUTER RESOURCES (SUPPORT) CONFIGURATION MANAGEMENT CONTRACT ADMINISTRATION CONTRACTING CORROSION CONTROL DATA MANAGEMENT DESERT SHIELD/STORM ENERGY MANAGEMENT ENGINEERING ENGINEERING DATA (TECH. DATA) ENVIRONMENTAL MANAGEMENT EXPERT SYSTEMS/A] FACILITIES FACTS (Fasteners, Actuators etc.) FOREIGN MILITARY SALES FUNDING (LOGISTICS SUPPORT) HAZARDOUS MATERIALS HUMAN FACTORS ENGINEERING IDENTIFICATION LIFE CYCLE COST LOGISTICS ASSESSMENT LOGISTICS MAT. INFO. SUPPORT LOGISTICS SUPPORT ANALYSIS MAINTENANCE CONCEPT (PLANNING) MANPOWER REQUIREMENTS MANUFACTURING MATERIALS MODIFICATION PLANNING OPERATIONAL REQUIREMENTS OPERATIONS ORDNANCE PACKAGING, HANDLING, STORAGE + TRANSP PERSONNEL PROGRAM CONTROL PROGRAM MANAGEMENT PROGRAM MANAGERS CONCERNS PROGRAM MAT. RESP. TRANSFER PROPULSION SYSTEMS PROVISIONING Lessons Learned Handbook: DOE-HDBK-7502-95 Lessons Learned Handbook: DOE-HDBE-7502-95 QUALITY ASSURANCE RELIABILITY & MAINTAINABILITY REPAIR TECHNIQUES SAFETY SECURITY SOFTWARE SOFTWARE MANAGEMENT SOURCE SELECTION SUPPLY SUPPORT SUPPORT EQUIPMENT SURVIVABILITY SYSTEMS INTEGRATION (HARDWARE) SYSTEMS INTEGRATION (MANAGEMENT) TECHNICAL ORDERS (TECH. DATA) TECHTAP TECHTIP TEST AND EVALUATION . TEST EQUIPMENT TOTAL QUALITY MANAGEMENT (TOM) TRAINERS/SIMULATORS TRAINING AND TRAINING SUPPORT TREATIES WARRANTIES NOTE: The assignment of IMPACT AREA is at the validators call and may be more than one area. V-10 Lessons Learned Handbook: DOE-HDBE-7502-95 a z FORMAT FOR LESSONS LEARNED *NOTE: The potential lesson must conform to the following format (AF Form 1251, Jan 90, may be used to submit lessons). The potential lesson may contain references to weapon systems or programs and contractors associated with those weapon systems/programs.

TOPIC: (Use a brief topic (one or two lines) that accurately describes the content of the lesson.) LESSON LEARNED: (One or two sentences stating the single most important finding. It must show & "cause and effect" relationship.) PROBLEM: (A concise statement (preferably no longer than one or two sentences) describing what went wrong. If writing a positive lesson, enter "NONE.") DISCUSSION: (Describe the situation, giving a complete, concise account of the findings as they relate to the specific situation, procedure or design. This account usually consists of one to three paragraphs. RECOMMENDED ACTION: (This part of the lesson learned must provide the reader with a course of action and tell who should take what action (program manager, contracting officer, etc.). Show the program phase (when) (Conceptual Exploration & Definition, Engineering & Manufacturing Development, etc., if it is an acquisition or logistics related lesson) in which this lesson should be applied. This block should answer the questions "WHO, WHAT, WHEN .") NOTES: If acronyms are used, be sure to spell them out the first time they are used. If the Lesson Learned statement does not show a cause and effect relationship or if the Recommended Action statement does not answer the questions ‘who, what and when,' the validator will rewrite those portions of the lesson to conform to this format. We requested our legal department to review the Air Force Lessons Learned Program for the need to comply with the Arms Export Control! Act. Our consultations with them and our experience has demonstrated that the data contained in the data base does not meet the- criteria or intent of the Act. In order to broaden the base of availability of the program to our customers, each validator/writer is responsible to ensure that no Classified or For Official Use Only data is included im their lessons Learned submissions. The validator/writer of potential lessons must ensure that the proposed lesson(s) can not matrix with other data to allow an unauthorized disclosure of sensitive data. The US Government assumes no liability for direct patent infringement, or contributory patent infringement, or the misuse of technical data. The US Government does not warrant the adequacy, currency, or completeness of the technical data. The- US Government assumes no liability for loss, damage, or injury resulting from manufacture, or use for any purpose or any product, article, system, or material involving reliance of any or all technical data furnished in response to the request for technical data. The US Government does not sponsor nor promote any companies or products mentioned in the database. V-11 Lessons Learned Handbook: DOE-HDBKE-7502-95 This page intentionally left blank. V-12 Appendix VI Functional Categories Lessons Learned Handbook: Sad een re vee DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 APPENDIX VI FUNCTIONAL CATEGORIES One or more functional category(s) should be assigned to each lesson learned prepared for electronic dissemination. The functional category(s) indicate the general subject area(s) of the lesson learned and facilitate Indexing and accessing lessons learned information and analysis of related lessons. The functional categories that have been selected for the DOE Lessons Learned Program may be expanded or reduced, as necessary, to meet the needs of each individual organization.

The lessons learned functional categories are consistent with the categories established under the new DOE Directives Classification System. These categories are based on criteria developed for the Malcolm Baldridge Award. The Malcolm Baldridge Award recognizes U.S. companies that excel in quality management and quality achievement. The Award was initiated on August 20, 1987, when the President signed Public Law 100-107, the Malcolm Baldridge National Quality Improvement Act. The Malcolm Baldridge Award is presented annually to up to six companies. The exact criteria used to evaluate the applicants have been refined each year, with the trend toward requiring more detailed Information in fewer, but more important, areas. Many companies view the Malcolm Baldridge criteria as a useful diagnostic tools for evaluating the effectiveness of their management practices. The application of the Malcolm Baldridge criteria to the DOE Directives Classification System supports the Department's strategic goal of improving its management practices. This goal is included in the DOE strategic plan and Is part of a 1995 performance agreement signed between the President and the Secretary of Energy. < ¢ The old DOE Directives Classification System was based on a 1977 Department of Transportation model that contained 51 main categories. The new model contains 5 main categories. These categories cover key areas of DOE business and provide a consistent framework for categorizing DOE activities. Some of the categories also include subcategories that support a lower level of detail. The lessons learned functional categories are consistent with the Malcolm Baldridge criteria at top levels. The lower levels have been altered slightly to address lessons learned categories that were not covered in the Directives Classification System. To avold the burden of using two separate classification systems, it is recommended that sites develop systems that include the DOE functional categories provided below. Attached is the most recent version of the DOE directives classification system and a cross-walk of old DOE Orders to the new classification system. However, because this classification system is still evolving, it is important to obtain the most current list from DOE's Office of Human Resources and Administration when developing lessons learned programs and to keep functional categories current as the categories/subcategories change. Lessons Learned Handbook: DOE-HDBK-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 DIRECTIVES CLASSIFICATION SYSTEM 100 == LEADERSHIP/MANAGEMENT PLANNING 110 Organization and structure. Includes directives on authorities, functions, and internal relationships. . 120 Planning. Includes process for determining how best to do work, including strategic planning, institutional and program planning, implementation planning, and economic analysis and forecasting. This category does not include performance measurement, goal setting, and development of objectives. 120. ~=General 121 Strategic Planning 122 Institutional Planning 123 Economic Forecasting 124 Implementation Planning 130 Budget. Includes the financial budgeting process. Staffing budgets are covered under the Human Resources area. 130 General 131 Field Budget Process 132 Headquarters Consolidation Process 133 OMB Budget Process 134 Congressional Budget Review 135 Budget Execution 136 Allotments and Reprogramming

140 External Relationships. Includes overall processes for public relations, congressional relations, intersovernmental affairs and agreements. 140 ~~ General 141 Public Relations 142 International Relations 143 Congressional and Domestic Intergovernmental Affairs 150 Emergency Management and Planning. Includes succession planning and planning for operational emergencies. 150 General 151 Public Affairs in Emergencies 152 Governmental Emergencies 153 Operational, Energy, and External Emergencies 200 INFORMATION AND ANALYSIS 210 Performance Measures and Analysis. Includes establishment of contractor milestones and Incentives, performance indicators, and tracking/trending. A pets & Lessons Learned Handbook: DOE-HDBE-7502-95 220 Assessments. Includes all types of audits, oversight, appraisal programs, and accident investigations. 220 General 221 Inspector General Relations 222 GAO Assessments 223 Special Program Assessments 224 ~~ Accident Investigation 225 Audits and Appraisals 230 Reporting. Includes all cross-cutting reporting programs such as occurrence reporting. Reporting requirements tied to a single area such as budgeting are covered under that category. 230 General 231 Safety and Health Reporting Requirements 232 Occurrence Reporting 233 Interagency Reporting Requirements 240 Records Management. Includes forms management, records disposition, and records management. 240 General 241 Records Management 242 Forms Management 250 Standardization. Includes all aspects of how DOE issues policy, rules, directives, other requirements, technical standards, and formal Suidance both internally and to contractors; and how exemptions are processed. 250 General 251 Policies, Orders, Notices, Manuals, and Guides (DOE Directives) 252 DOE Standards 253 Procedures 300 HUMAN RESOURCES 310 Human Resources Planning and Management. Includes staffing, planning, and budgeting; EEO; and affirmative action programs. 310 General 311 EEO 312 Staffing Budgeting 320 Federal Employment. Includes employee recruitment, selection, placement, pay-setting, and reductions in force for various types of employment. 320 General . 321 Employment 330 Lessons Learned Handbook: DOE-HDBEKE-7502-95 322. Pay Administration and Hours of Duty 323 Promotion 324 Priority Placement 325 Position Classification 326 Employee Suitability and Position Sensitivity 327 Employment Reductions in Senior Executive Service Federal Employee Performance and Recognition. Includes performance appraisals, awards, disciplinary actions, and removals for poor performance or cause. 340 330 General 331 Performance Appraisal 332 Incentive Awards 333 Work Force Discipline Federal Employee Well-being and Satisfaction. Includes insurance and retirement, employee counseling and medical programs, drug testing, employee participation campaigns, labor relations, Grlevances, and appeals. 350 340 —_— General 341 Leave Administration 342 Grievances 343 Substance Abuse and Employee Assistance 344 Parking Contractor Resources Program. Covers management of contractor personnel policies and programs In all areas including employment, education and training for federal and contractor employees, performance and recognition, and well-being and satisfaction. 350 General 351 Pension and Insurance Programs 352 Equal Employment Opportunity 353 Reductions in Employment 354 Federal Labor Standards 355 Reporis 360 Employee Education and Training. Includes education and training activities for DOE and contractor employees.

360 General 361 Federal and Contractor Employee Training 400 | WORK PROCESSES 401 General Lessons Learned Handbook: DOE-HDBE-7502-95 410 Management. Includes major management systems such as project management, configuration management, program management, quality assurance and total quality management, and commitment tracking. 410 General 411 Assignments and Responsibilities 412 Management Systems 413 Program Management 414 Quality Management 420 Facility Authorization. Includes safety analysis, technical safety requirements, unreviewed safety questions, and other issues related to the authorization basis of nuclear and non-nuclear facilities. 420 General 421 Safety Analysis 423 Technical Safety Requirements 424 Unreviewed Safety Questions 430 Life Cycle Facility Operations. Includes design/engineering, construction, maintenance, operations, waste management, decontamination and decommissioning, and environmental restorations. 430 General 431 Desion/Engineering 432 Construction 433 Maintenance 434 Operations 435 Waste Management/D&D/ER 440 Worker Protection. Includes OSHA, aviation safety, radiation protection for workers, and other safety programs that relate to the protection of workers and others entering DOE sites. 440 General 44] Radiation Protection 442 OSH-type Issues 450 Protection of the Public and Environment. Includes various programs for ensuring public health and safety protection of the environment. 450 General 451 National Environmental Policy Act 460 Packaging and Transportation. Includes transportation of hazardous and non-hazardous goods and materials, except for household goods. 460 General 461 Packaging and Transportation Lessons Learned Handbook: DOE-HDBE-7502-95 470 Safeguards and Security. Includes physical and personnel security, information security, security classification, and nuclear materials protection and accountability. 470 General 47] Information Security 472 Personnel Security 472 Physical Security 473 Material Control and Accountability 480 Work for Others and Technology Transfer. Includes work performed for other government agencies and private industry, and programs for transferring technology to the private sector. 480 General 481 Technology Transfer 482. Work for Others 500 = BUSINESS AND SUPPORT SERVICES 510 Legal. Includes Freedom of Information Act (FOIA) and Privacy Act, and any directives related to legal and patent/copyright processes. 510 General 511 Hearings and Appeals 512 Data Integrity Board 513 FOIA/Privacy Act 514 Participation in Political Activities 520 Finance. Includes special methods of financing programs. 520 General 521 Financial Incentives Program 522 Pricing of DOE Materials and Services 530 Accounting. Includes all types of accounting except accounting for special nuclear materials. 530 General 531 Transfer of Contracts Between Department Elements 532 Interagency Sharing of Costs 533 Employee Indebtedness 534 Accounting 535 Time and Attendance Reporting 540 Procurement and Grants Management. Includes contractual arrangements for procurement of goods and services, and for grants to organizations. It does not include procurement of utilities, laundry, and other similar commercial services, or procurement of ADP and telecommunications equipment. jah Lessons Learned Handbook: DOE-HDBK-7502-95 540 541 542 543 544 545 546 547 General Reporting Systems Contracting Officials and Conflicts of Interest Competitive Requirements in Contracting

Indirect Cost Rate Responsibilities, Priorities and Allocations Program Funds-Out Interagency Agreements Civil Rights Compliance in Federally Assisted Programs 550 ‘Travel and Transportation. Includes policies and reimbursement procedures for local travel, temporary duty travel, permanent change of station, and transportation of household goods. Also includes motor pool management. 550 551 552 553 General Travel Policy and Procedures Foreign Travel Authorization Travel Charge Card Program 560 Telecommunications and Data Systems. Includes procurement and management of telecommunications, telephone services, ADP equipment, software, maintenance, and services. 560 561 562 563 564 565 General Telecommunications Management of Computer Systems Information Technology Telephone Systems Unclassified Computer Security Program 570 ~— Administrative Services. Includes mail, file, office space management, reproduction, printing, library services, and general office services. 570 571 572 573 574 General Scientific and Technical Information Management Audiovisual and Exhibits Management Mail Management Library Services 580 Property Management. includes personal and real property management, acquisition, and disposition. 580 General Lessons Learned Handbook: DOE-HDBE-7502-95 DIRECTIVES CLASSIFICATION SYSTEM / DOE ORDER CROSS-WALK 100 = LEADERSHIP/MANAGEMENT PLANNING 110 Organization and Structure. Includes directives on authorities, functions, and internal relationships. P 110.1 SEN-19A-92 Department of Energy Executive Committee P 110.2 SEN-36-92 Senior Nuclear Manager's Group 0111.1 1100.6A Departmental Organization Control System 0112.1 1100.4 Organization and Functions - Board of Contract Appeals 0113.1 2030.3 Federalism Guidelines 120 Planning. Includes processes for determining how best to do work, including strategic planning, Institutional and program planning, and economic analysis and forecasting. This category does not include performance measurement, goal setting, and development of objectives. P 121.1 SEN-25A-91 Strategic Planning Initiative O 122.1 5000.1B Institutional Planning of Multi program Laboratories O 123.1 5900.1A Energy Information Collection, Analysis and Dissemination 130 Budget. Includes the financial budgeting process. Staffing budgets are covered under the Human Resources area. 0 131.1 5100.3 Field Budget Process 0 132.1 5100.4 Internal Review Budget Process 0 133.1 5100.5 Office of Management and Budget - Budget Process O 134.1 5100.6A Congressional Budget Review 0 135.1 5100.11A Budget Execution - Office of Management and Budget Apportionment and Treasury Warrant Process O 135.2 5100.12A Budget Execution - Department of Energy Base Table O 135.3 5100:13A Budget Execution - Rescissions and Deferrals O 135.4 5500.68 Shutdown of Departmental Operations Upon Failure by Congress to Enact Appropriations O 136.1 5100.14A Allotment and Approved Funding Program Process O 136.2 5160.1B Reprogramming, Restructuring, and Appropriation Transfer Procedures 140 External Relationships. Includes overall processes for public relations, Congressional relations, Intergovernmental affairs and agreements. P 141.1 P 1210.1 Guidance on Implementation of the Department's Public Participation Policy P 142.1 SEN-17-90 Coordination of Global Climate Change Activities O 142.1 1240.2B Unclassified Visits and Assignments by Foreign Nationals N 142.1-1 N 1240.2 Unclassified Foreign National Visits and Assignments

N 142.1-2 N 1240.3 Extension of DOE N 1240.2 O 142.2 1270.2B Safeguards Agreement with the IAEA Lessons Learned Handbook: DOE-HDBK-7502-95 O 143.1 1220.1A Congressional and Intergovernmental Affairs O 143.2 1230.2 American Indian Tribal Government Policy O 143.3 2100.12A Payment for Special Burdens and in Lieu of Taxes 150 Emergency Management and Planning. Includes succession planning and planning for operational emergencies. O 151.1 5500.1B Emergency Management System O 151.2 5500.11 Power Marketing Administration Emergency Management Program O 152.1 5500.4A Public Affairs Policy and Planning Requirements for Emergencies O 152.2 5500.5A Public Affairs Policy and Planning Requirements for a Fuel Supply Disruption Emergency O 153.2 5500.10A Emergency Planning, Preparedness, and Response to Continuity of Government Emergencies (Will include 5500.9A.) O 154.1 5500.3B Comprehensive Emergency Management Program (Will include , - 5500.28, 5500.3A, 5500.7B, and 5500.8A.) O 154.2 5530.1A Accident Response Group O 154.3 5530.2 Nuclear Emergency Search Team O 154.4 5530.3 Radiological Assistance Program O 154.5 5530.4 Aerial Measuring System O 154.6 5530.5 Federal Radiological Monitoring and Assessment Center 200 INFORMATION AND ANALYSIS 210 Performance Measures and Analysis. Includes establishment of contractor milestones and incentives, performance indicators, and tracking/trending. 0210.1 Performance Indicators and Analysis of Operational Information 220 Assessments. Includes all types of audits, oversight, appraisal programs, and accident investigations. . 0 221.1 250 DOE Assessments O 221.2 2321.1B Auditing of Programs and Operations 0 221.3 5000.28 Multi program Laboratory Appraisals O 222.1 1000.38 Internal Control Systems O 222.2 2030.4B Reporting Fraud, Waste, and Abuse to the Office of Inspector General N 222.2-1 N 2030.7C Reporting Fraud, Waste, and Abuse O 222.3 2320.1C Cooperation with the Office of Inspector General O 222.4 2320.2B Establishment. of Departmental Position on Inspector General Reports 0 223.1 2200.13 Oversight of Integrated Contractor Financial Management O 223.2 2300.1B Audit Resolution and Follow-up O 224.1 2340.1C Coordination of General Accounting Office Activities 0 225.1 44) Accident Investigation O 226.1 5480.17 Site Safety Representatives VI-10 Lessons Learned Handbook: DOE-HDBE-7502-95 230 Reporting. Includes all cross-cutting reporting programs such as occurrence reporting. Reporting requirements tied to a single area such as budgeting are covered under that category. O 231.1 260 Safety and Health Reporting Requirements 0 232.1 261 Occurrence Reporting 0 233.1 1323.2B interagency Reporting Requirements 240 Records Management. Includes forms management, records disposition, and records management. O 241.1 '1324.5B Records Management Program O 241.2 1324.2A Records Disposition O 242.1 1322.2C Forms Management 250 Standardization. Includes all aspects of how DOE issues policy, rules, directives, other requirements, technical standards, and formal suidance both internally and to contractors; and how exemptions are processed. P 251.1 SEN-0-89 Secretary of Energy Notices 0 251.1 281 DOE Directives System M251.1-1 281 DOE Directives Manual N 251.1-1 N 1321.146 Cancellation of Directives N 251.1-2 N 1321.147 Cancellation of Directives O 252.1 280 DOE Technical Standards Program 300 =HUMAN RESOURCES 310 Human Resources Planning and Management. Includes staffing planning and budgeting, EEO, and affirmative action programs.

P 311.1 1600.2B Secretary's Commitment to Equal Opportunity P 311.2 1600.3 Policy on Sexual Harassment P 311.3 SEN-38-92 Policy on the Prevention and Eradication of Sexual Harassment in the Workplace 0 311.1 1130.4 Federal Women's Program Advisory Councils O 311.2 1130.5 Hispanic Employment Program Advisory Councils O 311.3 1600.1A Federal Women's Program 0 311.4 1600.4 Hispanic Employment Program O 311.5 1600.5 System for Processing Complaints of Discrimination O 311.6 3300.2A Affirmative Action Program for Handicapped Persons O 311.7 3330.1A Federal Equal Opportunity Recruitment Program 320 Federal Employment. Includes employee recruitment, selection, placement, pay-setting, and reductions-in-force for various types of employment. O 321.1 3300.3 Employment O 321.2 3304.1A Employment of Experts and Consultants O 321.3 3305.1 Presidential, Supergrade, and Schedule C Positions VI-11 Lessons Learned Handbook: DOE-HDBE-7502-95 O 322.1 3550.1A Pay Administration and Hours of Duty O 323.1 3335.1C Merit Promotion O 323.2 3410.2A Upward Mobility Program O 324.1 3330.2 Priority Placement and Consideration O 325.1 3511.1A Position Classification O 326.1 3731.1 Suitability, Position Sensitivity Designations, and Related Personnel Matters 0 327.1 3350.1 Furlough in the Senior Executive Service O 327.2 3351.2 Reduction in Force in the Senior Executive Service 330 Federal Employee Performance and Recognition. Includes performance appraisals, awards, disciplinary actions, and removals for poor performance or cause. O 331.1 3430.3A Departmental Performance Appraisal System O 332.1 3450.1B incentive Awards O 333.1 3750.1 Work Force Discipline 340 Federal Employee Well-Being and Satisfaction. Includes insurance and retirement, employee counseling and medical programs, drug testing, employee participation campaigns, labor relations, Srievances, and appeals. 0 341.1 3630.1B Leave Administration O 341.2 3630.2 Voluntary Leave Transfer Program O 342.1 3771.1 Grievance Policy and Procedures O 343.1 3792.1A Employee Assistance Program , O 343.2 3792.3 Drug-Free Federal Workplace Testing Implementation Program O 344.1 3900.1B Parking 350 Contractor Human Resource Programs. Covers management of contractor personnel policies and programs in all areas including employment, performance and recognition, and well-being and satisfaction. 0351.1 © 3220.1A Management of Contractor Personnel Policies and Programs O 352.1 3830.1 Policies and Procedures for Pension Programs Under Operating . and On-site Service Contractors O 352.2 3890.1A Contractor Insurance and Other Health Benefit Programs O 353.1 3410.1B Federal and Contractor Employee Training 0 354.1 3220.2A Equal Opportunity in Operating and On-site Service Contractor Facilities 0 355.1 3309.1A Reductions in Contractor Employment O 356.1 3220.6A Federal Labor Standards O 357.1 3220.4A Contractor Personnel and Industrial Relations Reports 360 Employee Education and Training. Includes education and training activities for DOE and contractor employees. O 361.1 3410.1B Federal and Contractor Employee Training VI-12 Lessons Learned Handbook: DOE-HDBK-7502-95 400 | WORK PROCESSES 410 Management. Includes major management systems such as project management, configuration management, program management, quality assurance and total quality management, and commitment tracking, M411.1 N 1321.141 Manual of Functions, Assignments, and Responsibilities for Nuclear Safety

O 412,1 5700.2D Cost Estimating, Analysis, and Standardization O 412.2 5700.7C Work Authorization System P 413.1 SEN-14-89 Clean Coal Technology Demonstration Program Implementation Arrangements O 413,1 5000,4A Laboratory Directed Research and Development O 414.1 5600.1 Management of DOE Weapon Program and Weapon Complex O 414.2 5610.13 Joint Department of Energy/Department of Defense Nuclear Weapon System Safety, Security, and Control Activities 0 415.1 5660.1B Management of Nuclear Materials O 416,1 5700.6C Quality Assurance 420 Facility Authorization. Includes safety analysis, technical safety requirements, unreviewed safety questions, and other issues related to the authorization basis of nuclear and non-nuclear facilities. P 420.1 SEN-35-91 Nuclear Safety Policy O 420.1 5480.25 Safety of Accelerator Facilities O 421.1 5610.10 Nuclear Explosive and Weapon Safety Program O 421.2 5610.11 Nuclear Explosive Safety O 425.1 440 Startup and Restart of Nuclear Facilities 430 Life-Cycle Facility Operations. Includes design/engineering, construction, maintenance, operations, waste management, decontamination and decommissioning, and environmental restoration. O 430.1 4000.XX Life Cycle Asset Management O 431.1 5480.30 Reactor/Non-Reactor Design Criteria P 435.1 SEN-37-92 Waste Minimization Crosscut Plan Implementation O 435,1 5820.2A Waste Management 440 Worker Protection. Includes OSHA, aviation safety, radiation protection for workers, and other safety programs that relate to the protection of workers and others entering DOE sites. P 440.1 1300.3 O 440.1 470 O 440.2 471 N 441.1 N 5400.9 N 441.2 N 5400.13 N 441.3 N 5480.11 P 442.1 SEN-39-92 O 442.1 3790.1B Policy on the Protection of Human Subjects Worker Protection Aviation Sealed Radioactive Source Accountability Sealed Radioactive Source Accountability (Extension of DOE N 5400.9) Extension of Radiological Control Manual, Revision 1 DOE Occupational Safety and Health Incentives Program Federal Employee Occupational Safety and Health Program VI-13 Lessons Learned Handbook: DOE-HDBK-7502-95 O 442.2 3791.2A Federal Employee Motor Vehicle Safety Program 450 Protection of the Public and Environment. Includes various programs for ensuring public health and safety and protection of the environment. P 450.1 SEN-22-90 , DOE Policy on Signatures of RCRA Permit Applications O 450.1 490 . General Environmental Protection Program O 451.1 491 National Environmental Policy Act Compliance Program 460 Packaging and Transportation. Includes transportation of hazardous and non-hazardous goods and materials, except for household goods. O 460.1 4120 Packaging and Transportation Safety O 460.2 1540.1A Materials Transportation and Traffic Management O 460.3 1540.2 Hazardous Material Packaging for Transport - Administrative Procedures O 460.4 1540.3A Base Technology for Radioactive Material Transportation Packaging Systems O 460.5 5610.12 Packaging and Offsite Transportation of Nuclear Components and Special Assemblies Associated with Nuclear Explosives O 460.6 5610.14 Transportation Safeguards System Program Operations 470 Safeguards and Security. Includes physical and personnel security, information security, security classification, and nuclear materials protection and accountability. O 470.1 5630.11C Safesuards and Security Program O 470.2 5630.12A Safeguards and Security Inspection and Assessment Program O 471.1 5610.2 Control of Weapon Data

O 471.2 5630.8A Safeguarding of Naval Nuclear Propulsion Information O 471.3 5639.1 Information Security Program O 471.4 5650.4 Unclassified Controlled Nuclear Information O 471.5 5650.2B Identification of Classified Information 0 472.1 5631.2D Personnel Security Program 0 473.1 5632.1C Protection and Control of Safeguards and Security Interests M 473.1 M5632.1C-1 Manual for Protection and Control of Safeguards and Security Interests O 473.2 5632.7A Protective Force Program M 473.2 M5632.7-1 Firearms Qualifications Courses Manual 0 474.1 5633.3B Control and Accountability of Nuclear Materials 480 Work for Others and Technology Transfer. Includes work performed for other government agencies and private industry, and programs for transferring technology to the private sector. P 480.1 SEN-30A-92 Staying on the Course for Technology Transfer at the Department of Energy O 480.1 5800.1A ‘Research and Development Laboratory Technology Transfer Programs O 481.1 4300.2C Non-Department of Energy Funded Work (Work for Others) VI-14 Lessons Learned Handbook: DOE-HDBKE-7502-95 500 = BUSINESS AND SUPPORT SERVICES 510 Legal. Includes FOIA and Privacy Act, and any directives related to legal and patent/copyright processes. O 510.1 O 511.1 O 512.1 0 512.2 0 513.1 1100.3 1130.8A 1700.1 1800.1A 3733.1 Office of Hearings and Appeals Data Integrity Board Freedom of Information Program Privacy Act Employee Participation in Political Activities 520 ‘Finance. Includes special methods of financing programs. P 520.1 SEN-34-91 0 521.1 0 522.1 530 Accounting. O 530.1 O 531.1 O 532.1 O 532.2 O 533.1 O 533.2 O 533.3 O 533.4 O 533.5 O 533.6 O 533.7 O 534.1 5700.5A 2110.1A 2100.3A 2100.8A 2200.2B 2200.11 2200.4 2200.5B 2200.6A 2200.7 2200.8B 2200.9B 2200.10A 3600.1B Implementation of the Chief Financial Office Act of 1990 Policy and Management Procedures for Financial Incentives Program - Pricing. of Departmental Materials and Services r Transfer of Contracts Between Departmental Elements Cost Accounting, Cost Recovery, and Interagency Sharing of Information Technology Facilities Collection from Current & Former Employees for Indebtedness to the United States Processing Garnishment Orders for Child Support and/or Alimony Accounting Overview Fund Accounting Financial Accounting Cost Accounting Accounting Systems, Organizations, and Reporting Miscellaneous Accounting Accounts, Codes, and Illustrative Entries Time and Attendance Reporting 540 Procurement and Grants Management. O 540.1 O 540.2 O 540.3 O 541.1 O 541.2 O 541.3 O 542.1 O 542.2 1331.1D 1331.2B 1332.2 4200.4A 4210.1C 4220.4 4200.1C 4210.9A Procurement and Assistance Data System Departmental Business Instrument Numbering System Uniform Reporting System for Federal Assistance (Grants and Cooperative Agreements) Selection, Appointment, and Termination of Appointment of Contracting Officers Designation of Source Selection Officials Organizational Conflict of Interest Processing Procedures ' Competition in Contracting Unsolicited Proposals VI-15 Lessons Learned Handbook: DOE-HDBK-7502-95 0542.3 4250.1A Small Business/Labor Surplus Area Set- Aside and 8(a) Program Review Procedures 0 543.1 4210.7B Indirect Cost Rate Responsibilities 0 544.1 5560.1A Priorities and Allocations Program 0 545.1 1270.1 Funds-Out Interagency Agreements 0 546.1 1600.6A Civil Rights Compliance in Federally Assisted Programs

550 Travel and Transportation. Includes transportation of non-hazardous goods and materials, motor pool management, and travel policies and reimbursement procedures. O 550.1 1500.2A Travel Policy and Procedures 0551.1 1500.3 Foreign Travel Authorization 0 552.1 1500.4A Travel Charge Card Program 560 Telecommunications and Data Systems. Includes procurement and management of telecommunications, telephone services, ADP equipment, software, maintenance, and services. O 561.1 5300.1C Telecommunications O 561.2 5300.2D Telecommunications: Emission Security (TEMPEST) O 561.3 5300.3D Telecorhmunications: Communications Security O 561.4 5300.4D Telecommunications: Protected Distribution Systems O 562.1 1330.1D Computer Software Management O 562.2 1360.1B Acquisition and Management of Computing Resources O 562.3 1360.6A Automatic Data Processing Equipment/Data Systems O 562.4 - 1450.1C Acquisition, Utilization, and Administration of Teleprocessing Services O 563.1 1360.3C information Technology Standards O 563.2 1360.8A Analyses of Benefits and Costs for Information Technology Resources Initiatives O 564.1 1450.3A Call Control/Verification Programs and Authorized Use of Government Telephone Systems O 564.2 1450.4 Consensual Listening-In to or Recording Telephone/Radio . Conversations O 565.1 1360.2B Unclassified Computer Security Program 570 Administrative Services. Includes mail, file, office space management, reproduction, printing, library services, and general office services. 571.1 -1430.1D Scientific and Technical Information Management 571.2 1340.1B Management of Public Communications Publications and ; Scientific, Technical, and Engineering Publications 572.0 1350.1 Audiovisual & Exhibits Management 573.0 1410.2 Mail Management 574.0 1430.4A Library Services 580 Property Management. Includes personal and real property management, acquisition, and disposition. VI-I6 Appendix VII Examples of Electronically Shared Lessons Learned Lessons Learned Handbook: DOE-HDBKE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBKE-7502-95 APPENDIX VII EXAMPLES OF ELECTRONICALLY SHARED LESSONS LEARNED Appendix Vil includes five examples of lessons learned that have been posted on the DOE Lessons Learned List Server. These examples include one red (urgent) lesson learned requiring immediate attention; two yellow (caution) lessons learned requiring timely (but not urgent) attention; one green lesson learned providing information on a good work practice; and one blue lesson learned providing useful information that does not fit into any of the earlier categories. These categories are fully explained in the DOE Lessons Learned Technical Standard, available through the Office of Scientific and Technical Information, Oak Ridge, Tennessee. EXAMPLE I: RED LESSONS LEARNED Title: Roll-Up Door Component Fails Identifier: 1995-SR-WSRC-LL-0003 Date; 5-4-95 Originator: WSRC, Operations Oversight & Compliance Site Lessons Learned Coordinator Contact: J. W. McEvoy, WSRC, 803-644-5696 Name of Authorized Derivative Classifier: Gorman C. Ridgely Name of Reviewing Official: Gorman C. Ridgely Priority Descriptor: Red/Urgent Functional Category: Occupational Safety and Health Keyword: Door, Roll-Up, Near-Miss, Locking Pin, Safety References: SR-WSRC-CMD-1995-0001 Lesson Learned Statement: The following Lesson Learned is issued to provide preliminary information on the failure of a component for a standard type roll-up door. The component, a 25 pound tension wheel, detached from the top of the

door and fell from a height of 15 feet, breached an office ceiling, and landed in an office trash can about 8 feet from three personnel. VH-1 Lessons Learned Handbook: DOE-HDBE-7502-95 Preventive Maintenance (PM) should be completed on a routine basis for roll-up doors. The PM program should include detailed inspections of the door, and of the mechanical and electrical components of the drive mechanism. Discussion of Activities: On April 10, 1995, a construction laborer was lowering a steel roll-up door when the tension wheel on the roll-up door assembly broke off without warning. The tension wheel, which weighs 25 pounds, fell 15 feet, broke through an adjacent office ceiling, and landed in a trash can sitting next to a chair in the office. The office was occupied by three employees; however, the personnel were about eight feet away from where the wheel landed. Analysis: A construction safety investigation revealed that the shaft that holds the tension wheel in place had been inadvertently cut by mechanical action between the shaft and a metal end cover plate. A locking pin that goes through the tension wheel and the shaft was missing. This condition allowed the shaft, which should be stationary, to rotate. The rotation of the shaft allowed the end cover plate to act as a saw on the shaft and cut through it. Routine preventive maintenance had not been performed on the door or the drive mechanism. All roll-up doors in this area are being rigorously inspected and identified deficiencies are being corrected. initial inspections of other doors have identified other serious vulnerabilities. The Site Lessons Learned Group is investigating and has brought this issue to management's attention. Recommended Actions: The Site Lessons Learned Group is working with the Senior Management Maintenance Council to address site-wide concerns and will issue either a Directive or Bulletin to all Divisions defining the necessary corrective actions to ensure personnel safety. The investigation of this occurrence is continuing. Further information will be made available when the investigation is complete. VII-2 Lessons Learned Handbook: DOE-HDBE-7502-95 EXAMPLE II: YELLOW LESSON LEARNED Title: Polycarbonate Bottle Failure Identifier: 1995-RL-PNL-0001 Date: April 26, 1995 Originator: Westinghouse Hanford Co. Contact: Roger A. Pollari, (509)376-4188 e-mail: RA_Pollari@PNL.gov Name of Authorized Derivative Classifier: Terry Vail, (509)373-2092 Name of Reviewing Official: J. C. Bickford, (509)373-7664 Priority Descriptor: Yellow/Caution Functional Category: 4.2 Worker Protection Objectives Keywords: Naphthalene, aromatic hydrocarbon, polycarbonate, packaging, polymer, thermoplastic References: None Lesson Learned Statement: Although polycarbonate is a high density, extremely tough and impact-resistant thermoplastic, that has an added feature of being transparent, it has explicit limitations in how it can be used. It is not recommended as a container for naphthalene. This incident serves to illustrate the need for consulting proper references and/or experts to make sure of the compatibility of all materials and chemicals associated with a project; even the compatibility between a product and its proposed container. Discussion of Activities: A Ready SafeTM liquid scintillation cocktail with naphthalene mixture was prepared at Pacific Northwest Laboratories for a customer on February 8, 1995. The mixture was put into a polycarbonate 1-liter bottle and placed in the same box in which the Ready SafeTM cocktail start material was originally received. The package was then placed near the door of the lab to await customer pickup.

On February 9, 1995, staff members discovered that the polycarbonate 1-liter bottle had split open and some of the naphthalene/Ready SafeTM mixture had leaked onto the floor. After receiving Input from a number of sources, appropriate safety precautions and regulations were followed and the material was removed from the floor. VII-3 Lessons Learned Handbook: DOE-HDBE-7502-95 Analysis: The presence of the naphthalene mixture was determined to be the probable cause of this incident for two reasons. First, as an aromatic hydrocarbon, naphthalene will chemically react with some polymers. Second, as naphthalene sublimes it will build up a small amount of pressure within a closed container. The combination of increasing pressure and weakened polycarbonate resulted in the bottle splitting open. Recommended Actions: N/A Lessons Learned Handbook: DOE-HDBE-7502-95 EXAMPLE III: YELLOW LESSON LEARNED Title: Heat Expansion May Cause Electrical Leads to Slip Off Aluminum Termination Lugs Identifier. 1995-OH-WVNS-0001 Date: May 23, 1995 Originator: West Valley Nuclear Services Co., Inc. (WVNS) Contact: Meg Hoffman, Operations Support (716)942-4166 NAME OF AUTHORIZED DERIVATIVE CLASSIFIER: N/A Name of Reviewing Official: N/A Priority Descriptor: Yellow/Caution Functional Category: 4.0 Work Processes Keywords: Material Compatibility, Electrical, Termination Lugs, Heat Expansion Reference; OH-W-WVNS-CF-1995-0010 Lesson Learned Description: Material compatibility is of the utmost importance in equipment operation. Although aluminum termination lugs are acceptable per the National Electric Code, they may not be adequate in all equipment applications. Discussion: During a routine weekly switching of exhaust blowers in the WNS Head End Ventilation (HEV) system, one of the two primary electric motor driven exhaust blowers failed to restart. The system automatically returned to the backup blower and continued to operate. Troubleshooting of the system revealed that one of the electrical leads had slipped off the aluminum termination lugs to the motor, due to heat expansion/thermal cycling. Analysis: The exhaust blower motors generate a large amount of heat during operation. This causes heat expansion/thermal cycling and can cause the electrical leads to slip off the termination lugs. WVNS Electrical Engineering personnel stated in the occurrence investigation meeting that termination lugs used in this type of application should be made of copper to prevent heat expansion to the greatest extent possible, even though aluminum termination lugs are acceptable for installation and use per the National Electric Code. Recommended Actions: WVNS Operations and Maintenance personnel upgraded the affected motor blowers with copper termination lugs, connectors, capacitors and motor leads. In addition, termination lugs and connections on similar equipment in other site facilities were inspected for similar situations. VII-5 Lessons Learned Handbook: DOE-HDBE-7502-95 Follow-up Actions: Information in this report is accurate to the best of our knowledge. As a means of measuring the effectiveness of this report, please notify Meg Hoffman, WWNS Operations Support at (716)942-4166 or by electronic mail at hoffman@tis. inel.gov of any action taken as a result of this report, or of any technical inconsistencies you find. Your feedback is important and appreciated. VII-6 Lessons Learned Handbook: DOE-HDBK-7502-95

EXAMPLE IV: GREEN LESSON LEARNED . | Title: Centralized Consolidation/Recycling Center tee Identifier: 1995-RL-WHC-0002 | Date: May 11, 1995 Originator: Westinghouse Hanford Co. Contact: Lynn St. Georges; (509)376-4652 [phone], (509)376-2816 [FAX], lynn_t_st_Seorges@rl.gov [e-mail] or John Bickford; (509)373-7664 [phone], (509)373-6120 [FAX], John_C_Bickford@rl.gov [e-mail] Name of Authorized Derivative Classifier: Terry Vail, (509)373-2092 Name of Reviewing Official: J. C. Bickford, (509)373-7664 Priority Descriptor: Green/Good Work Practice . Functional Category: 435 Waste Management/D&D/ER Keywords: Hazardous waste, consolidation center, recycling References: CENTRALIZED CONSOLIDATION/RECYCLING CENTER, WHC-EP-0863, by L. T. St. Georges and A. D, Poor Lesson Learned Statement: A centralized consolidation facility for "nuisance" hazardous wastes can eliminate many satellite accumulation areas, reduce the number of hazardous waste containers generated, and significantly reduce operating expenses. Discussion of Activities: There are approximately 175 separate locations on the Hanford Site where dangerous waste is accumulated in hundreds of containers according to compatibility. Materials that are designated as waste can be kept out of the waste stream by establishing collection points for these materials and wastes and then transporting them to a centralized consolidation/recycling center (hereinafter referred to as the consolidation center). Once there the materials are prepared for offsite recycling or consolidated for disposal. Removing batteries, partially full aerosol cans, and DOP light ballasts ("nuisance" wastes) from the traditional waste management approach would eliminate 89 satellite accumulation areas from the Hanford Site (43 for batteries, 33 for aerosols, and 13 for DOP ballasts). Eliminating these 89 satellite accumulation areas would reduce by hundreds the total number of containers shipped offsite as hazardous waste (due to lack of consolidation at the Hanford Site's TSD Facility). Lead-acid batteries are excluded because they already are collected and sent offsite for recycling. Items with radiological contamination are not considered. Other waste streams will continue to be evaluated as candidates for the consolidation center, including both regulated and non-regulated waste streams. VH-7 Lessons Learned Handbook: DOE-HDBE-7502-95 Examples include shop rags, fluorescent light tubes, and incandescent lamps. In most cases, offsite recycling will occur as an alternative to disposal. Analysis: The actions described in this Good Work Practice are consistent with reinventing government, the U.S. Environmental Protection Agency's (EPA) draft Universal Waste Rules for these "nuisance" and common waste streams, The Waste Minimization National Plan (EPA530-R-94-045, November 1994), Federal Executive Orders, and Washington State Law (RCW 70.105). They are endorsed by the Washington State Department of Ecology. Recommended Actions: DOE Sites with multiple facilities generating their own waste steams should work with their state regulators to implement a similar system. Lessons Learned Handbook: DOE-HDBE-7502-95 EXAMPLE V: BLUE LESSON LEARNED Title: Lessons Learned from Y-12 Plant Power Outage Identifier: L-1995-OR-MMESY12-0301 Date: 5/5/95 Originator: Martin Marietta Energy Systems, Inc.; Y-12 Plant (E. C. Hunt) Contact: J. C. Bell (615)576-8011 Name of Authorized Derivative Classifier: Name of Reviewing Official:

Priority Descriptor: Blue/Information Functional Category: 4.1-Operations Keywords: Electrical, Outage, Switching, High Voltage References: "Type C Investigation of Y-12 Plant Electrical Power Failure, November 11, 1994", Prepared by Oak Ridge Y-12 Plant, January 20, 1995. Facilities Management Organization Standing Order 047-11-94, “Electrical System Operation Compensatory Measures”. "OffF-Shift Emergency Switching compensatory Directive", Issued November 18, 1994 Lesson Learned: Electrical switching operations can be performed with a higher degree of safety and with a reduction in the potential for power outages and damage to equipment by adhering to the principles of conduct of operations. This Increase in Safety and reliability can be achieved by implementing: 1, adequate Identification and conirol of all applied personnel protective srounds, 2. formal transfer of control for system equipment, 3, an assessment of equipment readiness, 4, procedures to define the roles and responsibilities of personnel, and 5, a system to ensure communications among all participants. VI-9 Lessons Learned Handbook: DOE-HDBK-7502-95 Discussion: On Friday, November 11, 1994, members of the Y-12 Plant Electrical and Electronics Maintenance Department were performing an approved switching operation on the 161-kilovolt (kV) Distribution System when the system faulted, resulting in the loss of all electrical power to the Y-12 Plant. Two sets of ground cables, installed as personnel protective equipment (PPE), had been left attached to Transformer 599. As the switching sequence progressed, the primary switch on the transformer was closed and the electrical system was tripped in the Elza | switchyard resulting in a total loss of normal AC power to the plant. Analysis: The purpose of the planned 161-kV electrical switching operation performed on Friday, November 11, 1994 was to (1) phase lines Y-12-1 and Y-12-2; (2) re-establish the normal power supply configuration for the plant; and (3) re-energize a 50-MVA (megavolt amperage) transformer in preparation for it being placed back in service. NOTE: The transformer had been out of service for energy conservation since August 23, 1994, and a High Voltage Hold Off Order had been issued on September 22, 1994 for oil reclamation. Two sets of personnel protective grounding clusters were applied to the primary and secondary of the transformer at this time. On October 14, the final test of the transformer oil confirmed that it was satisfactory for use and the oil reclamation effort was shut down. The grounds were still in place as the electrical switching operations were being performed on November 11. These grounds went unnoticed by the field personnel performing the switching. Also, the electrical dispatcher failed to notice that the "grounds applied" box was checked on the high voltage tag order indicating that two sets of grounds were applied. When the primary circuit switcher feeding the transformer with grounds was closed, the entire Y-12 Plant was de-energized as both 161 kV lines feeding the plant were tripped at the Elza | primary switchyard. Also, one of the voltage redulating transformers in the Elza | switchyard received internal damage to the windings due to the high current surge generated by the fault. An investigation team was convened to perform a Type C Investigation in accordance with Department of Energy Order 5484.1 requirements. The Team identified the following as probable causes for the incident: inadequacies in planning, job control and communication, administrative controls including procedures, and human factors issues.

Recommended Actions: Several compensatory measures have been initiated by the Y-12 maintenance organization and the Power Operations and Maintenance Department: 1. Astanding order was issued on compensatory measures for high-voltage switching, tagding, use of Grounds, etc. This order includes measures to require: a. a review of all high voltage switching orders by the Y-12 Electrical Dispatcher, the originator, and the Field Switching Supervisor; 'b. review of the switching order'by the Field Switching Supervisor with the high voltage qualified electricians who will perform the actual switching activities; c. field verification by the Switching Supervisor of the condition of the equipment prior to and * immediately following each switching activity; Vii-10 Lessons Learned Handbook: DOE-HDBK-7502-95 d. an overtag be provided by the Electrical Dispatcher to the Field Switching Supervisor and to the Operations Supervisor, Maintenance Supervisor, Engineer, Service Contract Coordinator, or other appropriate party responsible for equipment/system activities; e. a "flag" to be hung on the power system status board indicating when personal protective grounds are installed on the high voitage distribution system; and f. the words "Grounds Applied,” along with the number of ground sets installed, to be added by the Field Switching Supervisor on each High Voltage Absolute Hold-Off Tag installed for that tag order under which the grounds were applied. 2. A directive was issued describing off-shift emergency switching operations. This directive states that any emergency switching required during the off-shift hours will be performed only after call-in of an authorized field switching supervisor and one of three designated managers. 3. An “All-Hands" meeting was conducted for all Power Operations and Maintenance Department (department) personnel to cover the incident and to review the new requirements established by the new standing order and directive. 4, The department conducted a review of all existing high voltage tag orders to identify all previously installed system Srounds. 5. The Contract Mentor assigned to the department conducted an assessment of Conduct of Facilities Operations as related to the power system. Follow-up Action: Information in this report is accurate to the best of our knowledge. As a means of measuring the effectiveness of this report please notify Carol Bell at (615)576-8011 or by electronic mail at belljc@ornl.gov of any action taken as a result of this report or of any technical inaccuracies you find. Your feedback is important and appreciated. Vi-11 Lessons Learned Handbook: DOE-HDBKE-7502-95 This page intentionally left blank. VIH-12 Appendix VIII Lessons Learned Transmittal Documents Lessoiis Learaéd Hindbéok: DOE-HDBK-7502-95 This pagé intentionally teft blank. Lessons Learned Handbook: DOE-HDBE-7502-95 APPENDIX VIII LESSONS LEARNED TRANSMITTAL DOCUMENTS For Internal dissemination of lessons learned information, organizations may use electronic and/or non- electronic methods. This appendix provides examples of newsletters, bulletins, and other types of publications that are used to disseminate lessons learned information. This appendix contains: QO Westinghouse Savannah River Company, SRS Lessons Learned Bulletin,Oversight and Compliance Integration Section Bulletin, ESH-061-95-0028, Westinghouse Savannah River Company, dated February 1, 1995, Volume 4, No. 1.

Oo Westinghouse Savannah River Company, SRS Lessons Learned Digest, Oversight and Compliance Integration Section Bulletin, ESH-OCI-950043, Vol. 3, No. 2, dated February 1995. oO Westinghouse Savannah River Company, Lessons Learned Newsletter, Site Lessons Learned Program’s Digest of Nuclear Industry Information, ESH-OCI-950120, Vol. 7, No. 8, dated week ending April 14, VIlI-1 Lessons Learned Handbook: DOE-HDBK-7502-95 This page intentionally left blank. VIll-2 Lessons Learned Handbook: DOE-HDBE-7502-95 APPENDIX VIII LESSONS LEARNED TRANSMITTAL DOCUMENTS (Description of Site Lessons Learned Program Transmittals) Appendix VIli-B provides examples of Savannah River Site Lessons Learned Program transmittal documents. Three types of transmittal documents are provided: Oo Westinghouse Savannah River Company, SRS Lessons Learned Bulletin oO Westinghouse Savannah River Company, SRS Lessons Learned Digest O° Westinghouse Savannah River Company Lessons Learned Newsletter VItI-3 Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Vill-4 Lessons Learned Handbook: DOE-HDBE-7502-95 Vol. 4, No. 1February 1, 1995 This bulletin is issued by OCIS to alert SRS personnel to important SRS safety and performance degradations which are recurring or have a high significance. DIVISION LESSONS LEARNED COORDINATORS ARE EVALUATING THE NEED FOR CORRECTIVE ACTIONS AND TRACKING THEIR SUBSEQUENT IMPLEMENTATION. The bulletin is also disseminated to WSRC level 5 managers and above and DOE-SR management to enhance lessons learned awareness and training. CRANE BOOM BRAKE FAILURE On November 28, 1994 at 0715, a Crane Subcontractor started a crane (Figure 1) being used for construction of a new facility in H Area. During a routine morning checkout procedure, the boom brake system apparently malfunctioned and would not hold the boom. The boom lowered to the ground causing significant damage to the boom and the jib and minor damage to some plumbing supplies in the area (Figure 2). Although no personnel injuries occurred, the potential for serious injury existed because the boom struck the ground approximately 8 feet from (1) an occupied Port-O-Let, and (2) a 480 volt power source (Figure 3). The construction area was very congested and the operator correctly determined that the specific area he used for the testing would be the safest. Although the construction area was barricaded as required by the Employee Safety Manual, Manual 8Q, there were no means in place to prevent construction personnel from entering the direct area where the boom checkout was taking place. Barricades for crane boom checkout areas are not currently addressed in either the Employee Safety Manual or the Site Hoisting and Rigging Manual, WSRC-TM-90-7, Investigations by the subcontractors involved indicate the cause of the occurrence to be wet brakes; however, further investigation by WSRC is continuing to determine if other causes may have contributed to the occurrence. AWSRC Root Cause Analysis is in progress and final corrective actions will be issued following its completion. The crane involved was a conventional 90 ton capacity, rubber tired, "Lorain," friction brake operating crane with a 130' boom and a 30' jib. The crane had been through the vendor's shop for a safety check prior to being sent to SRS. The facility construction work is being performed by a subcontractor who hired another subcontractor to perform the crane work.

The routine morning checkout of the crane consisted of a functional check of all hoisting mechanisms including the hoist lines, boom hoist, brakes, and clutches. This checkout is always done regardless of the weather conditions; however, it helps dry out the equipment if moisture is present. The crane had been secured for the Thanksgiving weekend holiday (November 24-27) and rain and cold temperatures during that period caused an anticipated moisture buildup in the crane braking equipment. The crane operator successfully raised and lowered the hoist lines three times and the boom twice before the failure occurred. There is no standard number of times required to exercise the equipment, it is left to the operator's best judgement. VIIL-5S Lessons Learned Handbook: DOE-HDBE-7502-95 Immediate actions to correct this problem included replacing the conventional friction brake type crane with one that operates on hydraulics. The hydraulic type of crane cannot have the same type of failure that occurred with the friction type crane. In addition, the subcontractor modified their Safety Plan to require a qualified flagman to be used during all crane operations. This is to include normal work and any checkout required. LESSONS LEARNED All SRS personne! must be alert to potential safety hazards in their work areas or areas that they visit. This is particularly important for personnel working in or visiting construction areas. Use technical inquisitiveness throughout your work day to help ensure that adequate safety defense-in-depth exists. Crane operators should check all structures near their test area, where personnel may not be visible from the crane controls, to ensure that the areas are clear of personnel, or that personnel are aware of the crane operations and adequate safety precautions have been taken. The WSRC TM-90-7 (SRS Hoisting and Rigging Manual) provides guidance relevant to the proper operations requirements for Mobile Cranes. A revision to this manual is being prepared to emphasize the importance of maintaining the area under the boom clear of personnel during checkout activities, as well as, normal operations. Personnel working in the vicinity of cranes should be alert to crane movements and take measures to avoid being below the crane boom. Itis a safety restriction/requirement that the crane operator ensures that no live loads travel over any personnel at any time. The WSRC Employee Safety Manual 8Q, Procedure 9, Barricades, does not specifically require that crane boom swing areas be barricaded to prevent pedestrian traffic. It does specifically require the swing radius of the rear of a rotating crane to have barricades whenever an operator is at the controls and work is in progress (This barricade was present at the time of this occurrence). The procedure also requires a warning barricade in any area where construction or maintenance work is in progress and control of pedestrian traffic is necessary. Facility managers or construction managers should evaluate the use of barricades for crane operations and checkouts, and ensure barricades are always placed when determined to be necessary. Although not a problem in this particular occurrence, it should be emphasized that WSRC Subcontract Technical Representatives (STRs) must know the safety requirements that apply to their work and ensure the subcontractors know and follow those requirements. Note: For Mobile Crane operations STRs should refer to guidance as provided by the WSRC-TM-90-7 Manual, the Area Rigging Authority, and Safety personnel.

ACKNOWLEDGMENT The Site Lessons Learned Program appreciates the assistance of Mike Berry, Site Rigging Authority, Mark Szymanski, Subcontract Technical Representative, and Mark Mahoney, H Tank Farm Waste Removal Operations Manager, in preparing this Bulletin. Vill-6 Lessons Learned Handbook: DOE-HDBE-7502-95 Vol. 3, No. 2 issue No. 25 February 1995 This digest is issued by OCIS to: 1) serve as a general training resource for enhancing job performance by increasing personnel awareness of the process and personnel safety lessons (positive and negative) that fellow SRS employees have learned, and 2) provide a vehicle to all SRS employees for the sharing of lessons they learned on the job at SRS. NO RESPONSE IS REQUIRED BY THIS DIGEST. PROCEDURE WALKDOWN DETECTS VALVE LABELING ERROR On November 11, 1994, an ITP Tank Operator walked down a special procedure prior to performing it to ensure appropriate components could be located and all the procedure steps were accurate, clear, and could be executed. During the course of the walkdown, the operator detected a discrepancy between the Process and Instrument Drawings and two valves in the Tank 40 Gang Valve House. Subsequently, the Day Shift Manager compared the field installation to the system drawings and determined that the labels on the two valves were reversed. The valve labeling was subsequently corrected. A lockout involving the two valves, which was in place at the time of the discovery, was determined to be incorrect because of the previous misidentification of the two valves. The person performing the lockout had placed the locks correctly based on the valve labeling at the time of the lockout. Similarly, independent verification of the lockout also relied on the valve labeling. Manual 2S, Procedure 1.4, Paragraph C, specifies that procedure walkdown is the preferred method to validate new or revised procedures. The intent of the walkdown is to identify and resolve potential problems with the procedure. In this occurrence, the walkdown detected a labeling error on two valves. As a result of the procedure walkdown, potential safety and process difficulties (including a lockout in progress at the time of the occurrence) resulting from the incorrect valve identification were eliminated. LESSONS LEARNED e Newand revised procedures should be validated by walkdowns prior to their use unless ALARA, safety considerations, facility status, or equipment inaccessibility make walkdowns impracticable. Manual 2S, Procedure 1.4, Paragraph C e@ Walkdown should also be considered for existing, approved procedures if they are infrequently used, personnel performing the procedures are unfamiliar with the evolution being performed by the procedure, or the procedure is complex. VAll-7 Léssons Learned Handbook: DOE-HDBE-7502-95 INADEQUATE LIGHTNING PROTECTION The Defense Nuclear Facilities Safety Board (ODNFSB) and a Fire Hazards Analysis (FHA) identified lightning protection concems for F Canyon and the FB-Line. To address the concerns the Fire Protection Analysis Group of the Safety Engineering Department completed an engineering study of the lightning protection equipment and systems installed on the structures of F Canyon, FB-Line, F-Area Fan house and exhaust stack, and the canyon exhaust fan diesel generator building. The study compared the existing installed equipment and designs to the requirements and installation practices provided in the National Fire Protection Association Standard 780, Lightning Protection Code.

The results of the study concluded that equipment and components of the lightning protection system for the FB-Line were incomplete, poorly maintained, improperly installed, or missing. Therefore, the facilities of FB-Line are more vulnerable to adverse lightning events due to these deficiencies. Some general deficiencies included the following: - Structures and equipment on the canyon roof with no lightning protection - Equipment installed on the roof without basic grounding or bonding to other roof-top equipment = Ground conductors improperly installed . - No equipotential bonding of nearby metallic components or equipment - Ground conductors cut or missing; no connections to ground - Components on drawings that are missing or installed differently from the design, without "as built" changes - Lightning down conductors not properly installed to ensure shortest path to ground ~ Equipment installed in places of high lightning potential with little or no concern for lightning protection for equipment or personnel Several of the identified deficiencies have the potential to cause an unacceptable level of risk to the facilities or personnel. One example includes the lack of adequate grounding and down conductors for the communication tower on top of the FB-Line elevator/stair tower. A lightning strike to this tower has no direct path to ground to dissipate the lightning stroke current and could sideflash to the small enclosure on the tower, to the guard rail on the tower roof, or to the interior steel stair structure. This uncontrolled flow of electricity increases the potential to damage the structure and endanger facility personnel. Because the risk to the facility and personnel might have been greater than previously recognized, an unreviewed safety question (USQ) screening was performed for the FB-Line facilities to determine if safety margins were less than those assumed in the Safety Analysis Report (SAR). The screening detected no unreviewed safety questions, and corrective or compensating actions were not required. Other facilities may have concerns that their lightning protection is not adequate or may not satisfy the requirements of their SAR. Contact M. F. Perks (952-8068) or D. E. McAfee (952-8058), Fire Protection Analysis, for more information or to schedule an evaluation of existing lightning protection systems. LESSONS LEARNED ® Facilities may be damaged and personnel endangered by inadequate lightning protection. Each facility should ensure that their lightning protection meets the requirements of NFPA 780. Lessons Learned Handbook: DOE-HDBE-7502-95 e — SAR requirements may not be met if lightning protection is inadequate or not installed as designed. EXCAVATION DIFFICULTIES On July 22, 1994, an excavator installing a new fiber optic telephone cable in C Area struck and severed a single phase of a 13.8 kV power line with a backhoe. The presence of the line was known, and the excavator had hand dug the area to expose the red dye concrete marking the location of buried electrical cable. One phase of the power line was located by hand digging on one side of the concrete. The backhoe operator assumed that the exposed cable was the only interference and began excavation. In reality, each of the three 13.8 kV phases was routed in a separate cable. Fortunately, the cable had been de-energized by the Power Department to support this work, and no injuries occurred.

The Work Clearance Permit for the excavation required that an area three feet on either side of the concrete be hand dug. Hand digging was completed only on one side. The excavator was not a holder on the lockout for this job, which is a violation of the Manual 8Q, Procedure 32, Hazardous Energy Control. This occurrence illustrates the greatest concern of excavation activities: what lies underground where digging is to occur? Every reasonable effort must be expended to determine what lies underground before excavation is begun. Improper excavations can endanger personnel safety, interrupt services and communications, impair operations, and result in significant costs to effect repairs. A survey of occurrence reports issued since January 1, 1991, revealed that excavation activities have inadvertently cut four power lines, six signal cables, and ten water lines. An example of each follows: - An excavator broke a 6-inch water line near the 183-K water plant while digging to obtain fill dirt with a backhoe on October 28, 1991. All domestic, filtered, service clarified, and deionized water was secured in Building 105-K, and a 5000-gallon water tanker was brought into the area for backup fire protection. Investigation revealed that the equipment operator was digging below grade without a spotter or authorization to obtain fill dirt in this manner. - On September 30, 1993, the fire alarm system for 607-41T, Sanitary Treatment Facility, was interrupted when the conduit containing the 24 volt signal wires was damaged during excavation. The cause of the event was attributed to a failure of current prints to include the 24 volt fire alarm system in the TNX area. - Two energized underground 13.8 kV power cables were damaged during soil boring in K Area on August 16, 1990. Delays in actions to repair and protect the damaged cables from moisture intrusion resulted in estimated replacement costs exceeding one million dollars and the generation of an Off-Normal Occurrence Report on January 7, 1991. Some of the causes of this occurrence include the following: , a" Existing Safety Manual procedures did not adequately delineate specific requirements for excavation/drilling Print/drawing reviews were less than adequate Cables were not detected by ground penetrating radar VIII-9 Lessons Learned Handbook: DOE-HDBE-7502-95 = Verbal communications between the excavator and facility personnel were inadequate VIll-10 Lessons Learned Handbook: DOE-HDBE-7502-95 In addition to problems encountered cutting cables and pipes, excavation activities can pose other hazards: - On September 28, 1994, excavation to install a new communications system in the F-Tank Farm inadvertently uncovered the F-H Inter Area Transfer Lines. Fortunately, no transfers were in progress (reducing potential exposure), and the lines were not cut by the excavation. - AtITP on July 15, 1991, a construction employee fell into an excavation and bruised several ribs. - On January 31, 1995, a partial trench cave-in occurred during installation of telephone lines at SRTC. A worker, whose left leg was struck by falling dirt, received bruises on his knee and was assigned to light duty following the accident. To facilitate proper excavation techniques, Manual 8Q, Procedure 34, Excavations and Trenches, has been revised. The new revision greatly expands terms and definitions related to excavations and specifies in increased detail the minimum safety requirements necessary to perform excavations. All personnel performing excavations and trenching activities on the SRS must use this procedure, including construction, vendors, subcontractors, consultants, and site support groups such as E&CS or SRTC.

LESSONS LEARNED e = Allpersonnel involved with excavation activities should be aware of the potential hazards associated with excavation at SRS. ° e All personnel performing excavations at SRS must comply with the minimum safety requirements specified in the Employee Safety Manual 8Q, Procedure 34. e Personnel utilizing subcontract personnel to perform excavations must ensure that those personnel follow Manual 8Q, Procedure 34. Normally this is the responsibility of a Subcontract Technical Representative. The Subcontract Safety Team in the Occupational Safety & Hygiene (OSH) Department is responsible for safety oversight of all subcontract employees at WSRC. Contact your area safety engineer or Reuben Raysor, Manager, Subcontract Safety Team at 644-5663 for resolutions of concerns about subcontractor safety. e Personnel planning excavation work must realize that prints have not been adequately controlled in the past and may not reflect all buried power lines, signal cables, or water lines. Other methods, such as ground penetrating radar, should be considered, along with adequate print/drawing studies, if any uncertainty exists. e Personnel performing excavations around electrical power lines must realize that multiphase electrical sources may use a separate cable to conduct each phase. Vill-11 Lessons Learned Handbook: DOE-HDBE-7502-95 PROPER FORKLIFT OPERATION NECESSARY TO PREVENT DAMAGE, OPERATIONAL DIFFICULTIES Forklift problems are not new to SRS nor the rest of the DOE complex. The October 1993 SRS Lessons Leamed Digest documented forklift difficulties at SRS, but recent occurrences at SRS and other locations within the complex illustrate that forklift problems continue. While attempting to move a large shipping container inside Building 704-B with a forklift on April 29, 1994, a fire sprinkler head was struck by the container, and water spray initiated from the damaged sprinkler head. The spray wet two personnel at the scene, but no injuries occurred. The initiation of the water spray sounded a fire alarm, and the facility was evacuated. Investigation revealed that the ceiling provided 8' 10" clearance at the entrance to the building, but reduced to 7' 11" at approximately 20 inches into the room. Additionally, the sprinkler, with guard, protruded about four inches down from the ceiling. The forklift driver misjudged the clearances available. An investigation of a Victoreen Area Monitor Packet (VAMP) alarm near HDB-1 in the H-Tank Farm on June 29, 1994, revealed that the alarm was initiated when a B-25 radioactive waste box was moved near the monitor by a forklift truck. Two employees at an Oak Ridge facility attempted to relocate materials from a storage room to a different location on September 9, 1993. The protective overhead guard of the forklift struck the concrete lentil of the doorway, and the forklift became wedged in place. No injuries occurred, but the impact caused a 24-foot long crack in the block wall mortar joint above the doorway. Investigation revealed that two types of forklift were used in the facility. The forklift involved in this occurrence is 3 inches taller that the other type. Additionally, this doorway is shorter than other doors in the facility. No height warning signs were posted on either the forklift or the doorway to alert operators of clearance restrictions.

While relocating pallets of waste drums on October 1, 1993, a Hanford employee backed a forklift into a building beam causing damage to the beam. Investigation revealed that the forklift operator did not have a clear field of vision because the forklift inspection sheet, which was posted in the rear side window of the forklift, obscured the view of the beam. LESSONS LEARNED Forklift operators should remain alert and aware of their surroundings at all times while operating forklifts or other heavy equipment. This is particularly ttue when backing the equipment. Operators should ensure that clearances are adequate throughout the intended path of travel with the forklift. Pay particular attention to protrusions from walls and ceilings. Personnel in the vicinity of operating forklifts must be vigilant because of possible restricted vision of the forklift operators. VIll-12 Lessons Learned Handbook: DOE-HDBE-7502-95 Personnel should be aware of differences between types of forklifts. Slight differences in height, width or length of the forklift can cause significant clearance problems. VIII-13 Lessons Learned Handbook: DOE-HDBE-7502-95 e Donot place objects, such as inspection stickers, on forklifts in such a manner that visibility from the forklift is obscured. e Forklifts must not be unloaded at locations that will interfere with passageways, evacuation routes, or safety and monitoring equipment. Personnel directing the placement of loads should be aware of possible effects the load may have on that location (initiating alarms, for example) or that the location may have on the load (damage caused by the presence of water, for example). VIII-14 - - 2 ee Po eee Lessons Learned Handbook: DOE-HDBKE-7502-95 Vol. 7, No. 8 Week Ending April 14, 1995 This newsletter is developed and issued by the Site Lessons Learned Program Group of the Oversight & Compliance Integration Section for the purpose of informing SRS personnel of pertinent general information, activities, and good practices associated with the DOE and commercial nuclear industries. It is deemed important that SRS personnel remain cognizant of industry issues and the continuing change in public and regulatory expectations. NO RESPONSE IS REQUIRED BY THIS NEWSLETTER. IN THIS WEEKS NEWSLETTER: LANL DEVELOPS PLUTONIUM RECOVERY TECHNIQUE PREFABRICATED HUTS IMPROVE WASTE MANAGEMENT STATES, EPA DRAFT PLAN FOR REDUCING OVERSIGHT CRACKED TUBES CLOSE REACTOR INDEFINITELY NRC APPROVES DECOMMISSIONING PLAN FOR RANCHO SECO FFCACT PROPOSED SITE TREATMENT PLANS HEAT STRESS MANAGEMENT WORKER PROTECTION ORDER THE NUCLEAR EXCHANGE - RADIATION PROTECTION ITALIAN SCIENTISTS CLAIM COLD FUSION BREAKTHROUGH UTILITIES TO PURSUE MESCARLO MRS GENERAL NUCLEAR INFORMATION (The following publications are in the SRTC Library) e MATERIAL PROCESSING LANL DEVELOPS PLUTONIUM RECOVERY TECHNIQUE Weapons Complex Monitor - March 23, 1995 Los Alamos National Laboratory (LANL) scientists have developed and tested a new technology they say can recover plutonium from nuclear weapon components without generating large quantities of waste. The Hydride Dehydride Recycle Process is being touted as an alternative to traditional acid leachate techniques that produced large quantities of mixed waste. The hydride-dehydride technology takes advantage of plutonium's affinity for chemically bonding with hydrogen in a two-step process that, in prototype tests at Los Alamos, has been shown to offer an essentially waste-free option. ,

HELP THE SRS RECYCLE EFFORT -- REMOVE STAPLE AND FRONT PAGE, RECYCLE WHITE PAPER VIlI-15 Lessons Learned Handbook: DOE-HDBE-7502-95 The recovery process is initiated by placing a plutonium-containing weapon component in the upper portion of a vacuum chamber called the cold zone. An attached furnace tube with a resistive heating element is located directly below the nuclear component, a part of the device called the hot zone. Hydrogen gas, supplied by a uranium hydride storage bed, is emitted into the vacuum chamber. The hydrogen gas hydrides some of the plutonium from the weapon component. The plutonium hydride then falls into the hot crucible, thus initiating the release of hydrogen gas - the dehydriding part of the operation. The hydrogen gas released from the hydride is available to hydride more of the plutonium located in the cold zone, and the recycle reaction continues, cycling until the plutonium is completely extracted from the weapon component. Melting and subsequent cooling of the plutonium powder formed in the lower chamber produces a solid plutonium metal product that is ready for storage. The hydride-dehydride technology, which is already in regular use at Los Alamos for limited component destruction, generates far less waste than the old aqueous processing techniques. The old technique generated 400 kilograms of mixed waste per pit compared to zero for the new technology; 200 liters of caustic and acidic waste compared to zero. The new technology also requires less glove box space, less time, and results in lower average worker radiation exposure. e WASTE PREFABRICATED HUTS IMPROVE WASTE MANAGEMENT The Safety & Health Connection - Spring 1995 Westinghouse Savannah River Company (WSRC) is saving money and improving waste management by using prefabricated radiological containment structures. The huts are much less expensive than the structures built onsite. Supported by external frames, the new constructions offer improved structural integrity and reduce the potential spread of contamination. The containment structures are complete with airlocks, floors, walls, and roofs. They are prefabricated with flame-resistant, compactable nylon reinforced plastic, or other DOE-approved Material. A lightweight, reusable external support frame, which can be scanned for radionuclides, is used. The prefabricated units are stronger and more capable of withstanding wind and water damage than their predecessors. The huts are more easily and safely packaged for disposal to reduce overall waste. After a job is completed, the hut is cut free of its support frame and collapses. Internal air is removed by the same exhausting blower that maintained negative air pressure during operation, preventing a release of radiological contaminants during disassembly. The external frame can be removed from the area and stored for reuse. All parts of the structure, except the support frames, can be incinerated. The use of the radiological containment structures has yielded no external contamination during approximately 200 operations and cost savings of over $7 million. Lessons Learned Handbook: DOE-HDBE-7502-95 e ENVIRONMENT STATES, EPA DRAFT PLAN FOR REDUCING OVERSIGHT Inside E.P.A. - March 31, 1995 EPA and state officials are developing plans to significantly scale back federal oversight of state environmental programs, creating a new set of goals upon which states' achievements and ability to administer programs will be judged. The agency plans to unveil the new oversight procedures as a major agreement with state environmental commissioners at a state-EPA meeting in May, and states would be required to develop workplans reflecting the new goals by 1997.

The plans call for something similar to the memoranda of agreement which headquarters is developing with regional offices to set enforcement targets. The agreements with states would be based on three tiers of goals: national goals, such as protecting water bodies or limiting air emissions; program-specific goals, such as minimum procedural requirements for assuring drinking water quality; and state-specific goals, such as protecting a particular resource or ecosystem. EPA is trying to focus the agency's oversight on environmental impacts instead of bureaucratic procedures, and as such, the oversight reform effort will retain for the agency those environmental projects that inherently require federal control. ® REACTORS CRACKED TUBES CLOSE REACTOR INDEFINITELY ENR - April 3, 1995 Maine Yankee officials have decided to keep the 23-year-old nuclear power station closed indefinitely because of defects discovered in the pressurized water reactor's steam generator tubes. During a refueling in January, officials found 250 cracked pipes. Additional sample tests using a high-tech probe indicated that up to 50% of the 17,000 tubes may be faulty. Solutions include adding zinc to the water, sleeving the pipes, or replacing the generators, at a cost of $110 million to $150 million. There are 71 other pressurized water reactors in the U. S. The NRC has issued a notice about Maine Yankee's problems to other licensees. REGULATORY POLICY AND DECISIONS NRC APPROVES DECOMMISSIONING PLAN FOR RANCHO SECO Nuclear Energy Overview - April 3, 1995 Decommissioning activities at Rancho Seco can proceed following the NRC's recent approval of the cleanup plan. Based on the plan, the decommissioning process is expected to cost $344 million, plus $50 million more for restoration of the site. Spent fuel management at the site is estimated to cost an additional $15 million, and removal of the spent fuel to a dry cask storage system is expected to begin in April. Construction of the storage facility has already begun. The decommissioning plan would place the plant in safe storage for less than 20 years, then decontaminate and dismantle it for unrestricted use of the site. VIII-17 Agatha Lessons Learned Handbook: DOE-HDBE-7502-95 FFCACT PROPOSED SITE TREATMENT PLANS Defense Programs Health, Safety, and Environment Status Report - March 1995 To satisfy requirements of the Federal Facility Compliance Act (FFCAct), Proposed Site Treatment Plans (PSTPs) are being prepared by impacted DOE sites for the treatment of mixed waste. The PSTPs will be released to each site's regulator on April 6, 1995, and Notice will appear in the Federal Register for comments from the public. DOE has prepared a total of 37 PSTPs for 40 sites located in 20 states. Once the PSTPs are released, each DOE site will begin negotiations with their state or EPA Regional Office regulator to work towards an agreement to approve the Site Treatment Plans (STPs). By October 5, 1995, each site must have a consent order in place, signed by both DOE and the site's regulator stating the "path forward" in complying with the STPs and listing enforceable milestones and target dates. —————————————EE——q—&{&=£[—={=@a@m—N—[—>[[—[§€_—[a)ap]|]|]||]]|]|]=——l]]|==a=aa2a2_=__=a=__E=E=E=E=E=== SAFETY ISSUES HEAT STRESS MANAGEMENT

Safety/Industrial Hygiene Department It is that time of year that we should begin thinking about heat stress on-the-job as well as during our leisure activities. Personnel who will be working in hot environments should be familiar with Heat Stress Management Program that is outlined in 4Q-IH-502. Management is to ensure that heat stress exposures to their employees are minimized. Affected supervision must be trained in the recognizing the early signs and symptoms of heat stress related disorders, predisposing health conditions, and where applicable, administering aid when heat stress related disorders occur. For additional information, contact your local Industrial Hygienist. WORKER PROTECTION ORDER Defense Programs Health, Safety, and Environment Status Report - March 1995 Several new developments have occurred in the development of draft DOE Order 5483.0SH, "Occupational Safety and Health Programs for Contractor Employees." The Office of the Assistant Secretary for Environment, Safety, and Health (EH) plans to condense all orders pertaining to worker protection into a single DOE Order 470, “Worker Protection Management." The DOE Occupational Safety and Health Coordination Committee, established by EH to develop DOE Order 5483.0SH, reviewed Draft DOE Order 470 and provided constructive comments to EH. The committee developed a consensus list of mandatory Occupational Safety and Health standards for DOE operations. DOE Order 470 will require DOE and its contractors to assure worker protection with a program that integrates necessary components of occupational safety, industrial hygiene, occupational medicine, construction safety, radiological safety, explosives safety, and firearms safety. Central to program management are the core elements of management commitment, employee involvement, worksite analysis, hazard abatement and control, and safety and health training. The Order identifies mandatory standards. Implementation guides are expected to provide guidance in many programmatic areas. EH will forward the Order to the Office of the Assistant Secretary for Human Resources on March 31, 1995, to begin the formal concurrence process. Lessons Learned Handbook: DOE-HDBE-7502-95 GOOD PRACTICES / LESSONS LEARNED THE NUCLEAR EXCHANGE - RADIATION PROTECTION The Nuclear Professional - Winter 1995 Challenge: To provide a safe, effective way for workers dressed in protective clothing to carry hand tools, while at the same time reducing the volume of low-level radioactive waste. Response: A reusable tool pouch designed to be worn on the waist of workers dressed in protective clothing was developed. The pouch frees workers’ hands for safer climbing on ladders and scaffolding, and provides convenient access for small tools, cameras, and many other items. The idea evolved after observing makeshift too! sacks workers were constructing from plastic bags and tape. The handmade sacks cost job time to make and added to low-level waste volumes when discarded. After a search of material catalogs failed to find a suitable replacement for the hand-made sacks, design of the pouch was handled in-house. The resulting product is a 12" by 12” pouch made of strong nylon fabric, with a "see-through" window for easy viewing of tools. The nylon material is washable and durable for repeated use, and can be incinerated for volume reduction when worn out. The pouches come in magenta for radiological personnel and in yellow for all other workers.

—=—=—=————=—=_—==_$—=_==_$—=<_[_——<£—££_—>—<—$—$$$F[€F&EN€_§—&_aVa————=[————————E—EeE——————E—E—E=>=>=——ee———EEE—E—E>E—E~—>>———— MEETINGS, TRAINING, SEMINARS April 28 - May 5, 1995 - 54th Annual American Occupational Health Conference; Las Vegas, NV; Contact: 708-228-6850, ext. 195 May 2 - 4, 1995 - Process Safety Management; Las Vegas, NV; Contact: Cam Holbrook (PNL) - 509-372- 4178 May 7 - 10, 1995 - Nuclear Energy Assembly; Washington, DC; Contact: Sharon Salter - 202-739-8026 —_—_—_—_—_—_———————————— eee EEEE————=E—RxE_@Qx_{___Z£—ESS NOTES OF INTEREST ITALIAN SCIENTISTS CLAIM COLD FUSION BREAKTHROUGH Reuters - March 29, 1995 Italian physicists have detected what they believe may be evidence of nuclear "cold fusion" in experiments with hydrogen and nickel, according to the news agency AGI. It quoted a member of the team, Professor Sergio Focardi of the University of Bologna, as saying that 15 grams of nickel and one gram of hydrogen produced 30 to 40 watts of energy, sufficient to power a light bulb, for around three months. Focardi said VIII-19 Swe Lessons Learned Handbook: DOE-HDBE-7502-95 about 100 kilowatt hours of energy had been produced so far in the experiments, a quantity that ruled out a chemical reaction as the source of the power, AGI said. AGI said the Italian experiments were being carried out by physicists from the universities of Bologna, Siena, and Cagliari and quoted Focardi as saying in an interview, "We have the certainty that the system we are experimenting with produces energy through a process that is perfectly replicable and controllable. Measures based on controlling the external temperature of the system prove without a shadow of doubt that energy is emitted from this system." He added: "We have observed neutrons and gamma rays, which are fortunately few and can easily be eliminated. The presence of this radiation is proof that nuclear reactions are occurring, but they cannot be explained with current knowledge of physics." UTILITIES TO PURSUE MESCARLO MRS Nuclear Waste News - March 23, 1995 it looks like a high-level waste storage facility will be built on the Mescalero Apache reservation in New Mexico. Following a yes vote by their tribe, lead utility Northern States Power has decided there is enough interest to proceed with a private Monitored Retrievable Storage (MRS) facility. The consortium of utilities has decided to proceed in forming a partnership with the Mescaleros. A letter of intent on the interim storage facility is expected sometime in early May and it is hoped the MRS will receive a NRC license by 1996. To meet this ambitious goal, the group will be conducting site surveys, environmental impact statements, and any other studies needed to fulfill NRC requirements. Appendix IX Corrective Actions Tracking Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 APPENDIX IX CORRECTIVE ACTIONS TRACKING The DOE Lessons Learned Technical Standard encourages organizations to document and track required response actions that result from lessons learned. This appendix provides examples of corrective actions tracking material that may be useful for organizations that have not implemented a lessons learned corrective action process. The documents in this appendix include figures and tables from the Savannah River Site Lessons Learned Program, Semi-Annual Report. This section of the semi-annual report covers:

The number of lesson learned items reviewed, The status of material reviewed, The Program’s transmittal hierarchy, Lessons learned document sources, Statistics for transmitials and responses, Corrective action tracking tables, and 00000 0 0 Response statistics. eA LNG e Léssoné Learned Handbook: DOE-HDBK-7502-95 This page intentionally left blank. TOTAL INDUSTRY WSRC DOE COMPLEX FIGURE 1 Lessons Learned Handbook: DOE-HDBK-7502-95 SITE LESSONS LEARNED PROGRAM 711/94 - 12/31/94 LESSONS LEARNED ITEMS REVIEWED / ITEMS ISSUED THAT REQUIRED EVALUATION 3305 29 1214 14 (J ITEMS REVIEWED §8 ITEMS ISSUED 737 9 1354 6 { + t { 0 S00 1000 1500 2000 2500 3000 3500 Lessons Learned Handbook: DOE-HDBK-7502-95 WSRC DOE Complex 137 1354 3305 Items FIGURE 2 STATUS OF LESSONS LEARNED MATERIAL REVIEWED DURING JULY 1 - DECEMBER 31, 1994 Commercial Nuclear Industry 1214 Screened At Site Level Y Not Applicable 3276 Applicable and Transmitted to Divisions (29 Items) ' Review By Division Coordinators In Progress 0 (23 Items) Transmitted To Departnents Evaluated By Department Experts In Progress 25 Lf No Action To Date 6 La Items Closed (4) > No Action 2 Action Complete 2 we § Corrective Actions Complete 56 Corrective Actions Determined (49 Completed) WSRC DOEComplex Commercial 1434 FIGURE 2A Lessons Learned Handbook: STATUS OF LESSONS LEARNED MATERIAL REVIEWED DURING JANUARY 1 - DECEMBER 31, 1994 3460 7155 Items Nuclear Industry 2261 Screened At Site Level Not Applicable 7074 Y Applicable and Transmitted to Divisions (81 Items) ! Review By Division Coordinators pa In Progress 0 Evaluated By Department Experts In Progress 69 LJ No Action Te Date 25 Jp Action 4 DOE-HDBK-7502-95 Ly 145 Corrective Items Closed (12) No Action 8 Action Complete 4 Actions Determined (124 Completed) — pe 30 Corrective Actions Complete Lessons Learned Handbook: DOE-HDBE-7502-95 Directive Bulletin Notification Special Information Notice Digest Newsletter TABLE 2 SITE LESSONS LEARNED PROGRAM TRANSMITTAL HIERARCHY Transmitted Sent To For July through Purpose Vice Presidents 0 implement specific sitewide actions Division Cocrdinators 3 evaluate, correct recurring : or high significance degradations at SRS Division Coordinators 7 evaluate, correct significant items with potential wide spread applicability Selected Division Coordinators 0 provide helpful informational sources for selected activities, reviewers evaluate the need for corrective actions Level 5 managers and above & general training, vehicle for sharing Tssued via All-in-1 to ~ 700 25 relating current general managers industry issues and (also on Videotext) expectations Lessons Learned Handbook: DOE-HDBE-7502-95 TABLE 3 SITE LESSONS LEARNED PROGRAM LESSONS LEARNED DOCUMENT SOURCES (1/1/94 « 12/31/94) TOTAL REVIEWED 1.1.94 to 6-30-94 FA-94 10 12-31-98 INDUSTRY Network T 870 1026 % 2 Event 8 : aq Notice 43 1 3 Generic Letter Letter Rule or 21 DOE COMPLEX Note Notice Bulletin Connection Observer 193 APPLICABILITY COMPARISON July to December 1994 SOURCE DOE COMPLEX INDUSTRY WSRCE TOTALS of TOTAL NOMBER REVIEWED 1334 F234 137 355 - & of total reviewed 41% 37% 22% NUMBER APPLICABLE 6 14 9 23 1% % of tots} applicable 21% 48% 31% January to fune 1994 SOURTE DOE COMPLEX INDUSTRY wSRC TOTALS of TOTAL NUMBER REVIEWED 1436 372. S12 3299 % of total reviewed 43% 32% 25% NUMBER APPLICABLE 10 17 18 45 1% % of total applicable 22% B% 40%

VPLO PUE A ‘GOdD ‘AH Jo suonezuvdig jyrg ou wosy sosuodsor oipl JO OTRIBAL UB SL TTS IANO oe ‘oIep JOE] Be sUONTE ATION VSeaIIUT puB oSuTys Agu onsHUIS sip ‘sur uodO Wy» SNPIGAG SUOTOY SANIALION WIA sual] pesoja SUONSY SARSALION) Yili SAlaI], LE/T Aq pourmnoiap SuOToY SATIALIO[ UIA SUIS] HL CO) Ole ® Lé/T Aq paupamaiop suopoY SATOALIOD ON TIM Suis] [e/f Aq SIOBIUOZ UOISIAIC] O} pautcasuBsy, sua JO 44 milo mf es mimi et Orolo Wl SOLAN NES SIOVIUOZ UOISTAIGG AQ PASI suIaty 1 @ TRE MIE ALA OL o;o WMiM| Ol wo, ol oaroe ed = OTIC an Aq ayqeordd'y 10N pounuussocy sualy (96003 (4,001) ZI (%00T) € \@is) 8 (St) 8 (%68) Li Pesop) stu] 6 0 +t € z SjouIUGT UOStAtC Aq UOHENeAS Sulod zspun suIDy 0 0 0 6 0 TE/I 4q 03 pepucdsar 10u suraiy ME DlLol~iatealel[ololo a £ at as 61 OTIC sp 0% poyrrmasutsy, sus] JO HE eu dS LENO Bor] 2 upapy ISIIAG T $2288 VO 8 HSA G50 RF NOISIAIG 0 SNPIOAO SUOHOY SANIALIO[ UIA SUIDIT 6 Poso]d SUOHIY DATOALIOD IM sual] wy olo mim) Oo ot I¢/f Aq pauluusjsp suonsy SALOaLIOZ UKM SIAR] vt ét it + Té/1 AQ pourmuaiep SUOHDY OAHSOLIO[ ON Tim sualy 0z 0% % TE/T Aq siomuoD UOISTAICT 03 Panquusuery, SUIS] JO HE ot €t or BIIUIUOT WOISTAICT AQ PSsOLD SUras] £ T ALES Rialejo S OTIC 241 Aq aIqQuorddy 10N psuraUsed, Sardi] (%85) pt (4659) St (%L9) $1 (Ie) 8 (%18) 1% Pesoly sua] Or 8 L ST S SIOEIUO;) UOISIAIC] Aq UOREN[eAS SuIOs JOpun SuIdIT 0 0 0 0 0 Té/t 4q 0) papuodsar you seusyy Lessons Learned Handbook: DOE-HDBE-7502-95 b% £% 1? 9% 9% OTIC 94 01 pornsaesy, sus] JO HI SIHAIIS ANS OLAS UASVAS ATH GQdAN NOISTAIG (P66 ‘TE Joquiedeq 0} [ A[nf panssy] sjejjiwisuesy) SHUSNOdSada ANV STV.LLINSNVAL FOr SOLLSILV.LS GANUVAT SNOSSHT ALIS LAC UMAR Lessons Learned Handbook: DOE-HDBK-7502-95 TABLES SITE LESSONS LEARNED PROGRAM CORRECTIVE ACTIONS or Transmittals Issued to December Removal Scimic Concesma SWER ERD facilities, no such concem exited (ERD) Spscificatios Incorrect NMPD no such valve found (Sep) Diewl Generator Wooden Pins Thrust Calculaitons Incomect Generator Fuct amp Mounting Valve Calcalatiuns incorrect teading (CSWE) wading (CSWH) COMPLETE useol PVC Pipe wading (ANALAB) COMPLETE Water Fitter Units Rua found on hot side tnaated bear as RD tane hot Waser Filter Units inspected, aff SAT’ (Constroctivn} in Lasge Vertical Pumps teading (CSWE} “Weather Siexel Generator Operntions reading (CSWE} Maguetic Reversing Contrutlers none of this of this texling (CSWE} Lessons Learned Handbook: DOE-HDBK-7502-95 TABLE 5 SITE LESSONS LEARNED PROGRAM CORRECTIVE ACTIONS (CONTINUED) (¥or Transzittals Issued July to December 1994} Prosaure Reties Valves SRTC with antoclaves corrected valves found © to be provided to alt FPEs Generator Delecis te reading (CSWE) Voador Safery Alert item on prohibited procerement list. Breaker Vendor Safety Alort indicaed that dis does not spply i breakers in stock Causes Ales Feilure mading (CSWE) Purnps Overspeed Trip Failare seading {CSWE} Bud Practice Canyos Hazank Task Foam Task reading (CSWE} COMPLETE completed {ANALAB} System Overpressasization w IX-10 re ee ol neneaaeeiaenaaene ~ way > 5 - sae ee ate Lessons Learned Handbook: DOE-HDBK-7502-95 TABLE 5A SITE LESSONS LEARNED PROGRAM CORRECTIVE ACTIONS (For Transmittals Issued January to June 1994) swiches TBM printed cizeult omds Motor Operaund Valves Failure Iyverter Failure Modas Monitor Failure Modes Area Moniws Parkas

EX) Style Overinad Relays Col-off Saw casses injury 4.AGGEV Magre-Blast Circuit Breakers BC with Intel Math Copracessor SSES temove delective fiems exh Tectifier chip found, ite be replaced nw Stores Datahexs, no Weatinghrase 7300 chreukk cards found. fa NMPD verified a0 Velan MOVs none of thin Reading (CSWE} performed w. air stripper, none of this equipment found Reading (HPI OF facilities sovealed ne such rolaya (SW) one SMI 5! walkdown of Service saws with ont shields DNO tegged (F3} Remding (CSWE) % alt and on cach none found Group evalsated, issued instructions to DNTSC's Note: Shaded items were reported during July through December 1994 IX-11 Lessons Learned Handbook: DOE-HDBK-7502-95 . TABLE SA SITE LESSONS LEARNED PROGRAM CORRECTIVE ACTIONS — (Continued) (For Transmittals Issued January to June 1994) Skipping Container Eavuonmental A Sampling Unit DR, DHF Breaker Failure 4AG&V Magne-Biast Circuit Breakers Inc. Sucket oanestor Fallore D Fractional Horsepower Motors Prowection Sesto Actuation SSO & Brumfickt Motor Driven Relays } ADMIN Fucng Tape Mixaypiicaion Smew Coauntot Calibration Gate and Globe Vaive Yokes Generator Rocker Arms inoperable ADMIN Lift Trock Retrofit Kt HPD and nw Aresstam containers vetified that all containers sxe haried Resting (CSWE) Stores 29 n venductad, none of this ype breaker fornd {rit} in condoused, none of this type beeuker found {Trit) no nich in now Readicg {CSWE) Reading (CSWE) Resting FSS) Roses na Fach miter chiven COMPLETE of SWER facilities performed, nosie exist COMPLETE to ste if condition exists. Planchets, no twesches found (ANALAB) COMPLETE ne Walworth valves in ain strippers, no Walwyssth values found PCS datzhasy, no such engine found ne egmoment, nc such trucks fovad (Comaruciion COMPETE Note: Shaded items were reported during July through December 1994 IX-12 Lessons Learned Handbook: DOE-HDBK-7502-95 TABLE 5A SITE LESSONS LEARNED PROGRAM CORRECTIVE ACTIONS (Continued) (For Transmittals Issued January fo June 1994) of Fire Have Norzle Reading (CSWE) Iniine Morr Splice Kin Reading (CSWE) Tank Voltage Regulators SPE, Be tee ge tth tee Instrument potential ransfonnes Reading (CSWE) Gate Valves of Reading {ANALAB)} Response to Failed M & TE Note: Shaded items were reported during July through December 1994 IX-13 Lessons Learned Handbook: DOE-HDBK-7502-95 TABLE SA SITE LESSONS LEARNED PROGRAM CORRECTIVE ACTIONS {Continued} (¥or Transmittals Issued January to June 1994) Bonles Leaking Valves Acid Lins Failure system pips, ta establish NDE {aspaction CFNX} walkdown and aS aad walkdown snd Verification Reads HP boctle stations wad Note: Shaded items were reported during July through December 1994 TX-14 DOE-HDBK-7502-95 Lessons Learned Handbook: VRLO Bue CZ “GOED HH JO suonezTEtID j7e1g ap wy sasuodsar ain Jo aBnrDak UE ST BMS PMO » TOON GOO 3001 KAS 008 00% % ‘oouspusy Buna DIMMU pawery SUdssYy WIS MAUVE SAAHO PSH vr sgaen | SGA UT suK OT SHA MY SUARO | SAA Dy ONDE 1 SHA GT gaK BO (aie) SABP O} >) ‘sua UO polTUQns (7) suoday Spey BAAMT SHAM 7 SEK OE SBAHO | SIAUY SHAIO | ETAUH KERKO | SHAE SAADO | SHA OE SHA HO (Z} pamturgqns suodayy Ap29: LZ ze Lt ze % 6 skep ‘ouip ssuodsar uoday Anq-p¢ saRraay 0 0 0 0 z 0 Ae] Sep QT Hey? sour ponturqns suOdoY Sec7 OF JO JOquINNY £ zt & a tl 61 panruigns suodoy ARC] O¢ JO J9qQWURN: € a et a W 61 pasinbar suodsy At] O¢ JO JOquINA;

BOOT B00l BOL 001 B00t BOL % ‘saquaNaN) APE UOIslAtqy uo poruiqns sHoday pannhsy eBRSIMO [Zoe EELY | WimoY | SavsEs [VO FHSS} asd eA NOISIAIG ¥OS 6001 BOL OOK BO0I 36001 % ‘SOUEPLSNY SUNASAl BPMNUOD Pousesy suNSsS’y ONS SAAS BHAMO FETA MEL SHAHO | SIAMY STANO | SHAME SaKbO | BEAM SAK OD P oak ey SEA DO (rey sup OY >) ‘aun vo panseuqns (7) sucday Apsaaren yy SIAM FIAPO TP KIAWE SHAKO | SIX HIAMO | SASL SRAHO T KAA ME SHA | SAAT SAA PO (Z)} pemmugns spodsy Apauengy ot St 1% te 8% Sz skep ‘aunt osuodsos poday ARc-pg OsesaAY; g 0 0 £ 0 Q aie] SARp OY UBYI atour ponruiqns suuoday Avg O¢ JO JOqRINNE re $t $e 1% ¥ x Paunugns swoday Avy j¢ JO JoquINAy 4 st $t iz ve % paimbar suoday Arq G¢ JO s9qLEnNE %ES Bre 26008 BbG RG HB % ‘SASuAUNdIC Af UOISIAICY uo paniuigns syoday pamboy IPAAIIS TIS az DILYS YAMS ATH QAiwN NOISIAIC (P66E “TE Jaquiazeg 03 | Ant panssy Syez}IWwsuT. yj) SOLLSILV.LS ASNOdSaY YTOLVYNIGUCOD GANUVAT SNOSSAT NOISTAIG 9ATAVE IX-15 Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Appendix Xx Lessons Learned Program Review Lestohs Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 APPENDIX X LESSONS LEARNED PROGRAM REVIEW Perlodic reviews of lessons learned programs are a good means of measuring the effectiveness of the program and Identifying areas that need improvement. This appendix provides an example of a semi- annual site lessons learned program review report. This report can be used as a guide in selecting performance measures, planning program teviews, and/or preparing program review reports. oO Westinghouse Savannah River ‘Company, Semi-Annual Review of the Site Lessons Learned Program, July 1, 1994 - December 31, 1994. ~~ ee 7 Lessons Learned Handbook: DOE-HDBE-7502-95 This page intentionally left blank. Lessons Learned Handbook: DOE-HDBE-7502-95 SEMI-ANNUAL REVIEW OF THE SITE LESSONS LEARNED PROGRAM | July 1, 1994 - December 31, 1994 EXECUTIVE SUMMARY General The Site Lessons Learned Program screens lessons learned information from the DOE complex, commercial nuclear industry, and SRS and transmits applicable, significant items throughout the site for detailed evaluation and development of appropriate corrective actions. This site level screening process is very cost effective because it provides the desired extensive review of lessons learned information (~7,000 items/year), while drastically reducing the review workload for WSRC Divisions and minimizing distractions to their normal operations. The program, called for by the WSRC President (Reference 1), is directed by the Site Lessons Learned Coordinator. He is supported by matrixed Division Lessons Learned Coordinators (DLLC) from each of the 15 Division and Staff organizations (Table 1) and a direct report staff of five Lessons Learned Engineers. The Site Lessons Learned Coordinator reports to the Manager of the Oversight Compliance Integration Section (OCIS). Programmatic Improvement During the second half of 1994 the program continued to improve as demonstrated by the following items. ° Required Division Coordinator Reports verifying review of daily Division occurrences continued to increase: 70% (Jan - Jun “93), 75% (Jul - Dec ‘93), 89% (Jan - Jun ‘94), 97% (Jul-Dec £94). ° For items issued during the period, (Total Items Closed By All Divisions/Total Items Received By All Divisions), increased from 66% (Jan-Jun ‘94) to 71% (Jul-Dec ‘94). ° For all items issued since 1/1/93, (Cumulative Division Items Fully Closed/Cumulative Division Items Received) has continued to increase from 5% (Jan-Jun ‘93) to 15% (Jul-Dec 93) to 24% (Jan-Jun ‘94) to 39% (Jul-Dec ‘94). _ ° Division lessons learned items detected by the Division Coordinator and forwarded to the Site Coordinator for review continued to increase: 39 (Jan - Jun ‘93), 47 (Jul - Dec ‘93), 80 (Jan - Jun *94), 104 Jul-Dec ‘94), ° Site Lessons Learned Committee meeting attendance continued to increase: 69% (Jan - Jun ‘93) to 73% (Jul - Dec *93) to 82% (Jan - Jun 94) to 93% (Jul-Dec