Requirements for the restart of MDF

An Investigation into the Falsification of Pellet Diameter Data in the MOX Demonstration Facility at the BNFL Sellafield Site and the Effect of this on the Safety of MOX Fuel in Use

5.1 Plant and Equipment
5.2 Process Workers
5.3 Supervisors
5.4 Plant Management
5.5 Site Management
5.6 BNFL Corporate Management

93. The NII investigation has revealed significant shortcomings in the suitability of the plant, safety culture and management, especially the control and supervision of operations. The plant is currently shut down and NII will only consent to its restart when significant improvements have been made. The required improvements are discussed below.

Plant and Equipment

94. As described above MDF is a demonstration facility: it is not a purpose built production facility like the Sellafield MOX plant. Consequently the ergonomics of the plant leave a good deal to be desired. NII recognises that there are only limited improvements that can be made. However, it is essential that the ergonomics of the pellet diameter measuring station should be improved. NII fully supports BNFL's own recommendation to automate this process so that the readings from the laser micrometer are fed directly into the computer spreadsheet without the need for manual intervention.

Recommendation 1:

BNFL should automate the recording of the AQL sample fuel pellet diameter measurements

95. The measurement of fuel pellet diameter to meet customer's Quality Assurance needs is a necessary but tedious manual task. Consideration should be given to improving the plant measuring station to reduce the amount of operator involvement.

Recommendation 2:

BNFL should give consideration to improving the measuring work station to reduce the need for operator involvement in the selecting and positioning of fuel pellets in the laser micrometer

96. The ease with which the computer data logging system could be manipulated was certainly a factor in the fabrication of the QA records. Improvements in this system should be made to prevent interference with data, especially the ability to copy data both within, and from one spreadsheet to another.

Recommendation 3:

BNFL should improve the computer security of the QA data logging system in particular to prevent copying both within and from one spreadsheet to another.

5.2 Process Workers

97. HSE's statistical analysis has shown that four out of the five shifts are implicated in the falsification of pellet diameter data. This means that some people actively bypassed the required procedures for measuring and recording AQL data. Others almost certainly knew what was going on but did not report it. This shows that there is a serious safety culture problem and a lack of awareness and/or care about why specific tasks are done in the production of MOX fuel. This attitude is unacceptable on a nuclear installation, especially one which is producing the fuel for use in nuclear reactors. NII will not allow restart of this plant until significant changes have been made in the staffing of the plant.

Recommendation 4:

BNFL should make every effort to identify all those people who deliberately falsified records and take appropriate disciplinary action. Any persons found to have been involved in deliberate falsification of records should not be allowed to work in MDF or in any other safety related plant on the Sellafield site until such time as they have been retrained and demonstrate they are competent to undertake safety related work.

Recommendation 5:

BNFL should make every effort to identify all those people who knew about the practice of falsifying records but did not take action. These people should be removed from MDF and retrained.

Recommendation 6:

BNFL should ensure that all other staff in MDF are retrained to improve their awareness of the importance of the operations in MDF, why they need to be done and why process workers must follow procedures.

98. The practice of allowing process workers to hold QC stamps which in effect allow them to check their own work is another contributory factor to this event. The question needs to be asked whether such practices are appropriate for the manufacture of nuclear fuel. BNFL should re-examine this practice. NII will expect to see clear accountabilities for QC inspectors who must be trained and dedicated to the task. A QC inspector must have the independence and strength to resist any potential pressures from both the process workers and management to ensure that tasks are completed properly.

Recommendation 7:

BNFL should review the role of QC inspectors in MDF to ensure they have the independence and accountability to give confidence that work is being completed properly.

5.3 Supervisors

99. Clearly front line supervision failed on this plant. The Shift Team Leaders and Shift Team Managers concerned did not adequately perform their jobs either in supervising or controlling these key activities. The roles of these supervisors need to be re-examined. In particular, BNFL needs to establish to what extent they knew about what was going on - if they did then BNFL should take appropriate action. NII will not allow the restart of MDF with any supervisors who condoned falsification of records.

Recommendation 8:

BNFL should re-examine the role of Shift Team Leaders to ensure that management functions are clearly identified and justified.

Recommendation 9:

BNFL should make every effort to identify any supervisors who knew about and condoned falsification of records. Such people should be appropriately disciplined.

Recommendation 10:

BNFL should ensure that all other STLs and STMs are retrained to ensure they are aware of the importance of their jobs and the need to ensure staff who report to them follow procedures

5.4 Plant Management

100. The NII investigation has shown that the plant management allowed a situation to develop where some people thought it was acceptable to falsify records rather than to follow procedures. The management should take responsibility for staffing the plant with some people who did not have the right skills or attitude required for the production of nuclear fuel. Also the managers should take responsibility for allowing poor ergonomic practices and not initiating plant improvements to ease process worker tasks. It was also evident from the NII investigation that plant managers did not spend sufficient time on the plant, observing what was going on and talking to staff. If they had, they would have realised that improvements could have been made. Their absence of 'walking the plant' also had a negative effect on staff morale and general attitude to the importance of the task the staff were engaged on. NII will not allow restart of MDF with the current management arrangements or practices.

Recommendation 11:

BNFL should review the roles of previous plant management to determine the extent to which they contributed to the degradation in working practices in the plant.

Recommendation 12:

BNFL should review the suitability of the current plant management to run MDF.

Recommendation 13:

BNFL should ensure that any future management team members are aware of their responsibility to ensure the plant is operated to standards required of a nuclear establishment and that they are given sufficient time to spend on the shop floor talking to their staff.

5.5 Site Management

101. At the same time as BNFL first notified NII of falsification, NII was conducting a team inspection into control and supervision at Sellafield. Many of the findings of this investigation are reflected across the site in the findings of the team inspection. NII has written to BNFL specifying under its licence that it refers to its Nuclear Safety Committee a report or reports on:-

the findings of BNFL's investigation into the possibility of data falsification at the Sellafield site
the additional countermeasures implemented at the Sellafield site to prevent data falsification
the implementation across the Sellafield site of improvements arising from the investigation into data falsification at the B33 MOX Demonstration Facility.

NII requires the site management to urgently consider the implications of this event for other parts of the site.

Recommendation 14:

BNFL should urgently consider the implications of the MDF event for the Sellafield site and provide to NII a report or reports on its proposed remedial actions.

5.6 BNFL Corporate Management

102. For an event of this significance to have occurred, there has clearly been a lapse in the communication chain between the plant and BNFL's corporate management. Such lapses should not be allowed to occur. It is obvious that higher levels of management were unaware of day to day practices, which when exposed by this event, were considered unacceptable.

Recommendation 15:

BNFL should investigate why its senior management had allowed the situation in MDF to develop and to provide a report to NII on how it intends to prevent a recurrence.

Added to the HSE website on 18th February 2000