External Subject Matter Reports on the Feb. 3, 2021, Alert at the NCNR

Introduction

Following the Feb. 3, 2021, incident in which a fuel element in NIST’s research reactor was damaged, NIST retained external, independent subject matter experts to provide their individual assessments of 1) the conditions that allowed the Feb. 3, 2021, incident to occur; 2) the NCNR’s emergency response to the incident; 3) NIST’s organizational response to the incident; and 4) the efficacy and completeness of the proposed corrective actions. Each expert provided a report that included recommendations to help avoid future incidents and to improve safety performance and incident response. 

The subject matter experts were:

• Julia Phillips, Vice President & CTO, Sandia National Laboratory (retired); Executive Emeritus, National Science Board
• Eric Kaler, President, Case Western Reserve University
• Thom Mason, Director, Los Alamos National Laboratory; President and CEO, Triad National Security LLC
• Alexander Adams, Chief, U.S. Nuclear Regulatory Commission Research & Test Reactors Licensing Branch (retired)

Assessment Process

NIST provided a series of briefings to the subject matter experts covering the incident timeline and event response, a review of the incident investigation, the reports to the Nuclear Regulatory Commission (NRC), the NIST communication and public engagement actions, and an overview of the NIST Incident Response Team charter and actions. The experts also participated in an on-site visit where they observed NCNR facilities and operations firsthand and interviewed NIST staff directly. 

Key Findings

NIST received a report from each expert assessing the elements identified above. NIST leadership, including the acting director, the acting associate director for laboratory programs, and the NCNR director, reviewed the reports carefully and identified a number of key findings and recommendations.

These include:

• Recognition that the NCNR is an important national resource, and, as such, there is an imperative to restart safely.
• The NIST root cause analysis was thorough and comprehensive.
• NIST leadership should provide the resources needed to complete corrective actions, which include:
  • Ensuring adequate staffing, through the recruitment and retention of qualified staff;
  • Improving reactor operator training, including emergency response training; and
  • Supporting long-term efforts to improve safety culture and continuous improvement, including external benchmarking to ensure best practices.
• NIST leadership should be engaged in providing support for NCNR operations, which include:
  • Elevating risk management of NCNR to the NIST level and including attention to regulatory risks;
  • Ensuring adequate resources to support the nuclear safety culture program at the NCNR;
  • Ensuring adequate internal and external oversight by NIST’s Safety Evaluation Committee (SEC) and Safety Advisory Committee (SAC); and
  • Aligning and integrating NCNR programs with NIST-level safety management programs.
• NIST should institutionalize lessons learned from this event, such as developing narratives to incorporate it into the NIST story to be shared with current and future staff members.

NIST Response

NIST leadership concurs with the findings and recommendations from the subject matter experts and is working to implement both short-term corrective actions and long-term operational changes. NIST is committed to ensuring that a fuel damage incident like the one that occurred on Feb. 3, 2021, never happens again, and that improvements to our safety culture are embraced and guide us into the future.

Read the Reports 

Julia Phillips
Eric Kaler
Thom Mason
Alexander Adams