Executive summary
Date(s) of inspection:
- May 2023
Aim of inspection
The purpose of the inspection is to judge the adequacy of AWE’s implementation of its arrangements made under LC7 and LC 26. The 1-day inspection is to be undertaken in collaboration with AWE’s internal regulation will include a desk top review/discussion of key documentation as well as a plant visit.
For LC7: the aim is to assess the effectiveness of XTC’s arrangements for the identification of learning from events, and XTC’s demonstration of compliance against the requirements of LC7 and the regulatory expectations defined within ONR’s NS-INSP-GD-007 (Version 6.1).
For LC26: the aim is to assess XTC’s arrangements for the control and supervision of operations, arrangements against the requirements of LC26 and the regulatory expectations and relevant good practice identified within ONR’s NS-INSP-GD-026 (Version 6).
Subject(s) of inspection
- LC 07 - Incidents on the site - Rating: GREEN
- LC 26 - Control and supervision of operations - Rating: GREEN
Key findings, inspector's opinions and reasons for judgement made
ONR conducted an LC7 and LC26 inspection in XTC on 10th May 2023. Based on the sample undertaken, the evidence reviewed and the people spoken to on the day, I observed various shortfalls against my regulatory expectations. I considered the safety-significance of these gaps to be limited and observed AWE proactively making commitments to addressing them (which I shall monitor through routine regulatory engagements). On this basis I judge it would be disproportionate to generate any regulatory issues from the inspection and I assigned an inspection rating of GREEN.
Conclusion
From discussions during the inspection, I understand XTC’s LC7 arrangements focus on empowering all personnel to raise events (this can be done with the support of Lorraine Moffatt who is a senior facility specialist with XTC and performs the role of subject matter expert for event reporting). I observed XTC making deliberate-positive efforts to encourage and value staff for the reporting of near miss events, with initiatives implemented such as rewarding monthly prizes for the top 3 reports (this initiative is now regarded as best practice within AWE).
XTC perform weekly event governance reviews to analyse new events, near-miss reports and ongoing investigations. These reviews specifically consider trending and also feed into monthly events governance reviews. AWE provided evidence of where corrective measures have been implemented in response to the trending of these events – These reviews are undertaken by a TIGER team. XTC shared the terms of reference (TORs) for the larger, monthly governance review meeting. There has been a recent up turn in reporting of near miss events (currently @ 79 in the year to April). *** AWE took an action to introduce near miss trending into the ESH newsletter.
The reports for two recent events were sampled: One where a fire alarm had sounded during silent hours and the corrective actions inadvertently muted the fire alarm for the whole facility; and one regarding some electrical items where the PAT testing was not current. I judged the reporting templates had been completed appropriately.
XTC aims to complete its level 2 investigations within 10 working days (and with an emphasis on reporting quality rather than quantity). XTC management is informed where it is not possible for investigations to be completed within the 10 day time period. XTC was unable identify arrangements where the timescale or the upward reporting process is defined. There was an acceptance during the inspection that some of XTC's processes are not written down which is a shortfall to my expectations.
An investigation was briefly sampled (where a contractor’s vehicle contravened site arrangements by not giving way to another vehicle transporting explosives); I judged the investigation appeared adequate including consideration of whether an amber alert was justified (it wasn’t) and I saw evidence of the emails to staff and contractors to inform/train personnel in accordance with the corrective actions from the investigation.
To sample a further investigation, I observed a corrective action review panel (CAPA) regarding event EVE-00014252. The event was relevant to XTC’s LC26 compliance as it was associated with control (and deconfliction) of work within the licensed site. The event involved two different teams with different purposes arriving at the same job site, having completed different sign in sheets at the WCC and spoken to different coordinators. I observed what I judged to be a thorough review and investigation process, with effective root cause analysis (RCA) which identified the lack of an adequate procedure and raised 4 corrective actions (including reviewing and updating the work control arrangements for XTC's Work Control Centre (WCC) and defining a new role of building manager for each of the facilities within XTC. I judged the actions were given appropriate owners and target times for completion. There was also a check completed to ensure duplicate actions were not being raised.
I observed XTC’s arrangements for training it’s staff who undertake level 2 investigations. XTC explained those who are able to undertake investigations view the role as 'a badge of honour'. Based on the need to train personnel, XTC has forecast a demand of ~15 investigations per year (last year there were 17 investigations undertaken and so additional resource was called upon from across the organisation).
In response to my questioning about where contractor’s near misses are captured, it became apparent these are not readily recorded. AWE acknowledged this is a gap to their own expectations and it would be become increasingly important to resolve it as the contractor workforce is expected to grow in the coming years. *** AWE took an action to respond to how contractor near misses will actively be incorporated into the routine operations within XTC.
In response to my enquiries about how XTC interfaces across the organisation to share events and to learn from far field events, I discovered there is no routine interface with the corporate LC7 owner and therefore limited exposure to minor events from different tech centres. Furthermore, there is a limited feed of information shared on events on different nuclear sites (such as Sellafield or Magnox) due to the conventional nature of the hazards in XTC. *** AWE took an action to engage with the LC7 owner to improve communications.
I discussed XTC’s arrangements for control of keys and learned there is no formal process in place to manage the hand-off of keys to other teams within the building. *** XTC took an action to improve arrangements in this area (which may include placing a responsibility on those in the newly appointed roles of building managers). XTC acknowledged consultation would be needed across AWE as any changes to corporate arrangements will affect various tech centres.
3 further events were sampled (these were only level 1 events which are not significant enough to warrant investigations); EVE-00014727, EVE-00012524 and EVE-00014573. I judged the responses to each to be adequate.