Oct. 4 Update on the NCNR: Root Cause Analysis and Safety Review Submitted to NRC

The U.S. Department of Commerce’s National Institute of Standards and Technology (NIST) has submitted two reports and supplemental information on the Feb. 3, 2021, alert at the NIST Center for Neutron Research (NCNR) to the Nuclear Regulatory Commission (NRC). The reports include a root cause analysis of the alert, NIST’s planned corrective actions, and a review of the NIST response to the incident. With the reports, NIST has submitted a request for permission to restart the reactor, contingent upon all necessary corrective actions and restart preparations being completed.

The following root causes are identified in the reports: 

1. The training and qualification program for operators was not on par with programmatic needs;
2. Written procedures did not capture necessary steps in assuring fuel elements were latched in place;
3. Procedural compliance was not enforced;
4. The equipment and tools used to determine whether fuel elements were securely latched in place were inadequate;
5. Management oversight of refueling staffing was inadequate;
6. The NCNR’s change management program was insufficient; and
7. The reactor operations group had a culture of complacency.

“We take these findings very seriously, as they absolutely are not consistent with NIST’s dedication to safety and excellence,” said James Olthoff, who is performing the non-exclusive functions and duties of the under secretary of commerce for standards and technology and NIST director. “We have already begun implementing many corrective actions and I’m confident that these changes will strengthen our program and ensure the safe operation of this important national resource for years to come.”

The initial root cause investigation was completed by a working group of NIST technical experts who identified five root causes. A subcommittee of NIST’s Safety Evaluation Committee, which included NIST staff members and an outside expert, performed a further review of the technical working group’s analysis and added an additional two root causes. 

Both groups identified a total of 18 corrective actions that NIST will take to address the root causes and to ensure an event such as the Feb. 3 alert does not happen again.

The safety subcommittee also reviewed NIST’s response to the alert and determined that “safety systems functioned as intended, defined roles were fulfilled quickly and correctly, and defined processes and procedures were implemented.”

“While I am disappointed by the root causes, I am pleased that the safety systems and NCNR staff responded extremely well during the alert,” said Olthoff.

Four external experts will now review the NIST analyses and planned corrective actions, as well as the organizational response to the Feb. 3 event. The NRC will complete a special inspection and issue its own report before fully reviewing the restart request.

NIST’s reports to the NRC are available on the NRC’s public website.