Multiple TSR Violations

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Type:  Lessons Learned

Publisher:  Fluor Hanford, Richland, WA

Published As:  Public


Topics:  Nuclear/Nuclear Safety, Operations, Management Systems, Work Management/Planning

Multiple violations of Technical Safety Requirements (TSR) at the Plutonium Finishing Plant have occurred recently because of a wide variety of specific causes. However, poor communication, lack of knowledge concerning changes to safety basis documents, and inadequate attention to detail were elements in most of the events. This document briefly describes those individual occurrences, looks at the common underlying causes, and provides several recommendations to preclude recurrence.

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