Review of Systemization of the Tooele Chemical Agent Disposal Facility (1996)

The Stockpile Committee has reviewed the status of the Tooele Chemical Agent Disposal Facility (TOCDF) at the Tooele Army Depot in Utah with respect to a number of recommendations made by the committee in three major reports and one letter report concerning improvements to be made to the Tooele facility prior to the start of agent operations. These reports are: Evaluation of the Johnston Atoll Chemical Agent Disposal System Operational Verification Testing: Part II (NRC, 1994a); Review of Monitoring Activities Within the Army Chemical Stockpile Disposal Program (NRC, 1994b); a letter report to the Assistant Secretary of the Army for Installations, Logistics and Environment to recommend specific actions to enhance further the Chemical Stockpile Disposal Program risk management process (NRC, 1993a); and Recommendations for the Disposal of Chemical Agents and Munitions (NRC, 1994c).

The following findings are based on the Stockpile Committee's evaluation of implementation of prior recommendations, on knowledge and observation of the baseline incineration system, on information provided by the Army and others, and on four site visits to the TOCDF—one in November 1991, one in March 1993, one in May 1994 shortly after the start of systemization, and one in March 1995 towards the end of the systemization period. Four subgroups of the committee also visited the TOCDF during the spring of 1995. These findings are based on information obtained prior to August 31, 1995, and before the completion of all the requirements that must be met by the Army before the start of or during the first year of agent operations.

The following recommendations were made in the Stockpile Committee report Evaluation of the Johnston Atoll Chemical Agent Disposal System Operational Verification Testing: Part II (NRC, 1994a):

Current status. The Stockpile Committee reaffirms this position. The Army has stated its concurrence through a comprehensive safety oversight program. Nevertheless, the predominant focus of safety program implementation at the TOCDF seems to be upon agent-related operations and activities—with an apparent de-emphasis on nonagent operations. A strong safety culture in any organization requires consistent emphasis on all safety issues.

It is the committee's belief that the interrelationships and interdependencies between and among all on-site operations and activities mandate that agent- and non-agent-related safety programs should be on a par with each other prior to the start of agent operations.

The award fee criteria (or penalties) for EG&G Defense Materials, Inc., under their contract with the Army are still being finalized. The Stockpile Committee believes that the award fee criteria provide an opportunity for emphasizing safety priorities over production goals in the fee incentive (or penalty) structure.

• Develop and demonstrate an improved agent monitoring and identification system. (OVT2-2A)

Current status. A detailed discussion of this recommendation appears later in this chapter under responses to the Monitoring report recommendations.

• Complete the brine reduction area (to include its pollution abatement system) performance tests, or develop a satisfactory brine disposal alternative. (OVT2-2B)

Current status. The brine reduction area, including its pollution abatement system, has been tested at both the Johnston Atoll Chemical Agent Disposal System (JACADS) and the TOCDF. It has passed the environmental compliance test at JACADS and systemization testing at the TOCDF.

• Demonstrate the dunnage furnace performance with various levels of chlorinated waste; if needed, either modify the pollution abatement system (e.g., add acid gas scrubbing) or limit feed materials to those that can be handled by the existing design; alternatively, satisfactory land disposal options must be identified. (OVT2-2C)

Current status. The dunnage furnace has been tested satisfactorily at JACADS and has passed two major nonagent systemization tests at the TOCDF. The dunnage furnace must still pass an RCRA-required trial burn test at the TOCDF after the start of agent operations.

• Review the probable levels of NO_x production from VX destruction and the allowable emission levels at the other continental U.S. sites requiring VX destruction; if appropriate, develop needed NO_x abatement systems. (OVT2-2D)

Current status. The TOCDF furnaces are expected to be able to meet NO_x emission requirements. No NO_x abatement systems are required.

• Develop and demonstrate the proposed hot-slag removal system for the liquid incinerator system. (OVT2-2E)

Current status. A hot-slag removal system has been installed on each liquid incinerator, but these have not been tested under hot-slag conditions because the Army decided there was no adequate surrogate test material for the highly variable slag to allow for complete testing of the system. The Army will first test the system as the slag accumulates from agent destruction operations.

• Eliminate furnace feed errors by improved monitoring and control of the deactivation furnace and metal parts furnace feed systems and by improved methods for tracking the various types of munitions. (OVT2-2F)

Current status. The Army retained MITRE Corporation to perform a detailed study of the furnace feed systems, including improvements made on the basis of experience at JACADS, and to recommend any further improvements. A detailed report (MITRE, 1994) describes the analysis of improvements that have been made in the munitions handling system and concludes that the changes minimize the chances of recurrence of the problems at JACADS. A second report (MITRE, 1995) describes further improvements in the system. The reconfigured munitions handling system is also being analyzed in detail in the risk assessment study being performed by Science Applications International Corporation (SAIC). The risk assessment should identify potential munitions handling problems that might lead to safety problems and provide an independent review of the systems involved.

• Address all problems associated with residual gelled mustard, in particular, the use of suited personnel to perform functions that were intended to be automated. (OVT2-2G)

Current status. The Army has developed an improved agent extraction verification system that avoids the need for manual intervention in routine operations.

Current status. The TOCDF has organized an Army-staffed program management unit focused on safety, quality assurance, and environmental oversight. A similar organization exists within the EG&G program management organization. Environmental oversight includes both permitting and environmental compliance. Close working relationships have been established with the Utah Division of Solid and Hazardous Waste (DSHW) to maintain responsive interactions to facilitate preparation of the RCRA permit as the TOCDF makes some final modifications based on systemization experience and other factors. Once agent operations start, the DSHW will maintain a presence on site during operations.

Current status. EG&G has drafted an Environmental Compliance Plan (ENVCP), a document that summarizes general environmental compliance guidance, the background to the environmental impact statement, and the environmental requirements to which the TOCDF will adhere. Implementation of the ENVCP and strict adherence to the established environmental procedures should ensure continuing compliance with all environmental regulations.

Current status. The management structures in place at TOCDF and limited evidence gathered by Stockpile Committee members during site visits suggest that high quality safety management systems are in place. All action items identified in the Pre-Operational Survey must be resolved by the Army prior to the start of agent operations. The Stockpile Committee welcomes the Army's initiation of the Programmatic Lessons Learned program, creation of the Field Lessons Learned Review Team, commencement of Subject Area Reviews, and establishment of the Risk Management Plan, which is being developed by SAIC as an outgrowth of their TOCDF risk assessment work. The Stockpile Committee supports the Army's development of a process to identify "precursor events" at operating facilities (e.g., equipment failures and human errors) to maintain continuing emphasis on a philosophy of totally safe operations.

The Stockpile Committee is concerned about the focus on the start of agent operations at the TOCDF as the trigger for implementing full safety practices and about the lack of emphasis on industrial safety during the pre-agent, final systemization phase.

Current status. Because experience from Operational Verification Testing (OVT) at JACADS resulted in a number of changes to the design and planned operations at the TOCDF, the committee wanted to ensure that the effects of those changes on risk would be examined. The Army has adopted this recommendation in stepwise fashion. Because of time constraints, the entire risk assessment will not be completed before the start of agent operations at the TOCDF. However, risk assessment pertinent to each campaign will be completed and lessons learned will be applied to the facility before the start of each campaign. The first analysis for campaigns 1 and 2 (GB and VX M55 rockets with co-processing of bulk items) was completed in April 1995. Modifications to the TOCDF and its operations are in progress and will be completed prior to the start of agent operations. The draft report documenting the analysis for the first two campaigns was completed on June 26, 1995. The complete TOCDF risk assessment is expected to be published in the first quarter of 1996. The committee believes that the Army's approach to the TOCDF risk assessment meets the intent of the committee's recommendation for the first two campaigns.

The following recommendations were made as part of the Stockpile Committee's report Review of Monitoring Activities Within the Army Chemical Stockpile Disposal Program, (NRC, 1994b). The recommendations were grouped into three categories: general; agent/nonagent monitoring; and laboratory operations.

The general recommendations were:

Current status. Although existing instrumentation is adequate at the TOCDF, the Stockpile Committee continues to believe that the Army should investigate new monitoring technologies with the intent of continual improvement. The committee recognizes that the Army has instituted a program being conducted by the University of Denver (Fourier Transform Infrared technology and SAIC (literature search and market survey of near real-time monitoring technologies) to evaluate improvements in monitoring technology. However, these efforts may be not be sufficient to ensure implementation of an advanced monitoring system.

The recommendations for agent/nonagent monitoring were:

Current status. Speciation. capability has been added to the laboratories at the Chemical Agent Munitions Disposal System (CAMDS), JACADS, and the TOCDF with new gas chromatograph/mass spectrometers. Although the Army is working on the problem of chemical speciation, the Automatic Continuous Air Monitoring System (ACAMS) does not yet have this capability.

Current status. This requirement has been met by placing ACAMS monitors calibrated for various agents in the unpack areas of the TOCDF. A multiagent ACAMS is under development and being tested at CAMDS. Continuous monitoring has not yet been implemented in storage areas, but the Army has told the Stockpile Committee that plans are under way for continuous monitoring in these areas.

Current status. This requirement has not been met. ACAMS alarms still require the laboratory analysis of Depot Area Air Monitoring System (DAAMS) samples to confirm false positives. A single false positive requires the shutdown of agent operations, but does not by itself initiate the response appropriate for a major agent release. False positive signals result in plant disruptions and the potential for increased human error and equipment degradation. The Army expects that the multi-agent ACAMS will have a lower false positive rate. (A dual detector ACAMS is expected to be ready for field tests by the end of 1995).

Current status. The Army has developed a more comprehensive schedule for testing field sensors and has also installed some monitors that will more quickly and reliably signal detection of higher levels of agent in the event of a significant release.

Current status. Faster response monitors, set to higher detection levels (immediately dangerous to life and health), have been installed in the unpack area of the facility. A new type of detector (based on ion mobility), which has about a 30-second response time, is presently under development.

Current status. The TOCDF will be undergoing a series of RCRA- and TSCA-required state-supervised trial burns for the first 24 months of operations; a minimum of 16 trial burns (each consisting of 3 or 4 runs) are scheduled. The results of the trial burns will be used to revise the health risk assessment and formulate a monitoring approach for products of incomplete combustion, particulates, heavy metals, halogenated dioxins and furans, and volatile and semivolatile organics.

The recommendations for laboratory operations were:

Current status. The TOCDF laboratory incorporates a new bar code system for identifying samples and an improved automated record system. The Stockpile Committee believes these innovations constitute a major improvement in quality control over the procedures at JACADS. The committee still believes that a system is needed to track and evaluate the cause of lab errors. This system will continue to improve the quality of laboratory operations.

Current status. The laboratory now handles nonagent analysis of flue gas samples and includes mass spectroscopic analysis for agent in addition to gas chromatography. Laboratory operators are not presently cross-trained for all these techniques. The Army plans to start cross-training in the next few months to include instrument training, hazardous waste training, testing new monitors, and statistical analysis of data. Cross-training is an excellent way to enhance personnel attention and individual operator job performance.

Current status. The Army has established and implemented a system for providing double blind challenges to the laboratory in a way that will provide frequent checks on the quality and reliability of normal laboratory operations

Current status. The Army plans to have such a capability in place late in 1995.

The Stockpile Committee, in a letter report to the Assistant Secretary of the Army for Installations, Logistics and Environment, on January 8, 1993 (NRC, 1993a), made the following recommendations:

Current status. SAIC completed the first phase of an accident quantitative risk assessment (QRA) for the TOCDF, and a draft report summarizing the results was circulated to the committee on June 26, 1995 (SAIC, 1995b). The first phase covers the portions of the facility that will be involved in the first two campaigns (GB and VX M55 rockets with co-processing of bulk items). The full accident QRA for the storage risks and all campaigns will be completed in early 1996. For technical and administrative reasons, there are multiple risk assessment projects and reports: an accident quantitative risk assessment, a health effects risk assessment, and a reconfiguration risk assessment. Organizations other than SAIC may perform some of these studies. This situation could lead to misunderstanding among reviewers, government agencies, and the public. It is essential that the Army adopt standard language recognizing the ensemble of risk-related projects as ''the risk assessment." The individual studies should always be referred to as elements of the wider risk assessment.

Current status. The current status of the TOCDF risk assessment limits analysis to activities associated with the first and second campaigns. Risk associated with continued storage will be addressed later. The accident QRA team is currently obtaining additional expert assistance to help address specific aspects of the risk of continued storage and associated handling.

The risk assessments should be quantitative and include the following features:

• bottom-line results on the health effects to on-site and off-site personnel in terms of likelihood and consequence, including a site-specific atmospheric and health effects analysis and an analysis of emergency response capability;
• a clearly defined set of scenarios that, taken together, provide a comprehensive representation of the risk;
• dependency matrices that display inter- and intra-system dependencies;
• a human action analysis that represents the human role in controlling risk;
• quantification of risk from all causes, including both internal events (plant and plant-people failures) and external events (earthquakes, fires, floods, aircraft crashes, etc.);
• site-specific hardware, software, procedures, training programs, maintenance practices, and operations personnel (including site-specific storage facilities and munitions handling activities);
• risk contributors in such terms as random failures, common cause failures, multiple failures, and human error; and
• an uncertainty analysis to display clearly how much confidence the analysts have in the precision of the quantitative results. (RISK-3)

Current status. The Stockpile Committee believes that the accident quantitative risk analysis is progressing toward meeting the goals of this recommendation.

The Stockpile Committee provided five broad guidelines for conducting the site-specific risk analyses:

Current status. The accident QRA meets this guideline.

Current status. SAIC has recognized capability for performing risk assessments but is involved in the Chemical Stockpile Disposal Program (CSDP) because it has been a long-term support contractor for the Army. The Army reports that SAIC was chosen to avoid a long procurement process for selecting an independent contractor that would have delayed the program. The Army retained another long-term support contractor, MITRE Corporation, to organize an expert panel to oversee the SAIC risk assessment activity. Five experts were chosen for the oversight panel (Expert Panel) and the Stockpile Committee has reviewed their qualifications and concluded that they are all well qualified. One of the members is a combustion expert from Brigham Young University in Salt Lake City, who provides some degree of local perspective. A member of the Stockpile Committee with expertise in risk assessment was invited to monitor the meetings of the Expert Panel. The Stockpile Committee believes that the Army has complied with the intent of this guideline.

Current status. The Army attempted to involve the community as early as the spring of 1994 and at intervals since then. However, key elements of the community seem to have missed or misinterpreted these interactions. Additional efforts are required if the involvement is to be successful. The lessons learned here could be applied at future sites.

Current status. The QRA team has brought human reliability experts into the project. However, to this point, because of the limited quantity of agent that can be processed in the facility, no human-caused events significant to off-site release have been identified. The committee expects that the impact of human reliability on worker risk and stockpile handling accidents could be important. The committee believes that SAIC should examine these areas.

Current status. The Expert Panel is urging the QRA team to expand and clarify their efforts to characterize uncertainty. The Stockpile Committee expects that the QRA will meet the intent of this recommendation and will examine this area as the work proceeds. The committee is aware that several risk issues were raised as a result of the detailed risk assessment and that changes to equipment and procedures were made where appropriate to mitigate specific risks.

The Stockpile Committee report, Recommendations for the Disposal of Chemical Agents and Munitions (NRC, 1994c), presented a number of programmatic recommendations that pertain, in part, to the Tooele Chemical Agent Disposal Facility. The report addressed the potential for and made recommendations regarding alternative technologies to the baseline system. Because the baseline system was already under construction for the TOCDF, those recommendations did not pertain to that facility.

Current status. The TOCDF incorporates the baseline incineration system. Improvements have been made to reduce risk over the prototype baseline design in operation at JACADS. Considerable safety testing and configuration certification have been performed during systemization to meet operating permit conditions. Because more than 40 percent of the stockpile is at the TOCDF, safe operation of the facility is a major element in the Army's mission for expeditious chemical stockpile disposal.

Recommendations 2 through 5 of the Recommendations report pertain to risk assessment. However, all are not applicable to the TOCDF. The Stockpile Committee recommended that the Army's risk analyses completed in 1987 as input to the Programmatic Environmental Impact Statement (U.S. Army, 1988) be updated as soon as possible, on a site-specific basis. In addition, the Stockpile Committee recommended that the new risk analyses should explicitly account for latent health risks from storage, handling, and disposal. The Stockpile Committee noted that these analyses will confirm or refute the present belief that maximum safety dictates prompt disposal.

Current status. Work on the risk assessment is not yet complete, but a seismic analysis of the TOCDF strongly implies that storage area impacts would be even more severe than disposal system impacts than previously thought, and that maximum safety at the TOCDF dictates prompt disposal. The analytical work for the accident QRA of the first two campaigns at the TOCDF was completed as of late June 1995. Several aspects of the work on the risk of continued storage and stockpile reconfiguration and handling are continuing or will be revised. This work is not significant to the risk associated with the first two campaigns. The Stockpile Committee strongly believes that a final overview report should be prepared that presents a clear and integrated view of all potential risks and states the estimated confidence levels associated with the results. Further, the Stockpile Committee supports the Army's plan to keep the TOCDF risk assessment current as changes are made to the facility in the future and to integrate the assessment with a TOCDF Risk Management Plan.

The sixth recommendation focused on public concerns:

Current status. The committee finds the Army's efforts in Utah to obtain community input into the risk assessments were substantial, but not especially productive. The committee believes it is essential to obtain such involvement prior to the beginning of a risk assessment, as well as during its implementation, to improve risk communication and, ultimately, to gain public acceptance of the results.

The committee finds that the Army has begun to implement a large and comprehensive public information program in Tooele. This program is particularly impressive because few resources had been devoted to public information and outreach until recently. Nevertheless, the list of activities either planned or under way in this program suggests that not enough attention may have been given to soliciting citizen input into programmatic decisions.

Because emergency management issues are likely to become more important to the public when the TOCDF starts operations, efforts should be made by the Army to include the public in the Chemical Stockpile Emergency Preparedness Program (CSEPP) and to integrate more fully the Army's public outreach with the CSEPP.

The Occupational Safety and Health Administration recently approved personal protective equipment for responders. The committee is aware that, to both the Utah Division of Comprehensive Emergency Management (CEM) and the Tooele County Department of Emergency Management, the issues of funding a core team of responders and conducting associated training of personnel in Utah are key roadblocks to implementation of the CSEPP.

The risks presented by the stockpile require that emergency response plans be completed and exercised to ensure preparedness and successful response in the event of an actual release. The Utah CEM has indicated that, because of the lack of national planning standards, guidance has been incomplete with regard to reentry, emergency medical services, and recovery phase operations, and that this in turn has led to less than effective training and exercises (Utah CSEPP Readiness Issues, presentation by the Utah CEM to the Stockpile Committee, March 29,1995). Moreover, some counties opted not to participate in exercises, raising concerns about their level of preparedness for an emergency. The lack of national planning standards cannot be permitted to interfere with important planning for public safety and, if necessary, the Army must step in to rectify the situation.

The committee finds that the local CSEPP emergency planning efforts are not complete, as evidenced by the appendices of the Tooele County Emergency Operations Plan, which are still in a draft version.

The committee finds that the Communications Plan for Tooele County and the planned implementation of the communications system linking important operations centers in the emergency planning zone are not yet complete. In addition, as of this writing, public notification tone alert radios were not yet in place.

Recommendations 7 through 13 applied to the base-line incineration system. Recommendation 12 was:

Current status. The Programmatic Lessons Learned and Subject Area Review programs are good vehicles for identifying baseline system improvements and implementing them as appropriate across disposal facilities at different sites.

Recommendation 13 addressed the possibility of adding activated carbon filter beds to the exhaust gas stack:

Current status. The Army is presently doing the recommended evaluation. Filters can be added to the TOCDF facility at a later date if they provide a favorable benefit-to-risk ratio. Carbon filter bed testing and further evaluation are tentatively planned at the TOCDF, if the initial evaluations are positive.

Recommendations 14 through 20 addressed issues of alternative technologies and stockpile stability—not directly pertinent to the TOCDF systemization.

The final recommendation pertained to the entire program and is related to concerns about the safety implications of adequate staffing. With the finding that, as the program expands in scope, a shortage of skilled staff could potentially compromise safety and have obvious implications for slowing the program down, with attendant increased risks, the Stockpile Committee recommended:

Current status. The Stockpile Committee has noted the addition of qualified personnel, both in the office of the Program Manager for Chemical Demilitarization (PMCD) and in contractor organizations at TOCDF.

The committee has some concerns that major Army leadership is new and that acting positions have not been permanently filled. Additional PMCD staffing may be needed as activities expand in the future. The present level of staffing at TOCDF appears appropriate for safe and environmentally compliant operation of the facility. The retirement of the TOCDF EG&G general manager just before to the start of agent operations was a matter of concern. It appears that prompt action was taken to manage the transition safely.

Based on the Stockpile Committee's evaluation of the status of the TOCDF with respect to recommendations made in previous reports, the committee is generally satisfied with the progress made and recommends the following actions pertaining to safety and performance be taken at the TOCDF:

Recommendation 1. Development and implementation of the overall safety program at the TOCDF must be given high priority.

Recommendation 2. Safety and environmental performance goals should be given at least equal weight with production goals in establishing award fee criteria.

Recommendation 3. Applicable portions of the accident quantitative risk assessments must be completed and all safety-related concerns resolved before the start of specific agent-destruction campaigns.

Recommendation 4. A substantial effort should be made by the Army to enhance interactive communications with the host community and the Utah State Citizens Advisory Commission on issues of mutual concern (e.g., various elements of the Chemical Stockpile Emergency Preparedness Program, decontamination and decommissioning, future use of the facility, and risk reduction).

Recommendation 5. The Army should increase efforts to work with the Utah Division of Comprehensive Emergency Management to ensure that first-responders have been adequately trained to

use the personal protective equipment approved by the Occupational Safety and Health Administration. Tooele County must ensure their capability for responding to an emergency, especially because this condition relates to state requirements for the start of agent operations.

Recommendation 6. The Army, and where appropriate the Federal Emergency Management Agency (FEMA), should ensure that local and state Chemical Stockpile Emergency Preparedness Program plans for responding to potential chemical events are complete and well exercised as soon as possible.

Recommendation 7. The Army/FEMA should provide the necessary resources for completing the communications system planned by the Tooele County Department of Emergency Management.

Recommendation 8. All mandatory requirements of the Army's Pre-Operational Survey must be satisfied.

Recommendation 9. The liquid incinerator and deactivation furnace system must have demonstrated a destruction removal efficiency of 99.9999 percent (6-nines) during surrogate trial burns.

Recommendation 10. High-quality, adequately staffed safety management systems must be completely implemented (including procedures for testing critical equipment; all necessary operating, maintenance, and emergency procedures; management of change procedures; training and cross-training programs; programmatic lessons-learned activities; subject area reviews; and other safety oversight activities).

Recommendation 11. The liquid incinerator and the deactivation furnace system must pass all required Resource Conservation and Recovery Act trial burns; and the deactivation furnace system must also pass required Toxic Substances Control Act trial burns.

Recommendation 12. Testing and certification of the brine reduction area and the dunnage incinerator should be completed at the TOCDF, or a satisfactory disposal alternative must be implemented.

Recommendation 13. Performance of the slag removal system for the liquid incinerators should be demonstrated when sufficient slag has accumulated.

Recommendation 14. The Risk Management Plan must be fully implemented.

Recommendation 15. A comprehensive, integrated, and clear TOCDF risk assessment study, including a full description of all significant acute and latent agent and nonagent risks associated with disposal operations, as well as with the continued maintenance of the Tooele chemical stockpile, should be completed. A full explanation of the uncertainties associated with the various estimates should be included.

Recommendation 16. A system for documenting and tracking unexpected upsets, errors, failures, and other sources of problems that have led to ''near misses" during operation of the facility should be developed as soon as possible. A program for integrating this information into a plan for continual safety improvements at the TOCDF should be implemented.

Recommendation 17. An active program for continual improvement of monitoring instrumentation, including techniques for more rapid recognition of significant levels of agent release, should be pursued.

Recommendation 18. Evaluations of the stack-gas carbon filter bed system should be continued.