- Site: AWE Aldermaston
- IR number: 20-028
- Date: August 2020
- LC numbers: 7
Executive summary
Purpose of Intervention
This intervention at the Atomic Weapons Establishment (AWE) licensed site was undertaken as part of the 2020/21 intervention plan and Weapons Sub-division strategy.
This planned intervention was conducted as a follow up to ONR’s Licence Condition 7 (LC7) Readiness Inspection in 2019.
Interventions Carried Out by ONR
This intervention was a planned remote Compliance Inspection undertaken against the requirements of LC7 “Incidents on the site”. This involved examination of relevant licensee documentation and incident management system and targeted discussions with relevant members of the licensee’s staff.
The intervention was completed remotely due to COVID-19 restrictions. ONR could not therefore directly inspect incident follow-up activities being undertaken on the site or independently confirm actual compliance with sampled documentation.
The intervention was performed in line with ONR's guidance requirements (as described in our technical inspection guides) in the areas inspected.
The intervention was carried out jointly with AWE Internal Regulation.
Explanation of Judgement if Safety System Not Judged to be Adequate
Not applicable.
Key Findings, Inspector's Opinions and Reasons for Judgements Made
The LC7 team showed that there had been a lot of work to improve the arrangements. There were a number of areas of industry good practice observed during the intervention, including:
- LC7 corporate procedures updated.
- Training was updated, with a number of investigators trained in 2020.
- The incident management system ITRAC was implemented, with events adequately identified and reported internally.
- Positive feedback from AWE personnel, which has helped improve AWE’s compliance with its own LC7 arrangements.
The following shortfalls were identified during the compliance inspection and therefore ONR is seeking improvement in the following areas:
- Inadequate verification in ensuring that investigators are maintaining competency levels as Suitably Qualified Experienced Persons (SQEP).
- The scope and depth of root cause analysis could be improved to include more consideration of nuclear safety culture, how corrective actions are monitored for their effectiveness and reduce the likelihood of undue bias.
- How Learning from Experience (LFE) data is used to drive continuous improvement on site and reduce event reoccurrence.
I also identified a number of potential opportunities for improvement and will follow up as part of normal regulatory interactions. No matters were identified as requiring immediate regulatory attention during the course of the compliance intervention.
I have been provided with confidence by the LC7 team that improvements are continuing to be delivered and that the improvement plan will continue to address the shortfalls.
Conclusion of Intervention
Notwithstanding the above positive observations, although AWE has made good progress against its LC7 improvement plan, I judged that from the evidence sampled, the shortfalls have the potential to undermine the effectiveness of the licensee’s investigation of incidents. The recent reoccurrence of similar events adds weight to my judgement that further work is required to improve organisational learning in this area. The licensee has already identified these shortfalls and is working to address these. Therefore I judge that an inspection rating of AMBER (Seek Improvement) is merited.
Progress will be tracked via a Level 3 regulatory issue, with appropriate governance determined under the current regular Level 4 LC7 Regulatory Interface Meetings.