Dear Mr. Spears:
MAR 10 2006
CONTRACT NO. DE-AC27-99RL14047 - ENVIRONMENTAL MANAGEMENT SYSTEM (EMS) ASSESSMENT REPORT
This letter transmits for your action the results (Attachment) of the U.S. Department of Energy (DOE), Office of River Protection (ORP) assessment performed from November 14 through 18, 2005, of the CH2M HILL Hanford Group, Inc. (CH2M HILL) EMS Implementation.
The assessor found CH2M HILL had successfully implemented the EMS requirements of DOE 0 450.1, EMS, including the integration of the EMS into the CH2M HILL Integrated Safety Management System (ISMS). The assessor identified four Findings during this assessment.
Finding 1 identifies the need to update many implementing engineer, business management, and operations procedures to reflect the new EMS/ISMS requirements established by RPP-MP-003 (Revision 5), "Integrated Environmental, Safety, and Health Management System Description," and TFC-PLN-73 (Revision A), "Environmental Program Description."
Finding 2 identifies that RPP-16922, "Environmental Specifications Requirements," is not comprehensive or complete, and is not appropriately identified in other field implementing procedures as a mandatory source of environmental requirements. RPP 16922 is identified in RPP-MP-03 as a primary implementing procedure for environmental requirements.
Finding 3 identifies that significant environmental interfaces between CH2M HILL and other site contractors and site environmental programs identified in TFC-PLN-73 are not appropriately documented or controlled under CH2M HILL's own interface management procedure.
Finding 4 identifies deficiencies in RPP-MP-612, "Pollution Prevention/Waste Minimization Program," and TFC-PLN-58, "Chemical Waste Management Plan," which are cited by RPP-MP- 003 as principal EMS implementing procedures ( e.g. , both documents generally fail to provide citation to_ specific implementing procedures, interface controls, and EMS specific requirements).
CH2M HILL staff was provided the opportunity to review and comment on ORP's draft assessment report prior to finalization. Additionally, ORP conducted an out briefing with CH2M HILL to provide an additional opportunity for CH2M HILL to discuss and comment on the draft report.
Mr. M . S. Spears 06-ED-016
-2- MAR 1 O 2006
If CH2M HILL incorporates the Findings of the ORP assessment into its Corrective Actions Program, no response to the Findings is necessary. Please provide a copy of the Problem Evaluation Request(s) (PER) documenting incorporation to ORP no later than 30 days from
. receipt of this letter. ORP shall assess corrective actions during the next annual ISMS assessment.
If CH2M HILL elects not to document the Findings of this assessment in the Corrective Actions Program via PER, please provide the following information to ORP no later than March 31, 2006:
• Provide a statement of admission or denial of the Finding(s);
• Identify the causes(s) of the Finding(s);
• Identify corrective actions already taken to correct the Findings;
• Identify corrective actions that will be taken to prevent recurrence of the Finding(s); and
• State the date the contractor will be in full compliance with their contractual and regulatory commitments.
The direction herein is considered to be within the limitations of the Technical Direction (TD) clause in the Contract and does not meet any of the conditions described in paragraph (b) (1) through (4) of the TD clause. If, in the opinion of the Contractor, any instruction or direction by the COR in this letter falls within one of the categories defined in TD clause (b)(l) through (b )( 4 ), the Contractor shall not proceed but shall notify the Contracting Officer immediately orally, and in writing within five (5) working days, after receipt of any such instruction or direction and shall request the Contracting Officer to modify the contract accordingly. The Contracting Officer will respond as required by the TD clause.
If you have any questions, please contact me, or you may contact Richard R. McNulty, Environmental Division, (509) 373,.9304.
ED:RRM
Mr. M. S. Spears 06-ED-016
cc w / attachs: M. N. Jaraysi, CH2M HILL P. C. Miller, CH2M HILL K. Parnell, PAC C. R. Ungerecht, PAC Administrative Record
-3- MAR 10 2006
Environmental Safety and Quality
REPORT:
LOCATION: Hanford Site
ASSESSOR: Richard (Rick) McNulty, Lead Assessor Lori Huffman, Assessor Gae Neath, Assessor
APPROVED BY: Jim Rasmussen, Division Director Environmental Division
Executive Summary
The U.S. Department of Energy (DOE), Office of River Protection (ORP) conducted an assessment of the CH2M HILL Hanford Group, Inc. (CH2M HILL) implementation of DOE O 450.1, Environmental Management Systems (EMS). Specific EMS requirements were incorporated into the CH2M HILL contract through the Standard/Requirements and Identification Documents (S/RID) process. Effectively, the EMS documents show CH2M HILL complies with the Requirements Basis (e.g., DOE Orders, S/RID) and the Environmental Basis (e.g., permits, Hanford Federal Facilities Agreement and Consent Order [HFFACO], regulations) identified in the CH2M HILL-ORP Authorization Basis Agreement.
This assessment was limited to validating CH2M HILL's certification to ORP that its EMS has been implemented and incorporated into its Integrated Safety Management System (ISMS). An annual evaluation of the CH2M HILL EMS required by DOE 0 450.1 as a component of the ISMS will be conducted by ORP during the next scheduled ISMS annual review in July 2006.
CH2M HILL supported its EMS certification with a management assessment which included one Finding and 13 Observations. As a required component of its EMS system, CH2M HILL entered finding and observations into its corrective actions system (Problem Evaluation Request). ORP adopts CH2M HILL's management assessment finding and observations. Additionally, ORP has adopted two Observations and two Concerns from a 2005 Phase VPhase II Environmental Protection Functional Areas S/RID Independent Assessment Report.
Prior to this assessment, ORP reviewed and commented on the draft RPP-MP-003, ISMS Description, Revision 5 which integrated the CH2M HILL EMS into its ISMS. ORP's comments are now closed and formal approval of this ISMS revision incorporating DOE · comments is expected shortly.
Prior to this assessment, ORP also reviewed and commented on TFC-PLN-73 , Environmental Program Description, which describes the CH2M HILL EMS identified in RPP-MP-003 . This Plan did not require DOE approval and has been approved by CH2M HILL. The Plan addresses all of the specified DOE O 450.1 requirements. Additionally, CH2M HILL has an EMS management policy statement.
Based on prior extensive ORP staff reviews ofRPP-MP-003 and TFC-PLN-73 and closure of DOE comments, ORP concludes that CH2M HILL has successfully incorporated its EMS into the ISMS as required by DOE O 450.1.
ORP assessed implementation of EMS requirements through a substantial review of implementing policies, plans, procedures identified in RPP-MP-003 , TFC-PLN-73, and independently identified by the assessment team. This assessment concludes that
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CH2M HILL has implemented its EMS with additional findings, and observations which should be promptly addressed by CH2M HILL in its corrective action process (the effectiveness of the EMS corrective action system will be evaluated during the next annual ISMS assessment).
Four Findings resulted from this assessment: 1) absence of formal interface agreements with other Hanford contractors at EMS site interfaces and/or failure to place such agreements under configuration management; 2) inadequate identification of implementing procedures with requirements in the Pollution Prevention and chemical management program plans; 3) incomplete update of field implementing procedures to reflect the new EMS and EMS-IMS integration requirements; and 4) incomplete and ineffective incorporation of the environmental and requirements basis of the EMS (e.g., permit conditions, HFFACO requirements, environmental regulation compliance) into implementing procedures. Two Observations were made relating to training and environmental oversight of subcontractors. One concern was made regarding environmental staffing.
lll
Table of Contents ............................................................................................................. iv
List of Acronyms ............................................................................................................... v
DOE Assessment Results Derived from Prior Reviews ................................................. 9
Results of the ORP Assessment ....................................................................................... 9
Signature .................................................................................................... : ..................... 13
l V
CH2M HILL CRD DOE EM EMS EP ESQ HFFACO HGET ISMS NEPA ORP P2 S/RID TFC
List of Acronyms
'
V
CH2M HILL Hanford Group, Inc. (CH2M HILL) Environmental Management System (EMS) Program Assessment
Background:
U.S. Department of Energy (DOE) 0 450.1, "Environmental Management Systems," contains a contract requirements document (CRD) which, when incorporated into the contract, requires a management contractor to implement a documented and structured EMS and incorporate their EMS into their Integrated Safety Management System (ISMS). Additionally, the CRD mandates that the EMS addresses specific environmental programmatic requirements/components as appropriate ( e.g., wild fire protection, watershed management).
The compete DOE O 450.1 CRD requirement was implemented into the CH2M HILL contract without limitation or revision through the "S/RIDS" process in March 2004. CH2M HILL was given one year to fully develop and implement their EMS and incorporated the EMS into the ISMS. CH2M HILL committed to the DOE Office of · River Protection (ORP) to have a functioning EMS in place and integrated into their ISMS by October 31, 2005 . Following a CH2M HILL management assessment, CH2M HILL gave notice to ORP in November 2005 that their EMS had been successfully implemented, Enclosure 1.
The intent of DOE O 450.1 was to capitalize on existing EMS when they existed, rather than invent new systems. Additionally, Environmental Management (EM) facilities were authorized to utilize a graded approach, when appropriate, in analyzing the environment aspects of their operations and activities, and then identifying the significant environmental impacts to be managed through the EMS.
In consideration of the extraordinary external regulation of the Tank Farms operations and facility management through the Hanford Federal Facilities Agreement and Consent Order (HFF ACO), highly conditionized environmental operating permits, concurrent Comprehensive Environmental Response Compensation and Liability Act management of the Hanford Site and the existence of extensive National Environmental Policy Act (NEPA) site analysis, ORP determined that a graded approach was appropriate to CH2M HILL. ORP directed CH2M HILL to take credit for these environmental analyses, studies, and controls in lieu of conducting new environmental aspects and impacts analysis. A graded approach was not authorized for pollution prevention (P2) requirements since these requirements are minimally impacted through external regulation. ORP did not require CH2M HILL to develop new EM systems. However, it was ORP's expectation that CH2M HILL would coordinate and document their existing EM systems into an integrated EMS, develop and document interface controls for Hanford Site environmental interfaces, and integrate their EMS into their ISMS.
RPP-MP-003, "Integrated Safety Management System," identifies three components of the authorization basis agreement between CH2M HILL and ORP: 1) Safety Basis;
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2) Requirements Basis; and 3) Environmental Basis.
The Requirements Basis which CH2M HILL implements through Standard/Requirements and Identification Documents (S/RID) includes the specific EMS requirements derived from DOE O 450.1. The Environmental Basis includes laws and regulations, NEPA documentation, legal agreements (e.g., the HFFACO), and permits. Thus, the CH2M HILL EMS must appropriate address both the Requirements Basis and the Environmental Basis as defined by their ISMS.
As stated in CH2M HILL Policy, TFC-POL-04, "Procedure Compliance Expectations," procedures form the basis for the correct and safe operation of Tank Farm Contractor (TFC) processes and facilities. Procedures authorize activities within an authorization basis. CH2M HILL requires mandatory procedural compliance. CH2M HILL maintains configuration management over their procedures and electronically publishes them on their intranet site. CH2M-HILL "procedures" includes a variety of document classifications including policies, plans, procedures, interface control documents, and miscellaneous publications (e.g., documents adopted from other site contractors).
Scope of Assessment:
DOE O 450.1 requires that the contractor's EMS be evaluated annually as part ofDOE's line management annual review and certification of the ISMS. This is not an annual ISMS certification assessment (the next annual ISMS evaluation of CH2M HILL by ORP is currently scheduled for July 2006). This assessment has the limited purpose of validating, from a DOE prospective, CH2M HILL' s certification that it has successfully implemented the CRD requirements of DOE O 450.1. This assessment will be used as the supporting documentation for a December 2005 declaration by the ORP Manager that the CH2M HILL has implemented the applicable EMS requirements ofDOE O 450.1.
DOE O 450.1 did not impose new substantive environmental standards that were not already enforceable in CH2M HILL's contract. However, DOE O 450.1 required a new level of formality, primarily by requiring a system approach to EM and integration of the EMS into the ISMS. This assessment looked for objective evidence that the EMS described in RPP-MP-003 and TFC-PLN-73 has been implemented. Since CH2M HILL Policy TFC-POL-04 requires procedural implementation of the authorization basis, this assessment targeted appro1imately 50 relevant implementing procedures (i.e., plans, policies, procedures, and other controlled documents). These procedures were picked for review based on self-identification in RPP-MP-003 and TFC-PLN-73, because of internal references within cited procedures, or because the·audit team determined that the procedure has a rationale with the EMS.
Prior Reviews Considered by this Assessment:
In July 2005, ORP reviewed and commented on TFC-PLN-73, "Environmental Program Description," which describes the CH2M HILL EMS identified in RPP-MP-003. TFC­ PLN-73 did not require DOE approval and CH2M HILL approved the document in
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September 2005. CH2M HILL did revise the document based on ORP comments prior to approval. The TFC-PLN-73 addresses all of the CRD requirements of DOE O 450.1.
In September 2005, ORP reviewed and commented on the draft RPP-MP-003, "Integrated Environmental, Safety, and Health Management System Description," Revision 5 which integrated the CH2M HILL EMS into their ISMS. ORP's comments are now closed and formal approval of this ISMS revision incorporating DOE comments is expected shortly. CH2M HILL also published an EM Policy Statement which was reviewed by ORP and found adequate.
During 2005, CH2M HILL initiated as independent Phase I and Phase II environmental S/RIDs Assessment. However, the work on the independent assessment was terminated early due to funding issues and the assessment was completed internal to CH2M HILL. This assessment included observations and concerns.
CH2M HILL conducted a management assessment of their implementation of the EMS in September 2005 and documented the results in CH2M HILL Management Assessment Report No. FY 2005 ,-M-0147, "Environmental Management System Implementation." On November 9, 2005 , CH2M HILL provided ORP the results of the EMS management assessment and self-declared implementation of DOE O 450.1 , Enclosure 1. Enclosure 1 · concludes that the CH2M HILL EMS has successfully integrated with TFC-PLN-73 and RPP-MP-003 and appropriately integrated into applicable implementing documents/ procedures. Enclosure 1 notes one Finding and 13 opportunities for improvement. These deficiencies were entered into the CH2¥ HILL Corrective Action Program as PER-2005- 03661 and are pending resolution and verified by ORP during its assessment.
Assessment Findings Adopted From Prior Reviews:
The following concerns and observations are adopted from the S/RIDS assessment (See Enclosure 2):
Observation 2: Environmental Program (EP) requirements are not flowed down in a consistent manner. Numerous requirements throughout the S/RID are not specifically addressed in upper level (administrative procedures), such as the TFC-ESHQ series. . Although the majority of the requirements have some tie to this procedural series, there are clear gaps between the administrative procedures (TFC-ESHQ SERIES) and some key requirements.
Concern 2: Without the linkage between the base requirement and implementing procedure or plan, there is no clear means to ensure the requirement is being properly flowed down t9 appropriate organizations that implement the specific requirement.
Observation 3: Many of the requirements that are addressed in the administrative level (TFC-ESQH series procedures) do not appear to flow down to the field procedures where a specific requirement gets implemented. In the case of RPP-16922, Environmental Specifications Requirements, specific requirements are
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flowed down into field procedures; however, this covers only a relatively small set of the requirements in the EP S/RID.
Concern 3: Without traceability of the base requirement from the source to the field, it is difficult to verify the requirement is actually being implemented. This requires management to rely on the experience of key personnel as opposed to a clearly documented program that is capable of ensuring compliant conditions during times of personnel transition.
This assessment adopts the finding and 13 opportunities for improvement identified in the CH2M HILL EMS Management Assessment, Enclosure 2.
DOE Assessment Results Derived from Prior Reviews:
Based on prior comprehensive ORP staff reviews ofRPP-MP-003 and TFC-PLN-73 and the closure of DOE comments thereto, ORP concludes that CH2M HILL has successfully incorporated their EMS into their _ISMS as required by DOE O 450.1. Implementation deficiencies currently in the CH2M HILL Corrective Action Program are further augmented by the ORP assessment results below.
Results of the ORP Assessment:
The ORP assessment plan is provided as Enclosure 3. The ORP assessment results matrix is provided as Enclosure 4.
ORP has determined that CH2M HILL has substantively implemented their EMS with additional finds, observations, and concerns which are derived from Enclosure 4.
A required component of the EMS required by DOE O 450.1 is a corrective action program providing for feedback and continuous improvement. CH2M HILL has implemented a corrective actions process described in TFC-ESHQ-Q-C-C-01, Problem Evaluation Request. As with any new program with extensive requirements but few objective performance standards, implementing shortfalls will be identified. Provided that CH2M HILL appropriately utilizes their Corrective Action Program to resolve such shortfalls, the existence of findings, observations, and concerns in this assessment does not constitute a programmatic failure to implement the EMS . ORP expects CH2M HILL to make substantive progress in resolving the deficiencies identified in this assessment in their Corrective Action Program in advance of the 2006 annual ISMS assessment. Failure of the corrective actions system to substantively and timely address these deficiencies would be viewed as a failure of the EMS system itself.
Finding 1: RPP-MP-003 and TFC-PLN-73 clearly demonstrate that CH2M HILL understands and has adequately defined the scope of their required EMS and has appropriately integrated the EMS into the ISMS. TFC-PLN-73 provided a nominal roadmap of how the EMS and ISMS are procedurally mapped together and implemented through procedures. This assessment found that many implementing engineering,
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operations, and business management procedures have not been upgraded to include the requirements basis and environmental basis of the ISMS, or procedures were so poorly documented regarding EMS requirements that effective field implementation of environmental standards and requirements is not apparent. See Enclosure 4. For example, the Maintenance Plan, the Conduct of Operations Plan, Engineering Change Control Procedure, Equipment Temporary Modifications and Bypass Procedure, Startup and Testing Program Plan, the Configuration Management Plan, and the Operational Readiness Review Program have not been upgraded to include the requirements basis and the environmental basis of the ISMS including identification of interfacing EMS implementing and control procedures.
CH2M HILL adopted for use three comprehensive site EMS documents which are nominally required to implement EMS requirements between site contractors at site interfaces, HNF-PRO-15333, "Environmental Protection Processes," HNF-PRO-15335, "Environmental Permitting and Documentation Preparation," and HNF-PRO-15334, "Effluent and Environmental Monitoring." However, CH2M HILL failed to implement any of these requirements by incorporation into CH2M HLL procedures as required by TFC-BSM-AD-C-04, "FH Documents Used by CH2M HILL Hanford Group, Inc."
Finding 2: Paragraph 2.3.3 ofTFC-PLN-73 identifies RPP-16922, "Environmental Specification Requirements," as the supporting procedure for incorporating environmental requirements into technical procedures. The assessment found RPP-16922 was not comprehensive or complete, and almost no other field procedure acknowledges RPP 16922 as a control standard or source for environmental requirements as a component of the authorization basis. Weaknesses were found in documenting procedures for obtaining environmental permits (except air permits), HFFACO administration and compliance, and environmental regulatory compliance ( e.g. , most regulatory requirements are not actually identified). While some non-Office of Environmental Safety and Quality (ESQ) procedures identify a nominal ESQ interface, the assessment team could find no ESQ procedure which effectively mapped required ESQ interfaces into non-ESQ procedures although some interfaces are identified in TFC-PLN-73. TFC-ESHQ-ENV-RM-D-02, Resource Conservation and Recovery Act Operating Records, documents environmental regulatory requirements which need to be mapped into RP-16922, but the requirements list is incomplete (e.g., did not include the 242 Evaporator, Bulk Vitrification Research and Development, or the Integrated Disposal Facility) and had erroneous compliance entries reflecting non applicability ( e.g., siting requirements) . This finding is consistent with Observation 2 and 3 of the CH2M HILL S/RID Assessment adopted above.
Finding 3: CH2M HILL has a formal procedure for managing site interfaces under configuration management, TFC-BSM-CP-CPR-C-17, "Interface Management." Although significant environmental interfaces exist between CH2M HILL and other site contractors and environmental programs as described in the CH2M HILL EMS ( e.g., P2, environmental permitting and reporting, chemical management, HFF ACO administration, and environmental monitoring), no environmental interface agreements were found as either controlled documents or otherwise published with CH2M HILL procedures and
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directives. TFC-PLN-73 identifies the existence of at least one interface agreement which is not under configuration management as such: Memorandum of Agreement, CNN-112822, "Re-Issuance of Clarification of Contractor Responsibilities for Hanford Site Groundwater Management." Procedures generally failed to acknowledge the existence site interface agreements, the requirements of interface agreements, or identify how CH2M HILL integrates with site programs it has identified in the EMS (e.g., see Finding 4 below). If essential EMS interface agreements remain unpublished and without configuration management, procedure managers will have no technical basis to upgrade their implementing procedures to reflect site EMS integration requirements. ORP recognizes that informal site EMS interfaces do exist and site requirements are currently managed through informal staff contacts and formal information calls from the DOE Richland Operations Office. This finding is consistent with Concerns 2 and 3 of the CH2M HILL S/RID Assessment adopted above.
Finding 4: TFC-PLN-73 states that the CH2M HILL P2 Plan is implemented through RPP-MP-612, "Pollution Prevention, /Waste Minimization Program." Three pages of this six page procedure describes elements of the Hanford Pollution Abatement Program administered by another site contractor. There is no implementing instruction on how or when CH2M HILL interfaces or integrates with this site P2 Program. The remaining three pages of TFC-PLN-73 contain unsupported statements that CH2M HILL conducts a variety of P2 activities without citation to any specific implementing procedures or requirements (i.e. , the plan is not self implementing). TFC-PLN-73 has not been upgraded to reflect DOE O 450.1 or new P2 S/RID requirements. When other implementing procedures make reference to compliance with P2 requirements (e.g., engineering procedures), they typically reference only TFC-PLN-73 as the basis for the requirement.
Similar discrepancies were identified in TFC-PLN-58, "Chemical Waste Management Plan." This plan asserts the existence of various internal CH2M HILL controlled processes, but provides no cross reference to specific procedures or implementing instructions (i.e., it is also not self implementing). For example, Section 4.4 states CH2M HILL will track chemicals from acquisition, through storage and use, to their final disposition but provides no explanation of how this will be accomplished, how it will be documented, or what staff element(s) exercises operation responsibility for these activities. Furthermore, Section 6.0 states no records are generated in the performance of this plan (e.g., if no records are generated, how are chemicals "tracked"?).
TFC-PLN-58, Section 4.0 describes the existence of an unidentified sitewide chemical management plan which has been "signed" jointly by the Hanford site prime contractors. This interface agreement, if it exists, is not published with the CH2M HILL procedures and is not listed as a CH2M HILL interface control document. HNF-PR-10468, "Chemical Management Process," is the current Hanford site EMS chemical management plan. Howeyer, HNF-PR-10468 is not cited or identified in TFC-PLN-58 and HNF-PR- 10468 has not been adopted for use as required by CH2M HILL procedure HFC-BSM­ AD-C-04, "FR Documents Used by CH2M HILL Hanford Group, Inc." If chemical
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management integration with the Hanford site exists, it was not apparent in review of the CH2M HILL procedures or this plan.
Despite the substantial inadequacies of both plans in failing to associate implementing procedures with requirements, the assessment found many topic specific implementing procedures documenting P2 and chemical management activities. See Enclosure 4. Unfortunately, most procedures which logically should interface with P2 and chemical management requirements (e.g., engineer procedures) do not recognize the topical procedures ( e.g., asbestos management) as requirements at all and only reference the plans. CH2M HILL can substantially correct this finding by modifying the plans to appropriately associate implementing procedures with requirements.
TFC-OPSWM-D-16, "Management of Recycled Materials," requires procedural compliance with HNF-EP-0863, another contractor's document which was not available in the CH2M HILL procedures database and has not been officially adopted as required by CH2M HILL procedure, TFC-BSM-AD-C-04. TFC-BSM-CP-CPR-D-02.2, "Energy Conservation and Efficiency," and TFC-PLN-73 erroneously claim exemption from energy efficiency goals and standards alleging CH2M HILL does not manage "facilities." CH2M HILL adopted HNF-PRO-15333, "Environmental Protection Processes" which describes the site P2 Program and provides detailed P2 procedures. Although HNF-PRO- 15333 could potentially correct many deficiencies in the CH2M HILL P2 Program, CH2M HILL failed to implement this Fluor Hanford, Inc. document by incorporation into implementing CH2M HILL procedures as required by HFC-BSM-AD-C-04.
Observation 1: DOE O 450.1 requires that the contractor provide EMS training for the staff responsible for implementing the EMS. CH2M HILL did not prepare a staff training matrix to document how it accomplished EMS implementation training. Section 5.4 of TFC-PLN-73 cites the Hanford General Employee Training (HGET) Environmental Module for general EMS training. However, a review ofHGET did not reveal any meaningful training associated with EMS, even at the familiarization level. There is a Waste Minimization Module which does briefly address pollution abatement­ but that module is optional. A review of various qualification standards identified in TFC-PLN-07, "Dangerous Waste Training Program," identified a heavy bias towards waste management activities but little discussion of the other aspects of the EMS program.
Section 2.4 ofTFC-PLN-73 identified the basic and advanced environmental qualification card for TFC environmental management. Although the qualification card addresses many requirements and authorization basis components and requires reading of the Environmental Program Description, the qualification guide itself does not require a demonstrated knowledge of the P2 program, the EMS system, or ISMS-EMS integration.
Observation 2: TFC-ESHQ-ENV-AP-D-01 , Environmental Oversight of Subcontractors, expressly excludes subcontractor work performed in the tank farms. No corresponding procedure was found addressing environmental oversight of onsite work performed by subcontractors.
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Concern: TFC-ESHQ-ENV -AP-01 , "Environmental Surveillance/Compliance Inspection," assigns management of this program is assigned to the Environmental Program Coordinator. That position was recently terminated. The Environmental Program Coordinator was also the designated EMS coordinator and the only trained EMS auditor on staff. It is unclear how CH2M HILL will provide meaningful oversight of the EMS program without adequate trained staff.
Enclosure 1: CH2M HILL transmittal of EMS management assessment.
Enclosure 2: S/RID assessment observations and concerns.
Enclosure 3: ORP Assessment Plan.
Enclosure 4: ORP Assessment Results Matrix.
Signature
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Date
• CH2MHILL Hanford Group, Inc.
November 9, 2005
Mr. R. J. Schepens,Manager Office of River Protection U.S. Department of Energy Post Office Box 450 Richland, Washington 99352-0450
Dear Mr. Schepens:
CONTRACT NUMBER DE-AC27-99RL14047 - IMPLEMENTATION OF THE U.S. DEPARTMENT OF ENERGY ORDER 450.1, "ENVIRONMENTAL PROTECTION PROGRAM," AT CH2M HILL HANFORD GROUP, INC. FACILITIES
Pursuant to the U.S. Department of Energy (DOE) Order 450.1, "Environmental Protection Program," the U.S. Department of Energy, Office of River Protection (ORP) and the U.S. Department of Energy, Richland Operations Office are required to self-declare to the U.S. Department of Energy-Headquarters that the Hanford Site has a functional Environmental Management System (EMS) in place by December 31, 2005. In support of the ORP's self-declaration, CH2M HILL Hanford Group, Inc. (CH2M HILL) has implemented the requirements of DOE Order 450.1.
CH2M HILL staff conducted a management assessment ( enclosed) to assess CH2M HILL' s implementation of DOE Order 450.1 requirements. The assessment was conducted between September 7, 2005, and October 3, 2005. Although the management assessment determined that a functional EMS has been implemented, it identified 1 finding_ and 13 observations. The finding documents a concern with the flow-down of requirements to control and phase-out ozone depleting substances pursuant to Title 40, Code of Federal Regulations, Part 82. Even though the control and phase-out requirements have been implemented at Hanford and are reflected in Fluor Hanford, Inc. procedures, they have not been included in CH2M HILL procurement or environmental management procedures. The observations indicate opportunities to improve implementation ofrequirements in areas that are currently deemed satisfactory.
RECEIVED
CH2M-0503261
Should you have any questions regarding this matter, please contact Mr. P. C. Miller at 373-1920.
Very truly yours,
kjs
Enclosure
cc: ORP Correspondence Control R. C. Barr, ORP J.E. Rasmussen, ORP C. B. Reid, ORP T. Z. Smith, ORP
CH2M-0503261
Enclosure
Consisting of 28 pages, including coversheet
MANAGEMENT ASSESSMENT REPORT
Assessment No. FY2005-POPD-M-0147 Environmental Management System Implementation
A management assessment on CH2M HILL's implementation of DOE O 450.1., "Environmental Protection Program" and Attachment 2 of the order, titled "Contractor Requirements Document" (CRD), was conducted between September 7 and October 3, 2005. This report discusses the purpose, scope, and results of the assessment.
1.0 Executive Summary
DOE Order 450.1, Environmental Protection Program, hereafter referred to as the Environmental Management System, has been implemented at CH2M HILL Hanford Group, Inc. (CH2M HILL) facilities. The requirements of DOE O 450.1 are implemented at CH2M HILL through the Standards/Requirements Identification Document, Management Plans, Policies, Charters, Environmental Requirements Document, Emergency Plans, CH2M HILL procedures, and Hanford site-wide plans and procedures.
This assessment resulted in one finding and 13 observations. A finding has been developed concerning the £lowdown of requirements to control and phase-out Ozone Depleting Substances pursuant to 40 CFR 82. Although the requirement has been implemented at Hanford and is reflected in Fluor Hanford procedures, the requirement has not been included in the CH2M HILL procurement or environmental management procedures.
2.0 Purpose
This assessment evaluated CH2M HILL's implementation of DOE O 450.1, "Environmental Protection Program" and Attachment 2 of the order, titled "Contractor Requirements Document" (CRD), which imposes specific requirements on CH2M HILL. These requirements are intended to ensure integration of a structured Environmental Management System (EMS) within the Integrated Safety Management System (ISMS). CH2M HILL has committed to DOE Office of River Protection to have a functioning EMS in place by October 31, 2005. This assessment supports senior management' s verification to DOE ORP that an EMS is in place.
DOE is required to "self-declare" to DOE Headquarters that the Hanford site has a functional EMS in place by December 31, 2005. ORP has indicated that it will perform an assessment of CH2M HILL's EMS in November 2005. CH2M HILL's assessment supports preparation for the ORP assessment.
3.0 Scope
The assessment looked for evidence that the applicable elements of the CRD have been incorporated into the Standards and Requirements Document, flowed down into policies, procedures and plans (as appropriate), and implemented in the field. The assessment also evaluated how well the EMS itself is described in program documentation, and how well it is understood by tank farm contractor (TFC) staff and management.
4.0 Assessment Approach and Methodology
The assessment (Attachment 1, Management Assessment Plan FY2005-POPD-M-0147) consisted of document reviews, interviews, and record reviews. Documents were reviewed for mention of the applicable EMS elements, and evidence of a structured, well-integrated EMS. Interviews were conducted to assess awareness of EMS, the related Environmental Management Policy (TFC-POL-30), and implementing plans and procedures that comprise the EMS. Records were reviewed for confirmation that proceduralized requirements are being implemented.
5.0 Assessment Results
The Environmental Management System has been integrated within TFC-PLN-73, Environmental Program Description, and RPP-MP-003, Integrated Environment, Safety, and Health Management System Description for the Tank Farm Contractor. TFC-PLN-73 contains a roadmap which cross-references DOE O 450.1 EMS elements with elements contained within RPP-MP-003 . TFC-PLN-73 also contains a listing, by element, of the applicable implementing documents. Additionally, aspects of the Environmental Management System have been included in the Tanlc Farm Documented Safety Analysis (DSA) as Defense-In-Depth attributes .
The requirements of State of Washington issued Resource Conservation and Recovery Act (RCRA) permits, State Waste Discharge Permits, Hanford Air Operating Permit, and various toxic and radiological contaminant air operating permits have been implemented and incorporated in procedures and plans. -
A recently completed Phase I and Phase II assessment of the CH2M HILL Tanlc Farm S/RIDs indicated that the requirements of the S/RIDS have been implemented at Tank Farms. The assessment did reflect that additional evidence was required to prove compliance with some requirements. The assessment also indicated that there are several requirements contained within the Tank Farm S/RID that are not applicable and recommended the deletion of the subject requirements. The recommended corrective actions are pending.
A finding has been developed concerning the flowdown of requirements to control and phase-out Ozone Depleting Substances pursuant to 40 CFR 82. Although the requirement has been implemented at Hanford and is reflected in Fluor Hanford procedures, the requirement has not been included in the CH2M IDLL procurement or environmental management procedures.
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The review of applicable documentation indicates that DOE O 450.1 has been satisfactorily implemented at CH2M HILL facilities. Although satisfactorily implemented, there are 13 opportunities for improvement. There is one finding. Attachment 2 provides the assessment criteria, documentation, and the observations.
Attachments 1. Management Assessment Plan No. FY2005-POPD-M-0147 2. EMS Assessment Documentation
Management Assessment by:
Assessment Lead: Phil Miller Manager, Environmental Support and Assessment CH2M HILL Environmental Compliance Officer
Assessment Team: Lucinda Borneman
John Doughty Environmental Support and Assessment
John Guberski Environmental Compliance and Support
Cynthia Stratman Waste Services
Consisting of 3 pages, including coversheet
MANAGEMENT ASSESSMENT PLAN
Purpose
Scope
This assessment evaluates CH2M HILL's implementation of DOE O 450.l, "Environmental Protection Program." Attachment 2 of the order, titled "Contractor Requirements Document" (CRD), imposes specific requirements on CH2M IDLL. These requirements are intended to ensure integration of a structured environmental management system (EMS) within the Integrated Safety Management System. CH2M illLL has committed to DOE Office of River Protection to have a functioning EMS in place by October 31, 2005. This assessment supports senior management's verification to DOE ORP that an EMS is in place.
DOE is required to "self-declare" to DOE Headquarters that the Hanford site has a functional EMS in place by December 31, 2005. ORP has indicated that it will perform an assessment of CH2M HTLL's EMS in November 2005 . CH2M HILL's assessment supports preparation for the ORP assessment.
The assessment will look for evidence that the applicable elements of the CRD have been incorporated into the Standards and Requirements Document, flowed down into policies, procedures and plans (as appropriate), and implemented in the field. The assessment will also evaluate how well the EMS itself is described in program documentation, and how well it is understood by TFC staff and management.
Assessment Team
Assessment Lead:
Assessment Team:
Support Team:
Lucinda Borneman Environmental Lead, Analytical Technical Services Environmental Compliance Officer for A TS Has completed training and qualification as Assessment Team Lead
John Doughty Environmental Support and Assessment Has completed training and qualification as Assessment Team Lead
John Guberski Environmental Compliance and Support No TFC assessment training
Cynthia Stratman Waste Services Completed Course No. 350318 "TFC Assessment Training"
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Assessment Schedule
The assessment is to be conducted between September 7 and September 30, 2005. Completion includes issuance of final management assessment report.
Performance objectives and criteria, including source information used to perform the assessment, and implementing documents and checklists developed
The source document is DOE O 450.1, Attachment 2
Primary review documents are:
• TFC S/RID, chapters 16 and 20 • RPP-MP-003 • TFC-PLN-73 (draft) • TFC-PLN-58 • RPP-MP-612 • TFC-POL-16 • TFC-POL-30 • TFC-POL-10
This assessment evaluates the integration of EMS elements into the ISMS, and will touch on all Core Functions and Guiding Principles.
Assessment Approach and Methodology
The assessment will consist of document review, interviews, and records review. Documents will be reviewed for mention of the applicable EMS elements, and evidence of a structured, well­ integrated EMS. Interviews will be conducted to assess awareness of EMS, the related Environmental Management Policy (TFC-POL-30), and implementing plans and procedures that comprise the EMS. Records will be reviewed for confirmation that proceduralized requirements are being implemented.
Assessment Plan by:
Signature of Team Leader's Manager Date
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MANAGEMENT ASSESSMENT REPORT
Environmental Management Assessment Documentation and Observations
Consisting of 21 pages, including coversheet
Criteria DOE O 450.1, Environmental Protection Program Regardless of the performer of the work, contractors with this Contractor Requirements Document (CRD) incorporated into their contracts are responsible for (1) compliance with the requirements of the CRD and (2) flowing down the requirements of the CRD to subcontracts at any tier to the extent necessary to ensure the contractors' compliance with the requirements.
Contractors must: 1. General Requirements. Ensure their
integrated safety management systems (lSMSs) include environmental management systems (EMSs) that do the following.
(a) Provide for the systematic planning, integrated execution, and evaluation of programs for-
EMS Assessment
Documentation and Observations MP-003, Section 4.4.4, "Subcontractor ISMS Flowdown" specifically addresses Flowdown of requirements. While it does not specifically identify the CRD, it does describe the mechanism for ensuring all applicable requirements are flowed down. It cites
- RPP-8411 , "CH2M HILL Hanford Group, Inc. - Procurement Process Description," generically states that prime contract requirements will be flowed down, ·
- TFC-BSM-CP _ CPR-C-05, Procurement of Services - section 4.2, requires BTR to evaluate work scope and ensure review by appropriate SMEs; expectation is that environmental SME will ensure CRD requirements are flowed down in the SOW as appropriate, and that appropriate oversight is identified to ensure compliance.
- TFC-BSM-CP _ CPR-C-06, Procurement ofltems (Materials) - - BTR Process - TFC-ESHQ-ENV _AP-D-01, "Environmental Oversight of Subcontractors" -
subcontracted work not controlled by the TFC work control process is monitored using this oversight process, as well as S&H oversight process.
Section 4.5.2, last paragraph cites BTR process· as administrative control to ensure Flowdown
Section 4.6.2, states that the environmental and waste services programs are responsible for flowing down applicable requirements to subcontractors.
Result: Satisfactory
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Criteria public health and environmental protection,
Documentation and Observations MP-003 - References to systematic planning and integrated execution and evaluation begin in Section 1.1 with restating of the contractual requirement - "requires CH2M HILL to accomplish work " ... in a manner that achieves high levels of quality, protects the environment and the safety and health of workers and the public, and complies with requirements. " Systematic planning is discussed in detail in Chapters 4.4, 4.5, and 4.6.
Observation 1: The ISMS matrix for chapter 4.5 could be improved by adding the "Field Implementation of Env permits" procedure and the procedure covering project mgt of expense funded projects.
Integrated execution is discussed in Chapter 4.7. Evaluation is in Chapter 4.8
Observation 2: ISMS matrix - move SCI procedure from ·core Function 3 to core function 5
TFC-POL-30 and HNF-1773 (precursor to TFC-PLN-73) are called out.
Observation 3: Need to update -003 to callout TFC-PLN-73
TFC-POL-30 identifies responsibility to consider protection of public health and environment
TFC-PLN-73 Identifies mechanisms that the environmental organization uses to ensure public health and any protection is considered in planning, execution and evaluation.
No deficiencies noted.
Observation 4: May be more effective if TFC-PLN-73 identified and discussed specific implementing procedures in the body of the report.
Consider moving EMS discussion to MP-003; it may be appropriate to have the entire EMS described in one place, and MP-003 is where that would belong.
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compliance with applicable environmental protection requirements.
(b) Include policies, procedures, and training to identify activities with significant environmental impacts, to manage, control, and mitigate the impacts of these activities, and to assess performance and implement corrective actions where needed.
Documentation and Observations
Based on this review, it appears that the ISMS/EMS adequately provides for systematic planning, integrated execution, and evaluation of programs for public health and environmental protection.
MP-003 This is a subset of "public health and any protection" as addressed above. The S/RID process is specifically cited in section 2.1.2, and discussed in detail in section 4.6.1. The role of the S/RID in the evaluation process is mentioned in section 4.8.3.
Result: Satisfactory
Specific policies and procedures are cited in MP-003 and the associated EMS documents. Between MP-003 and TFC-PLN-73, all environmental protection policies, plans and procedures (and standards) are listed.
TFC-POL-30 and TFC-POL-1 Oare the policies.
The procedures driving implementation are the two project management procedures TFC-PRJ-PM-C-02, "Project Management for DOE O 413.3 Projects" TFC-PRJ-PM-C-11, "Project Management for Hanford Tank Waste Cleanup Expense Funded Projects"
These require consideration of environmental requirements, the need for permits, and NEP A/SEPA and natural/cultural resources. This will drive identification of activities with impacts, and development of appropriate controls.
The two PM procedures in conjunction with the TFC Work Control procedure drive implementation of the environmental procedures and standards, ensuring that the TFC will identify activities with significant environmental impacts, to manage, control, and mitigate the impacts of these activities, and to assess performance and implement corrective actions where needed.
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(c) Include measurable environmental goals, objectives, and targets that are reviewed annually and updated when appropriate.
Documentation and Observations For subcontracts, the Procurement of Services and Procurement of Items (Materials) procedures drive involvement of environmental subject matter experts, which we rely on to ensure that the TFC will identify activities with significant environmental impacts, manage, control, and mitigate the impacts of these activities, and assess performance and implement corrective actions where needed.
MP-003 discusses policies and procedures to assess performance and implement corrective actions in section 4.8. rt cites the CH2M HILL assessment program implementing documents as well as the Environmental SCI procedure.
Result: Satisfactory
TFC-PLN-73 includes specific discussion of environmental goals. Because CH2M HILL has used a graded approach, the goals are, for the most part, addressed outside the scope of the ISMS/EMS, coming instead from the TPA process. A snap-shot of relevant TP A goals was prepared during implementation of the EMS.
Observation 5: There is no TFC controlled process in place to ensure periodic review and update of the TFC-related TP A goals.
Other goals cited in TFC-PLN-73 include the P2 goals and the monthly performance indicators.
P2 goals are identified by DOE and communicated by FH. Goals are established annually in accordance with MP-612.
Observation 6: MP-612 appears to warrant review and update.
The environmental performance indicators track environmental releases, regulator citations (NOCs and NOVs), and TPA milestone compliance status. These are established at the company level (VPs) and tracked on a monthly basis. This process is governed by TFC-PRJ-PC-C-11, "Performance Indicator Program."
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Criteria Documentation and Observations
2. Integration of an EMS into ISMS. As part of integrating EMSs into their ISMSs, do the following.
(a) Consider the following for inclusion as applicable:
Conformity of DOE proposed actions with State Implementation Plans to attain and maintain national ambient air quality standards,
implementation of a watershed approach for surface water protection,
implementation of a site-wide approach for groundwater protection,
MP-003 , Section 4.8.2 states "The TFC publishes a monthly report of performance indicators (f'FC-PRJ-PC-C-11, "Performance Indicator Program "), which meets the objectives of DOE O 210.1. Annually, senior management establishes goals to achieve the mission in a safe manner (discussed in Section 4. 4. 1). "
CCN-112822, "Re-Issuance of Clarification of Contractor Responsibilities for Hanford Site Groundwater Management"
The Central Environmental CoW1cil, a consortium of Hanford site prime contractors, has issued a document describing its understanding of roles and responsibilities relating to groW1dwater protection at the Hanford site. The docwnent has been signed by representatives of the participating prime contractors and submitted to the DOE.
Observation 7: Assessors could find no TFC implementing documents for TFC roles and responsibilities identified in CCN-112822.
Though not directly referenced in the ISMS, it is referenced in TFC-PLN-73, and is considered part of the EMS.
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protection of site resources from wildland and operational fires, and
protection of cultural resources.
(b) promote the long-term stewardship of a site ' s natural and cultural resources throughout its operational, closure, and post­ closure life cycle;
Documentation and Observations This is implemented through the NEPA procedure, and driven by the two project management procedures and the TFC work control procedure.
Confirmatory records are EISs and related documents, categorical exclusions, completed work packages that indicate consideration of natural resources, and PNNL letters addressing TFC requests review of natural and cultural resources.
Result: Satisfactory
The TFC supports the Hanford Fire Department (FH) in the implementation of this activity. Specific activities addressing prevention of wildland and operational fires are found in TFC-ESHQ-FP-STD-01.
Result: Satisfactory
This is implemented through the NEPA procedure, driven by the two project management procedures and the TFC work control procedure.
Records generated include cultural resource reviews.
This is implemented through the NEPA procedure, driven by the two project management procedures and the TFC work control procedure.
PNNL implements the program on a site wide basis. The TFC supports this effort by ensuring related issues are addressed when appropriate.
No deficiencies noted.
Criteria (c) reduce or eliminate
a. the generation of waste, b. the release of pollutants to
the environment, and c. the use of Class I ozone­
depleting substances (ODS)
through source reduction, re-use, segregation, and recycling, and by procuring recycled content materiaJs and environmentally preferable proaucts and services;
Documentation and Observations Source reduction, re-use, segregation, and recycling : TFC-PLN-33 documents and implements a Facility Waste Management Strategy that specifically includes source reduction and waste segregation as means of reducing or eliminating waste. It also addresses management of recycled materials. The primary record generated is the waste planning checklist (TFC-OPS-WM-C-01, "Waste Planning Checklist").
Source reduction and segregation are applied to in-tank waste through engineering procedures that address stability of tank wastes, waste transfer, and evaporator campaigns. TFC relies on environ.mental review (TFC-ESHQ-Q_INSP-C-05) of related engineering documents and wo.rk packages to ensure that source reduction and segregation are considered.
"Procurement of Services" and "Procurement of items (Materials)" both drive review and approval of pertinent requisitions by S&H and Environmental. S&H has responsibility for the chemical management program which is implemented through TFC-PLN-58 .
"Procurement of Services" ensures that this EMS element is applied to subcontractors that use chemical products on the Hanford site.
TFC-BSM-CP _ CPR-D-01.2, "Recovered/Recycled Materials," implements federal guidance regarding purchase of recycled/recovered content materials and environmentally preferable products. The record generated by this desk instruction is the "Justification of Procurements not meeting recovered/recycled content requirements."
3. Update approved ISMS descriptions as TFC-PLN-73, Environmental Program Description, and RPP-MP-003, Integrated necessary to include EMS Environment, Safety, and Health Management Systems Description for the Tank Farm requirements of this CRD. Contractor.
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requirements under Executive Order 13148 by ensuring, where appropriate, implementation of centralized procurement and distribution programs (e.g., pharmacy) for purchasing, tracking, distributing, and managing materials with toxic or hazardous content at facilities under their purview.
5. Monitor progress toward meeting the P2 requirements of paragraph 2c above, and make such information available annually to the DOE operations/field/site office.
Documentation and Observations The procurement process within CH2M HILL addresses the control of purchasing the purchasing chemicals with toxic or hazardous content. Chemicals are prohibited from purchasing with a P-Card in the attachment A to the procedure, Purchasing Card (P­ Card), TFC-BSM_ CPR-C-01, rev. D. Chemicals are purchased in accordance with procedure Procurement of Items (Materials), TFC-BSM-CP-CPR-C-06, REV F-2. Formal Environmental approvals are required for radioactive material and items that involve the potential to release emission to the environmental (e.g., chemical or chemical waste storage tanks, chemical detectors or monitoring equipment, sampling pumps, etc.). IH and Chemical Management approval is required for the purchasing of potentially harmful chemicals/substances or hazardous materials, acids, or items that will result in the release of any regulated constituent.
Other procurement procedures that specify environmental or chemical management approvals of chemicals can be found in the following procedures: TFC-BSM-CP-CPR-C-01, Purchasing Card (P-Card) TFC-BSM-CP-CPR-C-03, BTR Process TFC-BSM-CP-CPR-C-05, Procurement of Services TFC-BSM-CP~CPR-C-06, Procurement of Items (Materials) TFC-BSM-FPM-C-01 , Material Receipt, Issuance, Return and Excess Control
Observation 8: The Environmental Program Description, TFC-PLN-73, REV.A, did not appear to address purchasing or procurement of materials with toxic or hazardous content. Responsibility for this process is does not fall to one organization, so this element needs to be more clearly addressed in RPP-MP-003.
CH2M HILL is currently conducting two pollution prevention operational assessments. The operational assessments will be submitted to ORP in January 2006. An additional assessment is scheduled as part of the annual Waste Services Fiscal Year 2006 assessment.
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acquisition of supplies to cost effectively maximize procurement of environmentally preferable products. As appropriate, all acquisitions must be coordinated with the DOE operations/field/site office "Green Acquisition Advocate." (See Acquisition Letter AL-2000-03, dated 05/16/00)
Documentation and Observations The integration of a Pollution Prevention program into the policies, procedures, and plans to be implemented in the field is comprehensive. The flow of pollution prevention activities is evident in the documents reviewed.
Good Practices:
• The Procurement process identifies the need to incorporate pollution prevention into procurement activities of goods or services.
• The internet page ( http://www.hanford.gov/chgcp/ProcurementProcedures.cfm) providing assistance to procurement provides a list of procedures applicable to solicitation. The procedures listed include pollution prevention.
• CH2M HILL facilitates the WTP recycle program. • Recycling is referenced in the waste management and planning documents used by
CH2M HILL.
Observation 9: Although procurement procedures require implementation of pollution prevention and waste minimization there is not a requirement to provide a product evaluation before procurement.
Procedures Reviewed
TFCBSM-CP _ CPR-P-01 - Procurement Planning - Includes planning for energy conservation and pollution prevention.
TFC-PRJ-CM-C-01 Construction Management - references RPP-MP-612
TFC-OPS-WM-D-16 MANAGEMENT OF RECYCLABLE MATERIALS GENERA TED AT TANK FARM FACILITIES - This guidance document describes handling and management of.recyclable materials generated at tank farms facilities to
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Criteria Documentation and Observations ensure compliance with the Hanford Site recyclable material management plan. Several recyclable materials streams, such as aerosol products, batteries, and light ballasts with dioctyl phthalate (DOP) capacitors, are generated at the tank farins facilities. Several collection/drop-off points are set up at the 200 East and 200 West Areas for operations and maintenance personnel and electricians for the material they generate. These materials will be collected on a regular basis and transferred to the 616 storage pad. The materials are segregated, packaged, and shipped to the Centralized Consolidation/Recycling Center (CCRC) at the 400 Area. At the CCRC, the materials are evaluated, consolidated, and shipped to off-site recycling contractors.
The Washington State Department of Ecology has concurred with the management plan for recyclable materials administered by the CCRC. In the plan, the recyclable material would not be considered to be solid waste until it was received at the CCRC where the determination is made concerning the material's disposition. Tank farms, as a generating facility, ensures compliance with the CCRC plan. Acceptance criteria for receipt of recyclable material at the CCRC is identified in Attachment A.
The process includes generation, collection and accumulation, segregation, packaging, and shipping of recyclable material generated at the tank farms facilities to the CCRC at the 400 Area. The plan also ensures compliance with the Hanford Site recyclable material management plan, CCRC acceptance criteria, and transportation to the CCRC.
TFC-OPS-WM-C-01- WASTE PLANNING CHECKLIST-This procedure describes the process for completing and approving a Waste Planning Checklist. This procedure applies only to tank farms waste generating activities associated with containerized solid waste. It does not apply to the management of tank waste.
This procedure applies to -activities that generate low-level radioactive waste, mixed waste, non-radioactive dangerous waste, non-regulated waste, and recyclable materials.
The Waste Planning Checklist is required per TFC-PLN-33 to ensure waste is designated, segregated, and packaged in compliance with state and federal regulations, and to ensure it meets the treatment, storage, or disposal (TSO) receiving facility's acceptance criteria for packaged waste. (7_1.2)
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Criteria Documentation and Observations This procedure is implemented in accordance with the core functions and guiding principles of RPP-MP-003. The plan describes the ISMS structure, policies, programs, processes, and implementing mechanisms to ensure that protection of the environment and safety and health of the workers and the public, and quality are integrated into management and work practices.
TFC-OPS-MAINT-C-01-TANK FARM CONTRACTOR WORK CONTROL­ This procedure defines work management from initiation of a work request through work order closeout. It specifies when formally written work instructions are required; and it specifies the degree of planning required. This procedure uses a graded approach to implement requirements and to provide the level of discipline required to perform work in a manner thus protecting the workers, the environment, and the public.
This procedure applies to all Tank Farm Contractor (TFC) personnel who schedule, plan, approve, release, perform operations acceptance or post review using work orders. This procedure applies to corrective maintenance, preventive maintenance, troubleshooting, modification, fabrication, select operational activities, and certain construction on structures, systems, and components at tank farms. This procedure does not cover operator rounds, radiological surveillances, or other operational activities specified in technical procedures.
Contractors for projects will perform work using their planning processes with release through the TFC Work Release for Construction/Service Organizations form (A-6003- 532), or using this process, dependent on the Notice of Intent (see TFC-PRJ-CM-C-07).
Subcontractors performing work in non-operational facilities, such as office buildings, or in non-TFC controlled facilities, must have the facilities manager or representative authorize the start of the work, but are otherwise exempt from this procedure.
References the Waste Planning Checklist
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Criteria Documentation and Observations TFC-POL-10 - POLLUTION PREVENTION AND WASTE MINIMIZATION POLICY - Operations and activities shall be conducted in a way that minimizes the quantity and toxicity of wastes generated, eliminates or minimizes pollutant releases to the environment, and minimizes the use of toxic substances. This shall be done by designing waste minimization/pollution prevention into new products and processes, through affirmative procurement, and by integrating waste minimization/pollution prevention into changes in technologies and existing policies and procedures.
RPP-MP-612 -POLLUTION PREVENTION/WASTE MINIMIZATION -This management plan establishes requirements and guidelines for CH2M HILL Hanford Group (CHG) to comply with federal, state, and Department of Energy (DOE) pollution prevention and waste minimization requirements.
This management plan also describes the CHG pollution prevention program to be implemented in compliance with pollution prevention and waste minimization requirements contained in WAC 173-303; 40 CFR 262, 264, and 265; 10 CFR 435; DOE 0 5400. I; and DOE O 5820.2A. The requirements of this plan apply to projects with responsibility for implementing the CH2M HILL pollution prevention program, includirig all dangerous, radioactive, mixed, and sanitary waste generators.
TFC-PLN-33- WASTE GENERATING PLAN -This plan describes the management activities of waste and recyclable material that is generated at the tank farms and associated facilities . This plan applies only to waste generating activities associated with containerized solid waste. This plan does not apply to the management of tank waste.
1. TFC-PLN-58 - CHEMICAL MANAGEMENT PLAN - Integrates the chemical management program with the infrastructural functions that are necessary to support and control chemical management at CH2M HILL, including:
• Procurement • Environmental
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7. Conduct operational assessments, such as Pollution Prevention Opportunity Assessments, of site operations to identify opportunities for source reduction, material segregation, recycle/reuse, or other P2 projects. Based on the results of these assessments, implement cost-effective P2 projects, using life-cycle assessment concepts and practices in determining return-on-investment.
Documentation and Observations TFC-PLN-37 - CH2M HILL RADIOACTIVE WASTE MANAGEMENT BASIS Waste Minimization and Pollution Prevention
(4.1.1 , 4.1.2, 4.1.7, 4.1.8,.4.1.1 0)
RPP-MP-612, "Pollution Prevention/Waste Minimization," describes waste minimization and pollution prevention at tank farms.
CH2M HILL is currently conducting two pollution prevention operational assessments. The operational assessments will be submitted to ORP in January 2006. An additional assessment is scheduled as part of the annual Waste Services Fiscal Year 2006 assessment.
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appropriate, to • support the site's ISMSs, • to detect and characterize
releases from DOE activities; • assess impacts; • estimate the dispersal patterns in
the environment; • characterize the pathways of
exposure to members of the public;and
• characterize the exposures and doses to individuals, and to the population; and
• to evaluate the potential impacts to the biota in the vicinity of the DOE activity.
Documentation and Observations Conduct environmental monitoring, as appropriate. Monitoring of effluents from Tanlc Farm Contractor facilities is effectively implemented by various processes. These processes collectively detect and characterize releases; assess their impacts on workers, public and biota; identify the dispersal patters and associated exposure pathways; and relate this to exposures and doses to individuals and the population. Documents reviews and personal knowledge were the assessment methods. Further detail is discussed below using TFC-PLN-73, Environmental Program Description, Section 2.9, bullets.
2.9 a not assessed at thls level
2.9 b not assessed at this level
2.9 c Pre-operational m01tltoring is conducted to characterize baseline values against which impacts of Tank Farm Contactor activities are measured. This is accomplished by the ongoing program of effluent monitoring supplemented as necessary with site specific monitoring. Site specific monitoring is normally limited to a biological review for threatened or endangered species. The far and near field monitoring programs conducted by the PHMC per reference 5 provide the ongoing characterization data. The Automated Bar Coding of All Samples at Hanford [ ABCASH] data base is the information repository for these programs as well as data collected from Tank Farm Contractor facilities per reference 8. ABCASH provides periodic reports [Quarterly Anomaly Report] that identify adverse trends in environmental impacts to biota and the public. This is done by identifying concentrations of radionuclides that have changed beyond a trigger level. The PHMC provides the report to the Tank Farm Contractor for investigation of facility related items. The PHMC investigates non-facility related items. The Problem Evaluation Request process would be the means to initiate response to an anomaly that impacts the environment.
The following documents also are involved:
TFC-ESHQ-ENV-STD-05, Radioactive Airborne Effluent Sampling RPP-QAPP-004, NESHAP Quality Assurance Program Plan/or Tank Farm Contractor Radioactive Air Emissions
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Criteria Documentation and Observations Observation 10: The QAPP was last revised four years ago; recommend it be reyiewed and, if needed. updated.
2.9 d This element is similar to 2.9 c and that discussion applies here also. In addition, TFC-ESHQ-S_IH-P-09, Industrial Hygiene Personal/Area Exposure Monitoring, provides data on non-radiological releases. Also, various radiological program procedures, used to meet DOE Order 435.1, provide methods that assist in detecting, characterizing, and responding to releases from DOE activities. No formal process for providing this information to the environmental organization was identified. In practice, the radiological control organization has provided radiological monitoring data to the environmental organization to assist in the characterization of detected releases and identification of appropriate environmental response. The airborne releases for the C-200 series hose-in-hose radiological contan1ination and the C-201 Articul~ted Mast System airline radiological contamination are two recent instances where information was provided to environmental to assess impacts to the environment where a release to the environment [air] occurred. RPP-13033 , Tank Farms Documented Safety Analysis, HNF-14755, 242-A Evaporator Documented Safety Analysis, HNF-12125, 222-S Laboratory Documented Safety Analysis, all provide information on the type and quantities of materials that could be released in an accident and estimated impacts on individuals and the population. New projects, such as Demonstration Bulk Vitrification, are similarly evaluated and the information included in one of these documents or· a new document.
2.9 e The near and far field monitoring programs discussed in 2.9.c apply. The core of the program is the additional documents identified in 2.9.c.
Observation 11: A review of the last few ABCASH anomaly reports identjfied repeated errors in some of the data. Some of these are human errors, others are due to differences in how the radiological and environmental organizations view a particular data item. This is an area for follow-up.
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9. Ensure the analytical work supporting environmental monitoring is implemented using-
( a) a consistent system for collecting, assessing, and documenting environmental data of known and documented quality;
Documentation and Observations 2.9 f DOE has a contract with PNNL to conduct meteorological data gathering for Hanford. PNNL and the PHMC then assemble this data, along with historical near and far field monitoring data to prepare various documents that estimate dispersal patterns in the environment. These include:
DOE-RL-2005-06, Radionuclide Air Emission Report for the Hanford Site, Calendar Year 2004 HNF-EP-0527-14, Environmental Releases for Calendar Year 2004 HNF-3602, Calculating Potential to Emit Release and Doses for Facility Effluent Monitoring Plan and Notice of Construction
2.9 g See reports discussed in 2.9 f
2.9 h See 2.9 f, HNF-EP-0527.
2. 9 i through knot assessed
Two environmental monitoring processes were investigated for this assessment, Air monitoring and Groundwater monitoring.
Both monitoring programs are managed by a centralized program; FH managed the air monitoring program, and PNNL manages the groundwater monitoring program. CH2M HILL provides air samples to the laboratory to be analyzed in accordance with the established protocols of the air monitoring program as established in the QA Project Plan for the NESHAPS Air Monitoring. PNNL collects groundwater samples and submits those samples to laboratories to be analyzed in accordance with the established protocols as found in the QA Plan for the Groundwater Monitoring Program.
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Criteria (b) a validated and consistent approach
for sampling and analysis of radionuclide samples to ensure laboratory data meets program­ specific needs and requirements within the framework of a performance-based approach for analytical laboratory work; and
( c) an integrated sampling approach to avoid duplicative data collection.
10. Develop and implement a program and procedures to maximize the use of safe alternatives to ODS whereby-
Documentation and Observations The air program assures consistency in the effluent monitoring program through the Environmental Monitoring Plan (DOE/RL-91-50, rev. 3). Consistency in analysis is assured through the use of a single QAPP for program and the Statement of Work for the Waste Characterization and Sampling Facility, the laboratory at which the analyses are perfonned (HNF-EP-0835, rev. 11). CH2M HILL carries the QA requirements into their internal document , NESHAPS Quality Assurance Program Plan for Tank Farm Contractor Radioactive Air Emissions, RPP-QAPP-004.
Observation 12: RPP-QAPP-004 was issued in October 2001; consider review and, if necessary, update
The Groundwater program assures consistency in sampling and and analysis of radionuclide samples through the use of a centralized monitoring program; CH2M HILL facilities are monitored by this program. The QA Project Plan for the Groundwater monitoring program is PNNL-15014, January 2005.
a) an integrated sampling approach to avoid duplicative data collection.
Environmental monitoring is organizationally integrated to avoid duplicative data collection. All requests for groundwater analysis or monitoring are coordinated within PNNL and scheduled for sampling and analysis within a single organization in that company. Air monitoring is coordinated though the Hanford Site Environmental Monitoring Plan. The use of the Ozone Depleting Substances is regulated pursuant to 40 Code of Federal Regulations, Part 82. The control and phase-out of ODS is documented in Flour Hanford procedures HNF-PRO-15333 and HNF-PRO-10468. Maintenance and repair of refrigeration units at Hanford are performed by certified FH repair technicians. The prohibitions on ODS are not reflected in CH2M HILL procurement or environmental management procedures.
Finding: The control and phase-out of Ozone Depleting Substances, pursuant to 40 CFR 82, are not reflected in CH2M HILL procurement or environmental management procedures.
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Criteria (a) the procurement of Class I ODS for all
nonexcepted uses is discontinued by December 31, 2010 [See Executive Order 13148], and
disposal of ODS removed or reclaimed from equipment (including disposal as part of a contract, trade, or donation) is coordinated within DOE and with DoD, and for situations in which the recovered ODS is a critical requirement for DoD missions, the facility transfers the ODS to DoD. (b) 11 . Assist the Department with its
requirement under Executive Order 13148 by meeting reporting and planning requirements under the Emergency Planning and Community Right-to-Know Act (EPCRA or Title III of Superfund Amendments and Reauthorization Act of 1986), 42 U .S.C. 11001 , and the Pollution Prevention Act of 1990, 42 U.S.C. 13101.
Documentation and Observations
EPCRA - Assessed using interviews of: Robin Fogg, Chemical Coordinator; John Guberski, Environmental Compliance Specialist, and work process contact between Guberski and Chad Wheeler/Steve Carlson, Construction [Demonstration Bulk Vitrification Project].
EPCRA and SARA Title III reporting is driven by the annual call letter from the Project Management Hanford Contractor [Flour Hanford, Inc.] for chemical inventory information. CH2M HILL procedures [TFC-PLN-58, Chemical Management Plan, and TFC-BSM-CP _CPR-C-05, Procurement of Services, TFC-BSM-CP _ CPR-C-06, Procurement of Items (Material)] require the involvement of Industrial Safety to assure information need to support chemical inventory reporting is provided as part of the procurement process. The Chemical Coordinator maintains an ongoing inventory of quantities of chemicals received and quantity on hand to support input to these reports .
Environmental staff provided examples of how involvement of Industrial Safety occurs by describing interaction amongst the Demonstration Bulle Vitrification Project construction contractor [George A. Grant], CH2M HLIL Construction, and Environmental. George A. Grant contacted CH2M HILL Construction regarding applying a chemical [herbicide] at the construction site, as required in their statement of work. CH2M HILL Construction contacted Environmental to determine if use of a herbicide was allowed, by permit and what controls applied. Environmental referred the question to Industrial Safety to address
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Criteria Documentation and Observations chemical inventory and safety questions [i.e., use a herbicide already applied at Hanford and inform the Chemical Coordinator of amount involved if contractor brought material to site].
Observation 13: A potential improvement could be the addition of a contract close out item for contractor to provide a report of chemicals used and quantity used
222-S Laboratory controls its chemicals using the Fluor Hanford Chemical Management System, as described in Fluor procedure, Chemical Management, HNF-PRO-10468. The ATS Plan showing ISMS, ISMS Implementing Document, ATS-MP-1014. Identifies this substitution. 222-S Laboratory continues to use the FH Chemical Management system because the FH system was developed to accommodate the extensive and diverse chemical inventory maintained at the laboratory and provides useful management functions for chemical management that the CH2M HILL process does not offer. The EPCRA reporting is performed using the Chemical Inventory Tracking System.
The Chemical Management System at 222-S is described in procedure, Chemical Management, LO-150-163. This procedure describes the process to procurement, storage and disposition of chemicals, how to perform a facility chemical inventory, and the required process to review and justify continued use of high hazard chemicals.
Other procedures used at 222-S Laboratory that defines the use and disposition of chemicals are: HNF-RD-10994, Occupational Carcinogen Control HNF-RD-13299, Hazard Communication HNF-PRO-259, Graded Approach HNF-PRO-10468, Chemical Management Process ASP-200, Section 4.01, "Analytical Services Hazard Communication Program" A TS-310, Section 1. l 2, "Administration of 222-S Laboratory Complex Criticality Safety Program" ATS-310, Section 4.5, "222-S Laboratory Complex Chemical Hygiene Plan" ATS-310, Section 6.4, "222-S Laboratory Complex Waste Management Process" LO-120-001, Labeling of Standards and Reagents by Standards Laboratory Personnel Standards Laboratory Quality Affecting Operations Chemical Management Program webpage, httn://www.rl.1rnv/cmo/.
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Criteria Documentation and Observations LO-120-007, Proper Labeling of Secondary Containers at 222-S Complex and WSCF LO-150-062, Management of Shock-Sensitive and Peroxide Forming Chemicals in the Laboratory LO-180-105, Operation of the MBAs at 222-S Laboratory and Transfer of Nuclear Material.
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Executive Summary
Attached are the results of the June 2005 Standards/Requir~ments Identification Document (S/RID) Phase 1/Phase 2 Assessment performed in accordance with TFC-BSM-AD-C-07, "Standards/Requirements Identification Document Process", Revision A. The assessment was conducted during the period of January through June 2005 by Portage Environmental, Inc. on behalf of CH2M Hill Environmental Protection (EP) Functional Area, and resulted in the following general conditions:
• A majority of requirements identified in HNF-SD-MP-SRID-001, Section 20.0 (EP S/RID) are appropriately implemented and evidence of compliance is available. The applicable
· requirements without evidence of implementation are identified per requirement in the attachment of this report. Corrective actions associated with compliance 'Yill be documented using the Problem Evaluation Request (PER) process as described in TFC­ ESHQ-Q__ C-C-01.
• Examination of records, interviews with key personnel, and observations of activities were conducted between January and June 2005 to corroborate that implementation and compliance either was or was not successfully achieved.
• Each requirement, and its implementing document was examined and the results are provided in the attachment to this report.
( ) BasisA1f..Phase 2 Assessment
)
. .. .. . . ~ -~ - .. .
1. That new requirement~ at the federal , state, and local levels are reviewed for applicability in a timely manner.
2. That interfaces at the appropriate organizational level are established with regulators to ensure notification of new and changing commitments and/or requirements . These · interfaces allow a means of clarifying and interpreting requirements and address the preparation, review, submittal and approval of exemptions.
3. That new or revised requirements are formally integrated into the management system through modifications or development of appropriate policies and procedures.
4. That a centralized system exists for tracking all requirements applicable to the Functional Area and the contractor' s work activities . The tracking system facilitates maintenance of the requirements database and provides a cross reference to policies and procedures incorporating the requirements to allow a consistent updating process.
Enclosure 3
•
ASSESSMENT PLAN EMS and DOE O 450.1 IMPLEMENTATION BY CH2M HILL
PURPOSE: This assessment evaluates CH2M HILL'S implementation DOE O 450.1, Environmental Protection Program . Attachment 2 of DOE O 450.1, Contractor Requirements Document (CRD), imposes specific requirements on CH2M HILL. These requirements are intended to ensure the implementation of a documented and structured environmental Management system (EMS) and the implementation of the EMS into the Integrated Safety Management System (ISMS). CH2M HILL has committed to the Office of River Protection (ORP) to have a functioning EMS in place and integrated into their ISMS by October 31, 2005. This assessment supports ORP's verification that CH2M HILL has implemented the EMS/CRD requirements of DOE O 450.1.
SCOPE: This assessment will look for evidence that the applicable elements of the DOE O 450.1 CRD have been incorporated into the Standards and Requirements Document (SRIDS), flow down into policies, procedures and plans (as appropriate), and implemented in the field. The assessment will also evaluate how well the EMS itself is described in program documentation, and how well it is understood by CH2M-HILL staff and management. This assessment, and the CH2M HILL management assessment certifying implementation of EMS, will be used as the supporting documentation for a December 2005 declaration by the ORP Manager that the contractor has implemented the applicable EMS requirements of DOE O 450.1 .
ASSESSMENT TEAM:
Assessment Lead Rick McNulty ORP-ED RCRA Permitting Lead, Tank Farms ISO 14001 Lead Auditor
Lori Huffman ORP-ED Senior Contributor and RCRA Permitting Lead WTP
Gae Neath ORP-ED P2 Lead
ASSESSMENT SCHEDULE: This assessment is to be connected 11/14-17/2005. An assessment report will be completed by 12/14/2005.
DOCUMENTATION: The source document is DOE 0450 .1, Attachment 2. Primary review documents included:
RP-MP-003, Integrated Environmental, Safety, and Health Management System Description for the Tank Farm Contractor, Revision 5 (Draft). Note: ED submitted RCR comments on the EMS component of the ISMS 09/05 to ES&H .. However, the EMS comments were not provided to CH2M HILL until 11/05.
TFC S/RID
TFC-POL-30 , Environmental Management Policy
Assessment Approach and Methodology:
The ORP has previously conducted staff reviews of RP-MP-003, Revision 5 (ISMS)and TFC­ PLN-73A documenting the incorporation of the EMS requirements of DOE O 450.1 into the ISMS Program Description, and the Environmental Program Description . The actual EMS system is documented in TFC-PLN-73 which includes a matrix roadmap between EMS CRD elements, RP­ MP-003, and program/field implementing procedures. CH2M-HILL completed a management aud it in 10/2005 concluding that the CRD requirements of DOE Order 450.1 had been successfully completed . Additionally, CH2M HILL conducted a Phase I and Phase II SRIDs Assessment in 2005 which concluded that the CH2M HIILL SRID requirements had been successfully implemented . ED reviewed ORP's incorporation of the DOE 450.1 CRD requirements into SRIDS in 2004. ·
EM facilities undergoing closure are authorized to utilize a graded approach for EMS implementation (See DOE G 450.1-1). However, DOE HQ has provided little to no guidance on graded implementation other than stating that credit can be taken for alternative documentation analyzing environmental aspects and significant impacts (e .g., CERCLA and NEPA documentation). Additionally, DOE O 450.1 does not require the development of new environmental management systems where pre-existing systems effectively exist.
During the early stages of EMS implementation, ORP determined that it would be appropriate for CH2M HILL to take credit for the extensive regulation of site closure activities via environmental permitting (e.g ., tank post closure permits), the TPA, CERCLA studies, and NEPA EIS documentation in lieu of conducting any extensive environmental aspect and significant impact analysis. As a practical matter, ORP concluded that CH2M Hill's activities and operations are so heavy analyzed, regulated, and documented in these alternative sources that there was no practical necessity for CH2M-HILL to engage in extensive new analysis to identify environmental aspects and significant impacts. In this same regard, with the exception of specific P2 requirements , a graded approach is also adopted for measurable environmental targets and goals. Using the graded approach, the measurable targets and goals for CH2M HILL are principally described in TPA requirements, environmental permit requirements, and incentive contract direction by ORP (e.g., accelerated tank closure).
Although all of the CRD requirements of DOE O 450.1 are captured in the CH2M HILL S/RID's, there are function areas in which CH2M Hill's actual responsibilities are limited and/or nominal because the primary function is performed by the Hanford site landlord, the Richland Operations Office and its site contractors . Examples of these limited responsibilities include wild fire management, watershed management, groundwater monitoring, and cultural resource management. Where operation interfaces exist because