Pursuing leads. - Continued

DOE-EM-STD-5505-96

is the shift supervisor disregarding written procedures and instructing the shift operators

accordingly.

So far, the assessor has been limited to observing only one shift. Therefore, an observation of an

operator on a different shift might be appropriate. During this observation, the assessor notes that

the second operator also bypasses the pH meter in the same way. When questioned, the operator

states that the shift supervisor provided the same instruction since it reduces the alarms that are

received in the control room. The assessor now can conclude that this practice which is not

allowed by procedure is not limited to one operator or shift.

There are several directions in which the assessor could proceed. For example, the assessor could

interview personnel from the engineering or maintenance or training organization. The

questioning may indicate that supervisors and operators are living with system deficiencies

because of a design or maintenance problem with the pH circuit or defective cell system. The

logical questions that the assessor should ask are: Have the problem alarms been identified? Has

engineering evaluated the problems? Is operations compensating for poor design or performance?

How was the determination made that the alarms received are false? What was the basis and who

authorized bypassing an NPDES instrument? Is bypassing the cell approved? Why are there no

compensatory measures in the procedure to ensure that the cell is not bypassed during the

discharge?

There are some areas of concern that may arise from this scenario. The fundamental issue of

concern related to conduct of operations is the bypassing of a safety or monitoring system.

Another area of potential concern is that there may be a reportable issue to the state or federal

environmental protection agency because the monitoring system is part of the site environmental

permit. An additional area of concern might be why is there a bypass at all. More generally,

why do trained personnel, who should be knowledgeable about alarms, permits, bypassing

systems, instrumentation, procedural protocol, not challenge the verbal direction to bypass