Sellafield - Inspection ID: 53289 | Office for Nuclear Regulation

Executive summary

Date(s) of inspection: September 2024

Aim of inspection

The Office for Nuclear Regulation (ONR) undertakes all its regulatory interactions with the Sellafield site licensee, Sellafield Limited, against a strategy defined by the ONR Sellafield, Decommissioning, Fuel and Waste (SDFW) Division. In accordance with this strategy a planned corporate Themed Compliance Inspection (TCI), targeted at Sellafield Enterprise Management System (SEMS) compliance management and implementation progress, was undertaken 11-12 September 2024.

SEMS replaced the Sellafield Limited Management System (SLMS) in March 2024 (2024/12960). This began an approximate five year period during which “SLMS style” management system content will be progressively replaced by “SEMS style” management system content.

This TCI was targeted at compliance management since ONR had concerns related to this matter which were raised during a corporate inspection of Licence Condition 28 (LC28) “Examination, inspection, maintenance and testing” in September 2022 (IIS-50317 “Sellafield Corporate - Inspection of LC28”). These concerns related to the completeness of the approximately fifty “Mandatory Standards” in place in the SLMS. These SLMS Mandatory Standards played a role in demonstrating compliance in the SLMS. ONR followed up these concerns with the SLMS team in January 2023 (2023/8714) and in September 2023 (2023/55134).

The transition to SEMS involved populating a database of obligations created from the content of the SLMS Mandatory Standards, which were then withdrawn. Populating the SEMS database of obligations with the extensive content from the SLMS Mandatory Standards was a significant undertaking which identified (2024/13188) issues which needed to be resolved prior to SEMS “go live” and also issues which needed to be resolved after SEMS “go live”. In addition, SEMS “go live” introduced a new nuclear baseline role, that of Compliance Requirement Owner (CRO).

This TCI was therefore timely to:

a. Follow up ONR’s compliance related concerns to determine whether or not they have or will be fully addressed by the transition to SEMS;

b. Consider implementation of SEMS since go live, with particular focus on key learning and how this is being acted upon; and,

c. Consider the forward plan for the replacement of SLMS style management system content by SEMS style management system content over the next year.

Subject(s) of inspection

LC12 - Duly authorised and other suitably qualified and experienced persons - Rating: GREEN
LC17 - Management systems - Rating: GREEN
Lifting / LOLER - Rating: AMBER
MHSWR - Rating: AMBER
Provision and Use of Work Equipment Regulations 1998 (PUWER) - Rating: AMBER

Key findings, inspector's opinions and reasons for judgement made

The Office for Nuclear Regulation (ONR) undertakes all its regulatory interactions with the Sellafield site licensee, Sellafield Limited, against a strategy defined by the ONR Sellafield, Decommissioning, Fuel and Waste (SDFW) Division. In accordance with this strategy a planned corporate Themed Compliance Inspection (TCI), targeted at Sellafield Enterprise Management System (SEMS) compliance management and implementation progress, was undertaken 11-12 September 2024. The SDFW strategy describes strategic ways of working, these include effective use of resources. In line with this strategic way of working, this TCI:

a. Covered both ONR’s nuclear safety purposes and ONR’s Nuclear Site Health and Safety (NSHS) purposes; and,

b. Utilised and supported Selllafield Limited’s internal challenge function via a Sellafield Limited Nuclear Independent Oversight (NIO) Inspector participating in the inspection.

SEMS replaced the Sellafield Limited Management System (SLMS) in March 2024. This began an approximate five year period during which “SLMS style” management system content will be progressively replaced by “SEMS style” management system content.

This TCI was targeted at compliance management since ONR had concerns related to this matter which were raised during a previous corporate inspection. This TCI was therefore timely to:

a. Follow up ONR’s compliance related concerns to determine whether or not they have or will be fully addressed by the transition to SEMS;

b. Consider implementation of SEMS since go live, with particular focus on key learning and how this is being acted upon; and,

c. Consider the forward plan for the replacement of SLMS style management system content by SEMS style management system content over the next year.

In terms of ONR’s nuclear safety purposes the TCI sampled and rated:

a. Licence Condition 12 (LC12) “Duly authorised and other suitably qualified and experienced persons”; and,

b. Licence Condition 17 (LC17) “Management systems”.

In terms of ONR’s NSHS purposes the TCI sampled and rated:

a. The Management of Health and Safety at Work Regulations 1999 (MHSWR);

b. The Provision and Use of Work Equipment Regulations 1998 (PUWER); and,

c. The Lifting Operations and Lifting Equipment Regulations 1998 (LOLER).

The objectives of this inspection were to determine the adequacy, judged against ONR’s expectations, of:

a. Sellafield Limited’s site-wide corporate arrangements for establishing and maintaining SEMS Compliance Requirements and the implementation of these arrangements on a sampling basis, focussing on ONR’s nuclear safety purposes and ONR’s NSHS purposes;

b. Implementation of SEMS since go live, with particular focus on key learning and how this is being acted upon; and,

c. The forward plans for the replacement of SLMS style management system content by SEMS style management system content over the next year.

The inspection was led by a Sellafield Corporate Site Inspector/ nuclear safety Inspector with support from a NSHS Inspector. Henceforth, the use of the pronoun “we” refers to this team whilst the pronoun “I” refers to the Sellafield Corporate Site Inspector for judgements relating to LC12 and LC17 and to the NSHS Inspector for judgements relating to MHSWR, PUWER and LOLER. As noted earlier, a NIO Inspector supported this inspection.

The following regulatory guidance establishes a need to include regulatory requirements such as Licence Conditions (LCs) and health and safety regulations in the management system:

a. Regulation 5 of MHSWR;

b. Paragraph 4.12 of International Atomic Energy Agency (IAEA) General Safety Requirements (GSR) No. GSR Part 2, “Leadership and Management for Safety”;

c. Paragraph 3.9 of IAEA Safety Guide No. GS-G-3.1, “Application of the Management System for Facilities and Activities”;

d. Sections 5.1.2 and 8.2.2 of BSI Standards Publication BS EN ISO 9001:2015, “Quality management systems Requirements”; and,

e. Section 6.1.3 of BSI Standards Publication BS EN ISO 45001:2023, “Occupational health and safety management systems Requirements with guidance for use”.

Item a is a Defined Standard and items b-e are Established Standards in terms of ONR’s Enforcement Management Model (EMM).

The need to include regulatory requirements in a management system is addressed via one of the SEMS principles “A clear line of sight to our obligations”. These “obligations” include legal obligations. This principle ensures that if SEMS processes and arrangements are followed, relevant obligations will be met by design. These obligations are stored in a “SEMS Compliance Matrix” which has links to relevant SEMS processes and arrangements.

To meet the objectives of this inspection we undertook a desktop review of documentation prior to the inspection, this focussed on the SEMS Compliance Matrix entries relevant to LC12, LC17, MHSWR, PUWER and LOLER.

This was followed by a face-to-face inspection with members of the SEMS team and with selected persons throughout the business having SEMS responsibilities. A particular focus was on SEMS Compliance Requirement Owners (CROs), which is a new role introduced by the transition to SEMS.

We consider that the engagement prior to and during this inspection has allowed us to complete a meaningful corporate TCI of SEMS compliance management and implementation progress.

Key Findings

Key findings are recorded separately in relation to the following areas:

a. The overall inspection;

b. Licence Condition 12;

c. Licence Condition 17/ SEMS;

d. The Management of Health and Safety at Work Regulations 1999;

e. The Provision and Use of Work Equipment Regulations 1998;

f. The Lifting Operations and Lifting Equipment Regulations 1998;

g. Extent of condition matters; and,

h. Hot debrief.

The Overall Inspection

We identified the following observations as areas of good practice relating to delivery of the overall inspection:

a. Delivery of the information requested prior to and during this inspection;

b. Preparation for the inspection; and,

c. Open, honest and helpful discussions and those persons involved were knowledgeable and receptive to challenge.

Licence Condition 12

Prior to the inspection, a number of issues had been identified relating to the LC12 Compliance Matrix. We were satisfied that these are being addressed via the SEMS team’s ongoing compliance data cleanse exercise.

Given this, neither providing regulatory advice nor identifying regulatory findings was appropriate. The issues identified relating to the LC12 Compliance Matrix were noted as an observation.

Licence Condition 17/ SEMS

On the basis of the evidence sampled before and during this inspection we identified the following observations as areas of good practice relating to Sellafield Limited’s LC17/ SEMS arrangements and/ or their implementation:

a. The SEMS team is providing a significant level of support, guidance and mentoring to SEMS CROs and SEMS Process Owners (POs);

b. The SEMS team is monitoring SEMS CRO and SEMS PO progress to demonstrate that they are Suitably Qualified and Experienced Persons (SQEPs) for these roles and beginning to escalate in appropriate cases to ensure that all achieve SQEP status within one year from SEMS “go live”;

c. The SEMS team is beginning to consider a reduced timescale for demonstration of SQEP for these roles when business as usual changes occur to SEMS CROs and SEMS POs;

d. The SEMS team has responded positively to the generic matters identified during a recent corporate inspection of Licence Condition 24 (LC24) “Operating instructions” via two initiatives.

e. The SEMS team has put in place effective arrangements to capture learning and has taken actions based on the lessons learned.

f. The SEMS team has put in place effective planning arrangements which have identified active process development work fronts to be released [some of these are of significant interest to ONR].

On the basis of the evidence sampled before and during this inspection we provided the following regulatory advice relating to Sellafield Limited’s LC17/ SEMS arrangements and/ or their implementation. Sellafield Limited to consider:

a. Making relevant SEMS CROs and SEMS POs aware of the special legal status of Approved Codes of Practice (ACoPs) and the need to take this into account when exercising their duties; and,

b. Providing guidance on ONR’s interpretation of Relevant Good Practice (RGP) to the CROs for relevant SEMS Compliance Topics.

We observed that some SEMS CROs had responsibilities relating to a large number of health and safety regulations, many of these being large and complex, in addition to other responsibilities. We consider that there would be challenges for any person to demonstrate that they had the capacity and subject matter competence to discharge all their SEMS CRO and other responsibilities effectively.

We identified a regulatory finding relating to this matter which has now been recorded as a Level 4 (the lowest level) Regulatory Issue (RI).

The Management of Health and Safety at Work Regulations 1999

We reviewed the obligations associated with MHSWR in the SEMS Compliance Matrix and found significant gaps and anomalies between these and the duties placed on Sellafield Limited as an employer by MHSWR. We consider that this situation for MHSWR represents deficient arrangements for compliance with legal requirements.

We identified a regulatory finding relating to this matter which has now been recorded as a Level 3 RI. To address this RI Sellafield Limited is required to:

a. Establish a SEMS Compliance Matrix which identifies all the duties placed on Sellafield Limited as an employer by MHSWR;

b. Undertake a gap analysis between this SEMS Compliance Matrix and the extant Sellafield Limited processes/ arrangements related to MHSWR; and,

c. Fill any gaps by modifying the extant SEMS processes related to MHSWR.

The Provision and Use of Work Equipment Regulations 1998

We reviewed the obligations associated with PUWER in the SEMS Compliance Matrix and found significant gaps and anomalies between these and the duties placed on Sellafield Limited as an employer by PUWER. We consider that this situation for PUWER represents deficient arrangements for compliance with legal requirements.

We identified a regulatory finding relating to this matter which has now been recorded as a second Level 3 RI. The actions to address this RI are equivalent to those summarised earlier relating to MHSWR.

The Lifting Operations and Lifting Equipment Regulations 1998

We reviewed the obligations associated with LOLER in the SEMS Compliance Matrix and found significant gaps and anomalies between these and the duties placed on Sellafield Limited as an employer by LOLER. We consider that this situation for LOLER represents deficient arrangements for compliance with legal requirements.

We identified a regulatory finding relating to this matter which has now been recorded as a third Level 3 RI. The actions to address this RI are equivalent to those summarised earlier relating to MHSWR and PUWER.

Extent of Condition Matters

It is possible that similar shortfalls to those we identified in the SEMS Compliance Matrix relating to MHSWR, PUWER and LOLER apply to Acts and other regulations relevant to ONR’s NSHS purposes.

Since we obtained no evidence relating to this matter during this inspection, no ONR findings have been raised.

These possible extent of condition matters will be progressed in the first instance as part of routine SEMS regulatory update meetings.

Hot Debrief

The Sellafield Limited personnel present at the hot debrief were in broad agreement with the outcomes of this inspection.

The judgements are recorded separately in relation to the following areas:

a. Licence Condition 12;

b. Licence Condition 17/ SEMS;

c. The Management of Health and Safety at Work Regulations 1999;

d. The Provision and Use of Work Equipment Regulations 1998; and,

e. The Lifting Operations and Lifting Equipment Regulations 1998.

Licence Condition 12

On the basis of the evidence sampled before and during this inspection no regulatory findings nor regulatory advice was identified relating to LC12 arrangements and/ or their implementation, although one observation was made.

Based on this, I considered that an Inspection Rating of Green (No Formal Action) for LC12 was appropriate, noting the relevant guidance within ONR documentation.

Licence Condition 17/ SEMS

On the basis of the evidence sampled before and during this inspection then in relation to MHSWR we identified an ONR finding which represents deficient arrangements for compliance with legal requirements.

Based on this, I considered that an Inspection Rating of Amber (Seek Improvement) for MHSWR was appropriate, noting the relevant guidance within ONR documentation.

I have reviewed this shortfall against ONR’s EMM, noting the relevant guidance within ONR documentation and submitted an Enforcement Decision Record (EDR).

The Provision and Use of Work Equipment Regulations 1998

On the basis of the evidence sampled before and during this inspection then in relation to PUWER we identified an ONR finding which represents deficient arrangements for compliance with legal requirements.

Based on this, I considered that an Inspection Rating of Amber (Seek Improvement) for PUWER was appropriate, noting the relevant guidance within ONR documentation.

I have reviewed this shortfall against ONR’s EMM, noting the relevant guidance within ONR documentation and submitted an EDR.

The Lifting Operations and Lifting Equipment Regulations 1998

On the basis of the evidence sampled before and during this inspection then in relation to LOLER we identified an ONR finding which represents deficient arrangements for compliance with legal requirements.

Based on this, I considered that an Inspection Rating of Amber (Seek Improvement) for LOLER was appropriate, noting the relevant guidance within ONR documentation.

I have reviewed this shortfall against ONR’s EMM, noting the relevant guidance within ONR documentation and submitted an EDR.

Conclusion

Judgements are recorded separately in relation to the following areas:

a. Licence Condition 12;

b. Licence Condition 17/ SEMS;

c. The Management of Health and Safety at Work Regulations 1999;

d. The Provision and Use of Work Equipment Regulations 1998; and,

e. The Lifting Operations and Lifting Equipment Regulations 1998.

Licence Condition 12

On the basis of the evidence sampled before and during this inspection then in relation to Sellafield Limited’s LC17/ SEMS arrangements and/ or their implementation we identified:

a. Six areas of good practice;

b. Two items of regulatory advice; and,

c. A single ONR finding which I have judged to represent a relatively minor deficiency.

Based on this, I considered that an Inspection Rating of Green (No Formal Action) for LC17 was appropriate, noting the relevant guidance within ONR documentation.

The Management of Health and Safety at Work Regulations 1999

On the basis of the evidence sampled before and during this inspection then in relation to MHSWR we identified an ONR finding which represents deficient arrangements for compliance with legal requirements.

Based on this, I considered that an Inspection Rating of Amber (Seek Improvement) for MHSWR was appropriate, noting the relevant guidance within ONR documentation.

I have reviewed this shortfall against ONR’s EMM, noting the relevant guidance within ONR documentation and submitted an EDR.

The Provision and Use of Work Equipment Regulations 1998

On the basis of the evidence sampled before and during this inspection then in relation to PUWER we identified an ONR finding which represents deficient arrangements for compliance with legal requirements.

Based on this, I considered that an Inspection Rating of Amber (Seek Improvement) for PUWER was appropriate, noting the relevant guidance within ONR documentation.

I have reviewed this shortfall against ONR’s EMM, noting the relevant guidance within ONR documentation and submitted an EDR.

The Lifting Operations and Lifting Equipment Regulations 1998

On the basis of the evidence sampled before and during this inspection then in relation to LOLER we identified an ONR finding which represents deficient arrangements for compliance with legal requirements.

Based on this, I considered that an Inspection Rating of Amber (Seek Improvement) for LOLER was appropriate, noting the relevant guidance within ONR documentation.

I have reviewed this shortfall against ONR’s EMM, noting the relevant guidance within ONR documentation and submitted an EDR.