Root - Cause - Report Example TapRoot

ATTACHMENT C
TapRooT® Investigation Report
Subsurface Contamination Incident

Port Hope UF6 Plant
July 13, 2007
October 15, 2007

Attachment C: TapRooT ® Report Page 2 of 63
Subsurface Contamination Incident October 15, 2007
Glossary of Terms
AECB Atomic Energy Control Board

A&E Audits and Evaluations
BH50-2, etc. Borehole series wells
CARs Corrective Action Recommendations
CNSC Canadian Nuclear Safety Commission
CTCW Cell Tempered Cooling Water
Eldorado Eldorado Nuclear Ltd.
ERA Environmental Risk Assessment
‘Floors, Sumps & Trenches’ Floors, Sumps, Trenches, Pits and any associated Joints
Golder Golder Associates Ltd.
KOH Potassium Hydroxide
MOC Management of Change
MOE Ontario Ministry of the Environment
NI Needs Improvement
NDE Non Destructive Examination
N-S Trench North-South Trench
PHA Process Hazard Analysis
Pit Effluent Pit
PM Preventive Maintenance
RW Refinery Well
SPAC Standard, Policy or Administrative Control
Specs Specifications
Study Area Effluent Treatment, Cell Room, and Cell Maintenance
Area
UF6 Uranium Hexafluoride
UO2 Uranium Dioxide
Table of Contents
1.0 EXECUTIVE SUMMARY .................................................................................. 4
2.0 OVERVIEW OF THE INVESTIGATION PROCESS..................................... 8
2.1 INVESTIGATION SCOPE ......................................................................................... 8
2.2 ROOT CAUSE ANALYSIS PROCESS........................................................................ 8
2.3 INFORMATION COLLECTION (I.E. “WHAT HAPPENED”)........................................ 8
2.4 CAUSAL FACTOR (PROBLEM/ISSUE) DEFINITION ................................................. 8
2.5 ROOT CAUSE ANALYSIS....................................................................................... 9
2.6 CORRECTIVE ACTION RECOMMENDATIONS ......................................................... 9
3.0 EVENTS LEADING UP TO THE INCIDENT ............................................... 10
4.0 CAUSAL FACTORS AND SUPPORTING INFORMATION ...................... 18
4.1 CAUSAL FACTOR #1 – SOME ‘FLOORS, SUMPS & TRENCHES’ ARE NOT DESIGNED TO
RESIST A CORROSIVE ENVIRONMENT ...................................................................... 18
4.2 CAUSAL FACTOR #2 – LIQUID ENTERING ‘FLOORS, SUMPS & TRENCHES’ IS
FREQUENTLY CORROSIVE AND ATTACKS THE STRUCTURES .................................... 21
4.3 CAUSAL FACTOR #3 –URANIUM + CHEMICALS FREQUENTLY ENTER THE ‘FLOORS,
SUMPS & TRENCHES’.............................................................................................. 22
4.4 CAUSAL FACTOR #4 – LIQUID AND SLUDGE REMAIN IN THE ‘FLOORS, SUMPS &
TRENCHES’ FOR SUSTAINED PERIODS OF TIME ........................................................ 24
4.5 CAUSAL FACTOR #5 – SOME ‘FLOORS, SUMPS & TRENCHES’ DETERIORATED OVER
TIME AND BEGAN TO LEAK ..................................................................................... 27
4.6 CAUSAL FACTOR #6 – THE MONITORING PROGRAM DOES NOT DETECT
DETERIORATION OF AND/OR LEAKAGE FROM THE ‘FLOORS, SUMPS & TRENCHES’ . 31
5.0 CORRECTIVE ACTION RECOMMENDATIONS....................................... 34

APPENDIX 1................................................................................................................... 39
APPENDIX 2................................................................................................................... 43
APPENDIX 3................................................................................................................... 60
1.0 EXECUTIVE SUMMARY
In 1980, Eldorado (Eldorado Nuclear Ltd.) made an application to the AECB

(Atomic Energy Control Board) for Site Approval of Port Hope Conversion
Facility UF6 (Uranium Hexafluoride) Facilities Expansion. This was followed by
a Construction Application. Lummus carried out the detailed design of the new
UF6 Plant, which would be called Building 50. Building 50’s trenches and the
concrete floor were not considered as potential leak paths for uranium or
chemicals in the Lummus design and construction documentation. Further, there
were some ‘floors, sumps & trenches’ (term represents floors, sumps, trenches,
associated joints and the Effluent Pit) that were not designed to resist a corrosive
environment (e.g. the Cell Room trenches did not have a chemical resistant liner,
as there was no specific design requirement identified). The intent of Cell Room
trenches in the design documentation appeared to be to collect small amounts of
tempered cooling water from leaks in the cells and hold the tempered cooling
water pipes. Experienced personnel interviewed during the investigation into the
subsurface contamination did not recall much focus placed on the trenches during
the design and early operation.
The first UF6 Plant operating activities took place on April 2, 1984, at which point
the Operations Quality Assurance Manual took effect. The focus of this manual
was safety related systems, a designation for equipment and systems that had the
most significant environmental impacts. These systems were also identified as
part of the design and construction process. ‘Floors, sumps & trenches’ were not
considered part of a safety related system. The UF6 Plant experienced numerous
operating problems from the onset in all process areas, including liquid effluent.
According to one senior individual interviewed as part of this investigation,
"There were so many challenges associated with the UF6 plant in the beginning
that effluent/water related problems were of lower priority."
The water volume experienced during operation was greater than design
expectations. Being the low point, the Pit was primary collector for excess fluid.
These water balance problems in Building 50 resulted in flooding of the Pit,
causing water to back up into the unlined Cell Room trenches on several
occasions. Potentially corrosive liquid frequently entered ‘floors, sumps &
trenches’, including Cell Room trenches under normal process conditions.
Cameco Corporation purchased the assets of Eldorado on October 5, 1988.
Not only did corrosive liquids make their way into the ‘floors, sumps & trenches’,
but also uranium and chemicals frequently entered the ‘floors, sumps & trenches’
through other pathways, including floor sweepers. Right from start-up in 1984,
floor sweepers cleaned the process floors in Building 50 and were discharged into
the N-S Cell Room trench and equipment was routinely cleaned on the floor of
the effluent area.
A relatively significant source of uranium to the ‘floors, sumps & trenches’ would
have been the tanks, which by design, occasionally overflowed to the floor in the
Effluent Room. A channel for uranium containing liquids from this tank to get
into the Pit and Cell Room trenches was provided when a shallow trench was cut
into the floor in the Effluent Room.
Another problem that contributed to this incident was that the liquid and sludge
described above remained in the ‘floors, sumps & trenches’ for sustained periods
of time. The Cell Room trenches could not be routinely cleaned because they had
piping (between 4" and 8") running down their length. Golder Associates Ltd., a
technical consulting firm commissioned by Cameco to examine the integrity of
the concrete structures and the extent of the subsurface contamination, examined
the Cell Room trenches and indicated the solution in the trenches may have
pooled in places and did not flow through the trench as designed. During the
coring of the south trench, Golder noted that the coring water actually flowed a
short direction west (up gradient) instead of east (down gradient). As a result,
uranium contaminated sludge built up in the North and South Cell Room
Trenches.
There are strong indications that some ‘floors, sumps & trenches’ deteriorated
over time and began to leak. This resulted in uranium and chemicals seeping
through the cracks and holes in the concrete into the soil and eventually migrating
to the ground water below. This is a very slow process that could well have gone
on for years during which the cracks/holes in the concrete trenches and floors, for
the most part, went undetected. The monitoring system did not detect this
deterioration and/or the leakage from the ‘floors, sumps & trenches’.
In 2007, a contractor began work on a rectangular excavation in Building 50 of

the UF6 Plant. The excavation was to house a new CTCW (Cell Tempered
Cooling Water) tank, which is desired due to an increased number of cells. The
new CTCW tank was to be placed in a concrete in-ground structure. The design
specified double walled protection. As well, monitoring of the integrity of the
tank was to be part of the new design and operation.
On July 12, 2007, the contractor pulled a small tree root from the soil in the
excavation. Water was noticed leaking into the excavation from the hole left by
the tree root. The next day, the contractor noticed a yellow stain in the bottom of
the excavation. The yellow stain was found on the surface of freshly poured
concrete in the excavation. Cameco management were notified and began to
investigate. Cameco immediately recognized that the yellow stain was associated
with uranium.
Cameco then voluntarily shut down UF6 production operations and initiated an
investigation into the source of uranium contamination. Cameco promptly advised
the CNSC (Canadian Nuclear Safety Commission) and the MOE (Ontario
Ministry of the Environment) Spills Action Centre of the incident. The MOE
Spills Action Centre notified Environment Canada. On July 19th, a complete plant
shut-down was initiated to facilitate the expanded scope of investigation. In the
subsequent investigation, subsurface contamination was confirmed in Building

50.
Consistent with all large incidents, and most small ones, there is no single cause.
The investigation has identified 6 major problems (referred to as “Causal
Factors”) that preceded the incident. If these problems had not existed, there is a
reasonable probability that the subsurface contamination below Building 50
would either not have occurred or the consequences would have been less
extensive.
It is critical for the reader to understand that all 6 of these Causal Factors must
have occurred for uranium to be discovered in the excavation for the new CTCW
tank in the UF6 Plant on July 13, 2007, and subsurface contamination to be
subsequently confirmed. A discussion and basis for the 6 Causal Factors appears
in Section 4 of the report. Appendix 1 illustrates the relationship between the 6
Causal Factors. The Causal Factors are:
1. Some ‘floors, sumps & trenches’ are not designed to resist a corrosive
environment;
2. Liquid entering ‘floors, sumps & trenches’ is frequently corrosive and
attacks the ‘floors, sumps & trenches’;
3. Uranium and chemicals frequently enter the ‘floors, sumps & trenches’;
4. Liquid and sludge remain in the ‘floors, sumps & trenches’ for sustained
periods of time;
5. Some ‘floors, sumps & trenches’ deteriorated over time and began to leak;
and
6. The monitoring system does not detect deterioration of and/or leakage
from the ‘floors, sumps & trenches’.
Recommended corrective actions were developed to address all of these causal

factors and are summarized as follows:
a) there is a need to identify ‘floors, sumps & trenches’ as a safety related

system because of the potential for leak paths. This aspect must be
reflected in the Safety Report and application of the Quality Assurance
program. Appropriate design, construction and operating standard(s) and
management change controls must be established and maintained. Some
minimum requirements were identified;
b) there is a need to carry out a design related assessment of credible acute
and chronic challenges to ‘floors, sumps & trenches’ and then ensure their
structural surfaces are appropriately designed. The designs must be
developed as per an approved design standard to ensure requirements (e.g.
Preventive Maintenance (PMs) and maintaining as-built drawings) are
clearly documented, communicated and implemented;
c) there is a need to implement an effective corrective action program so that

problems are routinely identified and appropriate corrective action taken;
and
d) there is a need to assess the adequacy of the groundwater monitoring
program for early leak detection, and implement any necessary
improvements.
2.0 OVERVIEW OF THE INVESTIGATION PROCESS
2.1 Investigation Scope
The investigation examined the relevant events and conditions leading up to the
subsurface contamination incident at Port Hope on July 13, 2007. The
investigation reviewed information as far back as 1980 when the UF6 Plant was
designed and constructed.
Both basic and root causes of the contamination incident were identified, as well
as corrective action recommendations to significantly lessen the chances of this
type of incident occurring in the future.
2.2 Root Cause Analysis Process
The investigation was conducted using the TapRooT® Root Cause Analysis
process. This process was developed in 1988 and is internationally recognized and
used by organizations from many different industries. The investigation process
consisted of four main steps, namely, a determination of:
1. What happened (SnapCharT®);

2. Issues or Problems (Causal Factors);
3. Why the incident happened (Root Cause Analysis); and
4. Corrective Action Recommendations (CARs).
2.3 Information Collection (i.e. “What Happened”)
Numerous individuals (both current and retired) were interviewed as part of the
information collection process. Some of those interviewed were directly involved
in the design, construction and/or operations leading up to the contamination
incident. Others were more indirectly involved, and were interviewed for their
technical and background expertise and knowledge.
Numerous reports, detailed correspondence and photographs were also reviewed
and considered. An important information source for this investigation consisted
of reports from Golder, a technical consulting firm commissioned by Cameco to
examine the integrity of the concrete structures and the extent of the subsurface
contamination.
Relevant information was assembled into a detailed SnapCharT®, creating a time-

ordered listing of relevant events and associated conditions. The complete
SnapCharT® is detailed in Appendix 2 of this report.
2.4 Causal Factor (Problem/Issue) Definition
Six Causal Factors were identified for the subsurface contamination incident.
Causal Factors are general problems or issues. The Causal Factor numbering
reflects their order in time sequence and NOT their relative priority. This time
sequencing of Causal Factors may be observed in Appendices 1 and 2. There is no
prioritization of Causal Factors. The premise is that if any one Causal Factor had
been removed or significantly changed prior to the incident, then there would be a
good chance the incident would not have occurred or its consequences would
have been significantly reduced. A discussion of and basis for each Causal Factor
appears in Section 4 of the report. A visual illustration of the six Causal Factors,
and how they relate to each other and the subsurface contamination incident, may
be seen in Appendix 1.
Each Causal Factor is associated with, or more accurately the result of, numerous
conditions. The conditions provide additional information and help to explain
why the Causal Factor existed.
2.5 Root Cause Analysis
The TapRooT® Root Cause Analysis process calls for each Causal Factor to be
analyzed for root causes using the TapRooT® Root Cause Tree. The process
requires the investigator to identify as many root causes as are supported by the
information collected. The root causes detail why the Causal Factor was allowed
to exist. It is important to note that there is no ‘root - root cause’ to an incident (or
to a Causal Factor). Typically, there are several Causal Factors associated with an
incident and for each Causal Factor, there are several root causes. The Port Hope
UF6 Plant contamination incident was typical in this regard. Identification of valid
root causes permits the formulation of effective and practical Corrective Action
Recommendations (CARs).
2.6 Corrective Action Recommendations
A total of four CARs were developed to address the root causes stemming from
the six identified Causal Factors. These are detailed in a Corrective Action Matrix
in Section 5 of this report.
3.0 EVENTS LEADING UP TO THE INCIDENT
In a letter of October 29, 1980, Eldorado applied to the AECB for Site Approval
of the Port Hope Conversion Facility UF6 Facilities Expansion. Previously,
Eldorado carried out UF6 conversion in the East Plant.
In a letter of December 17, 1981, Eldorado applied to the AECB for Construction
Approval for the Port Hope Conversion Facility UF6 Facilities Expansion. At the
time, focus was placed on gaseous and liquid emission control and monitoring.
The groundwater-monitoring program was established as part of UF6 expansion in
advance of operation. The program was primarily intended to protect the
underground storage tanks at the municipal water works.
Lummus carried out the detailed design of the UF6 Plant. A task force, made up of
Eldorado personnel, was established to oversee the project. Their prime
responsibility was to provide oversight and technical input to Lummus. Lummus’
design documents and the construction manual did not consider ‘floors, sumps &
trenches’ as a potential leak path for uranium or harmful chemicals.
Lummus designed and constructed the concrete floors, sumps, pits and associated
joints in Building 50. ‘Floors, sumps & trenches’ were not considered to be a
safety related system and some structures were not designed to resist a corrosive
environment. The Cell Room trenches were not coated with a chemical resistant
substance as there was no specific design requirement identified to do so. Section
405, pg 22 of the design manual stated, "Floor in the 300 area is rarely (almost
never) washed down. Floor will be swept unless electrolyte spilled."
While the design documentation was not specific, the intent of Cell Room
trenches appeared to be to collect small amounts of tempered cooling water from
leaks in the cells and hold the tempered cooling water pipes. When additional
cells were added in 1996, the philosophy did not change. However, the design that
Spectrum Engineering provided for this project detailed specifications on the Cell
Room Expansion, including detailed directions on how to install water stop.
Lummus provided no equivalent detail for water stop for the original Cell Room.
As background, water stop is used to provide a water tight seal between two
joining concrete elements. The joints between joining concrete elements, such as
floor slabs and walls create a discontinuity (cold joint) in the concrete and form a
plane through which water can permeate. Water stop is used as a barrier across
this discontinuity and, when installed properly, prevents water migration across
the discontinuity.
Going back to the initial Lummus design, all process sumps were steel lined with
a space between the liner and the underlying concrete. The trenches in Cell
Maintenance, the Effluent Room and the Flame Reactor area were lined with a
chemical resistant coating. The floor of the effluent treatment area was coated, a
portion of which was covered with metal plating. The Pit was coated with a
chemical resistant liner.
The construction joints were “typically described” in Lummus Design Drawings.

For example, Section 9.1 of the concrete design document stated - "Where
indicated on the drawings, water stops shall be embedded in the concrete at
joints.” There was no indication on the Cell Room concrete drawings that a
vertical joint was present at the wall line of the trench. This may have had an
impact on the joint material used and may be why a water stop was not used in the
vertical joint that was later found to have failed. Experienced personnel
interviewed during the investigation into the subsurface contamination did not
recall the trenches being much of a focus at all during the design and early
operation of the UF6 Plant.
Lummus completed design documentation for Eldorado in the early 1980s and the
UF6 plant was commissioned. The first UF6 Plant operating activities took place
on April 2, 1984. The Operations Quality Assurance Manual, which applies to
safety related systems, took effect at the same time. As indicated earlier, ‘floors,
sumps & trenches’ were not considered part of a safety related system.
Right from the beginning and in all parts of the process, including liquid effluent,
the UF6 Plant experienced numerous operating problems. According to one senior
individual interviewed as part of this investigation, "There were so many
challenges associated with the UF6 plant in the beginning that effluent/water-
related problems were of lower priority.”
A Process Technology Group was set up in 1985. The intent of this group was to
improve operational effectiveness of the UF6 Plant. Members of the group were
involved during design and commissioning of the plant.
Being the low point, the Pit served as the primary collector for excess liquid. The
water volume experienced during operation was greater than design expectations.
Operational problems resulted in the Pit flooding on several occasions. The Pit
flooding resulted in water backing up into the unlined Cell Room trenches. This,
at times, necessitated the use of an outside tank.
Two tanks were originally located within the Pit to receive the process fluids from
Cell Maintenance. However, sludge from Cell Maintenance kept plugging the
tanks and it was difficult to remove the sludge from the tanks. A decision was
made in December 1984 to remove the two tanks and the associated pump from
the Pit. The change was implemented by the fall of 1986. As a result of the
change, the functionality of the Pit, as primary collector, was extended to include
what had been the influent to the tanks.
A shallow trench was cut to join the Effluent Room trench to the Cell Room
trench system very early in the operation of Building 50. The trench was to
provide a path for liquid from excursions in the Effluent Room to reach the Pit.
The trench also directed liquid flow away from Door 16. No formal design change
was carried out, as this system was not considered a safety related system.
Connecting the Effluent Room trenches to the Cell Room trench system
unintentionally introduced additional uranium into the Cell Room trenches and
into the Pit.
Moving forward in time, liquid frequently entered ‘floors, sumps & trenches’,
including Cell Room trenches. A resulting problem was the liquid entering
‘floors, sumps & trenches’ was frequently corrosive and attacked the structures.
During the current investigation, Golder found that some unlined concrete ‘floors,
sumps & trenches’ in the study area exhibited signs of deterioration from
aggressive solutions. In their report, Golder states - "In the area where the south
trench from Cell Rooms meets the north-south trench, the surface of the floor slab
exhibits deterioration similar to the walls of the trenches. It appears there may
have been aggressive solution on this surface in the past.”
There is a clearly a difference in appearance between the bottom half of the

concrete and the top half of the concrete in the original Cell Room trenches. The
bottom half appears as though it has been chemically attacked while the upper
half appears fully intact. This is an indication of a "wicking type action" from
chronic and corrosive wetness in the trenches.
It is probable that dilute acid, most likely from the electrolyte solution in the cells,
neutralization of the sticks used to manually check cell electrolyte level and/or the
acid wash station in the Effluent Room used to clean plant equipment removed
from service, pickled/attacked the concrete and any joints in the trenches.
Cell cooling coils sometimes failed and the electrolyte from the cells entered the
cooling water, making it mildly acidic. This, in turn, attacked the cooling water
pipes. Some failures have been experienced where the cell cooling water pipes
connect (e.g. on the threads) to the main header in the trench.
Electrolyte spills from cells and resultant cleanup was another way liquid in
trenches became corrosive. One Operator stated that all 30 Cells in the Cell Room
have “puked” several times due to over-pressurization. The standard approach has
been to wait for the electrolyte to dry and then scoop it into drums. The residue
was then washed into trenches.
Neutralization solution used to wash the sticks used to monitor cell levels was
discharged into the trench. There is no written procedure for this activity. The
solution could be corrosive if not done properly. Another source of corrosive
liquids reaching ‘floors, sumps & trenches’ was large equipment washing on the
floor near the trenches. This operation directed fluids to the trenches.
Going back to the chronological time sequence, Eldorado/Cameco made process

improvements in the UF6 Plant as time progressed. Several interviewees
commented, “We have better control of water now than with the original design.”
One person stated that it used to be batch operation through the scrubber towers
and now it is more continuous.
Cameco Corporation purchased the assets of Eldorado, including the Port Hope
conversion facility, effective October 5, 1988.
On October 7, 1990, a leak of process fluids/effluent out of Building 50 occurred
through Door 16 in the Effluent Room. A six-inch high berm in front of Door 16
in the Effluent Room was repaired in October 1990. However, it was not until
2003 that a formal PM on the berm was instituted, although an informal
operations check was being performed.
In combination with the problem that corrosive liquids presented to ‘floors, sumps
& trenches’, uranium and chemicals also frequently entered the ‘floors, sumps &
trenches.’ Most interviewees were not surprised to learn that uranium was found
in the Cell Room Trenches. Right from start-up in 1984, floor sweepers have
cleaned the process floors in the UF6 Plant and were emptied into the N-S Cell
Room trench. It was easy for the floor cleaners to empty their machines in close
proximity to the CTCW Tank because of the availability of water to flush the
equipment. The risk of this practice was not recognized. This operation likely
contributed to some of the uranium in the sludge in the Pit and the trenches.
Sludge sample results for this investigation for uranium in Cell Room ‘floors,
sumps & trenches’ are as follows:
1. North Trench - Middle Section = 2,100 ppm

2. North Trench - East End (old Cell Room) = <40 ppm
3. North Trench - West End (new Cell Room) = 1,200 ppm
4. South Trench - West End (new Cell Room) = 2,100 ppm
5. South Trench - Middle Section = 10,600 ppm
6. South Trench - East End (old Cell Room) = 5,300 ppm
7. CTCW enclosure = 56,000 ppm
into the Pit and Cell Room trenches was provided when a shallow trench, for
which no installation records have been located, was cut into the floor in the
Effluent Room.
Also, pieces of equipment that did not fit in the wash tank in the Effluent Room
were hosed down on the floor, the residue flowing to the Pit. When the Pit was
cleaned in 1990, the sludge was found to contain 17% uranium and 1,153 ppm
arsenic.
An additional contributor to this incident was that liquid and sludge remained in
the ‘floors, sumps & trenches’ for sustained periods of time. The Cell Room
trenches were not able to be routinely cleaned because they had piping (between
4" and 8") running down their length. The Cell Room trenches could only be
cleaned on a few occasions when the CTCW piping was changed out.
At times, the Pit partly flooded to the extent that its overflow flooded the North
and South Cell Room trenches. The CTCW Tank installation, which was
connected to the N-S trench, was designed such that liquid and sludge became
trapped in the interstitial space between the tank and the concrete. Also, the Pit
maintained a sludge and liquid level for extended periods of time. Effluent Room
trenches also contained sludge and liquid but these were frequently cleaned out
for operational reasons.
Trenches in and around the Cell Room appear to be sloped such that liquid flows
into them and is unable to fully drain out. There are also localized low points,
perhaps created partly by surface deterioration, in both the North and South
trenches. Elevation data may be viewed in Appendix 3.
The trenches in the East and West Cell rooms are roughly 50 and 36 metres in
length (164 and 118 ft) respectively. The design intent was to grade/slope the
trenches so that water flowed out. A Design Drawing Note states “all bottom of
trenches to slope max. 1/16 in. in 12 in. u.n. (unless noted).” This would result in
a maximum elevation change of 10.25 in. over 164 ft. The Design Drawing does
not specify a minimum slope. Elevation measurements show the as built
conditions for the Cell Room trenches have an average gradient of 1/32 inches in
12 inches. The difference between the highest and lowest measured elevations in
the South trench in the East Cell Room is approximately 4.8 inches.
There are localized low points in both the North and South trenches. Golder’s
examination of the Cell Room trenches indicated the solution in the trenches may
have pooled in places and did not flow through the trench as designed. During the
Golder coring of the south trench, they noted that the coring water actually flowed
a short direction west (up gradient) instead of east (down gradient).
Indications are that some ‘floors, sumps & trenches’ have deteriorated over time
and began to leak. This resulted in uranium and chemicals seeping through the
weakened locations in the concrete. Uranium and chemicals entered the soil and
slowly migrated. This was a very slow process that appears to have gone on for
years. As part of the UF6 plant construction, eight Refinery Wells (RWs) were
installed around Building 50 primarily to protect the municipal water supply.
These RWs have not yet detected any ground water contamination from Building
50 operations.
Following the discovery of subsurface contamination, Golder was contracted to

carry out a comprehensive study. They made the following observations in their
reports:
The groundwater monitoring data from the new borehole series wells
indicate general impacts beneath the Cell Maintenance Room, in the
general vicinity of the Pit and concrete trenching just upstream of the Pit;
The trench running north-south that connects the two trenches in the Cell
Rooms to the Pit is exhibiting considerable deterioration in areas and some
of the cracks observed are the likely sources of uranium and chemicals
leaking from the trench system into the soil;
Inspections undertaken as part of the concrete assessment indicate the
potential for leakage to the subsurface to have occurred from several
locations and/or features within the Study Area (Effluent Treatment, Cell
Room, and Cell Maintenance Area) in addition to the immediate vicinity
of the excavation for the new CTCW structure;
A 150 mm diameter core was taken vertically on the north side of the
South trench at the east wall through the joint. The core revealed that the
joint is approximately 15 mm wide with the top 12 to 20 mm of the joint
sealed. A metal rod could be inserted along most of the vertical length of
the joint deep enough to reach underlying soil;
The concrete around a drain pipe leading under the slab from the trench at
the North Door (Door 16) in the Effluent Room into the filled in trenches
exhibits considerable deterioration;
The CTCW concrete retaining structure that contained the cooling water
tank exhibits some surface deterioration but no cracking or delaminations;
and
The grout layer on the bottom of the Pit was delaminated but the
underlying concrete was sound. After further investigation, a leak path
from the Pit was not located.
The PM program in place to check the condition of ’floors, sumps & trenches’ in
the UF6 Plant was limited to the berms, checking of the sumps in the Effluent
Room and the AHF unloading area trench. While there is evidence that repairs
have been done to the “floors & sumps”, it appears these were carried out as
needed and not as part of an overall PM program.
One Golder concrete specialist stated that expansion joints typically have a
service life. There is no documented requirement for joint maintenance in any
design documentation and there is no indication that the expansion joint, found
leaking in the South Cell Room trench, had ever been inspected.
Deterioration in the concrete trenches and floors, for the most part, went
undetected. The only formal monitoring system (i.e. RW system) has not yet
detected leakage from the ‘floors, sumps & trenches.’
Some repairs to the ’floors, sumps & trenches’ were carried out on an individual
basis. Cell Room Operators indicated they did not notice the condition of the
trenches as they were behind the Cells, there was a steel grate on top of the
trenches and Operators did not go back there very often.
No requirement was specified for inspection in the design or safety manual

because it was not recognized as a potential leak path. As a consequence, there
was no program in place to inspect trenches.
As part of the PHA (Process Hazard Analysis) process, the area engineer was
asked to develop a NDE (Non Destructive Examination) test to determine whether
the sumps in the Effluent Room were leaking. He developed such a test and
checked the Effluent Room sumps on an ad hoc basis. An NDE test was not
developed to check for leaks in other “floors, sumps & trenches” beyond the
Effluent Room.
An area engineer began checking sumps for leaks in the Effluent Room in 1993-
94. By 2000, a leak test determined that sumps 405FA11 and 405FA01 needed to
be removed from service. Upon sump liner removal, the leakage was determined
to be by way of the carbon steel liner. No breach of the concrete chamber had
occurred.
The 1990 Annual Report indicated that the Pit was cleaned during the summer
shutdown. The liquid level in the Pit was visually monitored over the 3-month
shutdown and appeared to remain stable. The report indicates that any leak in the
containment, if it exists, is small.
The June 1990 ERA (Environmental Risk Assessment) listed current preventative
measures for the leakage scenario from the Pit as follows: "Pit was probably not
intended to continuously hold liquid. The bottom and part of the side walls were
acid-proofed in case tanks in the Pit failed. However, at present, there is no
evidence of significant leakage. Liquid level likely above the acid proofed section
of side walls but is caustic, not acidic. Pit level monitored, no sign of steady level
loss at present."
An assessment for ground water monitoring was carried out during the 1990’s. At
the CNSC’s request, this work was re-assessed in the late 1990’s and finalized in
early 2000. The work was done by Golder.
The June 2006 Safety Report (Issue 4) contained the following statement: "Sumps
continue to be checked for leakage at least once per year by the area engineer."
In April 2006, a CTCW tank inspection indicated it would need to be replaced

within a few years. Cameco decided to advance the schedule and replace the
CTCW tank in 2007.
Safety Report (Issue 4) in June 2006 indicated that only some sumps (401FA14
(UF6 plant), 35G18 and 51G106 (UO2 plant)) specify double lined, maintained dry
and solids regularly removed. In the Environmental Aspects Registry,
contamination of groundwater was only considered from sumps in the tote bin
area. There was no reference to elsewhere in Building 50. While the above
conditions show an increased awareness of the hazard as time went on, the focus
was still on sumps.
In 2007, a contractor began work on a rectangular excavation in Building 50 of

the UF6 Plant. The excavation was to house a new CTCW tank, which is desired
due to an increased number of cells. The new CTCW tank was to be placed in a
concrete in-ground structure. The design specified double walled protection. As
well, monitoring of the integrity of the tank was to be part of the new design and
operation.
On July 12, 2007, the contractor pulled a small tree root from the soil in the
excavation. Liquid was noticed leaking into the excavation from the hole left by
the tree root. The next day, the contractor noticed a yellow stain in the bottom of
the excavation. The yellow stain was found on the surface of freshly poured
concrete in the excavation. Cameco management were notified and began to
investigate. Cameco immediately recognized that the yellow stain was associated
with uranium.
Cameco decided to voluntarily initiate a shut down of UF6 production operations

and initiated an investigation into the source of uranium. Cameco promptly
advised the CNSC and the MOE Spills Action Centre of the incident. The MOE
Spills Action Centre notified Environment Canada. On July 19th, a complete plant
shut-down was initiated.
Subsurface contamination was confirmed in Building 50. Cameco initiated a

formal investigation into the incident to determine causes and the extent of the
contamination. Golder was contracted to carry out a comprehensive investigation.
KnoW Problem Inc. and CJB Consulting Associates Inc. were contracted to carry
out a root cause incident investigation.
4.0 CAUSAL FACTORS AND SUPPORTING INFORMATION
4.1 Causal Factor #1 – Some ‘floors, sumps & trenches’ are not designed to resist a
corrosive environment
Discussion of Causal Factor
While the trenches in Cell Maintenance, the Effluent Room and the Flame
Reactor area are lined with a chemical resistant coating, the Cell Room trenches
are not. There was no design requirement identified to do so. Experienced
personnel interviewed did not recall the trenches being much of a focus at all.
While the design documentation is not specific, the intent of Cell Room trenches
appears to be to collect small amounts of distilled water from leaks in the cells,
and to hold the cell tempered cooling water return piping. When the UF6 plant was
designed, not having a secondary barrier inside an operating plant was normal.
The assumption was if you had a concrete floor, it would not be a problem.
The construction aspects were discussed as a possible causal factor but the change
from a monolithic floor in the Cell Room appears to have been appropriately
handled with the installation of the water stops. Records associated with these
types of construction changes were not found.
Basis for Causal Factor
• While the design documentation is not specific, the intent of Cell Room
trenches appears to be to collect small amounts of water from leaks in the
cells, and to hold the cell tempered cooling water return piping;
• Cell Room trenches not lined with a chemical resistant coating. No design
requirement identified to do so;
• The two original tanks in the Pit were removed within a couple of years
after the UF6 plant began to operate. This was completed in the fall of
1986. However, the Pit is coated with a chemical resistant liner;
• The trenches in Cell Maintenance, the Effluent Room and the Flame
Reactor Area are lined with a chemical resistant coating;
• The area engineer removed some of the trenches in the Liquid Effluent
Room. The plan was to fill in others over time;
• All process sumps are steel lined with a space between the concrete and
the steel;
• Section 9.1 of the Lummus Engineering Specification # 9326-A-411
covering concrete material and construction for the UF6 plant states
"Where indicated on the drawings, water stops shall be embedded in the
concrete at joints";
• The failed construction joint at the east end of the East Cell Room is not
specifically identified on the Lummus Design Drawings. This may have
had an impact on the joint material used and the fact that a water stop was
not used in the joint;
• A section of water stop material was found at a depth of 660 mm on the

south side of the Core C1. Removing a small section of the trench wall
adjacent to the location of Core C1 showed the water stop was installed
parallel with trench wall and was located approximately 75 mm in from
the surface of the wall;
• With respect to the trench in the Cell Room where one leak point was
identified, Golder confirmed that the water stop does not continue across
the construction joint at the wall and therefore there is a leak point at this
location;
• Exposing the water stop also confirmed that the trenches in the Cell Room
had been cast in two sections. The floor was cast first, then the walls. This
construction may not reflect the intention of the construction drawings
(Detail 9 of Drawing No. E9326-1 00108-L), which imply monolithic
construction of the trenches. Failure to install the trench using a
monolithic pour technique could create “cold joints” that could lead to
small openings in the concrete structure, and that could provide focal
points for attack by aggressive solutions;
• The floor of the effluent treatment area is coated, a portion of which had
been covered with metal plating;
• A core was taken in the in-filled trench in the hallway leading by the Pit to
the entrance to the effluent treatment area. It shows that the trench in that
area was only about 75 to 100 mm deep, and was not lined;
• Regarding the Cell Room expansion, Spectrum Engineering Corp.
Drawing No. 94014, titled Cell Room Relocation - Slab on Grade
Sections, contains numerous specification notes. Note C9 states
“Construction joints required by the contractor shall be approved by the
engineer before construction. Construction joints in retaining wall on Line
H shall include a 6 inch water stop”;
• Spectrum Engineering provided detailed specifications on the Cell Room
Expansion, including detailed directions on how to install water stops.
Lummus provided no equivalent detail for the original Cell Room.
However, there were no specific instructions in the Spectrum Engineering
documentation for a water stop in the vertical joint between the East and
West Cell Rooms;
• Section 4.4.1 of the Lummus Engineering Specification # 9326-A-411
covering concrete material and construction for the UF6 plant states
"expansion joint filler shall be preformed, non-extruding, resilient type
conforming to ASTM D1751 unless otherwise specified on the drawings.
Joints shall be sealed with rubber-asphalt joint sealer";
• Section 4.6.1 of the Lummus Engineering Specification # 9326-A-411
covering concrete material and construction for the UF6 plant states "water
stop material shall be virgin, polyvinyl chloride, having a minimum depth
of 4" and a multiple ribbed cross-section with a center bulb, "Sealtight"
type number 4316 or equal";
• Section 405, pg 22 of the design manual states "Floor in the 300 area is
rarely (almost never) washed down. Floor will be swept unless electrolyte
spilled." The 300 area comprises the Cell Room and Cell Maintenance
areas;
• The June 2006 Safety Report (Issue 4) indicated that only some sumps
(401FA14 (UF4 dryer), 35G18 and 51G106 (UO2 plant)) specify double
lined, liquids not retained and solids regularly removed; and
• In the Environmental Aspects Registry, contamination of groundwater
from sumps is only considered in the tote bin area. There is no reference to
elsewhere in Building 50.
Interview Data - Recognizing that individual opinions and beliefs are subjective,
and in some cases not factual, interviewees had a fair amount to say in this area.
Most of it is quite consistent:
• One interviewee involved in commissioning and early operation stated

“much time and effort was placed in the design of the concrete floors,
trenches and sumps in the UF6 plant. Special, high density concrete was
used. The type that would not crack and would be non-porous”;
• A Golder concrete specialist commented that the concrete in the Cell
Room is good quality;
• Experienced personnel interviewed did not recall the trenches being much
of a focus at all;
• When the UF6 plant was designed, not having a secondary barrier inside
an operating plant was normal. The assumption was if you had a concrete
floor, it would not be a problem;
• The original Pit design called for two tanks located within the Pit. One
tank was to take the process fluid from Cell Maintenance. But there was
too much sludge and it kept plugging up the tank. No way to remove the
sludge once it plugged;
• One experienced person believed the trenches in the Flame Reactor Area
were of the same design as those in the Cell Room, but did not present a
problem. In fact, the trenches in the Flame Reactor area are coated, as per
drawing requirements;
• Several interviewees commented that the main thing they tried to do with
liquids is to keep them inside the building. They all thought "brand new
building, we are contained";
• One interviewee involved in the design of the Cell Room extension stated
“Water and electrical buses associated with the cells do not go well
together. The only purpose for the Cell Room trenches is to channel water
away from the electrical buses and to provide a channel to house the
cooling water pipe below floor level”;
• When additional cells were added, the philosophy did not change.
However, more detail was provided in the 1995 design specifications for
the expansion; and
• The investigation team was aware that the June 1990 ERA proposed the
long term plan for the Pit was to fill it with concrete and use an above
ground tank. This was initially targeted to be done in 1993/94. The team
was told by a couple of senior interviewees that the priority level for this
initiative has simply never reached the point where action has been taken.
Essentially, it was considered ‘nice to do’ but not ‘must do’. Golder’s
inspections of the Pit revealed that it was sound concrete with compressive
strength above 36 MPa. There were two layers of chemical resistant lining
on the bottom and one on the walls. There were no visible leak points
from the Pit.
4.2 Causal Factor #2 – Liquid entering ‘floors, sumps & trenches’ is frequently
corrosive and attacks the structures
It is generally acknowledged that corrosive chemicals have gone into the concrete
structures over the years. Some of the structures, including the floors in Liquid
Effluent and Cell Maintenance and the Liquid Effluent trenches, are designed to
withstand corrosive chemicals (e.g. overflows from tanks). Other areas, such as
the Cell Room trenches, are subjected to corrosive chemicals through process
upsets such as ‘puking’ from the electrolytic cells and water balance problems
that lead to back-flooding the trenches from the Pit. The Cell Room floors and
trenches do not have a chemical resistant liner. Modifications to the Liquid
Effluent trenches resulted in cross connecting these trenches with the Cell Room
trenches and increased the frequency of their exposure to these chemicals.
Golder Report Findings
• In the area where the South trench from the East Cell Room meets the N-S
trench, the surface of the floor slab exhibits deterioration similar to the
walls of the trenches. It appears there may have been aggressive solution
on this surface in the past;
• It appears that process liquids may have been spilled onto the unprotected
floor areas of the Cell Maintenance Area;
• It appears that all of the Cell Room trenches exhibit varying degrees of
surface deterioration from aggressive solutions and have delaminated
surfaces in isolated areas. The joints at the ends of the trenches at the east
wall are the most likely points where process liquids could leak out of the
trenches;
• There is a clearly a visual distinction between the bottom half of the
concrete and the top half of the concrete in original Cell Room trenches.
The bottom half appears as though it has been attacked while the upper
half appears fully intact. This is an indication of a “wicking type action”
from chronic and corrosive wetness in the trenches; and
• According to a Golder concrete specialist, caustic solutions above 25%
will attack concrete. The caustic solutions finding their way to the ‘floors,
sumps & trenches’ over the years would be quite a bit lower in
concentration than 25%. As such, it is likely that mildly acidic solutions

attacked the concrete.
• There was no identified design requirement to deal with chemical

resistance treatment of some ‘floors, sumps & trenches’, in particular the
Cell Room trenches;
• It is generally acknowledged that acid has gone into the trenches over the
years. The acid sources are cell body failures and header pipe leaks;
• Dilute acid, probably from the electrolyte solution in the cells,
pickles/attacks the concrete in the trenches;
• Cells fail and the electrolyte enters the cooling water, making it mildly
acidic. This, in turn, attacks the cooling water pipes. Some failures have
been experienced where the cell cooling water pipes connect (e.g. on the
threads);
• Electrolyte spills from cells and the resultant cleanup is another way liquid
in trenches can become corrosive;
• There is a sink right next to the failure point in the joint in the South Cell
Room Trench. The sink is used by Operators to wash their sticks used to
monitor cell levels. This is done 3 times per shift per cell and there are 54
cells. According to one interviewee, the sink is neutralized and dumped
into the trenches. If there is any deviation in following the accepted
neutralization practice, corrosive liquid may be released to the trench
system;
• The Cell Maintenance area is used, in part, to dismantle cells for
maintenance; and
• One employee interviewed suggested that a significant amount of sludge is
produced by Cell Maintenance.
4.3 Causal Factor #3 –Uranium + chemicals frequently enter the ‘floors, sumps &
trenches’
Higher than anticipated volumes of process chemicals periodically entered the

trenches and sumps as a result of operational problems. Process chemicals were
routinely introduced into the structures from cleaning and scrubbing operations.
Chemicals present in the process fluids would include uranium, fluorides,
potassium hydroxide, arsenic, copper, and nickel. Subsequent design changes to
address the problem of high liquid volumes may, in fact, have had unforeseen
adverse consequences by introducing additional uranium and chemicals into the
Cell Room structures.
• Right from start-up in 1984, floor sweepers cleaned the process floors in
the UF6 plant and were emptied into the N-S Trench just east of the Cell
Room. The sweepers were discharged and rinsed out in close proximity to
the CTCW Tank. It was easy for the floor cleaners to use this location as
there was a hose nearby that they used to rinse out their machines;
• The idea was that this water would then go to the Pit;
• Measured sludge sample results for uranium in nearby in-ground
structures are as follows:
o North Trench - Middle Section = 2,100 ppm

o North Trench - East End (old Cell Room) = <40 ppm
o North Trench - West End (new Cell Room) = 1,200 ppm
o South Trench - West End (new Cell Room) = 2,100 ppm
o South Trench - Middle Section = 10,600 ppm
o South Trench - East End (old Cell Room) = 5,300 ppm
o CTCW enclosure = 56,000 ppm
• A shallow trench was constructed between the Effluent Room and the
North Cell Room trench early in the operation in an attempt to control
water in the Effluent Room;
• The shallow trench from the Effluent Room provided a channel for
additional uranium containing liquids to get into the Pit and the Cell Room
trenches during water excursions. This was not recognized as an issue at
the time the trench was constructed and used;
• Sump 405FA11 and the Effluent Room trenches, as well as the connecting
trench between the Effluent Room and the Cell Maintenance Room were
both filled in around 2000; and
• Tanks in the Effluent Room contain uranium in solution. By design, they
occasionally overflowed to the floor. Initially, it overflowed to a trench in
the Effluent Room. When this trench and sump were filled in with
concrete in 2002, tank overflows were directed to the floor.
into the Pit and Cell Room trenches was provided when a shallow trench was cut
into the floor in the Effluent Room.
Interview Data - Again, recognizing that individual opinions, beliefs and

recollections are subjective, and in some cases not factual, interviewees had much
to say in this area. Most of it is consistent:
• Most interviewees were not surprised there was uranium found in the Cell
Room Trenches. However, one key individual indicated he was surprised
there is uranium in the Cell Room trenches;
• The area engineer made the decision to fill in the trench in the Effluent
Room. He indicated it really didn't matter because conceptually,
everything flows toward the Pit. That is what the PHA process concluded;
• Little grooves were then cut in the floor to help to channel the water
toward the Pit;
• Believe the purpose of the shallow trench connecting the Effluent Room to
the North Cell Room trench was to prevent water going out Door 16;
• The reason the area engineer filled in some of the trenches in the Effluent
Room was because they could be leak paths. Secondly, it was physically
very difficult to shovel sludge out of an 18" trench into drums;
• Filling in the trenches in the Effluent Room originated with the PHAs. A
question from the PHAs was "how do you contain chemicals?" The
answer was "the Pit";
• At one time, we used dirty KOH (i.e. KOH containing uranium) to
neutralize cells in the Cell Maintenance Area;
• Pieces of equipment that would not fit in the wash tank in the Effluent
Room would be hosed down on the floor. The residue would go to the Pit;
• Tank FB02 now overflows only a couple of times each year;
• At one point, the trenches were all connected;
• Have not seen the Pit fill with water and back flow into the trenches for
years;
• Not easy to dump floor machines directly into the Pit. Easier to dump into
the trenches because there is a hose nearby to rinse the machine;
• Floor machines from the Tote Room have been discharging there for 5 to 7
years. As long as they have had machines. In recent years, 25% discharged
to the N-S Trench near the CTCW pump and 75% to the lined trench in
the Cell Maintenance Room near the cell neutralization wash basins;
• On each occasion, 3 to 5 gallons of waste were discharged from each
machine and then the machines were rinsed with a garden hose for 10 to
15 minutes;
• While the shallow trench was in use, the uranium concentrations coming
to the N-S trench from the Effluent Room could have been elevated
relative to those from the floor sweepers; and
• There were more waste streams than intended from the scrubbing circuit.
4.4 Causal Factor #4 – Liquid and sludge remain in the ‘floors, sumps & trenches’
for sustained periods of time
The water balance problems experienced in the early operation of the plant meant
that the structures were subjected to more liquid than expected. When the water
balance improved, some portions of the Cell Room trenches continued to hold the
effluents because of their construction. Although the intent was to grade/slope the
trenches from west to east, some portions contained low spots and would retain
effluents. In the case of the Cell Room trenches, the construction drawings
required a maximum slope, which was met. The design did not specify a
minimum slope. Also, the design of the CTCW tank installation and the Cell
Room trenches did not allow for removal of trapped sludge.
• The Pit provides storage for spills and overflows. With liquid spilling on
the floor and tanks in the Effluent Room overflowing, the liquid in the Pit
would rise. When the Pit level became high enough, the liquid, bearing
uranium and chemicals from the Pit, would flow back into the trenches in
the Cell Room. This happened on several occasions;
• As reported in the 1990 Annual Report, the Pit was cleaned out during that
year. When the Pit was cleaned, the sludge was found to contain 17%
uranium and 1,153 ppm arsenic;
• The Cell Room trenches were not able to be cleaned because they had
piping (between 4" and 8") running down their length;
• Whenever the return piping in the Cell Room trenches was replaced, the
sludge and water was cleaned out from the trenches;
• The inter-space around the CTCW Tank was connected to the trench
system. Once this became full of sludge, it could not be cleaned without
removal of the Tank;
• Golder’s examination of the Cell Room trenches indicates the solution in
the trenches may have pooled in places and did not flow through the
trench as designed;
• During the coring of the south trench, it was noted that the coring water
actually flowed a short direction west (up gradient) instead of east (down
gradient) (Golder report);
• The apparent design intent was to grade/slope the trenches so that water
flowed out. A Design Drawing Note states "all bottom of trenches to slope
max. 1/16 in. in 12 in. u.n." This would result in a max elevation change of
10.25 in. over 164 ft. (No minimum slope is specified);
• Elevation measurements show the as built conditions for the Cell Room
trenches have an average gradient of 1/32 in. in 12 in.;
• Elevation measurements made as part of the investigation indicate the
slope of the trenches is variable. The actual survey data is shown in
Appendix 3; and
• With the elevations as they are, fluids can be trapped in localized low
points in the trenches.
• Several interviewees discussed the major imbalance of water in the

beginning few years and their impression that more water coming in than
could be handled or processed. This resulted in the ‘floors, sumps &
trenches’ receiving and retaining a greater than expected volume of fluid.
Some specific comments include:
o Couldn't turn the liquid around fast enough. Needed a repository

for the liquid;
o We needed to work hard to get the UF6 plant to work. We needed
to figure many things out for ourselves, including how to control
water;
o There were so many challenges associated with the UF6 plant in
the beginning that effluent/water related problems were of lower
priority;
o I definitely remember a few times when water overflowed out of
Door 16 of the Effluent Room;
o All streams must keep looping through the Liquid Effluent Room.
The challenge is managing the "water balance";
o We experienced plugging problems and this led to an abundance of
liquid effluent. We had to bring in an extra tank to accommodate it;
o If an evaporator fails, you need to order in extra tankage
immediately;
o Could get an overflow in Cell Maintenance if someone
inadvertently leaves a steam hose on over the weekend;
o When you have a power failure, Operators attempt to get the
chemical balance under control immediately. When that is done,
then they can focus on effluent;
o The Manager of Production set up a Process Technology Group
soon after commissioning of the plant with the purpose of getting
the UF6 Plant to work better;
o We have better control of water now than with the original design.
It used to be batch operation through the scrubber towers and now
it is more continuous;
• The Pit became the “liquid safety net” once the two original tanks were
removed;
• The trenches in the Effluent Room were cleaned out every summer
shutdown. We shovelled, into drums, the uranium that built up;
• The Cell Room trenches didn't always have liquid in them but they would
have a little bit in them very often. Another person stated there was always
water in the Cell Room trenches, which originated from various leaks in
the process;
• The Effluent Room has historically been referred to as "the swamp" as it is
always wet;
• There was definitely a build up of solids in all of the trenches;
• The current area engineer tries to reduce the sludge levels in the Pit to as
low a level as possible and then pump it to the large tank in the Effluent
Room;
• The trenches containing uranium sludge are back breakers to clean. They
are cut to a depth of about 18 inches;
• The trenches and sump in the Effluent Room were filled in and now the
floor is always wet. Operators were not happy about this;
• Don't think the Effluent Room was designed to have water on the floor.
We started to have water issues after the sump and trenches were filled in;
• Berms were constructed on many external doors, including the large door
(Door 16) at the north end of the Effluent Room;
• On occasion, the water in the Effluent Room gets above the berms and the
"coping" and into the cement wall;
• The floor in the Effluent Building was always wet. No one was concerned.
It was accepted practice; and
• The debris/sludge just pumped out of the Cell Room trenches was mostly
rust and mud. It was not very heavy.
4.5 Causal Factor #5 – Some ‘floors, sumps & trenches’ deteriorated over time and
began to leak
The extensive work conducted and reported by Golder identified and documented
several locations where structures had deteriorated and potential leak paths for the
uranium and chemicals were present.
Some of the deterioration was due to the design (e.g. no lining for the Cell Room
trenches). There were also instances of insufficient design detail, especially at the
floor slab to wall joints. Where this joint was present in a trench, there was no
specification for a water stop and thus the joint became a potential weak point.
All structures are subject to deterioration with time. The severity of deterioration
is subject to many conditions, such as environment (e.g. corrosive service),
materials of construction and construction methods. Although there was some
inspection of the sumps conducted by the production group and evidence of
repairs to floors, there was no requirement for a preventive maintenance program
associated with these structures because these structures were not identified as
‘floors, sumps & trenches’ or safety related.
• The PM program in place to check the condition of ‘floors, sumps &

trenches’ in the UF6 Plant was limited to the berms, checking of the sumps
in the Effluent Room and the AHF unloading area trench; and
• There is evidence that repairs were done to the ‘floors, sumps & trenches’.
However, it appears the repairs were carried out as needed and not as part
of an overall PM program.
Golder Report Findings (August 30, 2007)
• The concrete trench in the Cell Maintenance Room that connects the two
trenches in the Cell Rooms (N-S trench) with the Pit is exhibiting
considerable deterioration, especially the section where the excavation for
the new CTCW tank was dug;
• Uranium concentrations in groundwater were elevated in all 12 boreholes
in the Study Area relative to those of the external (RW series) Refinery
Wells outside of the building;
• The highest concentration of uranium (445 mg/L) in a groundwater sample
was collected from beneath the Cell Maintenance Room (Borehole BH50-
2);
• Concentrations decreased with distance from the Cell Maintenance Room,
decreasing to values of tens of milligrams per litre within approximately
20 m of this monitoring location;
• Inspections undertaken as part of the concrete assessment indicate the
potential for leakage to the subsurface to have occurred from several
locations and/or features within the Study Area in addition to the
immediate vicinity of the excavation for the new CTCW structure;
• The groundwater monitoring data indicate general impacts beneath the
Cell Maintenance Room, in the general vicinity of the Pit and concrete
trenching just upstream of the Pit. After further investigation, Golder has
found no evidence to suggest that there is a leak path from the Pit;
• Uranium and chemicals seep through the cracks and holes in the concrete,
enter the soil and eventually migrate to the ground water below. This is a
very slow process that could have gone on for years;
• Cores were taken from the floor of the N-S Trench in the Cell
Maintenance Room to investigate cracking observed during the visual
inspection;
• The trenches in the West Cell Room constructed in 1996 are in good
condition;
• The trenches of the East Cell Room constructed in 1984 have exposed
concrete surfaces. General loss of the concrete paste by aggressive
solutions was noted in the lower half of the trenches due to exposure to
process liquids, including dilute hydrofluoric acid;
• The severity of loss (scaling) on the trench walls varies depending on the
height of liquid in the trenches over time. In general, the depth of loss into
the concrete is about 10 to 30 mm;
• Delaminations (separations within the concrete) were noted in the concrete
in the bottom of both trenches in the East Cell Room near the east end;
• The inspection indicates that there appears to be a joint between the trench
floor and the trench wall at the east end of the East Cell Room. In several
locations, a piece of wire could be inserted up to approximately 75 mm

into the joint;
• In transition from East Cell Room to the Cell Maintenance Area,
construction joints exhibited considerable deterioration where the trenches
meet the East wall of the Cell Room;
• A 150 mm diameter core was taken vertically on the north side of the
south trench at the east wall through the joint. The core revealed that the
joint is approximately 15 mm wide with the top 12 to 20 mm of the joint
sealed. A metal rod could be inserted deep enough to reach underlying soil
along most of the vertical length of the joint;
• The North Cell Room Trench was also cored in an area of a suspected
delamination. Core C4 confirmed the presence of a delamination at a
depth of approximately 65 mm. Examination of the cores obtained from
the trenches indicates that the concrete below a depth of 60 to 75 mm
appears to be sound and of generally good quality;
• Core C8, shown on Figure 4.11 was taken over a longitudinal crack near
the south end of the trench. The core was advanced full depth through the
slab and the crack extended the full length of the core. A soil sample was
taken from below the C8 core location and was sent for analysis. The soil
sample under core C8 showed a positive result for uranium of 16,000 ppm;
• One possibility is that the jack hammering for the new CTCW Tank may
have created some of the damage (i.e. cracking of the concrete in the N-S
Trench). However, Golder discounts this and indicates that the crack is not
a new one;
• The CTCW concrete retaining structure that contained the cooling water
tank exhibits some surface deterioration, but no cracking or delaminations.
The grout layer on the bottom of the Pit was delaminated but the
underlying concrete was sound;
• The trenches in the Cell Maintenance Room do not have any
delaminations, but there is some minor chipping of the liner material along
the top edges of the trenches in isolated areas;
• In summary, the N-S Trench that connects the two trenches in the Cell
Rooms to the Pit is exhibiting considerable deterioration in areas and some
of the cracks observed are the likely sources of uranium and chemicals
leaking from the trench system into the soil;
• The visual inspection of the Pit indicated minor areas where the coating on
the walls was missing, usually in relation to some piece of equipment that
had been attached to the wall in the past;
• The floor topping in the Effluent Room is delaminated in sections,
especially over the concrete in-filled trenches;
• The core taken in the in-filled trench in the hallway leading by the Pit to
the entrance to the Effluent Room showed some evidence of deterioration
in the concrete below the trench;
• A detailed condition survey was carried out on the in-ground trench in
front of Door 16 in the Effluent Room. The concrete is delaminated and
spalled in the center portion of the trench to a depth of approximately 75-

80 mm.;
• The concrete around a drain pipe leading under the slab from the trench at
Door 16 in the Effluent Room into the filled in trenches exhibit
considerable deterioration and the pipe was filled with material;
• With respect to the trench near Door 16 in the Effluent Room, it is
Golder’s opinion that the evidence collected during inspection and testing
of the floor trench in that location indicates that the trench contains
structural cracks and joints. Again in Golder’s opinion, these cracks and
joints would facilitate releases of fluids that may have been contained in
the trench to the subsurface. There is visual evidence of uranium-
containing precipitates within the structural features observed in the
concrete and the soil beneath the trench contains elevated uranium;
• Cores taken from the floor slab near the north effluent drum dryer indicate
the concrete is sound and the floor slab is approximately 200 mm thick;
• Based on the observations and measurements completed related to the
steel sump linings in the Effluent Room, there is no evidence that these
sumps have contributed to process liquid releases to the environment; and
• Reinforcing with concrete does not prevent concrete from cracking. The
rebar essentially holds the concrete together when it does crack.
Interview Data - Again, recognizing that individual opinions, beliefs and

recollections are subjective, and in some cases not factual, interviewees had some
comments in this area. Most comments are consistent:
• In the early 1990s in the Effluent Room, the area engineer noticed a
crack/hole in the floor, through which water was disappearing. The
crack/hole was patched. The possibility was not recognized that the
crack/hole may have already provided a path for uranium and other
chemicals to reach the soil and water below the floor;
• Cell Room Operators really didn't notice the condition of the Cell Room
trenches as they were behind the Cells and Operators didn't go back there
very often;
• Because of the piping in the Cell Room trenches, it was not possible to
inspect them;
• One interviewee recalled the walls and the floor of the Pit being resurfaced
during one of the shutdowns. To do this, a contract company came in and
cut out a big hole in the lid of the Pit (the investigation team was unable to
find supporting documents);
• One interviewee recalled the Pit being cleaned and did not recall any
cracks being found (the 1990 Annual Report references cleaning the Pit);
• One Golder concrete specialist stated that expansion joints typically have a
service life. They do not last forever. There is no indication that the
expansion joint found leaking had ever been inspected. There is no
specific requirement for this in any design documentation;
• The same Golder concrete specialist indicated there was no such thing as a
maintenance free structure; and
• The Golder concrete specialist indicated that the crack found in the bottom
of the N-S Trench in the Cell Maintenance Room is not that large and
could have been caused by any one of several factors (shrinkage, cold
joint, etc.).
4.6 Causal Factor #6 – The monitoring program does not detect deterioration of
and/or leakage from the ‘floors, sumps & trenches’
The monitoring referred to actually consists of two types. The first is monitoring
of the ‘floors, sumps & trenches’ for deterioration and potential leakage. This can
take the form of planned and scheduled inspections or active leak detection with
real time reporting. The second method is that offered by the groundwater
detection system. In the latter case, the system will identify leakage long after it
occurs.
The ‘floors, sumps & trenches’ were not originally identified as safety related and
thus there was no requirement for monitoring. Therefore, none was conducted.
However, it is noted that over time the awareness of sumps and the Pit as potential
leak sources was identified and some action taken.
There is a formal groundwater monitoring program in place. This monitoring

program was established during the siting and construction processes, leading to
the development of the current program of Refinery Wells. A review of the
correspondence suggests that the primary concern was protection of the nearby
municipal water treatment facility. Early leak detection from Building 50 was not
identified as being necessary. As early as 1983, it was recognized that the
groundwater flow in this area is slow, which means that although it will take
several years to detect a leak that has occurred from Building 50, there would be
sufficient warning to initiate corrective action so as to limit environmental impact.
• There is no requirement, nor program in place, to inspect trenches, floors

or joints in Building 50;
• However, as part of the PHA process, the area engineer was asked to
develop an NDE test to determine whether the sumps in the Effluent
Room were leaking. The test was developed and the Effluent Room sumps
were checked on an ad hoc basis;
• There is no requirement for on-line monitoring for leakage in the
interspaces between the sump steel liners and the concrete;
• The 1990 Annual Report indicates that the Pit was cleaned. The liquid
level in the Pit was visually monitored over the 3-month shutdown and did
not appear to change. The conclusion drawn was, if there are any leaks,
they are small;
• An area engineer began checking sumps for leaks in the Effluent Room in
1993-94. By 2000, a leak test determined that sumps 405FA11 and
405FA01 needed to be removed from service. Upon sump liner removal,
the leakage was determined to be by way of the carbon steel liner. No
breach of the concrete chamber had occurred;
• An Environmental Risk Assessment document was issued in June 1990
(revisions in 1991 and 1993) and refers only to sumps and the Pit;
• The June 1990 ERA document details only one risk scenario related to this
incident, namely a KOH/uranium leak from the Pit to the groundwater
table. It is listed as a low probability scenario, caused by an undetected
leak of used scrubber solution from the Pit which formerly contained tanks
to handle cell maintenance waste waters and Cell Room ‘sumpage’;
• The June 1990 ERA lists current preventative measures for the leakage
scenario from the Pit as follows: “Pit was probably not intended to
continuously hold liquid. Bottom and part of side walls were acid-proofed
in case tanks in the Pit failed. However, at present, no evidence of
significant leakage. Liquid level likely above acid proofed section of side
walls but is caustic, not acidic. Pit level monitored, no sign of steady level
loss at present”;
• The June 1990 ERA lists Proposed Changes for the leakage scenario from
the Pit as follows:
o Plan to inspect condition of concrete in 1993. Suspect Pit will need

to be steel lined in near future to ensure integrity. (Visual tests in
1990, 91 and 92 indicate Pit leaking very little if at all. Requires
continued monitoring as a minimum);
o Should develop a testing method to prove the Pit and other area
sump Pits do not leak significantly. (No definitive plans yet.
Requires further action. Long term plan for the Pit is to fill it with
concrete and use above ground tank 1993/94);
Golder has found no evidence to suggest that there is a leak path from the Pit.
• The December 1997 Safety Report (Issue 1) states in the Process Hazard
Review portion for the Liquid Effluent Room that:
o “Hazards (1.3) - No regular QC inspection of process equipment.”

This was accompanied by a recommendation to implement a non-
destructive examination (NDE) program in this area. The
investigation team found only one Work Order for some sump
testing but the area engineer indicated he did periodic sump testing
in the Effluent Room;
o “Hazards (8.1) - Leaks at sumps. Caused by: Corrosion (steel
liners in sumps 405FA01, FA02 and FA11) or settling cracks at
concrete Pit 302FA03.” The consequence is listed as contaminated
leakage into the ground. The safeguard listed is occasional

inspections which tended to show that sumps do not noticeably
leak;
• The June 2006 Safety Report (Issue 4) contains the following assertion:
o Sumps continue to be checked for leakage at least once per year by

the area engineer;
• As part of the UF6 plant construction, eight RWs were installed around
Building 50 to protect the municipal water supply. These RWs have not
yet detected any ground water contamination from Building 50 operations.
5.0 CORRECTIVE ACTION RECOMMENDATIONS
CAR 1 - Cameco Port Hope needs to identify ‘floors, sumps & trenches’ as a safety related system because of the potential leak paths. This
aspect must be reflected in the Safety Report and application of the quality assurance program. Appropriate design, construction and operating
standard(s) and management change controls must be established and maintained. As a minimum, these must ensure that:
a) ‘floors, sumps & trenches’ have chemical resistant surfaces where appropriate;
b) ‘floors, sumps & trenches’ have double barriers, and monitoring between barriers for any chronically wet locations such as sumps or pits;
c) any spills to ‘floors, sumps & trenches’ are promptly cleaned and/or neutralized;
d) ‘floors, sumps & trenches’, and associated monitoring systems, are appropriately inspected and maintained; and
e) procedures are written and implemented to ensure that no contaminated or corrosive liquids are deliberately discharged to ‘floors, sumps &
trenches’ except where they have a chemical resistant liner.
Causal Factor # and Description Root Cause Summary of Rationale for Root Cause
1 - Some ‘floors, sumps & trenches’ are not Design Spec NI Not all potential operating conditions in the Cell Room addressed by the
designed to resist a corrosive environment. design
No SPAC No SPAC for design standards
Management of Not a safety related system so review not triggered; unknown if one
change NI carried out for many of the changes
Hazard Analysis Unknown whether hazard analysis on ‘floors, sumps & trenches’ done
NI at design; ‘floors, sumps & trenches’ are not on P&IDs and therefore
not captured in Safety Report
2 - Liquid entering ‘floors, sumps & trenches’ No SPAC Not recognized as problem
is frequently corrosive and attacks the A&E lacks depth Trenches not recognized in Safety Report evaluations
structures SPAC Incomplete Corrosive chemical spills should be neutralized, not specified in
instructions
No Procedure No written procedure for neutralizing sticks used to monitor cell levels
3 - Uranium and chemicals frequently enter the No SPAC Not safety related system and no governing policy was in place
‘floors, sumps & trenches’
4 - Liquid and sludge remain in the ‘floors, Design Spec NI Inadequate for CTCW tank and trenches
sumps & trenches’ for sustained periods of A&E lacks depth PHAs for Safety Report did not identify the floors and trenches as leak
time. paths; not part of P&ID
No SPAC Material remaining in trenches not recognized as a problem
Not safety related system, no SPAC for acceptable upkeep
5 - Some ‘floors, sumps & trenches’ No SPAC Potential problem not recognized; no SPAC for awareness, maintenance
deteriorated over time and began to leak or design
Not safety related system; rationale for not requiring a PM would noot
be documented
Specifications NI No maintenance criteria in design
Management of Not restoring to original spec in repair/maintenance work (refers to
change NI floor in liquid effluent)
Changes to trenches in liquid effluent
No PM Floor coating, trench, sumps etc not specified as a safety related system;
rationale for not requiring a PM would not be documented
PM NI No formal PM program
Informal inspection by area engineer about 10 years, sumps only
6 - The monitoring program does not detect Hazard analysis Unknown whether hazard analysis on ‘floors, sumps & trenches’ done
deterioration of and/or leakage from the ‘floors, NI at design; ‘floors, sumps & trenches’ are not on P&IDs and therefore
sumps & trenches’ not captured in Safety Report
A&E lacked depth Evaluation through Safety Report did not identify issue.
Not safety related system
SPAC not strict Scope of groundwater monitoring was not intended for early detection
enough
No SPAC No in-plant detection system for leaks; no inspection of structures
Management of When the tanks were removed from Pit, the Pit should have been
change NI brought to the standard of other sumps
CAR comments – Cameco should ensure that inspection/maintenance instructions for the wells that have been installed and cores taken through
the plant are received from Golder.
CAR 2: Cameco Port Hope needs to carry out a design related assessment of credible acute and chronic challenges to ‘floors, sumps &
trenches’ and then ensure their structural surfaces are appropriately designed. The designs must be developed as per an approved design
standard to ensure requirements (e.g. PMs and maintaining as-built drawings) are clearly documented, communicated and implemented.
Causal Factor Number and Description Root Cause Summary of Rationale for Root Cause
1 - Some ‘floors, sumps & trenches’ are not designed to resist Equipment environment Acidic environment following process upset not
a corrosive environment. not considered considered
Confusing or incomplete Design documentation lacks details for joints and
(SPAC) trenches
No PM Not recognized as safety significant; no PM
required
Drawings/ prints NI Discrepancies between the drawings and as-built
conditions (e.g. cell room trenches)
2 - Liquid entering ‘floors, sumps & trenches’ is frequently Problem not anticipated Extent of release of chemicals was larger than
corrosive and attacks the structures design anticipated
3 - Uranium and chemicals frequently enter the ‘floors, Problem not anticipated Overflows high enough to move liquid to other
sumps & trenches’ areas
4 - Liquid and sludge remain in the ‘floors, sumps & Problem not anticipated Slope & pipe in trenches
trenches’ for sustained periods of time. Liquid & sludge trapped in interstitial space
CTCW tank
5 - Some ‘floors, sumps & trenches’ deteriorated over time Equipment environment Presence of acidic and corrosive chemicals not in
and began to leak not considered design
6 - The monitoring program does not detect deterioration of Problem not anticipated Not anticipate a breach to this significance level
and/or leakage from the ‘floors, sumps & trenches’
CAR Comments - When assessing the challenges, note that Cameco is installing sprinklers throughout the tower and this has potential impact.
CAR 3: Cameco Port Hope needs to implement an effective corrective action program so that problems are routinely identified and appropriate
corrective action taken
3 - Uranium and chemicals frequently enter the ‘floors, Employee Feedback NI Floor sweeping and the acceptance of the swamp
sumps & trenches’ Employee Acceptance of the swamp
Communications NI
5 - Some ‘floors, sumps & trenches’ deteriorated over Corrective Action NI Early indication of leaks was not recognized as a
time and began to leak pathway to the subsurface; did not realize significance
CAR 4: Cameco Port Hope needs to assess the adequacy of the groundwater monitoring program for early leak detection, and implement any
necessary improvements
6 - The monitoring program does not detect Specifications NI Refinery Wells (RWs) only address the fence line,
deterioration of and/or leakage from the ‘floors, not immediate enough/real time.
sumps & trenches’
CAR Comments – This assessment for ground water monitoring was done several years ago and at CNSC’s request was re-assessed again in
late 1990’s and finalized in early 2000. The work was done by Golder.
APPENDIX 1
CAUSAL FACTORS - RELATIONSHIP TO EACH OTHER
AND THE UF6 PLANT SUBSURFACE CONTAMINATION INCIDENT
Causal Factor #2
Causal Factor #1
Liquid entering ‘floors, sumps &
trenches’ is frequently corrosive and A
Some ‘floors, sumps & attacks the ‘floors, sumps & trenches’
trenches’ are not designed to
Eldorado decides to resist a corrosive environment
expand UF6 Plant Liquid entering ‘floors, sumps &
Conversion Capability trenches’ is either non-corrosive or is
in Port Hope All ‘floors, sumps & promptly neutralized and/or removed.
trenches’ are constructed to Liquids may remain in double-walled
be appropriately chemical structures with inter-space monitoring if
resistant appropriate
Liquid does not corrode the ‘floors,

‘Floors, sumps & trenches’ are sumps & trenches’
better protected and any chronic
contaminants are contained in
higher integrity structures
Causal Factor #4
Causal Factor #3
Liquid and sludge remain in the
Uranium and chemicals ’floors, sumps & trenches’ for B
frequently enter the ‘floors, sustained periods of time
sumps & trenches’
Any liquid and sludge quickly drains (or is
A cleaned) out of the ‘floors, sumps & trenches’,
Any chemical products entering ‘floors, or it is contained within a primary barrier with
sumps & trenches’ are promptly monitoring of the integrity of that barrier so that
removed or they are contained within the secondary barrier is not challenged
double protection with monitoring of
the integrity of the primary barrier
Liquid and sludge containing process fluids

do not have a chronic presence in the ‘floors,
Chemicals in process fluids are sumps & trenches’, without there being
generally not present at the secondary primary and secondary barriers with
boundary so that there is no inspection and/or monitoring of the barriers
contamination potential of the ground
Causal Factor #6
Causal Factor #5 Subsurface
The monitoring system does not
detect leakage from the ‘floors, contamination
Some ‘floors, sumps & confirmed in
sumps & trenches’
trenches’ deteriorated over Building 50
time and began to leak The monitoring system detects breaches
in ‘floors, sumps & trenches’ where
B liquid may be routinely present before
“Floors & sumps” are appropriately the concrete is challenged. “Floors &
protected to resist deterioration and sumps” are maintained typically dry,
there are PMs in place to inspect and and there are PMs to inspect and
maintain their integrity maintain their integrity so that any spills
do not leak to the ground water/soil
Any weakness is prevented or

promptly detected to prevent leak Advance warning provided and
paths from developing contamination is prevented
from reaching the environment
APPENDIX 2
SNAPCHART® OF EVENTS & CONDITIONS

SHOWING WHAT HAPPENED LEADING UP TO THE SUBSURFACE
CONTAMINATION INCIDENT AT PORT HOPE UF6 PLANT ON JULY 13, 2007
E ld o ra d o m a k e s a p p lic a tio n E ld o ra d o m a k e s a p p lic a tio n to

to AE C B fo r S ite Ap p ro va l o f AE C B fo r C o n s tru c tio n Ap p ro va l L u m m u s c a rrie s o u t th e d e ta ile d A
P o rt H o p e C o n ve rs io n F a c ility fo r P o rt H o p e C o n ve rs io n F a c ility d e s ig n o f th e U F 6 P la n t
U F 6 F a c ilitie s E xp a n s io n U F 6 F a c ilitie s E xp a n s io n
T a s k fo rc e s e t u p to
L e tte r o f O c t 2 9 , 1 9 8 0 L e tte r o f D e c 1 7 , 1 9 8 1
o ve rs e e th e p ro je c t
P rio r to th is , E ld o ra d o c a rrie d F o c u s w a s p la c e d o n T a s k fo rc e m a d e u p o f
o u t U F 6 c o n ve rs io n in th e g a s e o u s a n d liq u id E ld o ra d o p e rs o n n e l to
e m is s io n c o n tro l a n d p ro vid e o ve rs ig h t a n d
E a s t P la n t m o n ito rin g te c h n ic a l in p u t to L u m m u s
L u m m u s d e s ig n a n d th e
N o e xp lic it d is c u s s io n o f
C o n s tru c tio n Ap p ro va l d o c u m e n ts
b u ild in g 'flo o rs , s u m p s &
d id n o t c o n s id e r th e tre n c h e s o r
tre n c h e s '
c o n c re te flo o r a s a p o te n tia l le a k p a th
fo r u ra n iu m o r c h e m ic a ls
G ro u n d w a te r m o n ito rin g
p ro g ra m e s ta b lis h e d a s
p a rt o f U F 6 e xp a n s io n in T re n c h e s , flo o rs , s u m p s a n d
p its w e re n o t c o n s id e re d to b e
a d va n c e o f o p e ra tio n
s a fe ty re la te d
P ro g ra m w a s in te n d e d to p ro te c t
th e u n d e rg ro u n d s to ra g e ta n k s a t
th e m u n ic p a l w a te r w o rk s
Lummus designs and

A B
constructs the 'floors, sumps &
trenches' in Building 50
CF1
Cell Room trenches not coated

Some 'floors, sumps & All process sumps are steel
with a chemical resistant
trenches' are not designed to lined with a space between
substance. No design requirement
resist a corrosive environment the concrete and the steel
identified to do so
Section 405, pg 22 of the design Trenches in Cell Maintenance, Effluent

Experienced personnel
manual states "Floor in the 300 Room and Flame Reactor area are lined
interviewed did not recall
area is rarely (almost never) with a chemical resistant coating
the trenches being much
washed down. Floor will b e swept
of a focus at all
unless electrolyte spilled." The floor of the effluent treatment area
is coated, a portion of which had been
While the design documentation is not covered with metal plating
specific, the intent of Cell Room trenches
appears to be to collect small amounts of Pit is coated with a
tempered cooling water from leaks in the cells chemical resistant liner
and hold the tempered cooling water pipes
Section 9.1 of the concrete design
Golder found no
document states - "Where indicated
water stop used in
When additional cells were added in on the drawings, water stops shall b e
the failed vertical joint
1996, the philosophy did not change. emb edded in the concrete at joints."
The construction joints are typically described in

Spectrum Engineering drawings on the Cell Lummus Design Drawings. This may have had
Room Expansion also do not specify a an impact on the joint material used and may be
waterstop at the vertical joint connecting the why a water stop was not used in the vertical joint
East and West Cell Room trenches. that was later found to have failed
Lummus completes First UF6 Plant

B UF6 plant is C
design documentation for operating activities
commissioned
Eldorado in1983 on April 2, 1984
No records for any

commissioning related to
CF1 'floors, sumps & trenches'
When the UF6 plant was designed, not having a

secondary barrier inside an operating plant was The Operations Quality
not unusual. The assumption was if you had a Assurance Manual, which applies
concrete floor, it would not be a problem to safety related systems, took
effect at the same time
During the current investigation, a

Golder concrete specialist 'Floors, sumps & trenches' were
commented that the concrete in the not considered part of a safety
Cell Room is good quality related system
UF6 Plant experiences Water balance problems

C Process Technology Group D
numerous operating result in Pit flooding on
is set up in 1985
problems several occasions
Pit flooding results in fluid backing

up into the unlined Cell Room
Right from the beginning and trenches. Necessitated use of an
One of the focuses was to
In all parts of the process, outside tank at times
get the UF6 Plant to operate
including liquid effluent
more effectively
Being the low point, Pit is primary
collector for excess fluid. Volume
"There were so many challenges Members of the group were experienced during operation is greater
associated with the UF6 plant in the involved during design and than design expectations
b eginning that effluent/water related commissioning
prob lems were of lower priority" Original design included two tanks
located in the Pit to take the process
fluid from Cell Maintenance.
Sludge from Cell Maintenance kept

plugging the tanks. Difficult to
remove the sludge from tanks
Decision made to remove Shallow Trench is cut to join the

D two tanks and associated Effluent Room trench to the North E
pump in the Pit made in Cell Room trench early in the
December, 1984 operation of Building 50
The functionality of the Pit, as primary

collector, was extended to include what This shallow trench, was later filled in for
had been the influent to the tanks ergonomic reasons at the request of
Operations
Tanks and pump removed and

full cover plate is placed on top
of the Pit by fall 1986
Purpose of the trench is to provide a path for liquid

from excursions in the Effluent Room to reach the
Pit. Also directs flow away from Door 16
No formal design change carried

out as this system is not considered
a safety related system
"The Effluent Area has

Connecting the Effluent Room trenches to
historically b een referred to as
the N-S trench unintentionally introduces
"the swamp" as it is always wet"
additional uranium into the Cell Room
trenches and the Pit
Liquid enters 'floors, sumps &

E F
trenches', including Cell
Room trenches
During the current investigation, Golder found

Liquid entering 'floors, sumps &
that unprotected concrete 'floors, sumps &
trenches' is frequently corrosive
trenches' in the study area exhibit signs of
and attacks the structures
deterioration from aggressive solutions
Golder states "In the area where the south trench

from cell rooms meets the north-south trench, the Dilute acid, probably from the electrolyte solution
surface of the floor slab exhib its deterioration in the cells, neutralization of the sticks used to
similar to the walls of the trenches. It appears monitor cell levels and/or the acid wash station in
there may have b een aggressive solution on this Liquid Effluent, pickles/attacks the concrete and
surface in the past" any joints in the trenches
There is a clearly a difference in appearance

between the bottom half of the concrete and the top Cell cooling coils fail and the electrolyte enters
half of the concrete in original Cell Room trenches. the cooling water, making it mildly acidic. This, in
The bottom half appears as though it has been turn, attacks the cooling water pipes. Some
attacked while the upper half appears fully intact. This failures have been experienced where the cell
is an indication of a "wicking type action" from cooling water pipes connect (e.g. on the threads)
chronic and corrosive wetness in the trenches to the main header in the trench
Large equipment washing on the floor near the

trenches would direct fluids to the trenches Electrolyte spills from cells and resultant
cleanup is another way liquid in
trenches can become corrosive
Neutralization solution used to wash the sticks
used to monitor cell levels is discharged into
the trench. No written procedure. Could be
corrosive if not done properly
Cameco Corporation A leak of process

purchased the assets of Eldorado/Cameco makes fluids/effluent out of
F process improvements in G
Eldorado, including the Port Building 50 occurs
Hope conversion facility, the UF6 Plant. through Door 16 on
effective October 5, 1988 October 7, 1990
Six inch high berm in front of

Door 16 in the Effluent Room is
repaired in October 1990
Formal PM on the
north door berm
instituted in 2003
Several interviewees confirmed that "We have
b etter control of water now than with the original
design. It used to b e b atch operation through the
scrub b er towers and now it is more continuous"
Uranium and chemicals

G H
frequently enter the 'floors,
sumps & trenches'
By design, tanks containing uranium Right from start-up in 1984, floor
occasionally overflow to the floor in the Effluent
sweepers cleaned the process
Area. When shallow trench was constructed floors in the UF6 plant and emptied
and the area dykes were removed, there was
an increase in the frequency of the spread of their machines into the N-S Cell
At one point, the trenches
liquid Room trench
were all connected
Easy for the floor cleaners
Shallow trench from Effluent Room to empty their machines
provided a channel for additional Because of the operations, at this location
uranium containing liquids to get into the most interviewees were not
Pit and Cell Room trenches during water surprised there was uranium Discharge location in close
excursions. No records of this found in the Cell Room proximity to the CTCW Tank
installation have been located trenches because of availability of water to
flush the equipment
Also, pieces of equipment that would
not fit in the wash tank in the Effluent Widely known and an accepted
Room would be hosed down on the practice. Likely contributed to
floor. The residue would go to the Pit some of the uranium in the
sludge in the Pit and the trenches
When the Pit was cleaned in
1990 the sludge was found Sludge sample results for this investigation for uranium in
to contain 17% uranium and Cell Room containment structures are as follows:
1,153 ppm arsenic 1. North Trench - Middle Section = 2,100 ppm
2. North Trench - East End (old cell room) = <40 ppm
3. North Trench - West End (new Cell Room) = 1,200 ppm
4. South Trench - West End (new Cell Room) = 2,100 ppm
5. South Trench - Middle Section = 10,600 ppm
6. South Trench - East End (old Cell Room) = 5,300 ppm
7. CTCW enclosure = 56,000 ppm
U F 6 Pla n t co n tin u e s to e xp e rie n ce

H o p e ra tin g ch a lle n g e s , in clu d in g I
o cca s io n a l m a jo r liq u id o ve rflo w s
in to 'flo o rs, su m p s & tre n ch e s'
Th e tre n ch e s in th e Ea s t Th e C e ll R o o m tre n ch e s w e re n o t
L iq u id a n d s lu d g e re m a in in th e '
a n d W e s t C e ll R o o m s a re a b le to b e cle a n e d b e ca u s e th e y h a d
flo o rs, su m p s & tre n ch e s' fo r
ro u g h ly 5 0 a n d 3 6 m e tre s p ip in g (b e tw e e n 4 in . a n d 8 in .)
s u s ta in e d p e rio d s o f tim e
in le n g th (1 6 4 a n d 1 1 8 ft) ru n n in g d o w n th e ir le n g th
Tre n ch e s a p p e a r to b e s lo p e d
Go ld e r e xa m in a tio n o f th e C e ll s u ch th a t liq u id flo w s in to th e m Th e C e ll R o o m tre n ch e s w e re
R o o m tre n ch e s in d ica te s "th e a n d is u n a b le to fu lly d ra in o u t. o n ly a b le to b e cle a n e d w h e n
so lu tio n in th e tre n ch e s m a y h a ve
th e C e ll Te m p e re d C o o lin g
p o o le d in p la ce s a n d d id n o t flo w Th e re a re lo ca lize d lo w p o in ts in W a te r p ip in g w a s ch a n g e d o u t
th ro u g h th e tre n ch a s d e sig n e d " b o th th e N o rth a n d So u th
Tre n ch e s th a t m a y b e p a rtly fro m
D u rin g th e co rin g o f th e s o u th tre n ch , s u rfa ce d e te rio ra tio n At tim e s , th e Pit w o u ld p a rtly flo o d
Go ld e r n o te d "th e co rin g wa te r a ctu a lly to th e e xte n t th a t its o ve rflo w w o u ld
flo we d a sh o rt d ire ctio n we st (u p g ra d ie n t) flo o d th e N o rth a n d So u th C e ll
in ste a d o f e a st (d o wn g ra d ie n t)" R o o m tre n ch e s
C TC W ta n k d e s ig n tra p s liq u id
Th e a p p a re n t d e s ig n in te n t w a s to s lo p e th e tre n ch e s s o th a t w a te r a n d s lu d g e in in te rs titia l s p a ce
flo w e d o u t. A D e s ig n D ra w in g N o te s ta te s "a ll b o tto m o f tre n ch e s to b e tw e e n th e ta n k a n d th e
slo p e m a x. 1 /1 6 in . in 1 2 in . u .n ." Th is w o u ld re s u lt in a m a x co n cre te
e le va tio n ch a n g e o f 1 0 .2 5 in . o ve r 1 6 4 ft. (N o m in s lo p e s p e cifie d )
Pit h a d s lu d g e a n d liq u id le ve l
Ele va tio n m e a s u re m e n ts s h o w th e a s b u ilt co n d itio n s fo r th e Ea s t fo r e xte n d e d p e rio d s o f tim e
C e ll R o o m tre n ch e s h a ve a n a ve ra g e g ra d ie n t o f 1 /3 2 in . in 1 2 in .
Efflu e n t Are a tre n ch e s co n ta in e d
s lu d g e a n d liq u id a n d w e re
Th e d iffe re n ce b e tw e e n th e h ig h e s t a n d lo w e s t m e a s u re d e le va tio n s
fre q u e n tly cle a n e d o u t fo r
in th e So u th tre n ch in th e Ea s t C e ll R o o m is a p p ro xim a te ly 5 in .
o p e ra tio n a l re a s o n s
Sludge contaminated Operations cleans out

I with uranium builds up sludge in the Cell Room J
in the North and South trenches on a few
Cell Room trenches occasions over the years
Whenever the piping in the trenches

is changed out or repaired which
allows access to the bottom of the
trench for cleaning
This appears to have

taken place a few times
since 1984 start-up
Som e 'floors, sum ps &

J K
trenches' deteriorated over
tim e and began to leak
CF5
Uranium and chem icals s eep In the current inves tigation,
through weakened locations Golder, contracted to carry out a
in the concrete, enter the s oil com prehensive study, m ake the
and s lowly m igrate following obs ervations :
"The CTCW concrete retaining structure
that contained the cooling water tank
A very s low proces s that exhib its som e surface deterioration b ut
appears to have gone
no crack ing or delam inations" "The groundwater m onitoring data indicate
on for years
general im pacts b eneath the Cell
"The grout layer on the b ottom of Maintenance Room , in the general vicinity
the pit was delam inated b ut the of the effluent pit and concrete trenching
underlying concrete was sound" just upstream of the effluent pit"
"The trench running north-south that connects the two

"The concrete around a drain pipe leading trenches in the cell room s to the effluent pit is exhib iting
under the slab from the trench at the North considerab le deterioration in areas and som e of the
Door in the Effluent Room into the filled in cracks ob served are the lik ely sources of contam inants
trenches exhib its considerab le deterioration" leaking from the trench system into the soil"
"A 150 m m diam eter core was taken vertically on the "Inspections undertaken as part of the concrete
north side of the south trench at the east wall through the assessm ent indicate the potential for leakage to
joint. The core revealed that the joint is approxim ately 15 the sub surface to have occurred from several
m m wide with the top 12 to 20 m m of the joint sealed. A locations and/or features within the Study Area in
m etal rod could b e inserted along m ost of the vertical addition to the im m ediate vicinity of the excavation
length of the joint deep enough to reach underlying soil" for the new CTCW containm ent structure"
K L
CF5
The PM program in place to check the

condition of 'floors, sumps & trenches' in the
UF6 Plant was limited to the berms, checking
of the sumps in the Effluent Room and the
AHF Unloading Area trench
There is evidence that repairs were done to the

concrete floors & sumps. However, it appears
the repairs were carried out as needed and not
part of an overall PM program
A Golder concrete specialist stated that expansion

joints typically have a service life. They do not last
forever. There is no indication that the expansion
joint found leaking had ever been inspected.
There is no documented requirement for this in
any design documentation
Deterioration in the concrete

L M
trenches and floors, for the
most part, went undetected
The monitoring program does

not detect deterioration of CF6
and/or leakage from the '
floors, sumps & trenches'
Safety Report (Issue 4) in June, 2006

Some repairs are carried out on indicated that only some sumps (401FA14
an individual basis (UF4 plant), 35G18 and 51G106 (UO2 plant))
specify double lined, maintained dry and
solids regularly removed
Cell Room Operators indicated they
didn't notice the condition of the trenches
as they were behind the Cells, there is a In the Environmental Aspects
steel grate on top and Operators did not Registry, contamination of
go back there very often groundwater is only considered from
sumps in the tote bin area. There is
no reference elsewhere in Building
Because of the piping in the Cell 50
Room trenches and the heavy trench
covers, it was not easy to inspect them
The above conditions show an increased
awareness of the hazard as time goes on.
No requirement was specified for However, the focus is still on sumps.
inspection in the design or safety Floors and trenches are still not identified
documentation as a potential leak path
M N
As part of the UF6 plant construction, eight The 1990 Annual Report indicates that the
refinery wells were installed around Pit was cleaned. The liquid level in the Pit
Building 50 to protect the municipal water CF6 was visually monitored over the 3 month
supply. These RWs have not yet detected shutdown and didn't appear to change.
any ground water contamination from The conclusion drawn was, if there are any
Building 50 operations leaks, they are small
The June, 1990 ERA lists current preventative

measures for the leakage scenario from the
Pit as follows: "Pit was prob ab ly not intended
There is no program in to continuously hold liquid. Bottom and part of
place to inspect trenches side walls were acid-proofed in case tanks in
the pit failed. However, at present, no
evidence of significant leakage"
As part of the PHA process, the area engineer was
"Liquid level likely ab ove the acid
asked to develop a NDE test to determine whether
proofed section of side walls b ut is
the sumps in the Effluent Room were leaking. He
caustic, not acidic. Pit level monitored,
developed such a test and the Effluent Room
no sign of steady level loss at present"
sumps were checked on an ad hoc basis
June 1990 ERA proposed that the Pit be

An area engineer began checking sumps for leaks in filled in and replaced with an above
the Effluent Room in 1993-94. By 2000, a leak test ground tank as a precautionary measure
determined that sumps 405FA11 and 405FA01
needed to be removed from service. Upon sump liner
The June, 2006 Safety Report (Issue 4)
removal, the leakage was determined to be by way of
contains the following statement:
the carbon steel liner. No breach of the concrete
"Sumps continue to b e checked for leakage
chamber had occurred
at least once per year b y the area engineer"
7/12/2007
April, 2006 inspection of Contractor begins Contractor pulls a

N CTCW tank indicates it work on a rectangular small tree root from O
would need to be replaced excavation in Building the soil in the
within a few years 50 of the UF6 Plant excavation
Cameco decides to advance Fluid noticed leaking

the schedule and replace the Excavation to house a into the excavation
CTCW tank in 2007 new CTCW Tank from the hole left by
the tree root
A larger CTCW Tank

Contractor notices a
desired due to an
yellow stain in the
increased number of cells
bottom of the excavation
the next day
New CTCW tank to be

Yellow stain found on
placed in a concrete
the surface of freshly
in-ground structure
poured concrete in
the excavation
Design specified double Cameco management

barriers and monitoring notified and begin to
investigate
Cameco immediately
recognizes the yellow stain is
associated with uranium
7/13/2007
Existing monitoring
Sub-surface Cameco initiates a formal
Cameco decides to voluntarily wells do not detect
O initiate a shut down of UF6 contamination investigation into the
contamination in the
confirmed in incident to determine
production operations groundwater from
Building 50 causes and extent
Building 50
Contamination has
Cameco initiates an
not migrated to the
investigation into the Golder contracted to carry out
RW wells
source of uranium a comprehensive investigation
Cameco promptly advises

KnoW Problem Inc. and CJB Consulting
CNSC and the MOE Spills
Associates Inc. contracted to carry out a
Action Centre of the incident
root cause incident investigation
MOE Spills Action Centre

notifies Environment Canada On July 19th, a complete plant
shut-down was initiated
APPENDIX 3
ELEVATION DATA FOR TRENCHES IN THE STUDY AREA


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ATTACHMENT C

TapRooT® Investigation Report

Subsurface Contamination Incident

October 15, 2007

AECB Atomic Energy Control Board

5.0 CORRECTIVE ACTION RECOMMENDATIONS....................................... 34

1.0 EXECUTIVE SUMMARY

In 1980, Eldorado (Eldorado Nuclear Ltd.) made an application to the AECB

In 2007, a contractor began work on a rectangular excavation in Building 50 of

subsequent investigation, subsurface contamination was confirmed in Building

Recommended corrective actions were developed to address all of these causal

a) there is a need to identify ‘floors, sumps & trenches’ as a safety related

c) there is a need to implement an effective corrective action program so that

2.0 OVERVIEW OF THE INVESTIGATION PROCESS

2.1 Investigation Scope

2.2 Root Cause Analysis Process

1. What happened (SnapCharT®);

2.3 Information Collection (i.e. “What Happened”)

Relevant information was assembled into a detailed SnapCharT®, creating a time-

2.4 Causal Factor (Problem/Issue) Definition

2.5 Root Cause Analysis

2.6 Corrective Action Recommendations

3.0 EVENTS LEADING UP TO THE INCIDENT

The construction joints were “typically described” in Lummus Design Drawings.

There is a clearly a difference in appearance between the bottom half of the

Going back to the chronological time sequence, Eldorado/Cameco made process

1. North Trench - Middle Section = 2,100 ppm

Following the discovery of subsurface contamination, Golder was contracted to

No requirement was specified for inspection in the design or safety manual

In April 2006, a CTCW tank inspection indicated it would need to be replaced

In 2007, a contractor began work on a rectangular excavation in Building 50 of

Cameco decided to voluntarily initiate a shut down of UF6 production operations

Subsurface contamination was confirmed in Building 50. Cameco initiated a

4.0 CAUSAL FACTORS AND SUPPORTING INFORMATION

Discussion of Causal Factor

Basis for Causal Factor

• A section of water stop material was found at a depth of 660 mm on the

• One interviewee involved in commissioning and early operation stated

Discussion of Causal Factor

Basis for Causal Factor

Golder Report Findings

concentration than 25%. As such, it is likely that mildly acidic solutions

• There was no identified design requirement to deal with chemical

Discussion of Causal Factor

Higher than anticipated volumes of process chemicals periodically entered the

Basis for Causal Factor

o North Trench - Middle Section = 2,100 ppm

Interview Data - Again, recognizing that individual opinions, beliefs and

Discussion of Causal Factor

Basis for Causal Factor

• Several interviewees discussed the major imbalance of water in the

o Couldn't turn the liquid around fast enough. Needed a repository

Discussion of Causal Factor

Basis for Causal Factor

• The PM program in place to check the condition of ‘floors, sumps &

Golder Report Findings (August 30, 2007)

locations, a piece of wire could be inserted up to approximately 75 mm

spalled in the center portion of the trench to a depth of approximately 75-

Interview Data - Again, recognizing that individual opinions, beliefs and