Lessons learned from ventilation and glovebox flooding via overfilling of the wet vacuum system in a plutonium facility

In the summer of 2021, operations personnel requested maintenance personnel to fill a wet vacuum (Wetvac) seal water tank in a plutonium facility at Los Alamos National Laboratory (LANL). After the filling was finished, the fill valve of the Wetvac seal water tank was left open and a 'dead-man' valve on an isolation line failed to close properly. After a series of other failures, the water exited the glovebox and contaminated three rooms of the first floor of the facility and an underlying area in the basement. A retrospective analysis of this event determined that there was no risk of a criticality due to the inherent design features of the ventilation system. This paper will explain the driving factors behind how this event was able to happen, as well as some of the major lessons learned that can be universally applied to other nuclear facilities. One of the main causes of the event was the delegation of work to maintenance personnel that were not qualified for the work being asked of them. Additionally, there was a lack of coordination between criticality safety engineers and facility operations equipment owners regarding equipment and connections present on the seal water tanks for the Wetvac, specifically the presence of overflow drain lines. The respective criticality safety evaluation credited an overflow drain line being present on the seal water tanks that was later found to have not been present. Lastly, there are lessons to be learned regarding equipment configuration and designing systems with safety in mind.(author)