Date(s) of inspection:
- August 2023
Aim of inspection
The purpose of this inspection is to gain assurance that Magnox Limited’s (ML) arrangements for compliance with LC7 (Incidents on the site) and their implementation comply with legal requirements. The purpose of LC7 is to ensure that incidents on the site are notified, recorded, investigated and reported by the licensee. Organisational learning, including learning from incidents on the site, as well as from other relevant external sources make a key contribution to the continual improvement of any effective safety regime.
Subject(s) of inspection
- LC7 – Incidents on the site – Rating: Amber
Key findings, inspector’s opinions and reasons for judgement made
The purpose of this inspection was to gain assurance that Magnox Limited’s (ML) arrangements for compliance with Licence Condition (LC) 7 (Incidents on the site) and their implementation comply with legal requirements, including The Management of Health and Safety at Work Regulations 1999 (MHSWR) Regulation 5. The purpose of LC7 is to ensure incidents on ML’s sites are notified, recorded, investigated and reported by the licensee. Organisational learning, including learning from incidents within the business, as well as from other relevant external sources make a key contribution to the continual improvement of any effective safety regime.
The inspection included an overview of ML’s arrangements to comply with LC7 and other relevant legislation and a demonstration of how ML ensure their arrangements are consistently implemented across the fleet.
During the inspection ONR reviewed ML’s relevant safety management system processes, including S-190 and the associated arrangements. The inspection considered how the HSG65 ‘Managing for Health and Safety’ plan, do, check, act model is applied considering the overall processes, the gathering and categorisation of incident data, and how incidents are investigated. Additionally, ONR considered the assurance carried out by ML on the process implementation, the analysis of incident trends and how adverse trends are addressed.
The inspection identified significant shortfalls in the implementation of ML’s arrangements against the identified relevant good practice, specifically the reporting and investigation of events. As a result, the inspection was rated ‘Amber – Seek Improvement’, and a Level 3 Regulatory Issue (RI-11634) has been raised to track the actions that ONR has placed on ML to seek improvement on ML’s LC7 arrangements.
ONR considered applicable legislation and relevant good practices including, but not limited to,
- Licence Condition 7 (LC7) (1)
- Management of Health and Safety at Work Regulations 1999 (MHSWR) Regulation 5
- NS-INSP-GD-007 Licence Condition 7 Incidents on the Site
- HSG65 Managing for Health and Safety
- HSG245 Investigating accidents and Incidents.
- IAEA SSG-50 Operating Experience Feedback for Nuclear Installations
- IAEA TECDOC 1756 Root Cause Analysis Following an Event at a Nuclear Installation: Reference Manual
Based on the evidence sampled during this inspection, ONR judged there were significant compliance shortfalls in ML’s arrangements, specifically in making and giving effect to appropriate arrangements for the effective investigation and reporting of incidents.