IR 05000010/1974009
| ML19340A688 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 09/23/1974 |
| From: | Dance H, Maura F, Schumacher M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML19340A687 | List: |
| References | |
| 50-010-74-09-01, 50-10-74-9-1, NUDOCS 8009020617 | |
| Download: ML19340A688 (9) | |
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U. S. ATOMIC ENERGY COMMISSION DIRECTORATE OF REGULATORY OPERATIONS
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REGION III
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Report of Operations Inspection RO Inspection Report No. 050-010/74-09
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Licensee:
Comonwealth Edison Company P.O. Box 767 Chicago, Illinois 60690
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Dresden Nuclear Power Station - Unit 1 License No. DPR-2 Morris, Illinois Category:
C Type of Licensee:
G.E., BWR, 210 Mwe Type of Inspection:
Special, announced Dates of Inspection:
August 25 and 26, 1974
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Dates of Previous Inspection:
July 9 and 10, 1974 (Construction)
Principal Inspector:
F. Matfr (Date)
}ll.:nkit.Aatkt-7d' '(/
Accompanying Inspector:
M. Schumacher
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(Date)
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Reviewed By:
H. C. Dance 9/25/N Senior. Reactor Inspector (Date)
Reactor Operations Branch
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SUAMARY OF FINDINGS
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Enforcement Action
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The following violations are considered to be of Category II severity:
A.
Technical Specification 3.8.C.2 requires that the concentration of gross betaactivity(abovebackgreynd)inthecondensercoolingwaterdischarge canal be at or below I x 10- uCi/ml unless the discharge is controlled on a radionuclide basis in accordance with Appendix B, Table II, Column 2 of 10 CFR 20.
Contrary to the above, on August 25, 1974, four batches of liquid waste were released which cauyed the gross beta concentration in the discharge canal to exceed 1 x 10~ uCi/ml.
(Paragraph 5)
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B.
Technical Specification 3.8.C.3 requires that two independent samples from a tank shall be taken and analyzed and the valve lineup checked prior to discharge of liquid effluents from that tank.
Contrary to the above, on August 25, 1974, four batches of laundry liquid waste were released to the river inadvertently uncontrolled thrcugh an error in valve alignment and without analysis.
(Paragraphs 2, 4a, and 5)
C.
Technical Specification 6.2.A.1 requires that detailed written procedures
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including applicable check off lists shall be prepared, approved and adhered to for normal operation of systems on components involving nuclear safety of the facility.
Contrary to the above, valve 29, which permitted the liquid waste to be erronously released on August 25, was not locked closed as required by Station Procedure 2000-0-XXVIII.
(Paragraph 4.d)
D.
10 CFR 50, Appendix B, Criterion V requires that activities affecting quality shall be prescribed by documented procedures and the procedures shall include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished.
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Contrary to the above, Station Operating Procedure 2000-0-XXVIII contains no valve check list to assist the operator in ensuring the proper valve lineup has been accomplished.
Procedure 2000-0-XXVIII was found to con-tain an incomplete valve check list in that all boundary valves for the desired operation were not included.
(Paragraph 4.c)
E.
10 CFR 50, Appendix B, Criterion VI requires that measures shall be es-tablished to control the issuance of procedurca and that the procedures
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be distributed and used at the location where the prescribed activity is
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performed.
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Contrary to the above, the licensee was using an obsolete procedure valve check list during the discharge of the B secondary waste collector tank.
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(Paragraph 4.b)
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F.
10 CFR 50 Appendix B, Criterion XIV requires that measures shall be es-
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tablished for indicating the operating status of equipment, such as valves, by tagging or other means to prevent inadvertent operation.
Contrary to the above, the licensee has not established a system for clearly identifying all valves in the radwaste system.
Some valves have identical or similar identification and numbers, creating confusion.
In addition, one valve was noted to have three identification tags, each one describing the valve by a different name.
(Paragraph 4.c)
Licensee Action on Previously Identified Enforcement Items: Not inspected.
Unusual Occurrence Inadvertent uncontfolled release of liquid waste to the discharge canal.
Other Significant Findings A.
Current Findings On August 25, 1974,.an inadt.artent, uncontrolled, release of approximately 1130 gallons of liquid waste took place during four transfers of waste from the main laundry drain tank to the laundry holdup tanks.
The event
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occurred because a valve to the discharge canal was open. The licensee a
does not know why or when the valve, which was supposed to be closed,
was opened. The activity concentration in'the discharge canal during the release has been calculated to be in the range of 1.4 to 3.4 x 10-7
uCi/ml. This is based on analysis of samples taken for previous laundry J
waste batches and from a sample taken from the main laundry drain tank following the fourth release on August 25.
B.
Status of Previousiv Reported Unresolved Items:
None.
Management Interview The following subjects were discussed at the conclusion of the inspection on August 26, 1974 with Messrs. B. Stephenson, A. Roberts, E. Budzeckowski,
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D. Adam, G. Bergan and N. Jackiw.
t A.
The inspector noted that although the event did not present any danger to the health and safety of the public, due to the low concentration of activity discharged, it did constitute another error in the history of Dresden and that the frequency of such events does not appear to be decreasing.
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B.
The inspector reminded the licensee that approximately two years ago liquid waste being discharged was accidentally r6uted to another tank,
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because of the lack of check lists to ensure proper valve lineup. At
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that time, station management had committed to provide the checklists as part of the procedure improvement program.
Now, two years later, not much improvement is noted in the area of checklists and valve identification.
(Paragraph 4)
C.
The inspector expressed dissatisfaction with the lack of concern shown by the midnight shift operator in his failure to inform his supervisor about the problem encountered for approximately 5 1/2 hours.
(Paragraph 2)
D.
The inspector encouraged the licensee to determine when and why valve 29 was opened.
E.
The inspector questioned the apparent three hour delay before initiation of the emergency plan. The licensee stated that this time was spent evaluating the situation and determining the magnitude of the release.
(Paragraph 2)
F.
The inspector noted that several violations of AEC regulations and/or Technical Specifications appeared to have occurred and that the licensee would be informed by telephone as soon as the violations-were clearly-identified.
The violations identified under Enforcement Action were
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identified to Mr. Stephenson on September 3,'1974,-in the RO:III office.
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REPORT DETAILS I
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Personnel Contacted
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B. Stephenson, Station Superintendent E. Budzeckowski, Operating Engineer, Unit 1 D. Adam, Supervisor, Radiation Protection f
G. Bergan, Chemist F. Gebert, Shift Foreman, Day Shift E. Bartholmes, Shift Engineer J. Marshall, Shift Foreman R. Goodin, Shift Foreman 2.
Event
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At approximately 0120, 0250, 0545 and 0845 hours0.00978 days <br />0.235 hours <br />0.0014 weeks <br />3.215225e-4 months <br /> the licensee proceeded to pump the Main Laundry Drain Tank to the Laundry Holdup Tanks. The
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volumes of liquid pumped were approximately 150 gallons, 220 gallons, 290 gallons and 470 gallons respectively for a total of approximately 1130 gallons. The first three transfers were attempted into the "A" tank by the midnight shift and the last one into the "B" tank by the day shift. According to the licensee the midnight shift operator
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noted that the Holdup Tank level recorder was not showing an increase in level but he did not place any significance into the finding and
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suspected that it was a recording instrumentation problem. The operator also failed to. inform-the. shift foreman until approximately,
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0700 hours0.0081 days <br />0.194 hours <br />0.00116 weeks <br />2.6635e-4 months <br />, close to shift change. The day shift foreman stated that he personally took over the fourth transfer attempt after being informed by the previous shift of their experience. He decided to transfer into a different tank (B Laundry Holdup Tank)
but noticed the same lack of level instrumentation response. Next, he thought the line could be broken and later decided to make a valve lineup check at which time he found that valve 29 to the discharge canal was open. At this point he stopped the transfer.
The pump used has a flow capacity of approximately 50 gpm.
The shift engineer's log notes that the load dispatcher'was informed of the existence of GSEP (Generating Station Emergency Plan)
Condition William-(liquid release in excess of 100 picocuries/ liter)
at 1230. The condition was terminated at 1425.
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3.
Review ~of the Events A review of the events revealed that at approximately 1950'on August 24,
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1974, the "A" Laundry tank had been placed on recirculation. Prior to
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that the Main Laundry Tank had been pumped into the
"A" tank. The licensee is of the opinion that the above operatio - indicate valve
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29 was closed at that time.
Therefore the valve must have been
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opened sometime between 1950 on August 24 and 0120 on August 25, a period of approximately 5 1/2 hours.
According to the records,
"B" secondary Waste Collector was being discharged to the river early on August 24, 1974. The discharge was interrupted at 0540 and restarted at 0005 on August 25, 1974.
The inspectors reviewed the discharge flow rate charts to determine if the valving mistake could have occurred during the reinitiation of the discharge of
"B" secondary waste collector tank to~the river. The chart seems to indicate that the correct valve was open. The chart does not r.ule out the possibility that more than one valve was opened.
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Procedures A review of the station procedures used or applicable to the event showed that:
a.
Procedure 2000-0-XXVII, Sampling and Processing the Laundry Drain Tanks, step c.2 directs the operator to perform the required valving in order to transfer the liquid from one tank to the other, but does not supply the operator with a valve list or checkoff sheet to ensure proper valve lineup.
During May 19721/ valving errors occurred during the release
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of radwaste to the river. At that time review of 1971 records
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revealed similar experiences had occurred earlier. The cause of all the occurrences appeared to be lack of proper valving instructions. At that time station management stated that valve checksheets would be provided to prevent such incidents in the future and assured that such errors could not result in inadvertant releases to the discharge. canal. Two years
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later the procedures are found to still be deficient in this area and an inadvertent, unplanned release took place.
b.
P.rocedure 2000-0-XXVIII, Disposal to Discharge Canal, contains a checklist of valves to cover three separate operations (discharge of "B" secondary waste collector, C Holdup, or Laundry Holdup to the river). A review of discharge No. 8899, B secondary waste collector which took place on August 25 revealed that an obsolete (not latest revision) checklist was being used in violation of 10 CFR 50, Appendix B, Criterion VI.
1/ R0 Inspection Report No. 050-010-72-02.
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c.
It was noted that the valve in question, "29", was not included
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in the checklist although it is a boundary valve.
Confusion
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was created by the listing of another valve, L-29-Main Laundry'
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Tank Discharge to River. Valve 29 and L-29 are two separate valves.
Investigation revealed that the licensee's valve identification system is deficient in that it can easily lead to confusion or misunderstanding.
It is possible to have as many as three valves with the same number and close attention must be paid to their prefix or lack of it.
For example, one can have three different valves identified as 29, L-29, and V-29.
In addition there are valves which are only identified by name and cases exist where the names are very similar.
Specifically the Discharge to River Checklist lists the following valves:
(1) "A" or "B" Tank Outlet valve, and "A" or "B" Tank Discharge valve.
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(2) Two valves named " River Line To CST Return Line."
The main laundry tank valve, 29, was noted to have three identifiestion tags attached, each tag described the valve by a somewhat different name.
The above deficiencies are considered to be violations of 10 CFR 50, Appendix B, Criterion V and XIV.
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d.
Procedure 2000-0-XXVIII, Table l' lists all valves that should be locked closed when not in use for processing liquid waste.
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Valve 29 is listed as Item No. 5.
In addition, the station drawings ideatify the valve as locked closed. The licencee
could not recall ever seeing the valve locked closed.
The inspector noted that since the event a chain and lock had been installed on the valve.
Disregard of the instruction on Table I constituted a violation of Technical Specification 6.2.A.l.
5.
Release Four batches of liquid were mistakenly pumped from the main laundry tank to the Unit 1 discharge canal. The following details are taken from plant records including the laundry tank level recorder.
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Volume Pump Flow Discharge Canal Flow Release:
Duration Time (Min.)
Gallons (gal / min)
(gal / min)
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0102
150
160,000'
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0250-
, 4.4 220
160,000 s
0545 5.8 290
160,000 0845 9.4 470 50-160,000
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Total 22.6 1130
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Inferred from Volume and pump flow.
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Design rated flow.
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'Because the batches were not sampled before releases, the con-centrations occurring in the discharge canal are not accurately known. Asampletakenfrgmthemainlaundrytankat1305showed i
a concentraticn of 3 x 10 -picocuries per liter. During the 3 days
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preceeding the incident, eight (8) releases of laundry wastes were
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Based on this range, the concentrations in
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l the discharge canal from this occurrence would have been between 90 and 290 picoeuries per. liter while the pump was on.
The licensee's records also show that a controlled release from B
secondary tank was contributing 50 picocuries per liter to the Unit 1 canal.
Thus, the total concentration in the discharge
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canal would have been between 140 and 340 picocuzfes/ liter.
The j
license limit for unidentified isotopes is 100 picoeuries/ liter.
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i Water collected by proportional samplers located on the Unit 1 1'
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intake canal, the Unit 1 discharge canal and the EJLE Railroad
bridge on the Illinois River were counted by the licensee. No significant differences were observed between these samples.
Subsequent analyses by the licensee's environmental contractor
confirmed these-findings.
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UNITED STATES ATOMIC ENERGY COMMISSION
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DIRECTORATE OF REGULATORY OPERATIONS
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REGliON 111
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44rts 0* "
799 ROOSEVELT ROAD ynapgogg GLEN ELLYN. ILLINOIS 6o137 (312) ass 2660
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R0 Inspection Report No.
050-010/74-09 Transmittal Date
September 30. 1974 Distribution:
Distribution:
RO Chief, FS&EB R0 Chief, FS&EB RO:HQ (5)
RO:HQ (4)
DR Central Files L:D/D for Fuels & Materials Regulatory Standards (3)
DR Central Files Licensing (13)
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RO Inquiry Report No.
Transmittal Date
Distribution:
Distribution:
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R0 Chief, FS&EB RO Chief, FS&EB
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RO:HQ (5)
RO:HQ DR Central Files DR Central Files Reguletory Standards (3)
RO Files Licensing (13)
RO Files C.
Incident Notification From:
(Licensee & Docket No. (or License No.)
.s Transmittal Date
Distribution:
Distribution:
RO Chief, FS&EB R0 Chief, FS&EB RO:HQ (4)
RO:HQ (4)
Licensing (4)
L:D/D for Fuels & Materials DR Central Files DR Central Files RO Files RO Files
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