IR 05000267/1978003
| ML19308C212 | |
| Person / Time | |
|---|---|
| Site: | Fort Saint Vrain, Crane  |
| Issue date: | 03/08/1978 |
| From: | Thornburg H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | Volggnau NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| References | |
| TASK-TF, TASK-TMR NUDOCS 8001210545 | |
| Download: ML19308C212 (5) | |
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ME!DRAN XM FOR:
E. Volgenau Director
.HDThornburg, IE
. Central File 555 =?
Office of Inspection and Enforcement
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FROM:
Harold D. Thornburg, Director
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Division of Reactor Operations Inspection IE My
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Leo B. Higginbotham, Acting Director Division of Fuel Facilities and Materials
.J Safety Inspection. IE s.sg SUBJECT:,
RESULTS OF FORT ST. YRAIN INVESTIGATION
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,=2 A two phase investigation of an event that occurred at the Fort St._
Vrain facility on January 23, 1978, was conducted by the NRC Region fM IV (Dallas) office. Thefirstphaseoftheinvestigation(January 23-
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26,1978) dealt with identification of the cause of the event, the
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response by federal, state and local authorities (IE Investigation Report No. 50-267/78-03). The second phase of the investigation
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(February 6-10, 1978) dealt with an allegation that the event was
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intentionally caused by a person or persons tampering with certain centrols and instrumentation (IE Investigation Report No. 50-267/78-04).
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REASON FOR NRC INVESTIGATION Though the consequences of the event were minimal, conduct of an i
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in-depth investigation was deemed appropr.iate for the following
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reasons:
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1.
The NRC Incident Response Center was activated in response to
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licensee notification that a significant off-site radioactive M
release had occurred. Consistent with the long standing NRC
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policy of conducting prompt'on-site followup subsequent to
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significant events it was. determined that an investigation should be conducted to determine the cause of the release
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and assess the personnel and ' plant safety status.
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Site evacuation calling for coordination of licensee, federal, M,7 I.
state and local government response was effected.
It was
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decided that the effectiveness of such an evacuation should be evaluated so that weaknesses, if any, could be delineated T
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and subsequently corrected.
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NHC Fo*m 318 (2 76) NRCM D2040 c u.s. GOV ERNMENT PRIN TIN G O F FIC Et 1 76-4,4 703
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There was an allegation that the event was intentionally caused by plant personnel.
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There was considerable public interest in the event.
St#CMRY 1:
The initiating cause of the January 23 event was determined to be a malfunction of the water level controller for the Loop 2 Baring Water
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Surge Tank. This malfunction initiated a series of equipment inter-(fourcuries)of actions leading to the release of a small quantity (helium). The fission products contained in the primary coolant consequences of the release were minimal. The licensee implemented its emergency plan. Although the objectives of the emergency plan
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were achieved, some minor problems were identified. The NRC has
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taken action to assure that power operation will not resume at Fort St. Vrain until identified probless have been corrected. The
investigation established that the event was not intentionally caused.
DETAILS Cause of Event _
Failure of the primary water level controller for the Loop 2 Bearing Water Surge Tank was identified as the initiating cause of the event.
An investigation of allegations that the event might have been the result of tampering by a person or persons established that the event was not intentionally caused by such tampering. This conclusion is
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based on the following facts:
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Examination of the controller by NRC inspectors and the ifcensee R
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disclosed no evidence of tangering.
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Design review of the controller by MRC personnel revealed that a covert means of causing delayed failure of the. level controller was not probable. IE:HQ specialists and highly competent field inspectors considered the matter at length, ud concluded that i
if taapering with the controller had occurred, the effects would have been observed within a matter of seconds following the d
tampering.
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NRC interviews of two mechanical craftsmen working near the controller revealed that: ~
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They observed no one tampering with the controller oefore or during the event.
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They did at disturb or tamper with the contro11e
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f NRC Form 318 (2 76) NRCM 02040 c u.s. covanNusNT pas. reno orrscs: ts7s_s 4_7ea
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The two workers were employed by a contractor and did I
not have the background and familiarity with instrumenta-
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tion to have intentionally initiated the resulting sequence h
of events.
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The alleger did not h' ave evidence that intentional tampering had
occurred. During discussions with the investigators, the alleger 9=5 stated that he was concerned that the possibility of sabotage would d
be overlooked by the NRC during its review of the event. He did not mean to imply ht he had proof the event was an act of M.....
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Impact on the public M2 The radiological consequences of the event with respect to the impact i.A on the public and the environs was ned igible. Approximately 4 curies
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of noble gases and 5 microcuries of 1E I were released during the
event. This amount of radioactivity would have caused approximately W
.1 millirem (3-4 times that from natural background radiation level in Colorado) whole body exposure to a person located at the site boundary during the course of the event.
Inpact on Plant Personnel Exposure of plant personnel as detemined by personnel dosimeters was limited to approximately 10 mrem. hie body counts, urine samples and thyroid surveys of representative plant personnel revealed that a
no internal contamination resulted from the event.
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Response _by the Licensee _
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When confronted by an indicated elevated release of radio-fodine.
licensee management at the site activated the facility emergency plan.
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Given the existing circumstances, the licensee's response to the event was conservative. The licensee apparently predicated his actions on
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- J the readout free the iodine monitor in h plant stack. Since the E
iodine monitor was actually detecting energy from radionuclides other
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than todine, its reading resulted in the high initial estimate of l
radioactive release.
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l Criticism of the licensee in this regard must be aimed only at his need
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WRC Form 318 (2 76) NRCM 02040 tlr u.s. cow ERNMEN T P RIN TING oFFIC E: 9974_634_732
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Implementation of the emergency plan was found to be ossentially as designed. Evacuation of non-essential plant personnel to the primary
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assenbly point (Visitor's Center) was abandoned because of wind direction. Evacuees moved to the secondary assembly point where facilities were more crowded and connunications equipment was limited.
This relocation caused some confusion but it did not significantly inpact overall emergency response. The licensee was late with some of his notifications and initially did not supply sufficient informa-tion (category of incident and areas affected).
It does not appear l
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that these lapses were intentional; however. it did impact on the
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response of state and local agencies.
Responses by Government Agencies While there were some minor difficulties in coordination of the response activities of the federal, state and local authorities. each prformed its intended function in a timely fashion and the objectives of their respective emergency plans were achieved.
Enforcement Action The investigation revealed that the licensee was in noncompliance (infractions) with license requirements in the following areas:
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Provisions of the emergency plan regarding timing and content
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of notifications, 2.
The radioactivity release rate during the event exceeded the allowable release rate by a factor of approximately 3.7.
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The surveillance program associated with the Helium Circulator Auxiliary System was not fully implemented.
Regional Office Notices of Violation have been issued to the licensee on these matters.
Technical Matters Requiring Corrective _Act_ ion The investigation disclosed some specific technical matters which i
have been identified for action by the licensee prior to resumption
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of power operations.
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The event could probably have been terminated prior to O
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release of fission products if the helium dryers could have been isolated fm m the control room. Provision for
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MRC Form 318 (2-76) NRCM 02040 c U.S. GOV ERNMEN T PRIN TIN G O F FIC E: fHe_834_702
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A need for an improved failure mode and effects analysis for I +t the helium circulator auxiliaries was identified and will be
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completed by the licensee.
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Inadequacies in the surveillance program for the Helium b=
Circulator Auxiliary System were identified. The surveillance program will be revised by the licensee and reviewed by the
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NP.C staff.
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4.
The surge tank level controller that failed has been replaced.
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All four surge tank level controllers have been functionally
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tested.
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All damage resulting from the event has been repaired.
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I!arold D. Thorr. burg, Director
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/3 Leo B. Higginbotham, Acting Director
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Division of Fuel Facilities and Haterials Safety Inspection, IE
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-1 Enclosures:
b (1) Investigation Report 50-267R8-03
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(2)
Investigation Report 50-267BS-04
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