Text

IR 05000271-04-007 on 04/22/04 - 8/27/04 for Vermont Yankee Nuclear Power Station: Special Inspection Regarding the Loss of Control of Two Spent Fuel Rod Pieces; Other Activities
	ML043340149
Person / Time
Site:	Vermont Yankee
Issue date:	12/02/2004
From:	Blough A; Division Reactor Projects I
To:	Thayer J; Entergy Nuclear Operations
References
	IR-04-007
	Download: ML043340149 (28)
	v • d • e

December 2, 2004

EA-04-174

Mr. Jay K. Thayer

Site Vice President

Entergy Nuclear Operations, Inc.

Vermont Yankee Nuclear Power Station

P.O. Box 0500

185 Old Ferry Road

Brattleboro, VT 05302-0500

SUBJECT: VERMONT YANKEE NUCLEAR POWER STATION - SPECIAL INSPECTION

REPORT NO. 05000271/2004007

Dear Mr. Thayer:

Between April 22 - August 27, 2004, the U.S. Nuclear Regulatory Commission completed a

special inspection at your Vermont Yankee Nuclear Power Station. The enclosed inspection

report documents the inspection findings which were discussed on August 12, September 8,

and November 23, 2004, with you and other members of your staff.

This special inspection was in response to Entergys April 21, 2004, report to the NRC that two

spent fuel rod pieces were not in the location specified in its special nuclear material inventory

records. The NRC conducted a thorough and systematic review in accordance with a charter

developed for this special inspection. The charter is attached to the inspection report. The

inspection included a review of Entergys investigation and conclusions regarding the search for

the two spent fuel rod pieces. The inspectors reviewed selected procedures and records,

observed activities, and interviewed personnel.

This inspection report documents an apparent violation of 10 CFR 74.19 Material Control and

Accounting of Special Nuclear Material - Recordkeeping, that is being considered for escalated

enforcement action. The disposition of the escalated enforcement action is still under NRC

management review. We will advise you of the outcome of our review in separate

correspondence for which you will have an opportunity to respond. Based on the information

developed during the inspection, the NRC has determined that between January 1980 and July

13, 2004, Entergy and its predecessor did not keep adequate special nuclear material inventory

records of two spent fuel rod pieces, did not follow its written procedures when the two spent

fuel rod pieces were moved to a fuel storage liner, and did not conduct adequate periodic

physical inventories of the two spent fuel rod pieces. Because the two spent fuel rod pieces

remained in the Vermont Yankee spent fuel pool the entire time the apparent violation existed,

there was no actual safety consequence of this apparent violation. Nevertheless, the NRC

considers this apparent violation a potentially significant failure of your material control and

accounting program. This failure could have resulted in these two spent fuel rod pieces being

Jay K. Thayer 2

inappropriately included in a shipment of radioactive material to a low-level radioactive waste

site.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its

enclosures will be available electronically for public inspection in the NRC Public Document

Room or from the Publically Available Records (PARS) component of NRCs document system

(ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-

rm/adams.html (The Public Electronic Reading Room). (Note: Public access to ADAMS has

been temporarily suspended so that security reviews of publically available documents may be

performed and potentially sensitive information removed. Please check the NRC website for

updates on the resumption of ADAMS access.)

Sincerely,

/RA/

A. Randolph Blough, Director

Division or Reactor Projects

Docket No. 50-271

License Number: DPR-28

Enclosure: Inspection Report 05000271/2004007 w/Attachments

Jay K. Thayer 3

cc w/encl:

M. R. Kansler, President, Entergy Nuclear Operations, Inc.

G. J. Taylor, Chief Executive Officer, Entergy Operations

J. T. Herron, Senior Vice President and Chief Operating Officer

D. L. Pace, Vice President, Engineering

B. OGrady, Vice President, Operations Support

J. M. DeVincentis, Manager, Licensing, Vermont Yankee Nuclear Power Station

Operating Experience Coordinator - Vermont Yankee Nuclear Power Station

J. F. McCann, Director, Nuclear Safety Assurance

M. J. Colomb, Director of Oversight, Entergy Nuclear Operations, Inc.

J. M. Fulton, Assistant General Counsel, Entergy Nuclear Operations, Inc.

S. Lousteau, Treasury Department, Entergy Services, Inc.

Administrator, Bureau of Radiological Health, State of New Hampshire

Chief, Safety Unit, Office of the Attorney General, Commonwealth of Mass.

D. R. Lewis, Esquire, Shaw, Pittman, Potts & Trowbridge

G. D. Bisbee, Esquire, Deputy Attorney General, Environmental Protection Bureau

J. Block, Esquire

J. P. Matteau, Executive Director, Windham Regional Commission

M. Daley, New England Coalition on Nuclear Pollution, Inc. (NECNP)

D. Katz, Citizens Awareness Network (CAN)

R. Shadis, New England Coalition Staff

G. Sachs, President/Staff Person, c/o Stopthesale

J. Sniezek, PWR SRC Consultant

R. Toole, PWR SRC Consultant

Commonwealth of Massachusetts, SLO Designee

State of New Hampshire, SLO Designee

State of Vermont, SLO Designee

M. A. Roye, Government Accounting Office

ML043340149

After declaring this document An Official Agency Record it will be released to the Public.

To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy with attachment/enclosure

"N" = No copy

OFFICE RI/DRP RI/DRP RI/DRP

NAME TJackson/DJF for CAnderson/CJA ABlough/BEH for

DATE 12/01/04 12/01/04 12/02/04

U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Docket No. 50-271

Licensee No. DPR-28

Report No. 05000271/2004007

Licensee: Entergy Nuclear Vermont Yankee, LLC

Facility: Vermont Yankee Nuclear Power Station

Location: 320 Governor Hunt Road

Vernon, Vermont 05354-9766

Dates: April 22 - August 27, 2004

Inspectors: Todd Jackson, CHP, Senior Health Physicist (Team Leader)

Martha Williams, Senior MC&A Physical Scientist, NSIR

Ray Kellar, P.E., Health Physicist, Region IV

Amar Patel, Reactor Engineer

Observer: William Sherman, Vermont State Engineer

Approved by: A. Randolph Blough, Director

Division of Reactor Projects

Enclosure

TABLE OF CONTENTS

SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

REPORT DETAILS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

4. OTHER ACTIVITIES (OA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

4OA3 Event Followup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. (Closed) LER 05000271/2004002-00 and 01, Special Nuclear Material not

Accounted for at Vermont Yankee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

4OA5 Other Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. Loss of Control of Special Nuclear Material (SNM) . . . . . . . . . . . . . . . . . . . . . . 1

2. Entergys Investigation into the Circumstances that Led to the Loss of Control of

Special Nuclear Material (SNM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3. Characterization of the Two Spent Fuel Rod Pieces . . . . . . . . . . . . . . . . . . . . . 7

4. Root Cause Determination and Corrective Action Plan . . . . . . . . . . . . . . . . . . . 8

5. Special Nuclear Material Control and Accounting (MC&A) Procedures . . . . . . 10

6. Verification of Current SNM Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

7. Control of Spent Fuel Pool Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

8. (Closed) URI 05000271/2004002-02 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

4OA6 Meetings, including Exit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

ATTACHMENT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1-1

KEY POINTS OF CONTACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1-1

LIST OF ITEMS OPENED, CLOSED AND DISCUSSED . . . . . . . . . . . . . . . . . . . . A1-1

LIST OF SIGNIFICANT DOCUMENTS REVIEWED . . . . . . . . . . . . . . . . . . . . . . . . A1-2

LIST OF ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1-3

CHRONOLOGY OF SIGNIFICANT EVENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1-4

ATTACHMENT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2-1

CHARTER FOR VERMONT YANKEE SPECIAL INSPECTION . . . . . . . . . . . . . . . A2-1

ii Enclosure

SUMMARY OF FINDINGS

Inspection Report 05000271/2004007; 4/22/04 - 8/27/04; Vermont Yankee Nuclear Power

Station; Special Inspection regarding the loss of control of two spent fuel rod pieces; Other

Activities.

The special inspection was conducted by two Region l inspectors, an NSIR material control and

accounting (MC&A) inspector, and a Region IV inspector. The inspection identified one

apparent violation. The disposition of the apparent violation is under NRC management review.

The significance of most findings is indicated by their color (Green, White, Yellow, Red) using

Inspection Manual Chapter (IMC) 0609, Significance Determination Process (SDP). Findings

for which the SDP does not apply may be Green or be assigned a severity level after NRC

management review. The NRCs program for overseeing the safe operation of commercial

nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 3,

dated July 2000.

A. NRC-Identified and Self-Revealing Findings

Cornerstone: Safeguards

TBD. The inspectors identified an apparent violation of 10 CFR 74.19 because Entergy

and its predecessor did not keep adequate special nuclear material inventory records of

two spent fuel rod pieces, did not follow its written procedures when two spent fuel rod

pieces were moved to a fuel storage liner, and did not conduct adequate periodic

physical inventories of the two spent fuel rod pieces.

Because the two spent fuel rod pieces remained in the Vermont Yankee spent fuel pool,

the entire time the apparent violation existed, there was no actual safety consequence

of this apparent violation. Nevertheless, the NRC considers this apparent violation a

potentially significant failure of Entergys material and control accounting program. This

failure could have resulted in these two spent fuel rod pieces being inappropriately

included in a shipment of radioactive material to a low-level radioactive waste site.

The disposition of this apparent violation is still under review by NRC management.

(4OA5.1)

B. Licensee-Identified Violations

None

iii Enclosure

REPORT DETAILS

Background

On April 21, 2004, Entergy reported to the NRC that two spent fuel rod pieces were not

in the storage location designated in the inventory records. On April 22, 2004, NRC

Region I initiated a special inspection of the missing spent fuel rod pieces in accordance

with NRC Management Directive 8.3, NRC Incident Investigation Program, and NRC

Inspection Procedure 93812, Special Inspection. On July 13, 2004, Entergy

discovered that the two spent fuel rod pieces were still in the spent fuel pool but in a

different location. A chronology of significant events leading to and following the loss of

accountability of the two spent fuel rod pieces is included in the Attachment to this

report.

4. OTHER ACTIVITIES (OA)

4OA3 Event Followup

1. (Closed) LER 05000271/2004002-00 and 01, Special Nuclear Material not Accounted

for at Vermont Yankee

On April 20, 2004, Entergy determined that two spent fuel rod pieces were not in the

storage location designated in the inventory records. On April 21, 2004, Entergy notified

the NRC Headquarters Operations Center in accordance with 10 CFR 50.72 (b)(2)(xi).

Entergy submitted LER 2004-002-00 on June 17, 2004. On September 29, 2004,

Entergy submitted LER 2004-002-01, which revised the original LER following the

completion of Entergys investigation and root cause determination. In the revised LER,

Entergy provided the results of its investigation that located the two spent fuel rod

pieces, described the root causes and contributing causes of the event, described the

assessment of safety consequences, and described the corrective actions completed

and in-progress.

NRCs special inspection identified an apparent violation that is documented in Section

4OA5.1 of this report. This LER is closed.

4OA5 Other Activities

1. Loss of Control of Special Nuclear Material (SNM)

a. Inspection Scope

In accordance with the Special Inspection Charter (attached), the inspectors conducted

a thorough and systematic review of Entergys investigation into the circumstances that

led to the loss of accountability for the two spent fuel rod pieces in the Vermont Yankee

(VY) spent fuel pool (SFP). The inspection included a review of Entergys investigation

and conclusions regarding the location of the two spent fuel rod pieces. The inspectors:

observed the initiation of physical searches in the SFP and the opening of the fuel

storage liner determined to hold the two spent fuel rod pieces; reviewed selected

Enclosure

2

videotaped records of the detailed searches, including verification of a sample of spent

fuel assembly serial numbers; assessed Entergys effort to identify, retrieve, and review

pertinent documents; reviewed Entergy managements oversight of the investigation

work in-progress; assessed Entergys preparation for conducting personnel interviews;

and reviewed the results of interviews that Entergy conducted. The inspectors also

independently reviewed numerous documents related to material control and accounting

(MC&A) of special nuclear material (SNM), independently evaluated the root causes of

the event, and interviewed personnel involved in Entergys investigation.

b. Findings and Conclusions

Introduction: The inspectors identified an apparent violation of 10 CFR 74.19 because

Entergy and its predecessor did not keep adequate special nuclear material inventory

records of two spent fuel rod pieces, did not follow its written procedures when two

spent fuel rod pieces were moved to a fuel storage liner, and did not conduct adequate

periodic physical inventories of the two spent fuel rod pieces.

Description: In 1979, two spent fuel rods broke into several pieces during inspection and

reconstitution work in the SFP at VY. The longer pieces were reinserted into fuel

assemblies because these pieces were long enough to be securely held in place.

Station staff placed two smaller pieces, (9" piece from fuel rod in position D2 in fuel

assembly LJ3949 and 17" piece from fuel rod in position D2 in fuel assembly LJ3915)

into a specially fabricated container, that is referred to as a fuel storage bucket in VYs

documentation, for temporary storage.

In January 1980, station staff transferred these two smaller spent fuel rod pieces from

the fuel storage bucket to a fuel storage liner, but did not follow the instructions in

Revision 15 of procedure OP-0400, SNM Inventory and Accountability Procedure (the

revision used in 1980) to record the transfer. OP-0400 specified the use of four SNM

accounting record keeping devices. They were: a) The SNM Card File and Notebook,

b) The SNM Inventory Account, c) The SNM Inventory Summary, and d) The Fuel

Location Boards. The accounting record keeping devices were to be revised based on

information contained on an SNM Transfer Form (VYOPF 0400.02). SNM Transfer

Form No. 822A documented that on January 21, 1980, the two spent fuel rod pieces

were transferred from the fuel storage bucket to a fuel storage liner. The station staff

did not record that transfer information in either the SNM Card File and Notebook, the

SNM Inventory Account, the SNM Inventory Summary, or the Fuel Location Boards.

This failure to follow the written procedure resulted in misidentification of the location of

the two spent fuel rod pieces and loss of accountability.

From January 1980 through January 2004, SNM physical inventories at VY were not

performed in accordance with procedure OP-0400. OP-0400 required the station staff

to verify the presence of the two spent fuel rod pieces in the fuel storage bucket. A

periodic physical inventory of SNM is performed in accordance with the current version

(Rev. 32) of procedure OP-0400, using form VYOPF 0400.19, Physical Inventory.

Step 9 states, Verify that the SFP contains the same number of fuel assemblies as the

inventory records. Verify that fuel assemblies occupy the same locations in the SFP as

Enclosure

3

on the inventory records. Instead of verifying the presence of the two spent fuel rod

pieces in the fuel storage bucket, the practice of station staff was to ensure the fuel

storage bucket remained upright and in place on the bottom of the SFP when

performing their physical inventory. Operating Procedure OP-0400 allowed this type of

physical inventory provided a container was sealed with a tamper-safe locking device.

However, the fuel storage bucket had no tamper-safe or tamper-indicating device.

Analysis: The finding is a performance deficiency because station staff did not follow

procedure OP-0400 in 1980 when station staff transferred the two spent fuel rod pieces

from the fuel storage bucket to the fuel storage liner. Station staff did not properly

record the transfer and also did not verify the two spent fuel rod pieces were in the

location previously recorded during numerous periodic physical inventories from 1980

through January 2004. Entergys and its predecessors failure to follow procedure OP-

0400 led to the loss of accountability, and therefore, loss of control of the two spent fuel

rod pieces containing strategic SNM from January 1980 and continuing until July 13,

2004.

This finding did not have any actual safety consequences since the two spent fuel rod

pieces remained in the VY SFP the entire time that the violation existed. Nonetheless,

the two spent fuel rod pieces were misplaced in the SFP for over 24 years without the

discrepancy being identified during any of the periodic inventories. The NRC considers

this apparent violation a potentially significant failure of VYs material control and

accounting program. This failure could have resulted in these two spent fuel rod pieces

being inappropriately included in a shipment of radioactive material to a low-level

radioactive waste site.

Enforcement: 10 CFR 74.19 requires the licensee to (a) keep records showing the

inventory (including location and unique identity) of all SNM in its possession; (b)

establish, maintain, and follow written procedures that are sufficient to account for the

SNM in its possession; and (c) conduct periodic physical inventories of all SNM in its

possession. Contrary to the above requirements, beginning in January 1980 and

continuing until July 13, 2004, Entergy and its predecessor (a) failed to keep adequate

records of the location of special nuclear material in two spent fuel rod pieces (9" piece

from fuel rod in position D2 in fuel assembly LJ3949 and 17" piece from fuel rod in

position D2 in fuel assembly LJ3915); (b) failed to follow its written procedures for

accounting for the special nuclear material in its possession in that the instructions in

procedure OP-0400, Special Nuclear Material Inventory and Accountability were not

completed to record the transfer of two spent fuel rod pieces in the spent fuel pool from

a fuel storage bucket to a fuel storage liner; and (c) failed to identify through physical

inventory that the two spent fuel rod pieces were no longer in the location described in

the inventory records.

Because this finding is a potentially significant failure of Entergys and its predecessors

material control and accounting program designed to prevent or detect the theft, loss or

diversion of SNM, it is being considered for escalated enforcement action pending

further review by NRC management. (AV 05000271/2004007-001, Did Not Keep

Enclosure

4

Adequate Records, Follow Procedures, and Perform Physical Inventory of Special

Nuclear Material).

2. Entergys Investigation into the Circumstances that Led to the Loss of Control of Special

Nuclear Material (SNM)

a. Inspection Scope

The inspectors reviewed Entergys investigation into the circumstances that led to the

loss of control of SNM. The inspectors reviewed the SNM Investigation Team (SNM IT)

Project Plan and the procedures listed in the Attachment to this report that were

developed by Entergy to address specific investigation activities.

The inspectors reviewed the staffing and training of the SNM IT and observed SNM IT

daily briefing meetings regularly during the course of the special inspection. The

inspectors reviewed the results of Entergys physical searches within the SFP, searches

of historical plant documents for records that might contain pertinent information, and

interviews of current and past employees and other individuals identified as having

some role involved with spent fuel handling or activities associated with the SFP. The

inspectors reviewed selected videotape samples of portions of Entergys physical

inspection of the SFP. Inspectors reviewed the results of personnel interviews and

record searches performed at the General Electric (GE) Vallecitos Nuclear Center

(VNC). The inspectors also reviewed the results of an Entergy Corporate assessment

of the VY SNM control program, as well as the results of detailed examinations by

Entergy of the contents of five spent fuel assemblies and two spent fuel rod storage

assemblies.

b. Discussion

SNM Investigation Team Activities

Entergy initiated an SNM Investigation immediately after determining that two spent fuel

rod pieces were not in the location within the VY SFP as documented in the most recent

SNM inventory. The SNM Investigation Team Project Plan, Rev. 0, was approved by

Entergy on April 26, 2004. The Project Plan assigned a project manager and

established a structured management framework for the team. Procedures were

developed by the team to address activities in the project areas, including physical

searches in the SFP, interviews of key personnel, searches of plant records and review

of documents, stakeholder communications, and regulatory oversight. Team members

were required to complete training on the appropriate SNM IT procedures prior to

beginning independent investigation activities. Staffing of the team included Entergy

personnel from VY and from other Entergy office locations, supplemented by

contractors. Team members routinely met near the end of each day to discuss the

evidence discovered during the day to ensure all investigators were aware of important

information.

Enclosure

5

Initial Physical Search of the Spent Fuel Pool

The inspectors determined that SNM IT procedures provided appropriate guidance for

the conduct and documentation of the physical inspections of the SFP, including

identification of search areas, development of inspection techniques, and establishment

of acceptance criteria. On April 27, 2004, the inspectors observed the initiation of in-

pool searches under the spent fuel storage racks. Documented search plans covered

all accessible areas of the pool. Visibility was excellent for the remote and manually

manipulated cameras in the SFP. Searches were videotaped and catalogued for future

reference, including audio descriptions of what was being viewed. While these initial

physical searches were not successful in locating the two spent fuel rod pieces, the

videotapes were used with other information to locate the misplaced pieces on

July 13, 2004. Entergy initiated condition report CR-VTY-2004-02562 to evaluate why

the in-pool searches were not initially successful and to identify potential lessons-

learned for use in future investigation and troubleshooting efforts.

Inspection of Selected Assemblies

In addition to searching the SFP for the two spent fuel rod pieces, Entergy also

performed inspections of five spent fuel assemblies and two spent fuel storage

assemblies. Entergy determined that the contents were in accordance with Entergys

records. These assemblies were involved in past fuel reconstitution activities and

contained the remnant sections of the spent fuel rods that were the source of the two

spent fuel rod pieces. The inspectors reviewed portions of videotape SNM-028 that

recorded these inspections. These inspections verified inventory records for the

identification of individual spent fuel rods these assemblies contained. These

inspections were also used to obtain accurate measurements of the length of the fuel

rods within the assemblies.

In 1980, station staff did not place the two spent fuel rod pieces back into fuel

assemblies because they were too short to be stored within the fuel assemblies. The

remaining sections of the damaged spent fuel rods, which were the sources of the two

spent fuel rod pieces, were long enough to be reinserted into other spent fuel

assemblies for storage in the SFP. Entergy verified that these other sections of the

damaged fuel rods remained in the spent fuel assemblies into which they had been

inserted when the two spent fuel rod pieces broke apart. During Entergys investigation,

Entergy accurately re-measured the remnant sections of the fuel rods because of

uncertainty in the original length estimates of the two spent fuel rod pieces. The

investigation team determined that original measurements were made in 1979 by

comparing the pieces with a tape measure or other reference item viewed through many

feet of water, using either a periscope viewer or binoculars, resulting in original

estimates that were likely crude and inaccurate. Based on a more accurate

measurement method, Entergy revised the estimated lengths of the two spent fuel rod

pieces to 9 inches and 17 inches (instead of the 7 inches and 173/4 inches first reported).

The revised length estimates were determined by measuring the remaining fuel rod

remnants stored in the SFP and calculating the length equivalent missing from the

whole length of these fuel rods.

Enclosure

6

Other Sources of Spent Fuel Rod Pieces

Entergy investigated the possibility that the two spent fuel rod pieces had been

mistakenly shipped to the General Electric (GE) Vallecitos Nuclear Center (VNC) or GE

VNC shipped fuel pieces to VY. A shipment of spent fuel rods was made from VY to GE

VNC in March 1979. This shipment was the sole shipment of spent fuel from VY and

was completed prior to April 1979, when the first piece broke from its parent fuel rod.

This shipment therefore could not have included either of the two spent fuel rod pieces.

In addition, GE VNC confirmed to Entergy that no spent fuel rods or spent fuel rod

pieces were ever shipped to VY from GE VNC.

Search for Fuel Storage Liner

In June 2004, Entergy developed information from interviews and review of records at

the GE VNC indicating that VY ordered a fuel storage liner from GE in 1979 specifically

to contain pieces of broken spent fuel. Photos obtained of a typical fuel storage liner

depicted an aluminum cylinder, 45 inches long by 5 inches diameter. Entergy

subsequently re-examined the videotapes of the in-pool inspections and identified a

cylindrical object that matched the GE fuel storage liner description. The cylinder was

resting sideways on the top edge of the channel rack between the two fuel prep

machines and fitting snugly against the south wall of the pool. In the videotape images,

the cylinder appears to be part of the rack and is the same color as the wall and other

rack metal around it. Entergy carefully planned the opening of the fuel storage liner to

avoid damaging or losing control of its contents and documented the plan in work

instruction SNM-WI-09, Spent Fuel Pool GE Container Inspection. A special canister

support fixture was fabricated to securely hold the fuel storage liner while it was opened

in the SFP. When station staff opened the fuel storage liner on July 13, 2004, they

discovered the two misplaced spent fuel rod pieces.

c. Findings and Conclusions

No significant findings were identified. Entergys approach to planning and executing

the process for physical inspections and examinations of spent fuel was thorough and

comprehensive. While the initial in-pool searches did not identify the two spent fuel rod

pieces, the detailed videotape records created during the searches were readily used

when investigators developed new information and contributed to the eventual

identification of the fuel storage liner holding the two spent fuel rod pieces.

Enclosure

7

3. Characterization of the Two Spent Fuel Rod Pieces

a. Inspection Scope

The inspectors reviewed Entergys radiological and dimensional characterization of the

two spent fuel rod pieces discovered to be stored in the fuel storage liner in the SFP.

The inspectors observed the initial opening of the fuel storage liner and observed the

presence of the two spent fuel rod pieces through a boroscope. The inspectors

reviewed videotapes made using the boroscope that provided detailed views of the

inside of the fuel storage liner, including the two spent fuel rod pieces. Using the

videotape records, the inspectors independently estimated the lengths of the two spent

fuel rod pieces within the fuel storage liner. The inspectors reviewed the results of

radiation measurements taken by Entergy on the inside and outside of the fuel storage

liner. The inspectors compared the radiation and dimensional data collected for the two

spent fuel rod pieces in the fuel storage liner to the radiation and dimensional values as

documented in Entergy Technical Evaluation (TE) No. 2004-057, Radiological

Evaluation of the VY Misplaced Fuel Rod Pieces. TE 2004-057 described the expected

radiological characteristics of the two spent fuel rod pieces, based upon the known

material content of the original fuel rods, the neutron flux exposure during power

operations and radioactive decay time since discharge from the core, and also

described the manufacturing specifications for the fuel. Finally, the inspectors

interviewed Reactor Engineering department personnel.

b. Discussion

Following discovery of the two spent fuel rod pieces, the NRC inspection focused on

understanding the basis for Entergys conclusion that the two spent fuel rod pieces

were, in fact, the same two spent fuel rod pieces which had been misplaced. Entergy

verified that the two spent fuel rod pieces were the unaccounted spent fuel rod pieces

by measuring radiation levels and making estimates of the length and diameter of the

pieces. Entergys conclusion was supported by the following:

Lengths of the two found spent fuel rod pieces were consistent with the lengths

of the two misplaced spent fuel rod pieces, based on visual comparison with

items of known length.

Radiation measurements inside and outside of the fuel storage liner were

consistent with the expected radiation levels based upon Entergys detailed

radiological characterization of the two misplaced spent fuel rod pieces.

Diameter of the two spent fuel rod pieces was consistent with the diameter of the

original fuel rods based on boroscope observation.

Only two spent fuel rod pieces were misplaced and two spent fuel rod pieces

were recovered. No other record discrepancies were identified indicating any

other unaccounted for SNM (See Section 4OA5.6).

Enclosure

8

The fuel storage liner discovered on July 13, 2004, was consistent with the 1980

log entries and other documentation referring to a fuel storage liner.

Entergy interviewed a former employee who had been involved in the transfer of

the two spent fuel rod pieces from the fuel storage bucket to the fuel storage

liner on January 21, 1980. While the individual did not specifically recall the

transfer activity, his description of the fuel storage liner used to store broken

spent fuel rod pieces matched the fuel storage liner discovered on July 13, 2004.

A GE invoice dated August 9, 1979, indicated that a fuel storage liner was

provided to VY to contain broken fuel pins. This invoice indicated the intent to

use the fuel storage liner to contain broken spent fuel rod pieces, the first of

which was broken on April 23, 1979. This invoice and documents provided by

GE were consistent with the fuel storage liner found in the SFP by Entergy and

the 1980 SNM Transfer Form.

Based on the review of videotape records, the inspectors compared the lengths of the

two spent fuel rod pieces to the known distance between reference markings on a probe

and independently confirmed the two spent fuel rod pieces in the fuel storage liner were

9 inches and 17 inches in length.

c. Findings and Conclusions

No findings of significance were identified. The inspectors determined that Entergys

radiological characterization of the two spent fuel rod pieces was acceptable. The

inspectors determined that Entergy had sufficient supporting information to conclude

that the two spent fuel rod pieces found were the two misplaced spent fuel rod pieces.

Entergys characterization of the two spent fuel rod pieces supports the conclusion that

the fuel storage liner opened in the SFP on July 13, 2004, contained the two spent fuel

rod pieces described in the records.

4. Root Cause Determination and Corrective Action Plan

a. Inspection Scope

The inspectors reviewed Entergys Root Cause Analysis Report Rev. 00, dated

August 12, 2004, and an updated list of corrective actions provided in Licensee Event

Report 2004-002-01 issued on September 29, 2004. The inspectors also reviewed

condition reports documenting issues and corrective actions related to the two

misplaced spent fuel pieces, including CR-VTY-2004-01339, which was initiated on April

20, 2004, and was updated during Entergys investigation.

Enclosure

9

b. Discussion

As part of the SNM IT process, Entergy initiated a category A condition report (CR-VTY-

2004-01339), which required performance of a formal root cause analysis. After the two

spent fuel rod pieces were found on July 13, 2004, Entergys focus shifted from the

search for missing items to understanding what caused the pieces to be lost in the first

place. The facts identified by the SNM IT were used by Entergy in evaluating the root

cause of the problem. Entergy identified two specific root causes for the two misplaced

spent fuel rod pieces:

1. The SNM accounting recordkeeping devices required by procedure OP-0400,

Special Nuclear Material Inventory and Accountability Procedure, were not

properly maintained.

2. Procedure OP-0400 did not provide guidance for control of fuel pieces of SNM

versus whole fuel assemblies.

Entergy defined numerous corrective actions with assigned completion dates to address

specific issues identified during the misplaced SNM investigation and the Entergy

Corporate SNM Assessment of VY. The inspectors noted that Entergys plan for

corrective actions did not directly address the failure to follow procedure OP-0400, either

in the 1980 failure to record the transfer of the two spent fuel rod pieces from the fuel

storage bucket to the fuel storage liner or in the failure to conduct adequate periodic

physical inventories of the two spent fuel rod pieces. Following discussion with the

inspector, Entergy revised its plan and defined an additional corrective action for the

Reactor Engineering Manager to review the two cases in which procedures were not

followed and address the issue of compliance with procedures. (CR-VTY-2004-01339,

CA#23)

While Entergy identified in the second root cause that procedure OP-0400 did not

provide guidance to handle spent fuel rod pieces versus bundles, the inspector noted

that Entergy had not planned any specific corrective action to address the procedure

changes necessary to prevent recurrence of the problem. Following discussion with the

inspector, Entergy revised its plan and defined an additional corrective action to review

accounting methods for individual fuel rods and fuel pellets. (CR-VTY-2004-01339,

CA#24).

The corrective actions are scheduled for implementation by assigned due dates. In

addition, Entergys corrective action plan includes an effectiveness review of the

corrective actions to be completed by June 30, 2005, which is prior to any additional

planned movement of SNM in the SFP. (CR-VTYLO-2004-00329, CA#01)

c. Findings and Conclusions

No findings of significance were identified. Entergys root cause analysis did identify

appropriate root causes. Although Entergys initial corrective action plan addressed

issues identified during its investigation, its initial corrective action plan did not fully

Enclosure

10

address the identified root causes for the two misplaced spent fuel rod pieces.

Entergys subsequent corrective action plan was comprehensive.

5. Special Nuclear Material Control and Accounting (MC&A) Procedures

The inspectors reviewed Entergys written MC&A procedures and their implementation.

The review encompassed physical inventory, movement of SNM, record keeping, and

data reporting. The inspectors examined records, reviewed procedures, and

interviewed personnel. The procedures reviewed by the inspector are listed in the

Attachment to this report. In addition to the procedures in force at the time of the

inspection, the review covered historical versions of Procedure OP-0400, including Rev.

14, dated 1978 and Rev. 15, dated 9/14/79, which was in effect when the two spent fuel

rod pieces were placed in the fuel storage liner.

b. Discussion

Entergys methods for tracking inventory of SNM were contained in procedure OP-0400,

(Rev. 32, dated 6/17/2003). Total SNM quantity by isotope was calculated and tracked

using the computer application SNMtrac'. The procedure provided overall guidance

and also relied significantly on individuals who were knowledgeable of the plant

processes and data sources that interfaced with OP-0400 and SNMtrac'. SNMtrac'

tracked fuel assemblies as the physical unit of SNM. Adjustments to SNM inventory

isotopic quantities were calculated by fuel assembly unit using SNMtrac' to account for

radioactive decay, fission loss, and other operational changes.

In addition to SNMtrac', which was used for tracking SNM content, VY relied primarily

on two accounting record keeping devices to track SNM items, namely, notebook

pages and schematic layouts, including a SFP diagram. Both devices were prepared

using a computer and maintained by the Reactor Engineering Department. A notebook

page was prepared for each fuel assembly when it was received from the fuel

manufacturer. Information entered into the computer included the fuel assembly serial

number, date when it was received at VY, and location where it was placed. When a

fuel assembly location was changed, the date of change was recorded along with the

old and new locations, as well as any comments pertinent to the movement. Notebook

pages were printed as necessary from the updated spreadsheet database. Each line of

the notebook page represented a change to the fuel assembly or a re-location move,

thus creating a complete history of the assembly. The SFP diagram was a color-coded

map generated using a spreadsheet-type computer database, showing the physical

location of each fuel assembly in the SFP. In addition to the overall SFP layout, the

map also showed the relative location within the SFP of unique features and items such

as the prep machine, a pin canister, and blade guides. The pin canister was the

new designation for the fuel storage liner that held the two spent fuel rod pieces found

on July 13, 2004. (Fuel pin is an alternate term used interchangeably with rod by

Entergy.)

VYs method of tracking SNM physical inventory has changed very little since 1980 with

the exception of its reliance on the computer. In 1980 VY relied on notebook pages,

Enclosure

11

schematic layouts, and manually operated fuel location tag boards. The current practice

was to use the computer to emulate these manual devices.

While the procedure was adequate, the inspector identified a number of examples of

unclear and incomplete guidance in Procedure OP-0400. These examples involved:

SNM movements within a single inventory control area (ICA), time limits to complete

records of SNM movements, use of routine computer applications for isotope tracking

and planning fuel assembly movements, cross-references with other procedures, and

remnants of text or forms from past revisions. In general, Entergys procedure relied on

the procedure being implemented by knowledgeable individuals and as a result it did not

provide detailed instructions in all cases.

Revision 15 of OP-0400 specified the requirement, ...the Reactor Engineering

Supervisor will direct a member of the Reactor Engineering Department to perform a

physical inventory of all SNM on site. The inventory consists of physically obtaining

identification numbers of all units of SNM in accessible ICAs. OP-0400, Rev. 15, also

instructed, For the ICAs which are not physically accessible (such as the Reactor)

during normal periods of operation, the identification numbers will be obtained from

records, emphasizing that other identification numbers were to be obtained visually.

The current revision of OP-0400 (Rev. 32) contained modified guidance to Verify that

the SFP contains the same number of fuel assemblies as the inventory records. Rev.

32 also stated that a "piece count" satisfied this requirement. These differences

between revisions 15 and 32 of OP-0400 showed that the method for performing

physical inventory at VY had evolved from verifying the serial numbers of all SNM units

in 1980 into the current method of counting total units of SNM and confirming the total

number of SNM units was consistent with the previous inventory (piece count). The

omission of a visual verification of the two spent fuel rod pieces during inventories

contributed to perpetuating the incorrect recorded location from 1980 to 2004. Entergy

initiated a condition report to resolve the question of whether the current practice of

performing a piece count, which replaced the verification of serial numbers and

locations, is an acceptable method of performing a physical inventory of all SNM

possessed. (CR-VTY-2004-01339, CA#25).

c. Findings and Conclusions

No findings of significance were identified. The inspectors concluded that conduct of

the MC&A program relied heavily on individual knowledge. Although the written

procedures contained adequate instructions, the level of detail of the instructions in the

procedure could be enhanced. Entergy acknowledged the need for procedure

enhancements and has included in its corrective action plan a review of MC&A practices

and procedures.

Enclosure

12

6. Verification of Current SNM Inventory

a. Inspection Scope

The inspectors reviewed Entergys inventory results for the most recent inventory to

assure that Entergy accounted for all other SNM. The review included examination of

videotapes documenting the inspection of fuel assembly serial numbers in the SFP

storage racks and verification of selected non-fuel SNM materials. The inspectors also

assessed Entergys methods for tracking configuration changes caused by moving fuel

assemblies, as well as moving individual fuel rods from one assembly to another

assembly and within the SFP.

b. Discussion

Entergy fully verified the documented position of 100% of fuel assemblies in the SFP by

comparing the serial numbers on the fuel assemblies to the serial numbers recorded on

the SFP map for each rack position, with no discrepancies noted. The inspectors

independently selected 219 of the rack positions shown on the SFP map and compared

the serial numbers of fuel assemblies shown in those positions on the inspection

videotapes with the expected serial numbers. The inspectors identified no

discrepancies in the sample reviewed. The inspectors verified the location of selected

non-fuel SNM (i.e. fission detectors) by comparing the actual serial number of the item

to the inventory sheet. The inspectors also verified the balance of non-fuel SNM

inventory by matching the tamper-evident seal number to the corresponding item shown

on the inventory sheet. No discrepancies were found.

Procedure OP-1403, Fuel Bundle Non-Destructive Testing and Reconstitution,

Rev. 16, describes the methods used for examining fuel assemblies and individual rods,

and it specifies that records be created for accountability of fuel rods moved. While

discussed generally in procedure OP-1403, the inspectors interviewed Entergy

personnel who also described in detail the method used to track configuration changes

made to fuel assemblies through the movement of individual fuel rods, such as during

reconstitutions. When a rod was removed from an assembly, the action was recorded

on the notebook page for that assembly along with a note indicating where the rod was

moved. Exchange of one rod for another was also recorded on the notebook page,

creating the record that enabled tracking of the movements of individual fuel rods

among assemblies. When all such changes to an assembly have been completed

during a manipulation, the current SNM inventory of that reconstituted fuel assembly

was adjusted to reflect the incremental additions and subtractions appropriate for the

fuel rods added and removed. Entergy reviewed the records of all individual rod

movements within the SFP as part of the SNM Investigation Teams work and identified

no discrepancies. The inspectors reviewed a sample of these records and found that

each rod movement in the sample reviewed was properly recorded in the affected fuel

assembly records.

Enclosure

13

c. Findings and Conclusions

No findings of significance were identified. The inspectors concluded that as of July 13,

2004, Entergy was in full compliance with regulatory requirements to account for all

SNM in its possession.

7. Control of Spent Fuel Pool Materials

a. Inspection Scope

The inspectors reviewed Entergys radwaste shipping controls to determine whether

vulnerabilities existed that could have allowed shipment of misidentified SNM located in

a fuel storage liner to a low-level radwaste storage site. The inspectors reviewed the

controls that would preclude station staff from inappropriately disposing irradiated

material, such as the two spent fuel rod pieces, that were located in the SFP. The

inspectors interviewed personnel participating in recent radwaste shipping campaigns.

The focus of this review was restricted to radwaste generated within and shipped from

the SFP.

b. Discussion

The records indicate that station staff made at least five SFP cleanup campaigns and

subsequent shipments of radwaste materials between 1980 and 2000. These radwaste

shipments were composed of various types of irradiated hardware and miscellaneous

items. Plant personnel were knowledgeable of their individual responsibilities and

indicated that controls had been implemented to assure categorization of materials that

were intended to be placed into a radwaste liner for shipment to a low-level radwaste

disposal site. The inspectors reviewed the material categorization report for one recent

shipment of irradiated material from the SFP, Report WMG-9713, Packing Hardware at

VY During 1997," and found the categorization information provided sufficient detail of

the items included in the radwaste shipment.

During interviews, station staff acknowledged that the procedure controlling the

radwaste packaging and shipment did not require that a capped or closed container,

such as the storage liner housing the spent fuel rod pieces, be opened and examined

prior to placement into the radwaste liner for shipment. The inspectors reviewed the

most current revision of the Entergy procedure utilized to control the packaging and

shipment of radwaste, Operating Procedure OP-0044, Volume Reduction, Packaging

and Shipping of Irradiated Hardware from the Spent Fuel Pool, Revision 4. The

inspectors confirmed that the procedure did not provide directions for opening a closed

container prior to placement into the radwaste liner for shipment.

Additionally, the inspectors noted that while VY personnel indicated it was the stations

practice to categorize all materials prior to packaging, the procedure did not prohibit

placing other uncategorized hardware into a radwaste package. Completion of a dose

profile for waste items by radiation protection personnel was the only procedural

requirement for including the miscellaneous hardware in any radwaste shipment.

Enclosure

14

The inspectors also reviewed historical procedures that provided controls of radwaste

shipments originating from the SFP between 1983 and 1987. Revisions 0 and 1 to

procedure OP-2203, Procedure for Processing of Spent Control Rods Prior to

Disposal, were also found to not prohibit disposal of irradiated materials other than the

planned control rods, provided that a dose rate survey was completed and the liner

surface dose rate did not exceed a specified limit.

c. Findings and Conclusions

No findings of significance were identified. The inspectors concluded that station staff

were knowledgeable of correct radwaste shipment practices. The inspectors also

concluded that although the radwaste procedural controls and the practices in use at the

station for packaging and shipment of irradiated material originating from the SFP were

adequate, the instructions and the administrative controls in the procedure could be

enhanced to prohibit disposal of an unidentified piece of irradiated material. Entergy

acknowledged the procedural weaknesses and revised the affected procedures before

the on-site portion of the inspection ended on August 27, 2004.

8. (Closed) URI 05000271/2004002-02, Did not Adhere to Procedural Requirements for

Performing an Annual Physical Inventory of Two Spent Fuel Rod Segments

This URI is considered closed based on the results of the inspectors review of the event

as documented in Section 4OA5.1 of this report.

4OA6 Meetings, including Exit

The inspectors discussed the results of the on-site portion of the inspection with Entergy

management at VY on August 12, 2004. The inspectors further discussed inspection

results with Entergy on September 8, 2004, following completion of an in-office review of

Entergys Root Cause Analysis Report. On November 23, 2004, the inspectors

conducted inspection closeout discussions with Entergy management in a telephone

call.

Enclosure

A1-1

ATTACHMENT 1

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Entergy Personnel:

J. Thayer Site Vice President

K. Bronson General Plant Manager

J. Dreyfuss Director of Engineering

J. Devincentis Licensing Manager

J. Geyster Radiation Protection Superintendent

M. Hamer Licensing

R. Wanczyk Director of Nuclear Safety

J. Hoffman SNM IT Project Leader

T. White SNM IT, Manager of Quality Assurance

D. Mannai Reactor Engineering Superintendent

J. Card SNM IT

R. Ramsdell SNM IT

Others

W. Sherman Vermont Department of Public Safety

LIST OF ITEMS OPENED, CLOSED AND DISCUSSED

Opened

05000271/2004007-01 AV Did Not Keep Adequate Records, Follow

Procedures, and Perform Physical Inventory of

Special Nuclear Material

Closed

05000271/2004002-00, 01 LER Special Nuclear Material not Accounted for at

Vermont Yankee

05000271/2004002-02 URI Did not Adhere to Procedural Requirements for

Performing an Annual Physical Inventory of Two

Spent Fuel Rod Segments

Attachment

A1-2

LIST OF SIGNIFICANT DOCUMENTS REVIEWED

OP-0400, SNM Inventory and Accountability Procedure (Rev. 32, dated 6/17/2003 and earlier

revisions)

OP-1400, Fuel Receipt and Preliminary Handling, (Rev. 25, dated 01/06/04)

OP-1401, New Fuel Inspection and Channeling, (Rev. 29, dated 02/03/04)

OP-1403, Fuel Bundle Non-Destructive Testing and Reconstitution, (Rev. 16, dated 05/03/02)

OP-1410, Fuel Loading Schedule Generation, (Rev. 25, dated 04/09/01)

OP-1411, Core Verification, (Rev. 20, dated 11/04/03)

OP-0044, Volume Reduction, Packaging and Shipping of Irradiated Hardware from the Spent

Fuel Pool, Revision 4

OP-2203, Procedure for Processing of Spent Control Rods Prior to Disposal, Revs 0 and 1

DP-0545, Fuel Pool Storage Requirements, Revs 11 and 0

AP-0009, Condition Reports, Rev 16

Material categorization report for one recent shipment of irradiated material from the SFP,

Report WMG-9713, Packing Hardware at Vermont Yankee During 1997"

SNM IT Project Plan, Rev 0

SNM IT Procedure SNM-WI-01, Communication Plan

SNM IT Procedure SNM-WI-02, Regulatory Interface

SNM IT Procedure SNM-WI-03, Conduct of Interviews

SNM IT Procedure SNM-WI-04, Spent Fuel Pool Manual Camera Inspection

SNM IT Procedure SNM-WI-05, Spent Fuel Pool Camera Inspection under Racks

SNM IT Procedure SNM-WI-07, SNM Project Record Reviews

SNM IT Procedure SNM-WI-08, Scenario Process

Origination

Condition Reports Date

CR-VTY-2004-01350 4/21/04 Revise AP-0156 to reflect changes in 10CFR reporting

requirements

CR-VTY-2004-01389 4/22/04 Revise OP-0400 to reflect changes in 10CFR reporting

requirements

CR-VTY-2004-02562 8/12/04 Understand why physical searches missed the GE liner

CR-VTY-2004-02440 8/2/04 Documentation of the transfer of fuel pieces in the SFP in

1980

CR-VTY-2004-00671 3/24/04 Plan to examine bucket to verify fuel pin pieces are

present

CR-VTY-2004-01906 6/4/04 SNM container tamper-evident seal program not effective

CR-VTY-2004-01339 4/20/04 Investigate missing fuel pieces (all related issues)

ML043340149

Text

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