ML17100A499
| ML17100A499 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 04/10/2017 |
| From: | Anton Vegel Division of Reactor Safety IV |
| To: | Reddemann M Energy Northwest |
| Gepford H | |
| References | |
| EA-17-028 IR 2016009 | |
| Download: ML17100A499 (64) | |
See also: IR 05000397/2016009
Text
April 10, 2017
Mr. Mark E. Reddemann
Chief Executive Officer
Energy Northwest
P.O. Box 968 (Mail Drop 1023)
Richland, WA 99352-0968
SUBJECT: COLUMBIA GENERATING STATION - NRC SPECIAL INSPECTION
REPORT 05000397/2016009; PRELIMINARY WHITE FINDING
Dear Mr. Reddemann:
The U.S. Nuclear Regulatory Commission (NRC) has completed its initial assessment of the
circumstances related to an improperly packaged and manifested radwaste shipment sent by
Columbia Generating Station to US Ecology, on November 9, 2016. Starting in December 2016,
the NRC conducted a Special inspection to independently review the circumstances related to
this incident. The Special Inspection Team identified multiple performance deficiencies,
including an apparent violation which has been preliminarily characterized as White, a finding of
low to moderate safety significance. As described below a Regulatory Conference has been
scheduled for May 2, 2017. The conference is an opportunity for you and your staff to provide
your perspective on this matter including your views and facts that the NRC should consider in
determining the final significance of the apparent violation, and information related to the
completed and or planned corrective actions.
An NRC team performed an on-site inspection the week of December 12, 2016. On
February 24, 2017, the NRC completed its special inspection activities. On March 17, 2017, the
NRC inspection team discussed the results of this inspection with Mr. B. Sawatzke, Chief
Operating Officer and Chief Nuclear Officer, and other members of your staff. The results of
this inspection are documented in the enclosed report.
The enclosed inspection report documents a finding with an associated apparent violation that the
NRC has preliminarily determined as White, a finding with low to moderate safety significance that
may require additional NRC inspections. This finding involved the failure to ensure that the
radioactive contents of a radwaste container did not exceed the radiation level requirements for
shipping. As a result, the licensee transported a Type A package containing a Type B quantity
of radioactive material as low specific activity (LSA) even though it had an external radiation
level of 2.1 rem/hr at a distance of 3 meters from the unshielded material, exceeding the
1 rem/hr at 3 meters limit for LSA. The circumstances surrounding this apparent violation, the
preliminary significance of the issue, and the need for comprehensive corrective actions were
discussed with members of your staff at the inspection exit meeting on March 17, 2017.
M. Reddemann 2
The NRC assessed the significance of the finding using the NRC Significance Determination
Process (SDP) and readily available information. The finding was evaluated using Inspection
Manual Chapter 0609, Appendix M, Significance Determination Process Using Qualitative
Criteria, because Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety
Significance Determination Process, does not specifically address the situation where a Type A
package was used to ship quantities of radioactive material requiring a Type B package.
Therefore, in accordance with Appendix M, an initial qualitative bounding evaluation was
completed. This was accomplished using the Transportation Branch of the Public Radiation
Safety SDP and examples from Section 6.8 of the Enforcement Policy. The results of the
bounding evaluation is a finding preliminarily characterized as a White/SL-III issue in
accordance with this SDP qualitative process. This finding is being considered for escalated
enforcement in accordance with the NRC Enforcement Policy, which can be found at
http://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html. Because we have not
made a final determination, no Notice of Violation is being issued at this time. Please be aware
that further NRC review may prompt us to modify the characterization of the apparent violation.
In accordance with NRC Inspection Manual Chapter 0609, we intend to complete our evaluation
using the best available information and issue our final determination of safety significance
within 90 calendar days of the date of the enclosed report. The SDP encourages an open
dialogue between the NRC staff and the licensee; however, the dialogue should not impact the
timeliness of the staffs final determination.
Before the NRC makes its enforcement decision, a Regulatory Conference to discuss the
apparent violation has been scheduled for May 2, 2017, at 1:00 pm Central Daylight Time at the
Region IV office in Arlington, TX. This conference will be open to public observation in
accordance with Section 2.4, Participation in the Enforcement Process, of the NRC
Enforcement Policy. We encourage you to submit supporting documentation at least one week
prior to the conference in an effort to make the conference more efficient and effective. Please
contact Heather Gepford at (817) 200-1156 if you have any questions regarding the Regulatory
Conference. The final resolution of this matter will be conveyed in separate correspondence.
In addition, the NRC team documented seven findings of very low safety significance (Green) in
this report. Six of these findings involved violations of NRC requirements. Additionally, the NRC
team documented one Severity Level IV violation. The NRC is treating these violations as non-
cited violations (NCVs) consistent with Section 2.3.2.a of the Enforcement Policy.
If you contest any of the seven NCVs or their significance, you should provide a response within
30 calendar days of the date of this inspection report, with the basis for your denial, to the U.S.
Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001;
with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement,
U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC senior
resident inspector at the Columbia Generating Station.
If you disagree with a cross-cutting aspect assignment or a finding not associated with a
regulatory requirement in this report, you should provide a response within 30 days of the date of
this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory
Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the
Regional Administrator, Region IV; and the NRC senior resident inspector at the Columbia
Generating Station.
This letter, its enclosure, and your response (if any) will be made available for public inspection
M. Reddemann 3
and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document
Room in accordance with 10 CFR 2.390, Public Inspections, exemptions, requests for
withholding.
Sincerely,
/RA/
Anton Vegel, Director
Division of Reactor Safety
Docket No. 50-397
License No. NPF-21
Enclosure:
Inspection Report 05000397/2016009
w/Attachments:
1 . Supplemental Information
2. List of Acronyms
3. Appendix M - Significance Determination
Using Qualitative Criteria
U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Docket: 05000397
License: NPF-21
Report: 05000397/2016009
Licensee: Energy Northwest
Facility: Columbia Generating Station
Location: North Power Plant Loop
Richland, WA 99354
Dates: December 12, 2016, through February 24, 2017
Inspectors: L. Carson, Senior Health Physicist
N. Greene, Ph.D., Health Physicist
B. Tharakan, CHP, State Agreements Officer
Approved Heather J. Gepford, Ph.D., CHP
By: Chief, Plant Support Branch 2
Division of Reactor Safety
Enclosure
SUMMARY
IR 05000397/2016009; 12/12/2016 - 02/24/2017; Columbia Generating Station; Special
Inspection to Evaluate the Circumstances Surrounding a Radwaste Shipment that Arrived at the
Burial Site with Higher than Anticipated Dose Rates
The special inspection activities described in this report were performed between December 12,
2016, and February 24, 2017, by three NRC region-based inspectors. One preliminary White
apparent violation, six Green non-cited violations, one Severity Level IV non-cited violation,
and one Green finding were identified.
The significance of most inspection findings is indicated by their color (Green, White, Yellow, or
Red), which is determined using Inspection Manual Chapter 0609, Significance Determination
Process, dated April 29, 2015. Their cross-cutting aspects are determined using Inspection
Manual Chapter 0310, Aspects within the Cross-Cutting Areas, dated December 4, 2014.
Violations of NRC requirements are dispositioned in accordance with the NRC Enforcement
Policy, dated November 1, 2016. The NRCs program for overseeing the safe operation of
commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process,
dated July 2016.
A. NRC-Identified Findings and Self-Revealing Findings
Cornerstone: Public Radiation Safety
- TBD. The team reviewed a self-revealed finding and apparent violation of
49 CFR 173.427 associated with a shipment of low specific activity (LSA) material
consisting of radioactive filters, irradiated components, and dry active waste. The
licensee failed to ensure that the radioactive contents in a radwaste liner did not exceed
the radiation level requirements for shipping. Specifically, the licensee transported a
Type A package containing a Type B quantity of radioactive material as LSA even
though it had an external radiation level of 2.1 rem/hr at a distance of 3 meters from the
unshielded material, exceeding the 1 rem/hr at 3 meters limit for LSA. This issue was
entered into the corrective action program as Action Requests 357593 and 360236.
The failure to ensure that the radioactive contents of a radwaste container of low specific
activity material did not exceed the requirements for shipping was a performance
deficiency. The performance deficiency was more than minor because it was associated
with the program and process (Transportation Program) attribute of the Public Radiation
Safety Cornerstone and adversely affected the cornerstone objective of ensuring
adequate protection of public health and safety from exposure to radioactive material
released into the public domain. Specifically, the licensees failure to ensure that the
contents of a radwaste container did not exceed the requirements for shipping
resulted in radioactive material being transported in Type A packaging rather than the
required Type B packaging. The finding was evaluated using NRC Inspection Manual
Chapter 0609, Appendix M, Significance Determination Process Using Qualitative
Criteria, because Inspection Manual Chapter 0609, Appendix D, Public Radiation
Safety Significance Determination Process, does not specifically address the situation
where a Type A package was used to ship quantities of radioactive material requiring a
Type B package. In accordance with Appendix M, an initial qualitative bounding
evaluation was performed. This was accomplished using the Transportation Branch of
2
the Public Radiation Safety Significance Determination Process and examples from the
The finding has a cross-cutting aspect in the area of human performance, associated
with conservative bias, because licensee personnel did not use decision-making
practices that emphasized prudent choices over those that were simply allowable.
Specifically, on several occasions throughout the radwaste processing and packaging
evolution for shipment No. 16-40, decisions were made that did not exhibit the
appropriate conservative bias [H.14]. (Section 2.10a)
- Green. The team reviewed three examples of a self-revealed, non-cited violation of
10 CFR 20.1501 associated with the failure to conduct adequate surveys of the solid
radwaste contents of a shipment that was packaged and transported for ultimate
disposal. As a result of the inadequate surveys, the radwaste in shipment No. 16-40
was packaged in the incorrect type of shipping cask, the radwaste manifest and shipping
paperwork contained numerous errors, and the waste was not correctly classified in
accordance with 10 CFR Part 61. This issue was entered into the corrective action
program as Action Request 357593.
The failure to conduct adequate surveys of the solid radwaste contents in a shipment
that was packaged and transferred for ultimate disposal was a performance deficiency.
The team determined that the performance deficiency was more than minor, and
therefore a finding, because it was associated with the program and process aspect of
the Public Radiation Safety Cornerstone and adversely affected the cornerstone
objective to ensure adequate protection of public health and safety from exposure to
radioactive materials released in the public domain. Specifically, as a result of the
inadequate surveys, the radwaste in shipment No. 16-40 was packaged in the incorrect
type of shipping container, the radwaste manifest and shipping paperwork contained
numerous errors, and the waste was misclassified in accordance with 10 CFR Part 61.
Using NRC Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety
Significance Determination Process, the violation was determined to be of very low
safety significance (Green) because it was a finding in the transportation branch in
which: (1) radiation limits were not exceeded, (2) there was no breach of the package
during transit, (3) there were no Certificate of Compliance issues, and (4) the low-level
burial ground nonconformance did not involve a 10 CFR 61.55 waste underclassification.
The finding has a cross-cutting aspect in the area of human performance, associated
with documentation, because the organization failed to maintain complete, accurate, and
up-to-date documentation [H.7]. (Section 2.10b)
- Green. The team identified a non-cited violation of 10 CFR 20.1904 for the licensees
failure to ensure that each container of licensed material in the spent fuel pool bore a
label or had documentation providing sufficient information to permit individuals handling
the licensed material to minimize exposure. The immediate corrective actions were to
generate a condition report and assess the extent of the failure to label or provide
sufficient information for all items in the spent fuel pool, reevaluate the latest spent fuel
pool annual inventory to identify any missing information, and update applicable
procedures. This issue was entered into the corrective action program as Action
Requests 357593 and 360148.
3
The licensees failure to ensure that each container of licensed material stored in the
spent fuel pool bore a label or had sufficient written information to permit individuals
handling the licensed material to minimize exposure was a performance deficiency.
The performance deficiency was more than minor, and therefore a finding, because it
was associated with the programs and process (exposure control) attribute of the
Occupational Radiation Safety Cornerstone and adversely affected the cornerstone
objective to ensure the adequate protection of the worker health and safety from
exposure to radiation from radioactive material. Specifically, accessing highly
radioactive material without sufficient information and unknown radiological conditions
could result in unanticipated dose rates and unplanned exposures. Using NRC
Inspection Manual Chapter 0609, Appendix C, Occupational Radiation Safety
Significance Determination Process, the finding was determined to be of very low safety
significance (Green) because it did not: (1) involve as low as is reasonable achievable
(ALARA) planning or work controls, (2) did not involve an overexposure, (3) did not have
a substantial potential to be an overexposure, and (4) the ability to assess dose was not
compromised. The finding has a cross-cutting aspect in the area of human
performance, associated with avoiding complacency, because licensee personnel failed
to recognize and plan for the possibility of mistakes and inherent risk, even while
expecting a successful outcome, once these items are accessed [H.12]. (Section 2.10c)
- Green. The team identified a non-cited violation of 10 CFR 20.2006(b) for the licensees
failure to ship radwaste with an accurate shipping manifest. Specifically, the licensee
failed to provide the correct identification number and proper shipping name,
radionuclide activity, net waste volume, surface radiation level, and waste classification.
The incorrect surface radiation levels resulted in rejection of the package and the
licensees immediate suspension from usage of the land disposal site at US Ecology.
This issue was entered into the corrective action program as Action Requests 357593
and 359498.
The licensees failure to ship radwaste intended for ultimate disposal with an accurate
shipping manifest was a performance deficiency. The performance deficiency was more
than minor, and therefore a finding, because it was associated with the program and
process attribute of the Public Radiation Safety Cornerstone and adversely affected the
cornerstone objective to ensure adequate protection of public health and safety from
exposure to radioactive material released in the public domain. Specifically, inaccurate
information on a shipping manifest could result in inappropriate handling of radioactive
material while in the public domain. Using NRC Inspection Manual Chapter 0609,
Appendix D, Public Radiation Safety Significance Determination Process, the finding
was determined to be of very low safety significance (Green) because: (1) radiation
limits were not exceeded, (2) there was no breach of a package during transit, (3) it did
not involve a certificate of compliance issue, (4) it was not a low-level burial ground
nonconformance, and (5) it did not involve a failure to make notifications or provide
emergency information. The finding has a cross-cutting aspect in the area of human
performance, associated with avoiding complacency, because licensee personnel failed
to recognize and plan for the possibility of mistakes, latent issues, and inherent risk,
even while expecting successful outcomes, by not implementing appropriate error
reduction tools. Due to the lack of appropriate error prevention tools, inaccurate survey
data was provided to the vendor and errors in the waste characterization and shipping
manifest were not identified in a timely fashion [H.12]. (Section 2.10d)
4
- Green. The team identified a non-cited violation of 10 CFR Part 20, Appendix G, for the
failure to manage a quality assurance program to ensure compliance with 10 CFR 61.55
and 10 CFR 61.56. Additionally, licensee management failed to effectively evaluate the
significance of quality assurance audit findings in the area of radwaste processing and
radioactive material shipments.
The failure to manage a quality assurance program to assure compliance with
10 CFR 61.55 and 10 CFR 61.56 was a performance deficiency. The team determined
that the performance deficiency was more than minor, and therefore a finding, because it
was associated with the Public Radiation Safety Cornerstone attribute of program and
process and adversely affected the cornerstone objective to ensure adequate protection
of public health and safety from exposure to radioactive materials released in the public
domain. Specifically, the failure to manage quality assurance activities as part of the
radwaste processing and packaging program resulted in wastes that were not properly
classified or did not possess the proper characteristics for burial. Using NRC Inspection
Manual Chapter 0609, Appendix D, Public Radiation Safety Significance Determination
Process, the violation was determined to be of very low safety significance (Green)
because it was a finding in the transportation branch in which: (1) radiation limits were
not exceeded, (2) there was no breach of the package during transit, (3) there were no
Certificate of Compliance issues, and (4) the low-level burial ground nonconformance
did not involve a 10 CFR 61.55 waste under-classification. The finding has a cross-
cutting aspect in the area of human performance, associated with avoiding complacency,
because licensee personnel failed to recognize and plan for the possibility of mistakes,
latent issues, and inherent risk, even while expecting successful outcomes, by not
implementing appropriate error reduction tools, such as a proper quality assurance
program. Specifically, the licensee has failed to ensure the appropriate level of quality
assurance/quality control oversight and verification with respect to risk-significant
radwaste processing and radioactive material shipment activities [H.12]. (Section 2.10e)
- SLIV. The team identified a Severity Level IV non-cited violation of 10 CFR 50.71(e) for
the failure of the licensee to periodically provide the NRC a Final Safety Analysis Report
(FSAR) update with all changes made to the facility or procedures. Specifically, the
licensee changed its radwaste management strategy for the spent fuel pool cooling and
cleanup system and material being stored in the spent fuel pool. However, the licensee
had not changed its process control program or updated the FSAR to reflect the impact
on waste streams from processing items stored in the spent fuel pool including activated
metals, Tri-Nuke filters, filter socks, and demineralizer filter resins. This issue was
entered into the corrective action program as Action Requests 359293 and 359296.
The failure to update the final safety analysis report to reflect changes in solid radwaste
management and the process control program was a performance deficiency. The
Reactor Oversight Programs SDP does not specifically consider the regulatory process
impact in its assessment of licensee performance. Therefore, it is necessary to address
this violation which involves the ability of the NRC to perform its regulatory oversight
function using traditional enforcement to adequately deter non-compliance. Referring to
Section 6.1.d. of the Enforcement Policy, the finding is being characterized as a Severity
Level IV violation. Traditional enforcement violations are not assessed for cross-cutting
aspects. (Section 2.10f)
- Green. The team identified a finding for the failure to follow the requirements of
Procedure SWP-CAP-06, Condition Report Review, when determining the type of
5
cause evaluation required to assess the causes of the higher than expected dose rates
on a radwaste container. Specifically, Procedure SWP-CAP-06 required that if an event
has high risk and high uncertainty, the level of evaluation required is a root cause
evaluation. However, the licensee failed to adequately assess the uncertainty
associated with the causes of the event and performed an apparent cause evaluation
rather than a root cause evaluation. The licensee entered this finding into the corrective
action program as Action Request 360236.
The failure to follow the requirements of Procedure SWP-CAP-06 when determining the
type of cause evaluation required to assess the higher than expected dose rates on a
radwaste container and performing an apparent cause evaluation instead of a root cause
evaluation was a performance deficiency. The team determined that the performance
deficiency was more than minor, and therefore a finding, because it was associated with
the Public Radiation Safety Cornerstone attribute of program and process and adversely
affected the cornerstone objective to ensure adequate protection of public health and
safety from exposure to radioactive materials released in the public domain.
Specifically, the failure to adequately assess the causes of the event left the licensee
vulnerable to future radwaste processing and transportation errors of significance.
Using NRC Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety
Significance Determination Process, the finding was determined to be of very low safety
significance (Green). The finding has a cross-cutting aspect in the area of problem
identification and resolution, associated with evaluation, because the licensee failed to
thoroughly evaluate the issue to ensure resolutions address causes and extent of
conditions commensurate with their safety significance [P.2]. (Section 2.10g)
- Green. The team reviewed a self-revealed non-cited violation of 10 CFR 30.41(b)(5)
for the failure to transfer byproduct material to an authorized waste disposal facility
in accordance with the terms of the facilitys license. Specifically, License
Condition No. 22.C of the US Ecology license required that all radwaste shall be
packaged in such a manner that waste containers received at the facility do not show an
increase in the external radiation levels as recorded on the manifest, within instrument
tolerances. On November 9, 2016, the licensee transferred byproduct material to
US Ecology for disposal; the disposal facilitys surveys revealed that the dose rate on
contact with the waste liner was 90 rem per hour, whereas the manifest recorded a dose
rate 11.8 rem per hour. The licensee retrieved the shipment, stored it safely, and
entered the condition into the corrective action program as Action Request 357593.
The failure to transfer byproduct material to a low-level radwaste disposal facility in
accordance with the facilitys license was a performance deficiency. The performance
deficiency was more than minor because it was associated with the program and
process attribute of the Public Radiation Safety Cornerstone and adversely affected the
associated cornerstone objective to ensure adequate protection of public health and
safety from exposure to radioactive materials released into the public domain as a
result of routine civilian nuclear reactor operation. Using NRC Inspection Manual
Chapter 0609, Appendix D, Public Radiation Safety Significance Determination
Process, the finding was determined to be of very low safety significance (Green)
because it was a low-level burial ground nonconformance and a 10 CFR 61.55 waste
under-classification; however, it was not Class C waste or greater and the waste did
conform to the waste characteristics of 10 CFR 61.56. The finding has a cross-cutting
aspect in the area of human performance, associated with conservative bias, because
station personnel failed to use decision-making practices that emphasize prudent
6
choices over those that are simply allowed considering the licensee had multiple
opportunities to re-evaluate the shipment and determine the appropriate requirements
[H.14]. (Section 2.10h)
- Green. The team reviewed a self-revealed non-cited violation of 10 CFR 61.56(a)(3) for
the licensees failure to assure that void spaces within the waste packages were reduced
to the extent practicable. Specifically, a shipment of dry active waste sent to US Ecology
in May 2016 arrived at the disposal facility with voids in excess of 15 percent of the total
waste volume, contrary to the requirements of US Ecologys Radioactive Material
License WN-I019-2, License Condition No. 23. Corrective actions included inspecting
the other containers from waste shipment No.16-27 and testing each container for
voids. The licensee documented this issue in their corrective action program as Action
Request 352217 and performed an apparent cause evaluation.
The failure to ship radwaste for disposal without reducing void spaces to the extent
practicable was a performance deficiency. The team determined that the performance
deficiency was more than minor because it adversely affected the Public Radiation
Safety Cornerstone objective to ensure adequate protection of public health and safety
from exposure to radioactive materials released in the public domain. Specifically, the
failure to ensure that void spaces were removed in the radwaste container shipped to
US Ecology subjected the disposal facility to the possibility of improper disposal of the
waste, in that, the package was susceptible to stability issues. Using NRC Inspection
Manual Chapter 0609, Appendix D, Public Radiation Safety Significance Determination
Process, the violation was determined to be of very low safety significance (Green)
because: (1) radiation limits were not exceeded, (2) there was no breach of the package
during transit, (3) there were no Certificate of Compliance issues, and (4) the low-level
burial ground nonconformance did not involve a 10 CFR 61.55 waste under-
classification. The finding has a cross-cutting aspect in the area of human performance,
associated with teamwork, because individuals and work groups failed to communicate
and coordinate their activities within and across organizational boundaries to ensure
nuclear safety is maintained [H.4]. (Section 2.10i)
B. Licensee-Identified Violations
A violation of very low safety significance that was identified by the licensee was
reviewed by the team. Corrective actions taken or planned by the licensee have been
entered into the licensees corrective action program. This violation and associated
corrective action tracking numbers are listed in Section 4OA7 of this report.
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REPORT DETAILS
4. OTHER ACTIVITIES
Cornerstone: Public Radiation Safety Cornerstone
4OA5 Other Activities
.1 Basis for Special Inspection
On November 9, 2016, Columbia Generating Station (CGS) Shipment No. 16-40, which
contained a single package of non-fissile items removed from the spent fuel pool (SFP),
was sent to a low-level radioactive waste (LLRW) facility (US Ecology, Richland,
Washington) for disposal. Shipment No. 16-40 consisted of a carbon steel open top
waste liner (16-059-OT) containing Tri-Nuke filters, sock filters, and irradiated control rod
velocity limiters. The waste liner was transported within a Duratek model CNS 14-190H
cask. The package was shipped as an exclusive use shipment of low specific activity
(LSA) radioactive material.
The manifest specified an unshielded contact dose rate on the liner within the shipping
cask of 11.8 rem per hour (rem/hr). The 11.8 rem/hr dose rate specified on the manifest
was a calculated value and was not measured using a survey instrument. Upon
unloading the waste liner from the shipping cask, US Ecology personnel measured
unshielded contact dose rates of up to 90 rem/hr on the liner. As a result of the
significant discrepancy between the manifested dose rate and the actual dose rates
measured on the liner, the shipment was rejected by US Ecology and returned to CGS.
Columbia Generating Station was contacted by the Washington State Department of
Health (WSDOH) on November 10, 2016, and notified that their disposal use permit
privileges to the low-level waste facility had been suspended until a written plan
containing corrective actions was approved and an on-site inspection was completed by
WSDOH. A revised notification was sent on November 16, 2016, which documented
three violations.
Management Directive 8.3, NRC Incident Investigation Program, was used to evaluate
the level of NRC response for this event. In evaluating the criteria of Management
Directive 8.3, it was determined that this event met two of the deterministic criteria for a
special inspection. Specifically, this event resulted in unanticipated dose rates in excess
of 20 rem/hr in a restricted area and was related to the health and safety of the public
expected to cause significant, heightened public, or government concern.
Based on these deterministic criteria, Region IV management determined that the
appropriate level of NRC response was to conduct a special inspection. The special
inspection was chartered to identify the circumstances surrounding the radwaste shipping
event and review the licensees actions to address the causes of the event.
.2 Inspection Results
2.1 Charter Item 2: Develop a complete sequence of events related to the preparation,
shipment, and subsequent return of radioactive waste shipment No. 16-40. The
8
chronology should include any radiological surveys performed, determination of the
radiological contents of the liner, creation of the manifest, and communications between
the licensee, the waste disposal facility, and the state of Washington.
a. Inspection Scope
The team developed and evaluated a timeline of the circumstances and events leading
up to a shipment from CGS that arrived at the US Ecology waste disposal facility with
higher than expected dose rates. The team developed the timeline, in part, through a
review of shipping documents, licensee corrective action documents, and interviews with
station personnel.
b. Findings and Observations
The team established a timeline for three distinct phases associated with the shipment:
(1) preparation and characterization of the radioactive waste contained in the shipment,
(2) packaging the radioactive waste in the waste liner and shipping cask, and (3) shipping
and transportation of the radioactive waste package to the disposal facility.
Preparation
Circa 2010 Tri-Nuke filters, sock filters, control rod velocity limiters, and
control rod blades were stored in the spent fuel pool in
preparation for the spent fuel pool cleanup (SFPCU) project.
These items were not properly labeled or inventoried with
sufficient information.
July 22, 2015 Contract was established with DW James Services (DWJ) to
perform waste characterizations of the SFPCU project.
September 22, Radiation Surveys 5048 and 5049 were performed and
2015 incorrectly labeled as Local Power Range Monitor (LPRM)
Characterization, when they were actually 18 Tri-Nuke filters,
stored in 9 canisters, two in each canister. As a result of this
error the Tri-Nuke filters were not appropriately accounted for
in the waste characterization. This resulted in at least 20 Ci of
radwaste being excluded from the original shipment manifest.
September 23-28, Radiation Surveys 5067, 5105, and 5113 were performed of
2015 the Tri-Nuke and sock filters in the SFP. The lowest dose rate
was 100 mrem/hr; the highest dose rate was 84 rem/hr.
October 2, 2015 CGS SFPCU project team sent radiation survey documents to
DWJ for waste characterization. DWJ had stated they
preferred 6-inch survey measurements. CGS performed the
survey measurements at 6 inches; however, they were
improperly recorded as on contact dose rates.
9
March 1-8, 2016 Radiation surveys were performed of the control rod velocity
limiters in the SFP (Surveys 6385, 6402, 6411, 6422, 6437,
and 6448). The lowest dose rate was 170 mrem/hr; the highest
dose rate was 10 rem/hr.
April 5, 2016 DWJ contacted CGS to confirm surveys were taken at 6 inches
for the filter data. The licensee incorrectly stated they were
contact dose rates, which resulted in radiation filter surveys
being reported 40 percent lower than they actually were.
April 21, 2016 Preliminary characterization of the Tri-Nuke filters was
performed by DWJ and included 66 Tri-Nuke filters and 9 sock
filters.
Note: The characterization failed to include 18 Tri-Nuke filters
because the survey data was mislabeled as LPRM
Characterization.
May 2016 Licensee made the decision to split the SFPCU project into
two phases for economic and dose purposes. Disposal of
control rod blades would occur in the spring; disposal of filters,
control rod velocity limiters, and instruments would occur in the
fall.
May 23, 2016 Characterization of Tri-Nuke filters and control rod velocity
limiters completed by DWJ and documented in
Report DAC-0382. (Note: 18 Tri-Nuke filters incorrectly
characterized as LPRMs.)
May 2016 Radwaste Transportation Specialist (RWTS) and Reactor
Maintenance (RxM) personnel made the decision to use one
carbon steel open top liner in a 14-190-H Type A cask, instead
of two separate polyethylene high integrity containers shipped
in Type B casks. This decision was made based on the waste
characterization performed by DWJ.
June 2016 SFPCU campaign suspended due to fiscal budget overruns.
Sock filters, Tri-Nuke filters, and control rod velocity limiters
were left in the SFP and scheduled for disposal after July 1,
2016.
September 2016 Plan for loading Tri-Nuke filters and control rod velocity limiters
discussed by the RWTS and RxM supervisor. The plan was to
surround the outer perimeter of the liner with control rod
velocity limiters, and place Tri-Nuke and sock filters in the
middle, with the filters with the highest dose rates in the center.
This loading plan for the liner was not documented or
implemented.
10
Packaging
June 2016 Waste liner was pre-loaded in a Type A shipping cask for direct
transfer of items from SFP to liner/cask unit.
October 13, 2016 Loading of waste liner with items from SFP began.
October 13, 2016 Six filters were raised from the SFP to drip dry prior to moving
them into liner. When the filters broke the water surface,
several radiation monitors alarmed. Filters were placed in the
liner/cask, despite instructions to have them placed back into
SFP. SFPCU project stopped due to unexpected radiological
conditions.
October 21, 2016 Survey performed on three Tri-Nuke filters to verify dose rates.
Maximum dose rate identified was 14,000 rem/hr on contact,
inside of the filter.
October 14-31, Radiation Protection (RP), RxM, and RWTS worked to develop
2016 a formal recovery plan to reduce dose rates for shipment.
ALARA challenge meetings were held.
November 1, 2016 Off-cycle Senior Site ALARA Committee meeting was held and
approved the high risk and ALARA plans.
November 2-4, Licensee removed the four highest dose rate filters from
2016 shipping liner/cask to reduce the dose rates. Items were
shifted around and filters redistributed within liner to meet
Department of Transportation (DOT) regulations outside cask
(i.e., 200 mrem/hr).
November 3, 2016 Control rod velocity limiters were transferred from the SFP to
the waste liner. Contact dose rates were measured while the
control rod velocity limiters were underwater. Survey 8089
documented a maximum dose rate of 9.5 rem/hr.
November 4, 2016 Additional control rod velocity limiters were transferred from
SFP to the waste liner. Survey 8091 documented a maximum
dose rate of 32 rem/hr.
November 5, 2016 Last items (dry active waste) were loaded into the liner and the
cask lid was closed for transport.
November 5, 2016 Survey 8099 was performed on 14-190-H cask in the reactor
building 441' truck bay. Maximum dose rates were on the
bottom, 500 mrem/hr on contact, and 60 mrem/hr at 1 meter.
The licensee documented a transport index (dose rate in
mrem/hr at 1 meter) of 18 based on front/right side on the
11
shipping cask, which was deemed the maximum accessible
dose rate.
Shipping
November 5, 2016 Surveys were performed on the cask after being loaded on a
trailer to verify contact dose rates were below 200 mrem/hr on
all accessible surfaces. Maximum dose rate was determined to
be 250 mrem/hr with an RO2 survey meter.
November 7, 2016 Licensee contacted WSDOH to notify them shipment No.16-40
was prepared for shipment and verified the US Ecology license
was authorized to receive the documented waste type and
class. US Ecology's license conditions were confirmed by
WSDOH on November 7.
November 8, 2016 The shipping manifest and waste characterization package for
shipment No. 16-40 was approved and certified by the CGS
RWTS. Manifest specified a contact dose rate on the waste
liner of 11.8 rem/hr. Dose rate was calculated by DWJ using
the Integrated Shipping and Inventory Program (ISIP) computer
code.
November 8, 2016 As a result of the measured 250 mrem/hr contact dose rate on
the cask, approval was obtained to construct a fenced barrier
around the cask on the open transport trailer to convert it into a
closed transport vehicle, allowing contact dose rates of
1,000 mrem/hr on cask.
November 8, 2016 Upon review of the waste manifest and shipping papers,
US Ecology notified CGS that the shipment would be rejected if
the unshielded dose rate on contact with the liner exceeded
22 rem/hour.
November 9, 2016 Radiation Survey 8105 was performed on the 14-190-H cask
before it left the CGS site. The maximum dose rate on contact
with the fence barrier was 110 mrem/hr and the maximum
2-meter reading was 7 mrem/hr.
November 9, 2016 Shipment No. 16-40 was transported to US Ecology as an
@ 9:30 am exclusive use, closed transport shipment. The package and
shipping documentation was labeled as Yellow-III, UN 3321,
Radioactive Material - LSA-II, fissile-excepted, 7 RQ.
November 9, 2016 US Ecology confirmed receipt of shipment No. 16-40 within
@ 10:20 am 50 minutes of departure from CGS.
12
November 9, 2016 US Ecology contacted RWTS to inform CGS that the shipment
@ 1:00 pm was rejected because the liner was surveyed at 90 rem/hr on
contact of one side and 30 rem/hr on the other side.
November 9, 2016 US Ecology contacted WSDOH to inform them of the
unexpected dose rates.
November 9, 2016 WSDOH contacted the CGS RWTS and informed him that
CGS' disposal use permit privileges have been suspended.
November 9, 2016 RWTS contacted the radiation protection manager, shift
manager, and licensing supervisor to make them aware that
US Ecology had rejected shipment No. 16-40.
November 9, 2016 RWTS traveled to US Ecology with shipping papers and
returned the cask to CGS. WSDOH was aware of this action.
November 9, 2016 The licensee completed an evaluation of the events
surrounding shipment No. 16-40 for applicability of
10 CFR 50.72 reporting requirements and determined it was
not reportable.
November 10, WSDOH confirmed that authorization to use the commercial
2016 low-level radioactive waste disposal site had been suspended
until a point-of-origin inspection was satisfactorily completed.
November 10, Licensee contacted the NRC resident inspector and regional
2016 health physics inspector to inform them of the event.
November 30, CGS received a letter from WSDOH stating that
2016 shipment No. 16-40 containing liner 16-059-OT violated
requirements and was not LSA-II based on radiation levels
being greater than 1 rem/hr at 3 meters from the liner.
2.2 Charter Item 3: Determine what actions were taken by US Ecology prior to and after
receipt of shipment No. 16-40. Evaluate the licensees response to discussions with
US Ecology prior to and subsequent to the shipment arriving at US Ecology.
a. Inspection Scope
The team reviewed the US Ecology disposal site permit and radioactive materials
license issued by the state of WSDOH, the licensees procedures for shipping
radioactive material, the waste manifest and shipping paper for shipment No. 16-40,
the waste characterization data, radiation surveys performed on the package, and the
licensees corrective action documents.
13
The team also interviewed station personnel involved with shipment No. 16-40, and
held discussions with WSDOH personnel to determine the actions taken by US
Ecology prior to and after the receipt of shipment No. 16-40.
b. Observations and Findings
On November 7, 2016, CGS personnel contacted WSDOH to verify that US Ecologys
license authorized them to receive and dispose of the type and class of waste contained
in shipment No. 16-40. WSDOH personnel confirmed to CGS that US Ecology was
authorized to receive and dispose of the waste presumed to be in shipment No. 16-40.
On November 8, 2016, CGS personnel finalized the Uniform Low-Level Radioactive
Waste Manifest (NRC Forms 540 and 541) for shipment No. 16-40 and provided a copy
to US Ecology for review. After reviewing the waste manifest, US Ecology contacted
CGS and informed them that the calculated 11.8 rem/hr dose rate on contact with the
waste liner appeared to be excessively high for the type and class of waste indicated on
the manifest. US Ecology informed the licensee that if the contact dose rates on the
waste liner exceeded 22 rem/hr, they would not accept the waste package for disposal at
their site. Licensee personnel acknowledged the establishment of this upper limit on the
contact dose rates and assured US Ecology that the waste liner would not exceed the
established limit.
Licensee personnel prepared the shipping cask for transport on an open transport vehicle
(i.e., flatbed trailer). However, measured dose rates on contact with the shipping cask
were 250 mrem/hr, which exceeded the Department of Transportation (DOT) limit of
200 mrem/hr on the external surfaces of a package for an open transport vehicle. To
address this, licensee personnel constructed a chain-link fence around the cask to create
the equivalent of a closed transport vehicle. Use of a closed transport vehicle allowed for
dose rates up to 1,000 mrem/hr on contact with the package, provided the dose rates did
not exceed 200 mrem/hr at any point on the outer surfaces of the vehicle.
On November 9, 2016, CGS shipped the cask to US Ecology. Upon arrival at the
disposal facility, US Ecology personnel performed radiation surveys of the cask and the
waste liner. While lifting the waste liner from the shipping cask, dose rates as high as
90 rem/hr on contact were identified. The measured dose rates were significantly higher
than the 11.8 rem/hr stated on the manifest and the 22 rem/hr limit that US Ecology
previously stated would be allowed for this package. Upon identifying the high dose
rates, US Ecology lowered the waste liner back into the shipping cask. US Ecology then
contacted CGS personnel to inform them that the contact dose rates were too high and
the package would not be accepted for burial at the site.
The team evaluated the discussions between the licensee and disposal site, and
determined that given the information available to the two parties at the time, the level
and scope of the discussion were appropriate for the circumstances encountered.
However, the team also determined that the level of concern expressed by the disposal
site should have prompted additional scrutiny by the licensee such as performing physical
surveys of the waste liner.
14
2.3 Charter Item 4: Assess the licensees immediate actions and short-term corrective
actions following return of the shipment. Determine if the actions taken are sufficient to
ensure shipment No. 16-40 is correctly manifested, packaged, and prepared for shipment
prior to being returned to US Ecology for disposal.
a. Inspection Scope
To assess the licensees immediate actions and short-term corrective actions following
the return of shipment No. 16-40 to CGS, the team interviewed the CGS personnel
directly involved with the shipment. The team also reviewed documented radiation
surveys, action requests (ARs) and corrective actions, waste manifests, shipping
packages, licensee procedures, and apparent cause evaluations (ACEs).
b. Observations and Findings
Upon notification of the dose rates identified by US Ecology on the waste liner contained
in shipment No. 16-40, CGS personnel initiated plans to retrieve the shipment and store
the package on-site. A senior radwaste transportation specialist (RWTS) traveled to the
US Ecology site to return the shipment to CGS. The shipment was received at CGS at
approximately 4:00 pm local time and stored in a safe and secure condition pending
further investigation. In addition to initiating a condition report, the RWTS notified CGS
management and the NRC resident inspectors about the elevated dose rates identified
on the waste liner and the rejection of the package by US Ecology.
As will be discussed in greater detail in Sections 2.4 and 2.5, the licensee determined that
errors in the survey and inventory data provided to the waste characterization vendor
resulted in the errors in the waste manifest and shipping papers. As corrective actions,
the licensee reevaluated the survey data and provided corrected information to the
vendor. The vendor provided the licensee a revised waste characterization and shipping
paper for the contents of shipment No. 16-40 on January 13, 2017.
On January 13, 2017, CGS personnel removed the waste liner from the shipping cask
and conducted extensive surveys of the liner. The licensee measured dose rates as high
as 154 rem/hr on contact and 2.1 rem/hr at 3 meters from the waste liner. The measured
3-meter dose rate exceeded the maximum allowed for a shipment of low specific activity
material. After completing the surveys, the licensee moved the waste liner to a safe and
secure location behind a substantial concrete barrier in the radwaste building pending a
future decision on the disposition of the waste.
The team determined that the licensee completed appropriate immediate and short-term
corrective actions following the return of shipment No. 16-40 to ensure it was safely and
securely stored at CGS.
2.4 Charter Item 5: Evaluate the licensees compliance with, and adequacy of, procedural
guidance for loading and tracking the contents of radwaste liners, characterizing and
manifesting radwaste shipments, and preparing radwaste shipments for transport as it
pertains to the cause(s) of these events.
15
a. Inspection Scope
The team evaluated the effectiveness of the licensees programs for processing,
handling, storage, and transportation of radioactive material. The team reviewed the
solid radioactive waste system description in the final safety analysis report (FSAR) and
the licensees process control program (PCP).
The inspection team reviewed the licensees procedures and work orders related to
implementation of the SFPCU project and the process used for loading and tracking the
contents of radwaste liner 16-059-OT, in particular, and other liners in general. The
team evaluated whether the licensee effectively used procedures during the SFPCU
campaign to load radwaste into liners, characterize and classify the waste, and process
radwaste packages for shipment.
Lastly, the team evaluated whether containers and items from the SFP were labeled in
accordance with 10 CFR 20.1904, Labeling containers, or controlled in accordance with
10 CFR 20.1905, Exemptions to labeling requirements, as appropriate. The team
verified whether solid radwaste and SFP materials were processed as described in the
FSAR.
b. Observations and Findings
Relative to characterizing and manifesting shipment No. 16-40, the team identified
several human performance errors. The waste characterization used to manifest the
shipment was inadequate as a result of inaccurate information provided to the vendor by
the licensee. The licensee provided the vendor incorrect survey and inventory data,
such as documenting 6-inch survey measurements as contact measurements for
filters. In another error, surveys of filters were incorrectly documented as being for
LPRMs, resulting in mischaracterization. These and other inaccurate inputs used for the
waste characterization resulted in incorrect information on the waste manifest, such as
significantly lower activity (24 curies vs. 101 curies), surface radiation levels (11.8 rem/hr
vs. 154 rem/hr), and 10 CFR Part 61 waste classification (Class A vs. Class B).
The team reviewed at least four documents associated with the certified shipping record
and manifest that attested to the accuracy of shipment No. 16-40 contents, radiation
levels, and activity. The licensee was reasonably certain that 73 control rod velocity
limiters were placed in the shipment. However, the characterization data for the control
rod velocity limiters was uncertain because the validity of the dose rate measurements
had been questioned by the vendor. In addition, the survey package provided to the
vendor identified 13 LPRMs each having at least 36 inches of activated stainless steel
dry tubing. However, since return of the shipment, the licensee has not been able to
determine whether the LPRMs were in the SFP or the radwaste liner. Additionally, the
number of filters actually loaded in the shipment may have been 18 more than specified
in the manifest and characterization record. On January 12, 2017, the licensee
determined that the liner contained 18 more Tri-Nuke filters than was certified on the
waste manifest and shipping records.
16
The team determined there were no specific procedures for performing the
characterization surveys nor for validating the survey data prior to submission to the
waste characterization vendor. Additionally, there were no procedures or guidance to
ensure the surveyed items were identified/labelled or placed in a specific location in the
SFP for later retrieval.
The team also determined that there were no documented instructions for loading waste
liner 16-059-OT for shipment No. 16-40. Rather, the team learned that conversations
were held regarding how to place radioactive materials within the liner in order to
minimize external dose rates. However, this verbal plan was not implemented during
the loading of the liner. The failure to document and follow a loading plan may have
contributed to the unexpected dose rates on the exterior of the shipping cask.
The inspection team also determined there was no written documentation provided to
aid the inventory of items in the SFP as they were retrieved for loading into the liner, nor
were these items labeled to provide the radionuclides present, an estimate of the
quantity of radioactivity, or radiation levels in order to minimize exposure. This lack of
inventory resulted in a mismatch between the information provided to the waste
characterization vendor and what was loaded into the liner.
As the licensee prepared the shipment for transport, several procedures were used,
including Procedure PPM 11.2.23.1, Shipping Radioactive Material and Waste,
Procedure PPM 11.2.23.2, Computerized Radioactive Waste and Material
Characterization, Procedure PPM 11.2.23.4, Packaging Radioactive Material and
Waste, and Procedure PPM 11.2.23.20, The Use of Transport Cask Model 14/190L.
The team identified a few occurrences in which the procedures were not completely
followed. As examples, Procedure PPM 11.2.23.4 required the licensee to maintain an
accurate log of items placed into the liner (including contact dose rate) and attach the log
to the container, and Procedure PPM 11.2.23.20 required the licensee to survey the top
of the liner; the licensee was unable to provide documentation of either. The lack of
inventory and surveys contributed to the licensees failure to identify that the contents of
the waste liner would not meet the 10 CFR Part 71 and 49 CFR Part 173 criteria for
shipping LSA materials.
The licensees short-term corrective actions were to generate action requests, assess
the extent of their failure to label or provide sufficient information for all items in the SFP,
and reevaluate the latest SFP annual inventory to identify any missing information. The
identified issues were documented in the corrective action program as ARs 356390,
357593, 360148, and 360236.
2.5 Charter Item 6: Evaluate the adequacy of the licensees radiation surveys during the
various stages of liner loading, preparation, and final release of shipment No. 16-40.
Additionally, evaluate the licensees compliance with applicable DOT and NRC
transportation requirements for the shipment.
a. Inspection Scope
The team reviewed the licensees plans and procedures for the 2015-2016 SFPCU
project. The team assessed and evaluated the licensees survey methods used to
measure the radiation levels and radioactivity for the items in the SFP being disposed of
as radwaste. The team evaluated whether the licensees surveys methods were
17
adequate in the areas of waste stream analysis and classification as necessary to meet
the requirements of 10 CFR Part 20, 10 CFR Part 61, 10 CFR Part 71, and 49 CFR
Parts 172-173.
b. Observations and Findings
The team identified and reviewed a number of problems with the way the licensee
performed and documented the radiation surveys used for the waste characterization.
A number of errors resulted in inaccurate survey data being provided to the waste
characterization vendor.
- Radiation surveys were taken at 6 inches from the items being surveyed, as
requested by the vendor, but were recorded as contact measurements. When the
vendor asked for verification with regard to the distance at which the dose rates
had been measured, contract Radiation Protection (RP) personnel working on the
SFPCU project stated that they were contact dose rates after reviewing the survey
documentation. However, the in-house RP personnel that performed the surveys
were not consulted. As a result, when entering the survey data into the software
program used for the waste characterization, the vendor entered the dose rates as
contact readings.
- The survey form for 18 additional Tri-Nuke filters was titled, LPRM
Characterization. During characterization, these were treated as irradiation
components instead of spent filters.
These errors and others resulted in erroneous information being calculated for the waste
manifest and shipping documentation.
The team also determined that inadequate radiation surveys were performed during the
loading of the waste liner. For example, the team noted that Procedure PPM 11.2.23.20,
Use of Transport Cask Model 14-190H, Steps 4.12.9 through 4.12.11 for in-cask
processing and loading, had required actions that were not completed. Specifically,
Step 4.12.9 required a radiation survey of the accessible top of liner or high integrity
container, including documenting the container identification number, the highest contact
dose rate, and contamination levels. However, the licensee did not document a survey
measurement for the top of the in-cask liner. In a second example, the team noted that
Procedure PPM 11.2.23.4, Packaging Radioactive Material and Waste, Step 3.4.3,
required the licensee to keep a log of all items placed into the shipment container and to
attach the log as Attachment 7.1 and 7.2. The attachments were to document
information such as the description from the radioactive material label, contact dose rate
in mrem/hour, and estimated item surface area. However, the team could find no
records documenting the inventory or surveys.
The team noted that radiation surveys performed during the preparation of shipment
No. 16-40 for transport could have alerted the licensee to the inadequate packaging
(i.e., Type A vs. Type B cask). Specifically, during radiation surveys performed prior to
shipment, CGS personnel identified dose rates on contact with the shipping cask of
250 mrem/hr, exceeding the DOT limit of 200 mrem/hr for the external surface of a
package on an open transport vehicle (i.e., flatbed trailer). Rather than question the
adequacy of the cask for the radioactive contents of the shipment, the licensee
constructed a chain-link enclosure around the cask and flatbed trailer, effectively
18
creating a closed transport vehicle. Use of a closed transport vehicle allowed for dose
rates up to 1,000 mrem/hr on contact with the package, provided the dose rates did not
exceed 200 mrem/hr at any point on the outer surfaces of the vehicle.
As corrective actions, the licensee reevaluated the survey data and inventory, providing
updated information to the waste characterization vendor. On January 13, 2017, the
vendor provided the licensee a revised waste characterization and updated the shipping
manifest. The team determined the licensees actions seemed appropriate.
2.6 Charter Item 7: Review the licensees ACE efforts and determine if the evaluation is
being conducted at a level of detail commensurate with the significance of the problem.
Independently determine the probable cause(s) for the improper characterization of
shipment No. 16-40.
a. Inspection Scope
The team reviewed licensee procedures, corrective action documents, apparent cause
evaluations (ACEs), and interviewed CGS personnel to make an independent
determination of the causes of the improper characterization of shipment No. 16-40. In
addition, the team reviewed AR and ACE 357394 to determine if the evaluation was
being conducted at a level of detail commensurate with the significance of the problem.
b. Observations and Findings
In accordance with corrective action program Procedure SWP-CAP-01, Corrective
Action Program, the licensee initiated AR 357593357593to evaluate and resolve the
condition of the radwaste container reading higher than expected dose rates when
shipment No. 16-40 reached the disposal site on November 9, 2016.
To determine the type of cause evaluation required for this condition, the licensee used
station Procedure SWP-CAP-06, Condition Report Review. Procedure SWP-CAP-06
provided guidance on how to determine the severity of conditions and identify the level
of cause evaluation that was required. The licensee determined that, based on the high
severity and partial uncertainty associated with shipment No. 16-40, an ACE was
sufficient to identify the cause(s) of the shipping event and implement corrective actions
to reduce the likelihood of recurrence.
The ACE team used barrier and change analysis techniques and conducted a Human
Performance, Organizational, and Programmatic Evaluation to determine the apparent
and contributing causes. The ACE was completed on December 12, 2016. The ACE
team concluded that the analysis methods used confirmed the causal factors which led
to the following apparent cause and three contributing causes.
- Apparent Cause: Survey documentation was inaccurately recorded and
communicated to the characterization vendor which led to errors in the calculated
dose rates on the characterization used to ship the radioactive waste disposal
container.
- Contributing Cause 1: A formalized process and plan specific to Tri-Nuke filter
management, tracking, and disposal was not developed.
19
- Contributing Cause 2: Radiological conditions on the disposal container were not
verified and validated prior to shipment.
- Contributing Cause 3: Characterization results provided by the vendor based on
CGS data were not verified or validated.
The team determined that, while the ACE was successful in identifying an apparent
cause and several contributing causes for the elevated dose rates on the waste liner, the
ACE did not address the process or procedures used for obtaining accurate survey
results to ensure accurate information would be evaluated for the waste manifest. For
example, the ACE determined that surveys were taken at 6 inches from the source, but
were recorded as contact measurements. When the waste characterization vendor
asked for verification on the distance at which the dose rates were measured, contract
RP personnel working on the SFPCU project stated they were contact dose rates based
on the survey documentation. However, the in-house RP personnel that performed the
surveys were not consulted. As a result, the vendor input the numbers into the software
as contact dose rates instead of the actual 6-inch dose rates, resulting in erroneous
information being calculated for the waste manifest and shipping documentation. The
inspectors asked licensee staff what documents were created to ensure that the data
provided to the waste characterization vendor was correctly identified, tracked, and
validated. Licensee personnel stated that other than emails, verbal discussions, and
meeting notes between the vendor and the licensee, there was no formal verification or
validation of the data provided to the vendor. The ACE identified these contributors to
the vendor receiving incorrect survey data, but did not identify any procedural or process
weaknesses that caused these errors.
The team discussed with the licensee whether a root cause evaluation would have been
more appropriate to evaluate the event. The team determined that in addition to the use
of barrier analysis and change analysis techniques, the licensees cause evaluation
could have benefitted from a why charting analysis to determine the root cause of the
event. The team noted that if the licensee had performed a root cause analysis,
additional cause evaluation techniques such as analytic trees or events and causal
factors analysis may have provided additional insights not gained from the barrier and
change analysis used in the ACE. The inspectors concluded that performance of a root
cause evaluation, rather than an ACE, would have enabled the licensee to identify the
procedural and process weaknesses that contributed to the event. The inspectors also
concluded that licensee Procedure SWP-CAP-06, if used as written, directed the
licensee to perform a root cause analysis. The team, specifically, addresses this failure
by the licensee of page 43 of this report.
The team independently determined that, in addition to the causes identified by the
licensees ACE, the probable causes of this event were the licensees failure to establish
a program or procedure to identify, track, review, validate, and document the information
and data requested by the waste characterization vendor. Such a program or procedure
would have ensured an accurate waste characterization and shipping manifest were
developed for shipment No. 16-40.
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2.7 Charter Items 8 and 10: Review the licensees ACE efforts for the April 2016 and
October 2014 shipping events. Determine whether any similar/common causes to the
November 2016 shipping event or programmatic concerns in the radwaste processing
and/or shipping programs have been identified. Review actions taken or planned by the
licensee to evaluate and develop plans to address gaps in radwaste processing and
radioactive material shipment preparation issues at the station, as evidenced by recent
events discussed in this charter.
a. Inspection Scope
The NRC team reviewed documentation associated with the licensees ACEs for
ARs 348071 and 31676, as specified in the inspection charter. Specifically, the team
reviewed procedures, ARs, and cause evaluations.
The team also reviewed problems associated with radwaste processing, handling,
storage, and transportation that occurred in calendar years 2011 through 2016. The
team reviewed a trending action request, AR 353427353427 which documented a number of
recent radwaste packaging and shipping events since 2014, including events not
specifically identified in the charter.
The team reviewed the licensees plans to address gaps in radwaste processing and
radioactive material shipping preparation including immediate, short-term, and long-term
corrective actions. The team also interviewed station personnel to identify the licensees
plans to address gaps in the radwaste processing and radioactive material shipping
program.
During review of these issues, the inspectors assessed whether problems were being
identified by the licensee at an appropriate threshold, properly characterized, and
properly addressed for resolution in the corrective action program. In addition to the
above, the inspectors verified the appropriateness of the corrective actions for selected
problems documented by the licensee.
b. Observations and Findings
The team identified a number of ARs in the licensees corrective action program
associated with radioactive waste and radioactive material processing, disposal, and
transportation problems in 2015 and 2016. The team noted that seven of these ARs
required the performance of an ACE. The licensee performs ACEs when an event or
negative trend in an area requires analysis to determine the causes of the problem and
to ascertain if human performance, organizational, or programmatic factors are the
cause of the deficiencies.
(1) On April 15, 2016, the licensee determined that they had staged a shipping cask of
radioactive material outside the protected area without ensuring the appropriate controls
were in place. This issue was evaluated by the licensee in AR 348057348057and
ACE 348071.
The licensee determined that the apparent cause was a failure to ensure that all
necessary controls, storage, and shipment requirements had been developed and
approved by appropriate personnel. The inspection team determined that this apparent
cause was common to the shipment No. 16-40 event, in that, controls and storage
21
procedures for radioactive material in the SFP had not been fully developed and
approved by appropriate reactor engineering, chemistry, and radiation protection
personnel.
In ACE 348071, the licensee investigated organizational and programmatic causes of
the event. The licensee determined that decision-making was not being made at the
appropriate levels as evidenced by ineffective communication of responsibilities between
the various groups. The licensee found a lack of clear lines of communication between
organizations, lack of appropriate interface between groups, and deviations from plans.
Similarly, the organizational and programmatic section of the shipment No. 16-40 ACE
indicated that decision-making was not made at the appropriate level, specialized
expertise such as the RWTS or RP personnel were not solicited in the SFPCU project,
and this was a first experience for the team tasked to manage the SFPCU project.
The licensee identified weaknesses related to this issue that needed correction.
Specifically, the licensee identified the need to prepare a calculation to aid RP staff in
determining the storage location for radioactive materials. Additionally, the licensee
determined they needed to develop a radioactive material accountability process and
procedure.
The inspection team determined that these identified weaknesses were common to the
shipment No. 16-40 event, in that, the calculation methods and radioactive material
accountability process that the licensee used to estimate the amount of radioactivity in
shipment No. 16-40 was not documented by procedure.
Because the event documented in AR 348057348057overlapped in time with the activities
which culminated in shipment No. 16-40, the team concluded that corrective actions
would not have been implemented in a time such that the contributors to the problems
with shipment No. 16-40 could have been prevented.
(2) On October 28, 2014, the licensee sent a package of radwaste with greater than
0.5 percent freestanding water, in violation of 10 CFR 61.55, to US Ecology for
disposal. The NRC previously dispositioned this violation in NRC Inspection
Report 05000397/2015003. This event was evaluated by the licensee in ACE 316676.
The licensee identified two issues related to this problem, the first being that changes
were made to the dewatering process without a proper 50.59 screening. Additionally,
the licensee determined the dewatering process sequence, as outlined in
Procedure PPM 11.2.23.19, Operation of the Pacific Nuclear Resin Drying System
Steps, was not in accordance with manufacturers design and instructions to ensure
liners were effectively dewatered. The licensee also noted that the vendor manual had
clear guidance on how to operate the system that was not incorporated into the
procedures.
The inspection team identified three similarities between the dewatering event from
October 2014 and the issues with shipment No. 16-40:
- There were manufacturer instructions/guidance available that were not incorporated
into licensee procedures. Specifically, manufacturer guidance on the use of the
shipping cask, Energy Solutions Cask Book for Model CNS 14-190H, includes a
chart that shows the maximum liner dose rate for dewatered ion-exchanged resin
22
that would result in dose rates that are acceptable for shipping in this Type A cask.
This information was not found in any licensee procedures reviewed by the team.
- Failures to follow procedural requirements and inadequate procedures.
- Issues with the Process Control Program (PCP).
specifically associated with the dewatering process. Similarly, the ACE for the
shipment No. 16-40 event was narrowly focused to issues specifically related to the
event.
Because this event occurred in late 2014, the team concluded that had the ACE not been
so narrowly focused, some of the precursors to the issues with shipment No. 16-40 may
have been corrected. Specifically, the inspectors concluded that if the licensee had
performed a more thorough extent-of-condition for the PCP issues following the
dewatering event, additional weaknesses in the PCP may have been identified and
corrected.
(3) On October 21, 2016, the licensee initiated a trending action request, AR 353247353247 to
evaluate radwaste packing and shipping issues at the site. The licensee recognized an
increasing trend in human performance errors associated with radwaste packaging and
shipping beginning in 2014. Therefore, they initiated a common cause ACE to identify
and validate any commonalities or themes, and create actions necessary to improve
performance. Each event had been evaluated separately for significance and the effect
on nuclear safety, equipment safety, design basis, industrial safety, or radiological
safety. This trend document captured the nine ARs listed below.
- AR 316676316676 Radwaste resin liner exceeding freestanding liquid requirements. On
October 28, 2014, a condensate filter demineralizer radwaste disposal container
exceeded the radwaste disposal facilities freestanding liquid requirement which
resulted in a suspension of CGS ability to ship radwaste for disposal.
- ARs 323678 and 323841, Issues involving shipment No. 15-14. On
March 10, 2015, a C-van shipping container full of contaminated scaffold parts was
shipped to an offsite vendor using a vendor supplied tractor-trailer when the C-van
shifted during movement on licensee property.
June 2015 a radwaste transport cask and 8-120 polyethylene high integrity container
was ordered with the high-integrity container pre-loaded into the cask at the vendor
facility. Since the cask was ordered/delivered pre-loaded, the procedurally required
inspection was not completed prior to use.
November 30, 2015, an irradiated TIP detector could not be located in the
designated storage area. It was subsequently determined that the TIP had been
added to a radwaste shipment without proper documentation.
23
- AR 339249339249 Incomplete/Inaccurate Radioactive Shipping Documentation. In
December 1, 2015, during the Radiation Protection and Process Control Programs
Audit, AURP-RW-15, several examples of incomplete and/or inaccurate radioactive
shipment supporting documents were identified which did not meet procedural
requirements.
- AR 348057348057 Shipping cask of radioactive material outside protected area. On
April 15, 2016, the licensee determined that they had staged a shipping cask of
radioactive material outside the protected area without ensuring the appropriate
controls were in place.
requirements. Between March 16 and 17, 2016, a spare Entry Scan explosives
detector containing radioactive material was transported on a public road without
meeting DOT regulations.
- AR 352217352217 Radwaste box sent to disposal site with more than 15 percent voids.
On July 13, 2016, a B-25 box containing radioactive material was shipped to US
Ecology with greater than 15 percent void space, which was not in compliance with
US Ecologys radioactive materials license or 10 CFR Part 61.
The ACE team used the analysis methods of Common Cause Analysis, Performance
Analysis, and Human Performance/Organizational and Programmatic Evaluation to
determine the causal factors. The apparent cause identified for the increasing trend in
human performance errors was that decisions related to the handling, packaging, and
shipping of radioactive material were not made at the appropriate level or by persons
with adequate expertise. Additional contributing causes were that personnel did not use
established error prevention tools, individuals did not stop when faced with uncertain
conditions, and the risk was not appropriately evaluated and managed before
proceeding. To address these causes, the licensee evaluated providing additional
training on the importance of radwaste shipping/packaging, distributing the ACE to
applicable stakeholders, and conducting focused observations of relevant activities.
The trend ACE was completed on October 5, 2016. As a result, the inspection team
concluded that any relevant corrective actions would not have affected the causes of the
issues with the shipment No. 16-40, which were revealed on November 9, 2016.
The team determined that the licensees efforts, including the trend AR, failed to identify
a significant omission in their radwaste processing and radioactive materials shipping
programs. Specifically, the licensee had essentially removed the QC department from
activities associated with radwaste processing and shipment preparation. Further, the
inspectors questioned the adequacy of the quality assurance (QA) program to assure
compliance with the requirements of 10 CFR Part 61. The inspectors also concluded
that the trend AR failed to identify programmatic and procedural weaknesses in the
areas of radwaste processing and radioactive material shipments.
Because the licensee had completed the ACE for shipment No. 16-40 at the time of the
inspection, the team also reviewed the proposed corrective actions to determine if they
would address any identified gaps. As a result of the shipment No. 16-40 event, the
licensee planned to address gaps in radwaste processing and radioactive material
24
shipment by creating a new procedure for chemistry/RP personnel for SFPCU container
loading. The procedure would include when to survey and associated requirements for
characterization purposes, the characterization geometry, dose rate survey distance
(e.g., on contact, at 6 inches, etc.) and other survey documentation requirements. In
addition, verification surveys will be required prior to shipment, and the licensee will
exclusively be using polyethylene high integrity containers for waste disposal and Type
B casks for shipping. In addition to the new procedure, the licensee is revising other
procedures to better track and inventory irradiated nonfuel material. The revisions will
include dose rate tracking, labeling existing filter cans in the SFP, and ensuring
adequate engagement and availability of health physics and radwaste transportation
personnel to support these activities.
The team assessed the planned corrective actions and determined that they should
reduce the likelihood of future events. However, the team noted that additional NRC
follow-up will be required to evaluate the effectiveness of the long-term corrective
actions for the issues identified above.
On January 13, 2017, the licensee conducted radiation survey measurements on the
radwaste liner from shipment No. 16-40. Based on the results of the surveys, the
licensee initiated a root cause evaluation on January 16, 2017, to determine the causes
of this event. The team noted that the appropriateness and effectiveness of any
corrective actions developed as a result of the root cause evaluation will require
additional NRC follow-up.
2.8 Charter Item 9: Determine whether applicable internal or external operating experience
(OE) involving radwaste processing, manifesting, and shipment preparation was evaluated
by the licensee and assess the effectiveness of any action(s) taken by the licensee in
response to any such OE.
a. Inspection Scope
The inspection team reviewed written documents, plans, and schedules associated with
the 2015-2016 SFPCU project in order to ascertain what types internal and external OE
was used. Specifically, the team reviewed licensee procedures, work orders, radiation
work permits (RWPs), QA/QC audits, and corrective actions recorded in ARs. The team
also evaluated the effectiveness of actions taken by the licensee to incorporate available
OE involving radwaste processing and shipping of radioactive materials.
b. Observations and Findings
At the start of the SFPCU project planning in July 2015 the licensee did not use or find
any industry external OE related to processing items from the SFP. The team also
determined that the licensee did not benchmark or engage other licensees about their
SFPCU experiences until October 2016.
The team determined that reactor maintenance had overall responsibility for the SFPCU
campaign; however, none of the reactor maintenance staff had prior experience with
SFPCU activities. Further, the team identified that reactor maintenance personnel failed
to solicit input from radwaste subject matter experts, individuals who had been involved
with prior SFPCU campaigns at CGS, RP staff, or chemistry staff until late in the project.
This failure to engage individuals with prior experience with SFPCU campaigns or
25
subject matter expertise in radwaste processing and/or radwaste shipment contributed to
the errors in the waste characterization and loading of the waste liner.
The inspection team found, from an occupational radiation safety perspective, that the
licensee incorporated external OE into their SFPCU project RWPs. Specifically, the
licensee used external OE lessons learned from two radiation safety worker events in
2011 involving the movement of highly radioactive nuclear instruments. The SFPCU
project management also used lessons learned from the 2010 SFPCU and industry best
practices from Babcock Services, Incorporated, and Energy Solutions, Incorporated.
The inspectors noted that, based on historical data, dose rates were projected to be
higher than in the 2010 campaign because there were four times the number of items in
the SFP in 2015. The team reviewed licensee Procedure HPI 15.4, Operation of Tri-
Nuclear Underwater Filter/Vacuum. This procedure provided industry OE and lessons
learned regarding the following subjects:
- Radioactive filter handling
- Disintegrating materials stored in the SFPs
- Highly radioactive particles associated with SFP work
- Underwater vacuum hose broke into Pieces during removal from the SFP
- Unanticipated dose rates discovered on filters during SFPCU Campaign
Overall, the team determined that the licensee did not fully utilize relevant internal and
external OE associated with handling highly radioactive material and radwaste stored in
SFPs during the planning of the campaign.
2.9 Charter Item 11: Evaluate the licensees actions to comply with reporting requirements
associated with this event.
a. Inspection Scope
The team reviewed Procedure PPM 1.10.1, Notifications and Reportable Events, and
two ARs associated with events that resulted in CGS being temporarily suspended from
using US Ecology for low-level radwaste disposal by the state of Washington. The team
assessed the licensees procedural guidance and basis for the decisions not to report
the events in accordance with 10 CFR 50.72(b)(2)(xi).
b. Observations and Findings
Two waste shipments previously discussed, an October 2014 shipment in which the
radwaste resin liner exceeded the freestanding liquid requirements and the November
2016 shipment with dose rates higher than anticipated, resulted in the licensees
disposal site permit for the low-level radioactive waste facility being temporarily
suspended by the state of Washington. In both events, the licensee did not notify the
NRC Operations Center of the notification made by the WSDOH about the violations of
Department of Transportation radioactive material shipping requirements and State of
Washington radwaste burial site requirements. Following the October 2014 and
November 2016 events, the licensee promptly informed the resident inspector. The
licensee also notified a region-based health physics inspector of the November 2016
event.
26
The inspectors noted that 10 CFR 50.72(b)(2)(xi) requires notification reports to the NRC
Operations Center within four hours of any event or situation, related to the health and
safety of the public or on-site personnel, or protection of the environment, for which a
news release is planned or notification to other government agencies has been or will be
made. The inspectors concluded that a radwaste shipping event, including an event in
which a package was offered for disposal without meeting the burial requirements, were
related to the health and safety of the public or protection of the environment.
For both events, the licensee reviewed their reporting requirements as directed by
Procedure PPM 1.10.1. The licensee performed a review of the potentially applicable
reporting criteria in 10 CFR 50.72, 10 CFR Part 71, 10 CFR Part 20, 10 CFR Part 37,
and the DOT requirements. In both examples, the licensees Licensing Compliance and
Regulatory Affairs staff concluded that none of the reporting criteria were met.
Specifically, the licensee determined that the events were not reportable in accordance
with 10 CFR 50.72(b)(2)(xi) because the state of Washington (i.e., other government
agency) notified CGS of the issues, rather than CGS notifying the other government
agency. For both events, the licensee was officially contacted by the WSDOH and
notified that disposal use permit privileges to the low-level waste facility had been
suspended until a written plan containing corrective actions was approved and an on-site
inspection was completed by WSDOH.
The team noted that NUREG-1022, Section 3.2.12, News Release or Notification of
Other Government Agency states, in part, that, The purpose of this criterion is to
ensure that the NRC is made aware of issues that will cause heightened public or
government concern related to the radiological health and safety of the public or on-site
personnel or protection of the environment. As such, especially in light of the potential
for heightened public interest as well as interest by the NRC, the team questioned the
licensees decision not to report the event. The team, in consultation with Office of
Nuclear Reactor Regulation subject matter experts, evaluated these events against the
notification criteria in 10 CFR 50.72(b)(2)(xi) and the statement in NUREG-1022
regarding reporting governmental interactions to the NRC. The NRC determined that
these events met the threshold for public or government concern related to the
radiological health and safety of the public or on-site personnel or protection of the
environment. Additionally, because WSDOH was notified of the event by US Ecology,
this was a notification to another government agency. However, 10 CFR 50.72(b)(2)(xi)
is unclear as to whether the notification to another government agency must be from the
licensee. As a result, no violation of NRC requirements was identified.
2.10 Specific findings identified during this inspection.
a. Shipment of a Type B Quantity of Radioactive Material in a Type A Package
Introduction. The inspectors reviewed a self-revealed finding and apparent violation of
49 CFR 173.427 associated with a shipment of low specific activity (LSA) material
consisting of radioactive filters, irradiated components, and dry active waste. The
licensee failed to ensure that the radioactive contents in the radwaste liner did not
exceed the radiation level requirements for shipping. Specifically, the licensee
transported a Type A package containing a Type B quantity of radioactive material as
LSA even though it had an external radiation level of 2.1 rem/hr at a distance of 3 meters
from the unshielded material, exceeding the 1 rem/hr at 3 meters limit for LSA.
27
Description. During the 2016 SFPCU campaign, the licensee loaded a carbon steel open
top waste liner with a variety of radwaste items, including Tri-Nuke filters, sock filters,
control rod velocity limiters, source and intermediate range monitors, and miscellaneous
bags of dry active waste. The waste liner (16-059-OT) would serve as the ultimate
disposal container for the radwaste when buried at a low-level radwaste disposal facility.
The waste liner was packaged in a Type A shipping cask (Duratek model CNS 14-190H)
and denoted as shipment No. 16-40. The shipping cask provides a shielded, structurally
sound container in which to transport radioactive material. The shipment was
transported to the US Ecology, Richland, WA low-level radwaste disposal facility for
disposal and burial as an exclusive use shipment of LSA-II radioactive material.
Upon arrival at the disposal facility, US Ecology personnel removed the waste liner from
the shipping cask in which it had been transported to conduct radiation survey
measurements. The survey measurements identified significantly higher surface
radiation levels on liner 16-059-OT than documented on the associated waste manifest.
Specifically, US Ecology personnel measured unshielded contact dose rates on
liner 16-059-OT of 90 rem/hr on one side of the liner and 30 rem/hr on the opposite side
of the liner. In contrast, the waste manifest stated the contact dose rate was
11.8 rem/hr. In response, US Ecology returned the liner to the shipping cask and
documented their findings.
US Ecology contacted the WSDOH to inform them of the significant discrepancy and
survey measurements. US Ecology also notified CGS personnel that the package would
not be accepted because of the significant discrepancy between the manifested dose
rate and the actual dose rates measured on the liner. Based on the information provided
by US Ecology, WSDOH suspended CGS disposal use permit privileges at US Ecology
on November 10, 2016. The State stated that restoration of privileges was contingent
upon their approval of a written plan containing corrective actions and completion of an
on-site inspection.
On January 13, 2017, the licensee performed radiation surveys of waste liner 16-059-OT
and determined that the external radiation level at 3 meters from the liner exceeded a
dose rate of 1 rem/hr, the limit for material to be shipped as LSA. Specifically, during
surveys of the entire liner, the licensee identified maximum dose rate readings of
154 rem/hr on contact with the liner and 2.1 rem/hr at a distance of 3 meters from the
liner. In parallel, the vendor who performed the initial waste characterization reevaluated
the characterization using an updated inventory of the waste liner contents and
corrected radiation survey data for the inventoried items. The vendors updated waste
characterization documented a calculated 3-meter dose rate of approximately
2.7 rem/hr. Further, the updated waste manifest identified that the contents of this liner
did not meet the criteria for LSA-II, but rather, was required to be shipped as
Radioactive Material, Type B Package.
Regulatory Information Summary (RIS) 2013-04, Content Specification and Shielding
Evaluations for Type B Transportation Packages, notes that in 1996 the NRC amended
10 CFR Part 71 to conform NRC regulations to those of the International Atomic Energy
Agency. As part of this amendment, the definition of low specific activity material
became more explicit, and a quantity limit of radioactive material for shipment of LSA
material was added. The updated regulations required that packages containing LSA
material exceeding this limit would be subject to NRC Type B package regulations.
28
The RIS continues, In 10 CFR 71.14, Exemption for Low-Level Materials, it is required
that material quantity above these limits be shipped in an NRC-regulated Type B
package (versus a Type A package) and meet the requirements in 10 CFR Part 71. An
NRC Type B package has specific requirements for shielding and survivability of the
package during and after an accident that are different from a Type A package. The limit
above which LSA material has to be shipped in a Type B package can be found in
10 CFR 71.14(b)(3)(i) and is based on an external dose rate measurement from the
unshielded source at a specific distance. The external dose rate measurement limit in
10 CFR 71.14 is 1 rem/hr at a distance of 3 meters.
NUREG-1608, Categorizing and Transporting Low Specific Activity Materials and
Surface Contaminated Objects, states that NRC certification of the package design for
shipment of LSA materials is required if the dose rate from the unshielded material
exceeds 1 rem/h at 3 meters from the unshielded material. The NUREG further states
that if the unshielded LSA material exceeds 1 rem/hr at 3 meters, a Type B package is
required due to the quantity of material. The NUREG continues by stating if a material
can otherwise satisfy the LSA requirements, but the 1 rem/hr at 3 meters unshielded
dose rate limit is exceeded, then the material no longer meets the intent of the LSA
material regulations justifying the use of less robust packaging that would otherwise be
required for Type B quantities of material. The NUREG further states that, for packages
marked low specific activity, the Emergency Response Guidebook Guide does not
acknowledge that Type B quantities could be present and is therefore inappropriate for
packages containing LSA material exceeding 1 rem/hr at 3 meters.
The team noted that because Type B packages can be used to transport larger amounts
of radioactive material than Type A packages, the design and testing requirements are
more rigorous. Specifically, they are required to be designed and tested to withstand
and to retain the integrity of containment and shielding when subjected to the normal
conditions of transport and hypothetical accident test conditions set forth in
10 CFR Part 71. Type A packages can be used to transport LSA material; however, an
unshielded dose rate limit of 1 rem/hr at 3 meters was established to ensure adequate
protection of members of the public and emergency response personnel during accident
conditions. In this case, a Type A package was used to transport the material in spite of
the unshielded dose rate limit being more than double the limit, thereby increasing the
safety significance of the finding.
The inspection team noted that the licensee had several opportunities during the waste
characterization, loading of the liner, and preparation of the shipping package to identify
the excessive dose rates and the need for a more robust cask (i.e., Type B). The team
concluded that inadequate radiation surveys performed as part of the waste
characterization, combined with poor communication with the characterization vendor,
resulted in a waste manifest that documented incorrect (calculated) dose rates for the
liner. During loading of the liner, radiation surveys that would have identified the higher
than expected dose rates were not performed by the licensee. In addition, the team
identified discrepancies between what was loaded into the liner and the inventory
provided to the vendor performing the waste characterization. Lastly, during radiation
surveys performed prior to shipment, CGS personnel identified dose rates on contact
with the shipping cask of 250 mrem/hr, exceeding the DOT limit of 200 mrem/hr for the
external surface of a package on an open transport vehicle (i.e., flatbed trailer). Rather
than question the adequacy of the cask for the radioactive contents of the shipment, the
licensee constructed a chain-link enclosure around the cask and flatbed trailer,
29
effectively creating a closed transport vehicle. Use of a closed transport vehicle allowed
dose rates up to 1,000 mrem/hr on contact with the package, provided dose rates did not
exceed 200 mrem/hr at any point on the outer surfaces of the vehicle.
The issue was entered in the licensees corrective action program as AR 357593357593and
ACE 357593. The licensees immediate corrective actions were to retrieve the
shipment, develop plans to reevaluate the shipment, and update the shipping manifest
as appropriate. The licensee initiated a root cause evaluation, documented in
AR 360236360236 on January 16, 2017, following the performance of radiation surveys that
confirmed dose rates in excess of 1 rem/hr at 3 meters.
Analysis. The licensees failure to ensure that the radioactive contents of a radwaste
container did not exceed the requirements for shipping was a performance deficiency.
The performance deficiency was more than minor, and therefore a finding, because it
was associated with the program and process (transportation program) attribute of the
Public Radiation Safety Cornerstone and adversely affected the cornerstone objective of
ensuring adequate protection of public health and safety from exposure to radioactive
material released into the public domain. Specifically, the licensees failure to ensure
that the contents of a radwaste container did not exceed the requirements for shipping
(i.e., low specific activity material must have an unshielded dose rate less than 1 rem/hr
at 3 meters) resulted in radioactive material being transported in Type A packaging
rather than the required Type B packaging.
NRC Inspection Manual Chapter 0609, Appendix M, Significance Determination
Process Using Qualitative Criteria, was used to determine the significance of the finding
because Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety
Significance Determination Process, does not specifically address the situation where a
Type A package was used to ship radioactive quantities requiring a Type B package. In
accordance with Appendix M, an initial qualitative bounding evaluation was performed.
This was accomplished using the transportation branch of the Public Radiation Safety
Significance Determination Process and examples from Section 6.8 of the NRC
Enforcement Policy. Using the radiation levels leg of the Transportation Branch of the
Public Radiation Safety Significance Determination Process, it was determined that
radiation levels exceeding twice the limit, but less than five times the limit would screen
to White. However, it was noted that the radiation levels addressed by the SDP are
specified in 49 CFR 173.411 not 49 CFR 173.427. Additionally, it was determined that
the Enforcement Policy, Section 6.8.c, Transportation, states that SL-III violations
involve, for example, external radiation which exceeds 1 times, but not more than
5 times the NRC limit. Further, Section 6.8.c of the Enforcement Policy states, in part,
that an SL-III violation would involve a violation related to packaging that could
reasonably result in a significant failure to identify the type/quantity of material, a failure
of the carrier to exercise adequate controls, or a substantial potential for personnel
exposure above regulatory limits or improper transfer of material. The attributes in
Appendix M were then evaluated qualitatively, as described in Attachment 1. Based on
the qualitative analysis, this self-revealed finding has preliminarily been determined to
have low to moderate safety significance (White).
30
The finding has a cross-cutting aspect in the area of human performance, associated
with conservative bias, because licensee personnel did not use decision-making
practices that emphasized prudent choices over those that were simply allowable.
Specifically, on several occasions throughout the radwaste processing and packaging
evolution for shipment No. 16-40, decisions were made that did not exhibit the
appropriate conservative bias [H.14].
Enforcement. Title 10 CFR 71.5(a) requires, in part, that each licensee who transports
licensed material outside the site of usage, as specified in the NRC license, or where
transport is on public highways, shall comply with the applicable requirements of the
DOT regulations in 49 CFR parts 171 through 180.
Title 49 CFR 173.427(a)(1) requires, in part, that low specific activity material must be
transported in accordance with the condition that the external dose rate may not exceed
an external radiation level of 10 mSv/hr (1 rem/hr) at 3 meters (10 feet) from the
unshielded material.
Contrary to the above, on November 9, 2016, the licensee failed to transport low specific
activity material in accordance with the condition that the external dose rate may not
exceed an external radiation level of 10 mSv/hr (1 rem/hr) at 3 meters (10 feet) from the
unshielded material. Specifically, the licensee transported a package as LSA material
with an external radiation level of 2.1 rem/hr at a distance of 3 meters from the
unshielded material) in a Type A package instead of the required Type B package.
This finding was entered in the licensees corrective action program as AR and
ACE 0357593. Pending determination of the findings final safety significance, this
finding is identified as AV 05000397/2016009-01, Shipment of a Type B Quantity of
Radioactive Material in a Type A Package.
b. Failure to Conduct Adequate Surveys of a Solid Radwaste Shipment
Introduction. The team reviewed three examples of a Green, self-revealed non-cited
violation of 10 CFR 20.1501 associated with the failure to conduct adequate surveys of
the solid radwaste contents (activated metals, filters, etc.) of a shipment that was
packaged and transported for ultimate disposal. As a result of the inadequate surveys,
the radwaste in shipment No. 16-40 was packaged in the incorrect type of shipping cask,
radwaste manifest and shipping paperwork contained numerous errors, and the waste
was not correctly classified in accordance with 10 CFR Part 61.
Description. On November 9, 2016, US Ecology LLRW disposal site receipt surveys on
Columbia shipment No. 16-40 identified dose rates significantly higher than stated on the
manifest. The LLRW site operator measured dose rates as high as 90 rem/hr on contact
with the radwaste liner. The certified shipping manifest, in contrast, documented a
maximum dose rate of 11.8 rem/hr. The package was rejected, returned to the licensee,
and the licensees LLRW disposal privileges were suspended by the State of
As part of SFPCU campaign, the licensee performed waste characterization and
classification radiation surveys on control rod blades, nuclear instruments, and filters
intended for disposal as radwaste. During the course of the SFPCU campaign, the
licensee performed several radiation surveys. In September 2015 and March 2016, the
31
licensee conducted SFP characterization surveys of the items to be included in radwaste
liner (16-059-OT). During the fall of 2016, the licensee had several opportunities to
perform surveys on items in the SFP, both prior to being placed in the waste liner and
while being placed in the liner. In October 2016, some surveys were performed during
the transfer of radwaste from the SFP to the liner (16-059-OT). Additionally, surveys
were taken of the liner and shipping cask while preparing it for transit to verify
conformance with DOT shipping requirements.
- The team reviewed an example of inadequate surveys used to support the
vendors classification activities. Based on reviews of the September 2015 and
March 2016 surveys conducted by health physics technicians as part of the
waste characterization activities, the inspectors identified survey technique errors
and concerns: (1) In October 2015, the vendor performing the waste
characterization questioned if the filter dose rate measurement distance was on
contact or at 6 inches from each filter. Survey records indicated that the surveys
were taken at contact; however, the vendor had requested the surveys be
performed at 6 inches. Subsequent to the shipping event, it was determined that,
although the vendor was informed the surveys were taken on contact (in
agreement with the documentation), they had in fact been taken at 6 inches.
(2) The vendor identified that the license provided LPRM survey data that did not
match inventory serial numbers previously given. (3) During review of the survey
documentation, the vendor determined that the surveys conducted on the control
rod blades by the licensee were not as specified. Each of these surveys was to
be taken with a fixed detector geometry standoff distance of 4.5 inches to
6 inches, but had not been. (4) The licensee did not provide the vendor the
10 CFR Part 61 radionuclide spectrum for the control rod blades and filters. As
of November 2016, the licensee had not provided the correct radiological survey
data to the vendor necessary to accurately characterize the SFP campaign
radwaste shipments. The team noted that the inadequate surveys and poor
documentation of surveys resulted in the vendors characterization of the waste
shipment to be in error. However, the team acknowledged that the licensee
eventually recognized, during their event investigation, that these radiation
surveys had been conducted by the licensees staff, inadequately.
- The team reviewed a second example of inadequate surveys associated with the
licensees failure to survey items during the loading of radwaste liner 16-059-OT.
The team noted that Procedure 11.2.23.4, Packaging Radioactive Material and
Waste, Step 3.4.3, required the licensee to keep a log of all items placed into the
shipment container and attach the log as Attachments 7.1 and 7.2. The
attachments were to document information including the description from the
radioactive material label, general item accounting, contact dose rate in
mrem/hour, and estimated item surface area. The team concluded the licensee
failed to maintain an accurate log of items placed into the shipment container.
Further, the licensees RP staff, senior radwaste technical specialist, and
radiation protection manager did not supervise the liner loading. The team
determined that the lack of surveys during the loading of the waste liner resulted
in uncertainty with respect to which and how many items were placed into the
liner. Additionally, the lack of surveys contributed to discrepancies between the
inventory provided to the characterization vendor and inventories of liner
contents maintained by different licensee organizations.
32
- The team reviewed a third example of inadequate surveys during the loading of
radwaste liner 16-059-OT. The inadequate surveys involved procedurally
required surveys of the liner. During loading of the liner, the licensee used
Procedure PPM 11.2.23.20, Use of Transport Cask Model 14-190H. The team
noted that Steps 4.12.9 through 4.12.11, for in-cask processing and loading,
required actions that were not completed. Specifically, Step 4.12.9 required a
radiation survey of the accessible top of liner or high integrity container, including
documenting the container identification number, the highest contact dose rate,
and contamination levels. However, the licensee did not document a survey
measurement for the top of the in-cask liner. Step 4.12.10 required the
acceptance of the above survey and liner/high integrity container contamination
levels. This action was signed off as complete by the radwaste transportation
specialist even though the survey had not been performed. The team further
noted that Section 4.10.1 of the procedure documented the approval to load the
liner into the 14-190H cask with a contact dose rate exceeding 100 R/hr.
However, the licensee was unable to provide insights into the basis for approving
this action.
The three examples of inadequate surveys described above either directly caused, or
contributed to, the inaccuracies in the waste manifest and shipping papers. Ultimately,
after the vendor made corrections to the shipment No. 16-40 manifest following the
event based on a revised number of filters and radioactivity, and clarification on the
survey data itself, the shipping type for the package changed from Radioactive Material,
LSA-II to Radioactive Material, Type B and the 10 CFR Part 61 waste class changed
from Class A to Class B. The activity of the shipment was revised from 24.7 curies to
100 curies, the maximum contact dose rate on the liner was revised from 11.8 rem/hr to
154 rem/hr, and the 3-meter dose rate revised from 0.652 rem/hr to 2.66 rem/hr. In
addition, and more significantly, the inaccurate surveys directly contributed to the failure
to identify that the contents of the waste liner did not meet the requirements for shipment
as LSA material and, as a result, required transport in a Type B cask. In each of the
three examples above, the team independently evaluated licensee survey data and
techniques. Consequently, the team concluded that the licensees surveys for
shipment No. 16-40 were inadequate.
Analysis. The failure to conduct adequate surveys of the radwaste contents (activated
metals, filters, etc.) in a shipment that was packaged, transported, and transferred for
ultimate disposal was a performance deficiency. The team determined that the
performance deficiency was more than minor, and therefore a finding, because it was
associated with the program and process aspect of the Public Radiation Safety
Cornerstone and adversely affected the cornerstone objective to ensure adequate
protection of public health and safety from exposure to radioactive materials released in
the public domain. Specifically, as a result of the inadequate surveys, the radwaste in
shipment No. 16-40 was packaged in the incorrect type of shipping container, the
radwaste manifest and shipping paperwork contained numerous errors, and the waste
was misclassified in accordance with 10 CFR Part 61. Using Inspection Manual
Chapter 0609, Appendix D, Public Radiation Safety Significance Determination
Process, the team determined the violation was of very low safety significance (Green)
because it was a finding in the transportation branch in which: (1) radiation limits were
not exceeded, (2) there was no breach of the package during transit, (3) there were no
Certificate of Compliance issues, and (4) the low-level burial ground nonconformance
did not involve a 10 CFR 61.55 waste under-classification. The finding has a cross-
33
cutting aspect in the area of human performance, associated with documentation,
because the organization failed to maintain complete, accurate, and up-to-date
documentation. Specifically, the failure to accurately document the characterization
surveys (e.g., distance from source, type of item) and failure to document procedurally
required surveys resulted in several issues with the shipment [H.7].
Enforcement. Title 10 CFR 20.1501(a)(1) requires, in part, that each licensee shall
make surveys that may be necessary for the licensee to comply with the regulations in
10 CFR Part 20. Title 10 CFR 20.2006(e) requires, in part, that each licensee shipping
byproduct material intended for ultimate disposal at a land disposal facility document the
information required on the NRCs Uniform Low-Level Radioactive Waste Manifest.
Contrary to the above, on November 9, 2016, the licensee failed to make surveys
necessary to comply with the regulations in 10 CFR 20.2006(e). Specifically, inadequate
surveys and survey documentation completed at several stages during the preparation
of shipment No. 16-40, including survey data provided to a vendor for waste
characterization, resulted in significant errors in the waste manifest including the total
radioactivity in the package, calculated external dose rates on the waste liner (and
thereby type of packaging required), proper shipping name, and waste class.
Because the violation is of very low safety significance (Green) and the licensee has
entered the issue into their corrective action program, this violation is being treated as an
NCV, consistent with Section 2.3.2.a of the NRC Enforcement Policy:
NCV 05000397/2016009-02, Failure to Conduct Adequate Surveys of a Solid Radwaste
Shipment.
c. Failure to Label or Provide Written Information for Items Stored in the Spent Fuel Pool
Introduction. The team identified a Green, non-cited violation of 10 CFR 20.1904 for the
licensees failure to ensure that each container of licensed material in the SFP bore a
label or had documentation providing sufficient information to permit individuals handling
the licensed material to minimize exposure. This condition had existed since 2010 and
continued throughout 2016.
Description. In 2010, the licensee began storing radioactive materials in the SFP for
future disposal. These items included Tri-Nuke filters, sock filters, control rod blades,
control rod velocity limiters, and various instrumentation such as source and
intermediate range monitors. In 2015, the licensee began preparing for the SFPCU
project. During the planning phase, it became evident that the stored items would need
to be loaded into a waste liner prior to being shipped for final burial. In fact, in May
2016, licensee personnel changed the plan to use one carbon steel open top liner in a
14-190-H Type A cask instead of using two separate polyethylene high integrity
containers shipped in Type B casks. This decision was made based on the waste
characterization performed by the vendor.
In October 2016, radworkers began removing items from the SFP to load into the waste
liner. However, there was no written documentation provided to the workers to aid in
inventorying these items as they were retrieved. Additionally, none of the items were
labeled nor were records provided that contained information on the radionuclides
present, an estimate of the quantity of radioactivity, or radiation levels. As a result, as
individual items were removed from the pool the workers were uninformed on the
34
radiological characteristics and were unable to minimize their exposure. The unknown
radiological characteristics of the items resulted in unexpected radiological conditions
and exposure to workers accessing these items during the SFPCU project.
Guidance on how to label or provide sufficient written information for radioactive
materials stored underwater, such as in the SFP, is provided in NRC Health Physics
Position (HPPOS) 333. Specifically, HPPOS 333 states, a container stored underwater
for the purpose of shielding or storage of licensed material need not physically bear a
warning label required by 10 CFR 20.1904 as long as the container is accessible only to
individuals authorized to handle or use them, or to work in the vicinity of the container, if
the contents are made known to these individuals by means of a readily available written
record. In this case, these highly radioactive items were stored in the SFP and were
accessible to workers during the SFPCU campaign, but no labeling was readily available
nor were written records provided to ensure the radiological contents were known by the
workers.
Licensee Procedure 11.2.23.4, Packaging Radioactive Material and Waste, Step 3.4.3,
required the licensee to keep a log of all items placed into the shipment container,
including the description from the radioactive material label, contact dose rate in
mrem/hour, and estimated item surface area. The log was to be retained as
Attachments 7.1 and 7.2. The team concluded the licensee failed to maintain an
accurate log of the items placed into the waste liner in preparation for shipment.
Specifically, Attachment 7.2 noted various items of Tri-Nuke filters, sock filters, control rod
velocity limiters, and range monitors were placed in the liner. However, the team could
not verify the actual number of each of these items nor the contact dose rate for the
items, as placed in the waste liner for shipment No. 16-40.
Discussions with the licensee revealed that a lack of documentation or tracking of the
items stored in the SFP contributed to the inaccurate logs of items placed in the waste
liner for shipment No. 16-40. As a result, imprecise and incomplete information was
provided to the vendor performing the waste characterization, which resulted in errors in
the waste manifest and shipment documentation.
Analysis. The licensees failure to ensure that each container of licensed material stored
in the SFP bore a label or had sufficient written information to permit individuals handling
the licensed material to minimize exposure was a performance deficiency. The
performance deficiency was more than minor, and therefore a finding, because it was
associated with the programs and process (exposure control) attribute of the
Occupational Radiation Safety Cornerstone and adversely affected the cornerstone
objective to ensure the adequate protection of the worker health and safety from
exposure to radiation from radioactive material. Specifically, accessing highly
radioactive material without sufficient information or unknown radiological characteristics
could result in unanticipated dose rates and unplanned exposures. Using NRC
Inspection Manual Chapter 0609, Appendix, C, Occupational Radiation Safety
Significance Determination Process, the team determined that the finding was of very
low safety significance (Green) because it did not: (1) involve ALARA planning or work
controls, (2) did not involve an overexposure, (3) did not have a substantial potential to
be an overexposure, and (4) the ability to assess dose was not compromised. The
finding has a cross-cutting aspect in the area of human performance, associated with
avoid complacency, because licensee personnel failed to recognize and plan for the
possibility of mistakes and inherent risk, even while expecting a successful outcome.
35
Specifically, licensee staff placed items in the SFP without ensuring labels or a readily
available written record existed to assure individuals accessing them would be
adequately informed of the radiological risks [H.12].
Enforcement. Title 10 CFR 20.1904(a) requires, in part, that the licensee shall ensure
that each container of licensed material bears a durable, clearly visible label that
provides sufficient information (such as the radionuclides present, an estimate of the
quantity of radioactivity, the date for which the activity is estimated, radiation levels) to
permit individuals handling or using the containers, or working in the vicinity of the
containers, to take precautions to avoid or minimize exposures. Contrary to the above,
from 2010 through 2016, the licensee failed to ensure that each container of licensed
material bore a durable, clearly visible label that provided sufficient information (e.g., the
radionuclides present, an estimate of the quantity of radioactivity, the date for which the
activity is estimated, radiation levels) to permit the individuals handling or working in the
vicinity of the items to take precautions to avoid or minimize exposures. Specifically, the
licensee did not label or provide another readily available written record to inform workers
of the radiological characteristics of the items in the SFP. The licensees immediate
corrective actions were to generate an action request and assess the extent of their
failure to label or provide sufficient information for all items in the SFP, as well as
reevaluate their latest SFP annual inventory to identify any missing information.
Because this violation was determined to be of very low safety significance (Green) and
was entered into the licensees corrective action program as AR 360148360148 this violation is
being treated as a non-cited violation, consistent with Section 2.3.2.a of the Enforcement
Policy: NCV 05000397/2016009-03, Failure to Label or Provide Written Information for
Items Stored in the Spent Fuel Pool.
d. Failure to Provide an Accurate Shipping Manifest
Introduction. The team identified a Green, non-cited violation of 10 CFR 20.2006(b) for
the licensees failure to ship radwaste with an accurate shipping manifest. Specifically,
the licensee failed to provide the correct identification number and proper shipping
name, radionuclide activity, net waste volume, surface radiation level, and waste
classification. The incorrect radwaste liner radiation levels resulted in rejection of the
package and the licensees immediate suspension from usage of the land disposal site
at US Ecology.
Description. In July 2015, the licensee established a contract with a vendor to perform
the waste characterization for their upcoming SFP clean-up project. In support of this
project, the licensee conducted surveys and provided the vendor the survey data and an
inventory of items to be shipped. The items included in the waste characterization were
Tri-Nuke filters, sock filters, control rod blades, control rod velocity limiters, nuclear
instruments (source and intermediate range), and bags of dry active waste. However, it
was later determined that a significant portion of the survey data provided to the vendor,
as well as the inventory of items, was erroneous as a result of the failure to use error
reduction techniques such as peer checking and proper documentation of activities.
This resulted in flawed waste characterization results, incorrect information for the
shipping paper, and inaccurate calculations of the liner dose rates. All of this erroneous
information was recorded on the manifest for shipment No. 16-40.
36
On November 9, 2016, the Uniform Low-Level Radioactive Waste Manifest (NRC
Forms 540 and 541) for Shipment No. 16-40 was approved. The team noted that
information requested on NRC Form 540 includes the proper shipping name,
UN identification number, and total radionuclide activity in the package; information
requested on NRC Form 540 for each container includes the volume of waste, the
maximum radiation level at the surface of the disposal container, and the waste
classification pursuant to 10 CFR 61.55. The manifest for shipment No. 16-40 recorded
the following information that was subsequently determined to be incorrect:
- Identification number: UN3321
- Proper shipping name: Radioactive Material - low specific activity, (LSA II),
fissile-excepted
- Total package activity: 24.7 curies
- Net waste volume: 152 cubic feet
- Surface radiation level: 11.8 rem/hr
- 10 CFR Part 61 waste classification: Class A
The licensee provided corrected survey data to the waste characterization vendor.
Based on the revised waste characterization provided by the vendor, the team
determined the manifest for shipment No. 16-40 should have documented the following:
- Identification number: UN2916
- Proper shipping name: Radioactive Material - Type B(U)
- Total package activity: 101 curies
- Identification Net waste volume: 180 cubic feet
- Surface radiation level: 154 rem/hr
- 10 CFR Part 61 waste classification: Class B
Upon rejection of shipment No. 16-40 by US Ecology and its return to CGS, the
licensees immediate corrective actions were to reevaluate the package contents and
have the vendor perform a revised waste characterization.
Analysis. The licensees failure to ship radwaste intended for ultimate disposal with an
accurate shipping manifest was a performance deficiency. The performance deficiency
was more than minor, and therefore a finding, because it was associated with the
program and process attribute of the Public Radiation Safety Cornerstone and adversely
affected the cornerstone objective to ensure adequate protection of public health and
safety from exposure to radioactive material released in the public domain. Specifically,
inaccurate information on a shipping manifest could result in inappropriate handling of
radioactive material while in the public domain. Using NRC Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety Significance Determination Process, the
inspector determined the finding to be of very low safety significance (Green) because:
(1) radiation limits were not exceeded; (2) there was no breach of a package during
transit; (3) it did not involve a certificate of compliance issue; (4) it was not a low-level
burial ground nonconformance; and (5) it did not involve a failure to make notifications or
37
provide emergency information. The finding has a cross-cutting aspect in the area of
human performance, associated with avoid complacency, because licensee personnel
failed to recognize and plan for the possibility of mistakes, latent issues, and inherent
risk, even while expecting successful outcomes, by not implementing appropriate error
reduction tools. Due to the lack of appropriate error prevention tools, inaccurate survey
data was provided to the vendor and errors in the waste characterization and shipping
manifest were not identified [H.12].
Enforcement. Title 10 CFR 20.2006(b) requires, in part, that any licensee shipping
radwaste intended for ultimate disposal at a licensed land disposal facility must
document the information required on NRCs Uniform Low-Level Radioactive Waste
Manifest and transfer this recorded manifest information to the intended consignee in
accordance with Appendix G to 10 CFR Part 20. Appendix G to 10 CFR Part 20,
Section I, requires, in part, that a waste generator who transports, or offers for
transportation, low-level radioactive waste intended for ultimate disposal at a licensed
low-level radioactive waste land disposal facility to prepare a manifest reflecting
information requested on applicable NRC Forms 540 (Uniform Low-Level Radioactive
Waste Manifest (Shipping Paper)) and 541 (Uniform Low-Level Radioactive Waste
Manifest (Container and Waste Description). Contrary to the above, on November 9,
2016, the licensee failed to prepare a manifest that correctly reflected the information
requested on applicable NRC Forms 540 and 541. Specifically, for shipment No. 16-40,
the licensee failed to provide correct information for the proper shipping name,
UN identification number, total radionuclide activity, volume of waste in the container,
maximum radiation level at the surface of the disposal container, and classification of the
waste. The licensees immediate corrective actions were to reevaluate the package
contents and have the vendor perform a revised waste characterization. Because this
violation was determined to be of very low safety significance (Green) and was entered
into the licensees corrective action program as ARs 359496 and 359498, this violation is
being treated as a non-cited violation consistent with Section 2.3.2.a of the Enforcement
Policy: NCV 05000397/2016009-04, Failure to Provide an Accurate Shipping Manifest.
e. Failure of the QA program to assure compliance with 10 CFR 61.55 and 10 CFR 61.56
Introduction. The team identified a Green, non-cited violation of 10 CFR Part 20,
Appendix G, for the failure to manage a QA program to ensure compliance with
10 CFR 61.55 and 61.56. Specifically, licensee management has failed to effectively
evaluate the significance of audit findings in the area of radwaste processing and
radioactive material shipments.
Description. The team reviewed several examples of QA audit weaknesses and
deficiencies in the radwaste process and shipping program that were not effectively
evaluated by licensee management. This failure of the licensees QA program and audit
program to ensure compliance with 10 CFR 61.55 or 61.56 was evidenced by the
relatively high number of radwaste problems the licensee had recently experienced.
Specifically, the following items brought into question the adequacy of the licensees QA
program for radwaste:
- On November 9, 2016, the licensee transferred radwaste shipment No. 16-40 for
disposal at a licensed land disposal facility without adequate QA program or
processes to ensure compliance with 10 CFR 20.2006, 10 CFR 61.55, and the
disposal facilitys radioactive materials license.
38
- On July 13, 2016, the licensee shipped a B-25 box of radwaste for disposal. Upon
receipt, the waste disposal site operator identified that the box had greater than
15 percent void space in it. The licensee failed to have an adequate quality
assurance program or processes to ensure compliance with 10 CFR 61.56(b)(3)
which requires that void spaces within and between a waste package to be reduced
to the extent practical, as well as the disposal facilitys radioactive materials license.
- On August 11, 2014, the licensees resin dewatering and drying process failed to
reduce the free water, by disposal package volume, to less than 0.5 percent when
waste was packaged. Consequently, a radwaste liner 14-033-L containing
condensate resin was shipped for disposal to US Ecology with approximately
0.75 percent free standing liquid.
- In April and June 2015, new 8-120 polyethylene high integrity containers (PHICs)
were received on-site and not inspected by QA/QC. However, the licensee loaded
the PHICs with radwaste from the reactor water cleanup resin; the PHICs were
subsequently shipped for disposal and burial without inspections. The licensee did
not notice one of these oversights until October 2015.
- Computer software programs used by the vendor (e.g., Integrated Shipping and
Inventory Program [ISIP], MICROSHIELD, SCAN, ORIGIN, etc.) that are used for
radwaste and radioactive material classifications, characterization, and calculations
are Quality Class D, but are not QA audited.
- For the SFPCU Project in 2015 and 2016, activities critical to ensuring compliance
with 10 CFR 61.55 and 10 CFR 61.56 related to radwaste characterization,
classification, measurement, and packaging, vendor services were provided by
DW James, Incorporated, and Babcock Services, Incorporated. However, these two
vendors were not listed under the licensees Operating Quality Assurance Programs
approved vendors list. Because DW James, Incorporated, and Babcock Services,
Incorporated, were not on the approved vendors list, they are not subject to QA
audits by the licensee.
- The licensees QA/QC program was not involved with the 2016 SFP radwaste
disposal project, which used contractors to develop survey methods and computer
software in addition to hiring contractors for the packaging and shipment of highly
radioactive material for disposal.
In an effort to ascertain if the licensees management was appropriately evaluating audit
findings, the team reviewed the report on Select Continuous Monitoring Activities
Summary, Radwaste. The team determined that from 2011 through 2016, the
licensees Operational Quality Assurance Program Description (OQAPD) audits and
management evaluations of specific aspects of waste classification and waste
characterization activities, as necessary to assure compliance in the transfer for disposal
and disposal of waste, were not adequate to ensure compliance with 10 CFR 61.55 or
The team reviewed QA audits, Qualitys Continuous Monitoring Quality Activity Report,
focused self-assessments, ARs, and ACEs associated with radwaste and radioactive
39
material shipments since 2011. In addition, the team reviewed the licenses QA program
for solid radwaste, radioactive material shipment, the FSAR, and the PCP. The PCP
describes how the OQAPD is applied to radwaste and radioactive material
activities. The team also found that FSAR Chapter 11.4 describes the OQAPD. The
team determined that Procedure SWP-RMP-02, Radioactive Waste Process Control
Program, Section 2.11, Quality requires a QA program that meets 10 CFR 71, Subpart
H, Quality Assurance, and 49 CFR 173.475 QC requirements prior to each shipment of
Class 7 radioactive material, as specified in the OQAPD. Activities included in these
requirements are commercial grade or procurement level 3 items (radwaste shipping
containers), computer software codes supporting radioactive material shipping and
disposal activities, compliance monitoring computer codes supporting adherence to 10 CFR 61, 49 CFR 100-180, and 10 CFR 71, and validation computer codes supporting
radioactive material transport and disposal. Section 2.13 of SWP-RMP-02 requires that
procurement of items and services supporting radioactive material transport and
disposal be performed per SWP-PUR-01, Procurement of Services, and SWP-PUR-04,
Material, Equipment, Parts and Supplies Procurement. In addition, SWP-RMP-02,
Section 2.13.4, Processing Services and Equipment, requires that radwaste processing
items, systems, and services supporting disposal meet the requirements of
10 CFR 61.56 and of the specific disposal site license as applicable.
Since 2011, NRC inspectors have identified or documented at least five findings
associated with radwaste processing, handling, storage, and transportation. Similarly,
the licenses QA audits conducted in 2011-2015 (AU-RP-RW-11, 13, and 15) identified
at least 12 radwaste shipping program findings, weaknesses, and deficiencies. The
following are examples of QA audit identified findings, weaknesses, and deficiencies:
- Multiple examples were identified with incomplete or inaccurate radioactive
shipment documents.
- The radwaste liner was shipped to US Ecology and was buried without a
QC inspection or an evaluation stating it was acceptable for burial.
consequences to the station including NRC violations.
- The Chemistry Department has not formally designated personnel that have
responsibilities for the Radwaste Technical Reviewer (RWTR) function described
in SWP-RMP-01 and SWP-RMP-02.
- The audit team recommended revising procedures governing the use of
radioactive shipment transportation casks (11.2.23.20, 11.2.23.42, 11.2.23.37,
and 11.2.23.43) to ensure that they meet the guidance for documenting
verification steps.
- The audit team recommended that CGS perform benchmarking for industry
excellence to determine if chemistry oversight of the radwaste shipping
process is an accepted industry practice and to determine if any additional
process controls are needed to assure continuity between the departments if this
practice is retained.
40
- CGS is not in alignment with industry standards in regards to some aspects of
radioactive material packaging.
A focused self-assessment of the licensees radwaste, PCP, and radioactive material
shipment programs was performed in May 2015. The team found that the focused self-
assessment was comprehensive, in that, it reviewed the details of specific radioactive
material shipping packages and at least 20 corrective actions in ARs. There were no
significant program deficiencies or weaknesses identified. However, the following
observation was made from the focused self-assessment: Solid waste processing is
included in the OQAPD, but only to the extent that a quality audit is required every
24 months. The team interpreted the previous comment to mean that radwaste audits
are conducted routinely. However, audit evaluations of findings by management do not
result in significant and meaningful outcomes. The team interviewed staff regarding the
licensees QA/QC program for radioactive material and solid radwaste shipments. The
team determined that the licensee had no specific requirements for QC services to be
used to ensure manifest dose rates and radioactivity were correct. The licensees
QA/QC audits did not assure compliance with regulations or assure that radioactive
material/solid radwaste procedures contained second verification signoffs by supervision
or QA/QC as validation that a requirement was met. Further, licensee management
stated that based on QA audits and performance surveillances, it was unnecessary for
QC program to be intrusive in routine operations.
Analysis. The failure to manage a QA program to assure compliance with 10 CFR 61.55
and 10 CFR 61.56 was a performance deficiency. The team determined that the
performance deficiency was more than minor, and therefore a finding, because it was
associated with the Public Radiation Safety Cornerstone attribute of program and
process and adversely affected the cornerstone objective to ensure adequate protection
of public health and safety from exposure to radioactive materials released in the public
domain. Specifically, the failure to manage quality assurance activities as part the
radwaste processing and packaging program has resulted in wastes that were not
properly classified or did not possess the proper characteristics for burial. Using NRC
Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety Significance
Determination Process, the team determined the violation was of very low safety
significance (Green) because it was a finding in the Transportation Branch in which:
(1) radiation limits were not exceeded, (2) there was no breach of the package during
transit, (3) there were no Certificate of Compliance issues, and (4) the low-level burial
ground nonconformance did not involve a 10 CFR 61.55 waste under-classification. The
finding has a cross-cutting aspect in the area of human performance, associated with
avoid complacency, because licensee personnel failed to recognize and plan for the
possibility of mistakes, latent issues, and inherent risk, even while expecting successful
outcomes by not implementing appropriate error reduction tools, such as a proper quality
assurance program. Specifically, the licensee has failed to ensure the appropriate level
of QA/QC oversight and verification was provided for risk-significant radwaste
processing and radioactive material shipment activities [H.12].
Enforcement. Title 10 CFR Part 20.2006(d) requires, in part, that each person involved
in the transfer for disposal and disposal of waste shall comply with the requirements
specified in Section III of Appendix G to 10 CFR Part 20. Appendix G,Section III(A)(3),
states, in part, that any licensee who transfers radioactive waste to a land disposal
facility shall conduct a quality assurance program to assure compliance with
41
10 CFR 61.55 and 10 CFR 61.56 (the program must include management evaluation of
audits).
Contrary to the above, from 2014 through 2016 the licensees QA program and
management did not assure compliance with 10 CFR 61.55 and 10 CFR 61.56 for
transfer of radioactive waste to a land disposal facility. Examples of the failure of the QA
program to assure compliance include radwaste shipments that arrived at the disposal
facility with greater than 15 percent void space, greater than 0.5 percent water, and dose
rates significantly higher than documented on the manifest. Managements evaluation of
these finding were ineffective.
Because this violation is of very low safety significance and has been entered into the
licensees corrective action program as AR 360236360236 it is being treated as a non-cited
violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy:
NCV 05000397/2016009-05, Failure of the QA program to assure compliance with
10 CFR 61.55 and 10 CFR 61.56.
f. Failure to Update the Final Safety Analysis Report with Changes to Radioactive Waste
Processing
Introduction. The team identified a Severity Level IV non-cited violation of
10 CFR 50.71(e) for the failure of the licensee to periodically provide the NRC a Final
Safety Analysis Report (FSAR) update with all changes made in the facility or
procedures. Specifically, the licensee changed its radwaste management strategy for
the SFP cooling and cleanup system and material being stored in the SFP. However,
the licensee has not changed its PCP or the FSAR to reflect the impact on waste
streams from processing items stored in the SFP including activated metals, Tri-Nuke
filters, filter socks, demineralizer filter resins.
Description. The team conducted a review of CGS solid radwaste system operations
and identified that the system was not being operated in as described in the Final Safety
Analysis Report Update, Chapter 11. Section 11.4.1 of the FSAR states that plant
operations result in various types of solid radwaste that require disposal. Waste forms
can be wet solids like powdered ion exchange and expended bead resins from
demineralizers, miscellaneous liquids, and dry materials such as paper, rags, plastic,
and laboratory wastes. The objective of the system is to collect, monitor, process, and
package these waste in a suitable form for offsite shipment and burial.
Sections 11.4.3 and 11.4.3.4 of the FSAR describe the PCP and waste characterization,
respectively. Section 11.4.3.4 states that wet wastes at CGS are to be processed and
characterized in individual streams for reactor water cleanup resins, equipment drain
and floor drain powdered resins, equipment drain and floor drain bead resins, and
condensate resins. However, t he team determined that the FSAR did not describe and
include the backwash resins from the SFP system filter demineralizers as an individual
waste stream. The team also determined that waste stream characterizations had not
been performed for SFP filter media and items stored in the SFP since at least 2011.
The team noted that the FSAR stated that individual waste stream activities and
concentrations are determined for each batch prior to shipment for disposal. Further,
Section 11.4.2.1 of the FSAR describes the sources of the various radioactive wet resin
waste inputs to the solid radwaste system. The FSAR states that wet solid wastes
42
include backwash resin from the reactor water cleanup (RWCU) system, the condensate
filter demineralizer system, the fuel pool filter demineralizers, the floor drain and
equipment drain filter demineralizers, and spent resin from the floor drain demineralizer
and the waste demineralizer. However, the team determined that the licensee does not
process the waste streams on a per batch basis or per system as intended by the original
design. Instead, backwash resin wastes from the fuel pool filter demins, floor drain, and
waste collector filter demins are backwashed together. The team concluded the FSAR
description was not consistent with how the licensee is performing solid radwaste
operations for backwash resins.
The team determined that for a significant period of time, the licensee had been blending
and processing three distinct waste streams as a single batch in the waste sludge phase
separator tank, which is not in accordance with the system design. Further, the team
determined that this aspect of the PCP and solid radwaste management operations were
not appropriately described in the FSAR. Therefore, the team concluded that the
licensee had been operating outside of the FSAR design basis for at least 15 years.
A second example of inconsistencies between the FSAR and actual practice involves
dry active waste (DAW). Section 11.4.2.7, Miscellaneous Dry Solid Waste System,
of the FSAR states DAW may consist of air filtration media, miscellaneous paper,
plastic, and rags from contaminated areas, contaminated clothing, tools, and equipment
parts which cannot be effectively decontaminated, solid laboratory wastes, and
other similar materials. However, Section 11.4 of the FSAR, which describes the
PCP, waste characterization, and solid radwaste management did not describe the
processing of Tri-Nuke or sock filters. In addition, the solid radwaste management
procedure (SWP-RMP-01) and the PCP program (SWP-RMP-02) did not address
processing Tri-Nuke and sock filters. The team concluded the licensee had been
collecting and storing Tri-Nuke and sock filters since their last SFPCU campaign in 2011
without a description of this operation in Chapter 11.4 of the FSAR.
Analysis. The failure to update the FSAR to reflect changes in solid radwaste
management and the PCP was a performance deficiency. The Reactor Oversight
Programs SDP does not specifically consider the regulatory process impact in its
assessment of licensee performance. Therefore, it is necessary to address this violation
which involves the ability of the NRC to perform its regulatory oversight function using
traditional enforcement to adequately deter non-compliance. Referring to Section 6.1.d.
of the Enforcement Policy, the finding was characterized as Severity Level IV because
the licensee failed to update the FSAR as required by 10 CFR 50.71(e) and the lack of
up-to-date information had a material impact on safety or licensed activities.
Specifically, the licensees failure to process solid radwaste in accordance with FSAR
Chapter 11.4 and the PCP increased the likelihood of incorrectly characterized releases
of radioactive material to the public domain and environment. Traditional enforcement
violations are not assessed for cross-cutting aspects.
Enforcement. Title 10 CFR 50.71(e) requires, in part, that the licensee shall update
periodically, as provided in paragraph (e)(4), the FSAR, to assure that the information
included in the report contains the latest information developed. Paragraph (e)(4) states,
in part, subsequent revisions must be filed annually or 6 months after each refueling
outage provided the interval between successive updates does not exceed 24 months.
Contrary to the above, from 2011 through January 2017 the licensee failed to update
periodically, as provided in paragraph (e)(4), the FSAR, to assure that the information
43
included in the report contained the latest information developed. Specifically, during
this 40-month period the licensee made two significant changes to solid radwaste
management operations and the Process Control Program but did not update the FSAR.
The failure to update the FSAR was characterized as a Severity Level IV non-cited
violation. Because this violation was entered into the licensees corrective action
program as AR 359293359293 this violation is being treated as a non-cited violation, consistent
with Section 2.3.2.a of the NRC Enforcement Policy: NCV 05000397/2016009-06:
Failure to Update the Final Safety Analysis Report with Changes to Radioactive Waste
Processing.
g. Failure to Follow Procedure and Perform a Root Cause Evaluation to Assess the
Causes of a Radwaste Shipping Event
Introduction. The team identified a finding for the failure to follow the requirements of
Procedure SWP-CAP-06, Condition Report Review, when determining the type of
cause evaluation required to assess the causes of the higher than expected dose rates
on a radwaste container. Specifically, Procedure SWP-CAP-06 required that if an event
has high risk and high uncertainty, the level of evaluation required is a root cause
evaluation (RCE). However, the licensee failed to adequately assess the uncertainty
associated with the causes of the event and performed an ACE rather than a root cause.
The licensee entered this finding into the corrective action program as AR 360236360236
Description. On November 9, 2016, shipment No. 16-40 from CGS arrived at the
US Ecology radioactive waste disposal facility with higher than expected dose rates.
US Ecology personnel measured dose rates as high as 90 rem/hr compared to
11.8 rem/hr that was documented on the manifest. Because of the discrepancy, the
shipment was returned to CGS. The licensee initiated AR 357593357593to document the
event, as required by Procedure SWP-CAP-01, Corrective Action Program. One day
after the event, the licensee held a Condition Report Group (CRG) meeting to assign a
priority to the event and determine the required level of evaluation as required by station
Procedure, SWP-CAP-06, Condition Report Review. The CRG determined an ACE
was the appropriate level of review.
During 2015-2016, there were numerous ARs documented in the licensees corrective
action program associated with radwaste and radioactive material processing, disposal,
and transportation. The team reviewed three of these ARs from 2015 and six ARs from
2016. Eight of the following ARs had ACEs performed; one was evaluated using an
RCE.
AR 316676316676 Radwaste resin liner exceeding January 12,
freestanding liquid requirements 2015
AR 338421338421 Radwaste liner used to ship reactor water October 21,
cleanup decontamination resin without a 2015
QC inspection
AR 340546340546 A traversing incore probe detector stored December 8,
without proper labeling was mistakenly 2015
shipped offsite for radwaste disposal
(RCE)
44
AR 339249339249 Incomplete and Inaccurate radioactive January 13,
shipping documents. 2016
AR 348057348057 Radioactive material in quantities of June 9, 2016
concern (RAMQC) outside the protected
area without proper notification/control.
AR 351509351509 Movement of Items Containing August 15,
Radioactive Material did not meet DOT 2016
requirements
AR 352217352217 Radwaste B-25 box sent to the disposal September 12,
site with greater than 15 percent voids 2016
AR 353427353427 Trend: Radwaste packing/shipping October 21,
issues 2016
AR 357593357593 Radwaste disposal container has higher December 12,
dose rates than anticipated 2016
Apparent cause evaluations are performed by the licensee when an event or negative
trend in an area requires analysis by a team to determine the causes of the problem
and to ascertain if human performance, organizational, programmatic factors are the
cause of the deficiencies. The ACE identifies the probable cause of the event that, if
corrected, will reduce the potential for recurrence to an acceptable level, commensurate
with significance and risk. An RCE is conducted when there is a need to determine the
deepest, fundamental, or underlying cause(s) of a significant event in a causal chain
that can be resolved. Formal analysis is required to determine what causal factors, if
corrected, will preclude repetition. The team evaluated whether AR 357593357593should have
risen to the level of an RCE.
The team interviewed licensee personnel directly involved with shipment No. 16-40 and
the subsequent ACE to verify whether the evaluation was conducted at a level of detail
commensurate with the significance of the event. Procedure SWP-CAP-06,
Step 4.6.1.e, states that the CRG determines AR severity and level of evaluation for
action requests. Procedure Step 4.6.1.e.1 states that if an AR has been assigned a
condition adverse to quality (CAQ) or significant condition adverse to quality priority,
then the AR is evaluated according to Attachment 8.2, CAQ Risk and Evaluation Level
Guidance. Attachment 8.2 requires an RCE if both the risk (severity) and uncertainty of
an event or condition is high.
The priority of AR 357593357593was assigned as a CAQ. The CRG determined that the risk
(severity) was high and the uncertainty assessment was medium. The team reviewed
Procedure SWP-CAP-06 and determined the uncertainty assessment is based on
answering two questions: (1) Are the causes known and (2) are the corrective actions
known? The answers to these questions can be - Yes, No, or Partial. The answers are
cross-referenced against the Uncertainty Assessment table in Step 2 of Attachment 8.2
of Procedure SWP-CAP-06 to determine the level of uncertainty - High, Medium, or
Low. The procedure states, Partial can be used when direct causes are known and
verified. If the underlying causes are not known, consider no. The licensee
determined that the answer to both questions was Partial, which resulted in a Medium
45
uncertainty assessment. Coupled with the high risk (severity) of the event, the licensee
concluded that the level of evaluation warranted for the event was an ACE.
The team reached a different conclusion after reviewing the ACE, station procedures,
and conducting several interviews of station personnel directly involved with the shipping
event and personnel that attended the CRG. While the team agreed with the licensee
that there was a high level of risk (severity) associated with the event, the team
concluded that on the day after the event, the direct cause of the event (higher than
expected dose rates on the waste container) was not known and verified; nor could the
underlying causes of the event have been known until after the event investigation or
ACE was completed. Thus, the team concluded that corrective actions to mitigate the
higher than expected dose rates were also not known one day after the event.
The team concluded that the licensee should have answered No to both uncertainty
assessment questions, which would have resulted in a high level of uncertainty coupled
with a high level of risk (severity) and warranted an RCE. The team concluded the
licensee did not follow their procedures, which would have required them to perform an
RCE. Had the licensee performed an RCE on AR 357593357593 they would have identified
the underlying causal factor(s) rather than the probable causes, and subsequently they
would have developed corrective actions to address the root cause(s).
Analysis. The failure to follow the requirements of Procedure SWP-CAP-06 when
determining the type of cause evaluation required to assess the higher than expected
dose rates on a radwaste container and performing an apparent cause evaluation
instead of a root cause evaluation was a performance deficiency. The team determined
that the performance deficiency was more than minor, and therefore a finding, because it
was associated with the Public Radiation Safety Cornerstone attribute of program and
process and adversely affected the cornerstone objective to ensure adequate protection
of public health and safety from exposure to radioactive materials released in the public
domain. Specifically, the failure to adequately assess the causes of the event left the
licensee vulnerable to future radwaste processing and transportation errors of
significance. Using NRC Inspection Manual Chapter 0609, Appendix D, Public
Radiation Safety Significance Determination Process, the finding was determined to be
of very low safety significance (Green). The finding has a cross-cutting aspect in the
area of problem identification and resolution associated with evaluation, because the
licensee failed to thoroughly evaluate the issue to ensure resolutions address causes
and extent of conditions commensurate with their safety significance. Specifically, the
licensee failed to evaluate the uncertainty with which the causes were known at the time
of the event in accordance with procedural guidance [P.2].
Enforcement. The team did not identify a violation of regulatory requirements
associated with this finding. Although the licensee failed to follow the requirements
of Procedure SWP-CAP-06 for AR 357593357593 the team determined that this
was a self-imposed standard and did not constitute a regulatory requirement.
The licensee entered this finding into the corrective action program as AR 360236360236
Finding (FIN)05000397/2016009-07, Failure to Follow Procedure and Perform a Root
Cause Evaluation to Assess the Causes of a Radwaste Shipping Event.
46
h. Failure to Transfer Byproduct Material to a Disposal Facility in Accordance with the
Terms of the Facilitys License
Introduction: The team reviewed a self-revealed, Green non-cited violation of
10 CFR 30.41(b)(5) for the failure to transfer byproduct material to an authorized waste
disposal facility in accordance with the terms of the facilitys license.
Description: On November 9, 2016, CGS sent radwaste shipment No. 16-40 to the
US Ecology LLRW disposal facility for land burial. Upon arrival at the US Ecology
facility, a receipt survey was performed on the shipping cask by US Ecology personnel.
As the waste liner was being lifted out of the shipping cask for processing, the survey
instruments measured dose rates as high as 90 rem/hr on contact with the waste liner.
The waste manifest indicated that the dose rates on contact with the waste liner were
11.8 rem/hr. Because the measured dose rates were significantly higher than expected,
US Ecology personnel immediately lowered the waste liner back into the shipping cask.
The receipt survey was terminated, and US Ecology rejected the package for disposal at
the LLRW disposal facility. The package was returned to CGS using the same closed
transport vehicle that was used to ship the cask to US Ecology. Upon arrival at CGS,
the shipping cask was properly stored and secured pending further investigation into the
elevated radiation levels. During transit, the package met the external dose rate
requirements of 49 CFR 173.441.
License Condition No. 22.C of US Ecologys radioactive materials license WN-I019-2
requires that radioactive waste be packaged in such a manner that waste containers
received at the facility do not show an increase in the external radiation levels as
recorded on the manifest. US Ecology notified the WSDOH and CGS that shipment
No. 16-40 was rejected because the measured dose rates on contact with the waste
liner showed a significant increase in the external radiation levels from what was
recorded the waste manifest.
The team noted that US Ecology personnel had discussed concerns with the dose rates
documented on the manifest with CGS personnel prior to receipt of the package.
Specifically, US Ecology personnel contacted CGS and informed them that the
calculated 11.8 rem/hr dose rate on contact with the waste package appeared to be
excessively high for the type and class of waste indicated on the manifest. US Ecology
further informed the licensee that if the contact dose rates on the waste package
exceeded 22 rem/hr that they would not accept the waste package for disposal at their
site. Licensee personnel acknowledged the establishment of this upper limit on the
contact dose rates and assured US Ecology that the package would not exceed the
established limit.
The team also noted that when the initial outgoing shipping surveys of the cask indicated
dose rates that exceeded those allowed for an open transport shipment, licensee
personnel constructed a fence around the shipping cask to meet transportation
requirements.
On January 13, 2017, CGS personnel performed a survey of the waste container and
measured external radiation levels as high as 154 rem/hr on contact with the waste
container. The survey confirmed that the waste container exhibited significantly higher
external radiation levels that were recorded on the manifest.
47
Analysis: The failure to transfer byproduct material to an LLRW disposal facility in
accordance with the facilitys license is a performance deficiency. The performance
deficiency is more than minor because it was associated with the program and process
attribute of the Public Radiation Safety Cornerstone and adversely affected the
associated cornerstone objective to ensure adequate protection of public health and
safety from exposure to radioactive materials released into the public domain as a
result of routine civilian nuclear reactor operation. Using NRC Inspection Manual
Chapter 0609, Appendix D, Public Radiation Safety Significance Determination
Process, the team determined that the finding was of very low safety significance
(Green) because it was a low-level burial ground nonconformance and a 10 CFR 61.55
waste under-classification; however, it was not Class C waste or greater and the waste
did conform to the waste characteristics of 10 CFR 61.56. The finding has a cross-
cutting aspect in the area of human performance, associated with conservative bias,
because station personnel failed to use decision-making practices that emphasize
prudent choices over those that are simply allowed. For example, when the initial
outgoing shipping surveys indicated dose rates that exceeded those allowed for an
open transport shipment, licensee personnel constructed a fence around the shipping
cask to meet transportation requirements [H.14].
Enforcement: Title 10 CFR 30.41(b)(5) states, in part, that any licensee may transfer
byproduct material to any person authorized to receive such byproduct material under
terms of a specific license or a general license or their equivalents issued by the
Commission or an Agreement State. Contrary to the above, on November 9, 2016,
CGS transferred byproduct material to US Ecology (an Agreement State licensee) that
was not in accordance with the terms of the US Ecology License WN-I019-2.
Specifically, License Condition 22.C of the US Ecology license requires that all
radioactive waste be packaged in such a manner that waste containers received at the
facility do not show an increase in the external radiation levels as recorded on the
manifest. However, on November 9, 2016, CGS shipped a waste container to the
US Ecology disposal facility that showed external radiation levels as high as 90 rem/hr
on contact with the waste container, whereas the highest external radiation level on
contact as recorded on the manifest was 11.8 rem/hr.
Because this violation was determined to be of very low safety significance and was
entered into the licensees corrective action program as AR 360236360236 this violation is
being treated as a non-cited violation consistent with the Enforcement Policy:
NCV 05000397/2016009-08, Failure to Transfer Byproduct Material to a Disposal
Facility in Accordance with the Terms of the Facilitys License.
i. Failure to Minimize Void Spaces in a Radioactive Waste Package
Introduction. The team reviewed a Green, self-revealed non-cited violation of
10 CFR 61.56(b)(3) for the licensees failure to assure that void spaces within a waste
package were reduced to the extent practicable. Specifically, a shipment of dry active
waste sent to US Ecology in May of 2016 arrived at the disposal facility with voids in
excess of 15 percent of the total waste volume, contrary to the requirements of
US Ecologys Radioactive Material License WN-I019-2, License Condition No. 23.
Description. In late May of 2016 as part of the SFPCU project, reactor maintenance
personnel, contractors, and health physics technicians loaded DAW into 55 gallon
drums, and B-25 and B-80 boxes. Various metals and several bags of DAW were
48
loaded into B-25 box No. 10056. On June 1, 2016, workers reported to the radwaste
laborer, radwaste coordinator, and the radwaste transportation specialist that B-25 box
No. 10056 was fully loaded. By observation on June 1, 2016, the licensee determined
that the box was completely full. The B-25 box was fully prepped for shipment on
July 6, 2016, and shipped offsite July 13, 2016. However, the licensee failed to verify
that the bags and materials in the box had not settled or otherwise created void spaces.
Procedure PPM 11.2.23.4, Packaging Radioactive Material and Waste, provides
direction for preparing radioactive waste and radioactive material for shipment.
This procedure is used to load containers such as B-25 and B-88 boxes and
drums of non-compactable DAW contents for transportation. Licensee
Procedure PPM 11.2.23.36, Operation of Rad Waste Compactor, describes the
use of compaction and sorting methods. Licensee Procedure PPM 11.2.23.36,
Attachment 7.1, requires evaluation and visual inspection of radwaste box contents by
the radwaste transportation specialist or radioactive material control supervisor, to
ensure that void spaces are minimized prior to shipment for disposal. However, for
shipping package No.16-27, a health physics technician and reactor maintenance
worker led the filling of seven containers with DAW associated with the SFPCU project
and failed to ensure a visual inspection was performed by appropriate personnel.
In spite of these procedural requirements, the team determined that the licensee failed
to verify that void spaces did not exist in B-25 container No. 10056 prior to its shipment
to US Ecology on July 13, 2016. Additionally, the team concluded that this resulted in
a violation of License Condition No. 23 of US Ecologys Radioactive Materials
License WN-I019-2. The team learned that this issue also resulted in a Warning Call
from the state of Washington, informing them that a matter such as this one could
result in the suspension of their shipping privileges to the disposal site.
Analysis. Shipping radwaste for disposal without assuring void spaces were reduced
to the extent practicable was a performance deficiency. The team determined that the
performance deficiency was more than minor, and therefore a finding, because it was
associated with the Public Radiation Safety Cornerstone attribute of program and
process and adversely affected the cornerstone objective to ensure adequate
protection of public health and safety from exposure to radioactive materials released
in the public domain. Specifically, the failure to ensure that void spaces were removed
in the radwaste container shipped to US Ecology subjected the disposal facility to the
possibility of improper disposal of the waste, in that, the package was susceptible to
stability issues. Using NRC Inspection Manual Chapter 0609, Appendix D, Public
Radiation Safety Significance Determination Process, the team determined the
violation was of very low safety significance (Green) because it was a finding in the
Transportation Branch in which: (1) radiation limits were not exceeded, (2) there was
no breach of the package during transit, (3) there were no Certificate of Compliance
issues, and (4) the low-level burial ground nonconformance did not involve a
10 CFR 61.55 waste under-classification. The finding has a cross-cutting aspect in the
area of human performance, associated with teamwork, because individuals and work
groups communicate and coordinate their activities within and across organizational
boundaries to ensure nuclear safety is maintained. Specifically, the coordination of
activities among reactor maintenance, health physics, and radwaste personnel failed to
prevent this event [H.4].
Enforcement. Title 10 CFR 61.56(b)(3) states, in part, that void spaces within the
49
waste and between the waste and its package must be reduced to the extent
practicable. US Ecology Radioactive Material License WN-I019-2, License Condition
No. 23, requires that waste disposal containers have less than 15 percent void
spaces. Contrary to the above, on July 13, 2016, the licensee transferred a package of
radwaste for disposal with void spaces within the waste and between the waste and its
package that were not reduced to the extent practicable. Specifically, upon receipt of
B-25 box No. 10056, US Ecology identified void spaces in excess of 15 percent, in
violation of the limit specified in their radioactive materials license. Corrective actions
included inspecting the other containers from waste shipment No. 16-27, including
testing each container for voids. Because this violation is of very low safety
significance and has been entered into the licensees corrective action program as
AR 00352217, it is being treated as a non-cited violation, consistent with
Section 2.3.2.a of the NRC Enforcement Policy: NCV 05000397/2016009-09,
Failure to Minimize Void Spaces in a Radioactive Waste Package.
4OA6 Meetings, Including Exit
Exit Meeting Summary
On December 15, 2016, following the on-site portion of the inspection, the team provided a
debrief of the preliminary results to Mr. W. G. Hettel, Vice President, Operations, and other
members of the licensee staff. The licensee acknowledged the issues presented.
On March 17, 2017, the team presented the final inspection results to Mr. B. Sawatzke, Chief
Operating Officer and Chief Nuclear Officer, and other members of the licensee staff. The
licensee acknowledged the issues presented. The licensee confirmed that any proprietary
information reviewed by the team had been returned or destroyed.
4OA7 Licensee-Identified Violations
The following violation of very low safety (Green) significance was identified by the licensee and
is a violation of NRC requirements which meet the criteria of the NRC Enforcement Policy for
being dispositioned as a non-cited violation.
Failure to Perform QC Inspections of Radwaste Shipping Liners Prior to Use
Technical Specification 5.4.1.a requires, in part, that procedures be written, implemented, and
established for those areas recommended in Regulatory Guide 1.33, Appendix A, Revision 2,
1978. Section 7(b) of Regulatory Guide 1.33, Appendix A, requires procedures for control of
radioactive materials to minimize potential releases to the environment associated with solid
radwaste. Procedure SWP-RMP-02, Radioactive Waste Process Control Program,
Sections 2.11, Quality, and 2.13, Procurement, stated, in part, that:
- Procurement of items and services supporting radioactive material transport and
disposal shall be performed in accordance with procedure SWP-PUR-01, Procurement
of Services, procedure SWP-PUR-04, Material, Equipment, Parts and Supplies
Procurement, and procedure SWP-MMP-03, Packaging and Shipping of Material or
Equipment, and should be designated as Commercial Grade or Procurement Quality
Level 3 as applicable.
50
- Columbia Generating Station Programs and Procedures OQAPD, SWP-RMP-02,
SWP-PUR-01, and SWP-PUR-04 required the licensees QC staff to inspect PHIC liners
when received on-site and prior to first use.
Contrary to the above, in April and June of 2015, PHIC liners (later used in shipment Nos. 15-23
and 15-49) arrived on-site and were used without having QC procurement inspections performed
prior to use. Consequently, RWCU resin was disposed of at the US Ecology site on April 29 and
June 15, 2015, in PHIC liners that were not appropriately inspected. Because this violation was
determined to be of very low safety significance and was entered into the licensees corrective
action program as ARs 360572 and 338421, this violation is being treated as a licensee-
identified non-cited violation consistent with the NRC Enforcement Policy. The failure to perform
QC inspection of radwaste shipment liners is a performance deficiency. It adversely affects the
Public Radiation Safety Cornerstone objective to ensure adequate protection of the public.
Using NRC Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety Significance
Determination Process, the team determined this violation to be of very low safety significance
(Green) because: (1) radiation limits were not exceeded, (2) there was no breach of a package
during transit, (3) it did not involve a certificate of compliance issue, (4) it was not a low level
burial ground nonconformance, and (5) it did not involve a failure to make notifications or
provide emergency response information.
51
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
B. Sawatzke, Chief Operating Officer and CNO
V. Bhardwaj, Manager, Planning/Sched/Outage
D. Brown, Manager, System Engineering
S. Clizbe, Manager, Emergency Preparedness
M. Davis, Manager, Chemistry/Rad Safety
B. Dutton, General Counsel
D. Gregoire, Manager, Regulatory Affairs
G. Hettel, Vice President, Operations
G. Higgs, Manager, Maintenance
M. Hummer, Engineer, Licensing
A. Javorik, Vice President, Engineering
M. Kinmark, Health Physics Staff Advisor, Radiation Protection
D. Kovacs, Information Services Mgr/CIO
E. Kuhn, Auditor, Quality
M. Laudisio, Manager, Radiation Protection
S. Lorence, Manager, Human Relations
C. Moon, Manager, Quality
M. Nolan, Senior Radwaste Transportation Specialist
T. Parmalee, Compliance Engineer, Licensing and Regulatory Affairs
J. Pierce, Manager, Continuous Improvement
G. Pierce, Manager, Training
R. Prewett, Manager, Operations
A. Rice, Supervisor, Chemistry Operations
B. Ridge, Vice President, Corporate Services and Chief Financial/Risk Officer
R. Sanker, Supervisor, Radiation Protection
B. Schuetz, Plant General Manager
D. Wolfgramm, Supervisor, Regulatory Compliance
NRC Personnel
G. Kolcum, Senior Resident Inspector
D. Bradley, Resident Inspector
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
05000397/2016003-01 TBD Shipment of a Type B Quantity of Radioactive Material in a
Type A Package (Section 2.10a.)
Opened and Closed
05000397/2016009-02 NCV Failure to Conduct Adequate Surveys of a Solid Radwaste
Shipment (Section 2.10b.)
Attachment 1
Opened and Closed
05000397/2016009-03 NCV Failure to Label or Provide Written Information for Items
Stored in the Spent Fuel Pool (Section 2.10c.)05000397/2016009-04 NCV Failure to Provide an Accurate Shipping Manifest
(Section 2.10d.)05000397/2016009-05 NCV Failure of the QA program to assure compliance with
10 CFR 61.55 and 10 CFR 61.56 (Section 2.10e.)05000397/2016009-06 NCV Failure to Update the Final Safety Analysis Report with
Changes to Radioactive Waste Processing (Section 2.10f.)05000397/2016009-07 FIN Failure to Follow Procedure and Perform a Root Cause
Evaluation to Assess the Causes of a Radwaste Shipping
Event (Section 2.10g.)05000397/2016009-08 NCV Failure to Transfer Byproduct Material to a Disposal Facility in
Accordance with the Terms of the Facilitys License
(Section 2.10h.)05000397/2016009-09 NCV Failure to Minimize Void Spaces in a Radioactive Waste
Package (Section 2.10i.)
Closed
None
LIST OF DOCUMENTS REVIEWED
Section 4OA5: Other Activities
Procedures
Number Title Revision
CDM-01 Cause Determination Manual 16
HPI 15.4 Operation of Tri-Nuke Underwater Filter/Vacuum 001
M1-1.6 Peer Verification Program 010
SWP-CAP-01 Corrective Action Program 036
SWP-CAP-06 CR Review 023
SWP-CSW-01 Computer Software Quality Assurance Program 010
Description and Implementation
SWP-CSW-011 Software Quality Assurance and Configuration Control of 008
A1-2
Procedures
Number Title Revision
Non-SSC Software
SWP-PRO-04 Preparation, Review, Approval and Distribution of 045
Procedures
SWP-PUR-04 Material, Equipment, Parts and Supplies Procurement 015
SWP-PUR-01 Procurement of Services 015
SWP-MMP-01 Packaging and Shipping of Material or Equipment 001
SWP-RMP-01 Radioactive Waste Management Program 004
SWP-RMP-02 Radioactive Waste Process Control Program 006
SWP-RMP-02 Radioactive Waste Process Control Program 007
PPM 10.3.24 Processing of Irradiated Nonfuel Material 005
PPM11.2.23.1 Shipping Radioactive Materials and Waste 018
PPM11.2.23.2 Computerized Radioactive Waste and Material 020
Characterization
PPM11.2.23.4 Packaging Radioactive Material and Waste 025
PPM 11.2.23.14 Sampling of Radioactive Waste Streams 013
PPM 11.2.23.19 Operation of The Pacific Nuclear Resin Drying System 014
PPM11.2.23.20 Use of the Transport Cask Model 14/190L, 14/190M, 014
14/190H, 14/210L or 14/210H
PPM11.2.23.37 Use of the 14D-2.0 Type A Transportation Cask 005
PPM 11.2.23.44 Operation of the Self-Engaging Rapid Dewatering System 044
(SERDS)
PPM 1.10.1 Notifications and Reportable Events 039
QAP-ASU-007 Peer Verification Program Planning 002
A1-3
Procedures
Number Title Revision
QAI-02 Stop Work Authority 000
QSI 19 Escalation Process 009
QSI 8 Quality AR Type Condition Report (AR-CR) Resolution 010
QSI 2 Quality Oversight Activities for Continuous Monitoring 021
OQAPD-01 Operational Quality Assurance Program Description 051
Audits and Self-Assessment
Number Title Date
AU-RP-RW-15 Radiation Protection & Process Controls Audit Report November 5,
2015
AU-RP-RW-13 Radiation Protection & Process Controls Audit Report November 14,
2013
AU-RP-RW-11 Radiation Protection & Process Controls Audit Report November 10,
2011
AR-SA 305111 Focused Self-Assessment Report June 19, 2015
Select Continuous Monitoring Activities Summary, 2013-2016
Radwaste
QSI-8 &19 Inadequate Management of Radioactive Material Stored October 17,
Outside 2016
Action Requests
357593 352217 338421 316676
356397 351509 336940 316555
356390 348071 336939 297560
353427 339249 316835 248151
Action Requests Generated During this Inspection
360391 360572 360236 360148
359498 359496 359296 359293
A1-4
Radiation and Radiological Surveys
Number Title Date
M-20170115-3 Bottom of Liner 16-059-OT Survey January 13,
2017
M-20170117-8 Liner 16-059-OT Grid Survey January 13,
2017
M-20170116-4 Radwaste 437 Survey Title: Liner 16-059-OT January, 13,
2017
WOT 02104894 Move SFPCU Liner
RWP 30003788 SFPCU Cask Load
Radioactive Material Shipments
Number Title Date
16-40 SFPCU Project Cask/Liner 16-059-OT November 9,
2016
16-27 Four CFD, HIC, & Boxes July 13, 2016
16-14 SFPCU Control Rod Blades & LPRMs April 16, 2016
15-49 RWCU Chem Decon Resins June 17, 2015
15-23 RWCU Resins in 8-120 B Cask April 29, 2015
Miscellaneous Documents
Babcock Loading Waste Containers on RFF Using the In-Air Transfer
2016 US Ecology Site Use Permit
DAC-0405 Rev 0 Columbia Generating Station Liner 16-059-OT
DAC-0382 Rev 1 Columbia Generating Station Filter Liner Characterization
DAC-0381 Rev 1 Columbia Generating Station Velocity Limiter Characterization
DAC-0378 Rev 1 Columbia Generating Station Cartridge Filter Report
DAC-0337 Rev 1 Characterization of Irradiated Hardware at Columbia Generating Station -
February 2016
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LIST OF ACRONYMS
Acronym Full Acronym Description
ACE apparent cause evaluation
ALARA as low as is reasonably achievable
AR action request
AV apparent violation
CAQ condition adverse to quality
CFR Code of Federal Regulations
CGS Columbia Generating Station
CRG Condition Review Group
DAW dry active waste
DOT Department of Transportation
DWJ DW James Services
FIN finding
ISIP Integrated Shipping Inventory Program
LLRW low-level radioactive waste
LPRM low power range monitors
LSA low specific activity
mCi millicurie
mrem millirem
NCV non-cited violation
OQAPD Operational Quality Assurance Program Description
PHIC polyethylene high integrity container
QA quality assurance
QC quality control
radwaste radioactive waste
RCE root cause evaluation
RP radiation protection
RPM Radiation Protection Manager
RWTS Radwaste Transportation Specialist
RxM reactor maintenance
rem/hr rem per hour
SDP significance determination process
SFP spent fuel pool
SFPCU spent fuel pool cleanup
SWP site-wide procedure
TEDE total effective dose equivalent
FSAR Final Safety Analysis Report
WSDOH Washington State Department of Health
Attachment 2
Appendix M Assessment
Columbia Generating Station
Performance Deficiency: Failure to ensure that the radioactive contents of a radwaste container
of low specific activity material did not exceed the requirements for shipping.
Degraded Condition: As a result of the performance deficiency, the licensee shipped a Type B
quantity of radioactive material (5.5 times the allowed activity in curies) in a less robust Type A
cask, rather than the required Type B package. Specifically, the licensee shipped material as
low specific activity material, in a Type A package, even though the external radiation level was
2.1 rem/hr at 3 meters from the unshielded material.
Regulatory Requirement Not Met: 49 CFR 173.427(a)(1) requires, in part, that low specific
activity material must be transported in accordance with the condition that the external dose rate
may not exceed an external radiation level of 10 mSv/h (1 rem/h) at 3 meters (10 feet) from the
unshielded material.
4.1 Initial Bounding Evaluation
To the extent possible, given the circumstances of the finding, quantitative tools should be used
to frame the risk impact of the finding. If a quantitative bounding evaluation is not possible, then
an appropriate qualitative bounding evaluation can be used.
- Using Radiation Levels leg of Transportation branch of Public Radiation Safety
Cornerstone SDP yields WHITE. Specifically, an external radiation level was exceeded
(i.e. 1 rem/hr at 3 meters from the unshielded material), it was not accessible by the
public, it was greater than two times the limit, but it was not greater than five times the
limit.
- Enforcement Policy Section 6.8.c, Transportation, states SL-III violations involve, for
example:
2. External radiation exceeds 1 times, but not more than 5 times, the NRC limit
3. A violation involves labeling, placarding, shipping paper, packaging, loading, or other
requirements that could reasonably result in any of the following:
(a) a significant failure to identify the type, quantity, or form of material
(b) a failure of the carrier or recipient to exercise adequate controls
(c) a substantial potential for either personnel exposure or contamination above
regulatory limits or improper transfer of material
Thus we have a bounding evaluation of White/SL-III.
4.2 Attributes
1. Effectiveness of one or more Defense-in-Depth elements
The defense-in-depth philosophy has traditionally been applied in reactor design and
operation to provide multiple means to accomplish safety functions and prevent the
release of radioactive material. However, we can assess at the potential defense-in-
Attachment 3
depth elements that would have protected the public/emergency responders during an
event.
The intent of the dose rate limit is to restrict the LSA material contents allowed in
non-accident resistant packages such that the post-accident external radiation hazard
from the material would be comparable to that amount of non-LSA radioactive material
allowed in a non-accident resistant package. This limit helps to ensure that any such
releases of LSA material would not present a significant radiation hazard to nearby
members of the public or to emergency response personnel who are first to arrive at the
accident scene.
In this event, there were no defense-in-depth elements that would have effectively
reduced the risk of exposure to members of the public or emergency responders. In
addition to the radioactive material being improperly transported in a non-accident
resistant package, the defense-in-depth element of shipping paperwork provided
inaccurate information regarding the contents, dose rates, activity level, and emergency
response instructions. Further, LSA packages are exempt from the DOT marking and
labelling requirements, eliminating another potential defense-in-depth element.
2. A reduction in Safety Margin can be quantified.
N/A.
3. Extent to which the condition of the performance deficiency affects other equipment.
N/A
4. Degree of degradation of failed or unavailable components (assess in terms of
functionality, if mission time can be met).
The activity in the Type A cask exceeded the allowed activity by a factor of 5.5. This
could be considered a significant degree of degradation relative to the acceptable level
of risk associated with the breach of a Type A package and release of its contents.
5. Period of time the performance deficiency existed (exposure time); and if opportunity to
identify the finding during such period was missed.
Although the characterization surveys for the package began in 2015, it is more
reasonable to consider activities beginning with the loading of the liner to consider
exposure period for the performance deficiency. Note that the performance deficiency
was the failure to ensure that the radioactive contents of a radwaste container of low
specific activity material did not exceed the requirements for shipping.
The licensee began loading the radwaste liner on October 13, 2016, with the final items
being loaded on November 5, 2016. Note that some radiation surveys were performed
during the loading evolution, in addition to an event on October 13 during which several
radiation monitors alarmed. Of the six filters that caused the alarms, only four were
returned to the SFP and not included in the shipment. On November 5, initial surveys of
the loaded cask indicated contact dose rates of 386 mrem/hr, in excess of the DOT limits
for an open transport vehicle. The licensee rearranged items in the cask, and the new
maximum contact dose rate was 250 mrem/hr. This was still in excess of the
A3-2
200 mrem/hr limit, so the licensee constructed an enclosure around the cask to meet the
DOT requirement. The surveys taken during the loading of the liner and the pre-
shipment surveys of the cask both provided opportunities to identify the finding.
The licensee states that the improper package was only in transit on public roadways for
3 miles, on a roadway that is not highly used and had no railroads. Using Google Maps,
the team determined the distance from Columbia Generating Station to US Ecologys
facility was approximately 14 miles, approximately 12 miles which are denoted partial
restricted usage road. Note also that the incorrectly packaged material was also
returned to CGS, thus doubling the exposure time with respect to distance travelled.
10 CFR 71.0(c), Purpose and Scope, states, in part, the regulations in this part apply to
any licensee authorized by specific or general license issued by the Commission to
receive, possess, use, or transfer licensed material, if the licensee delivers that material
to a carrier for transport, transports the material outside the site of usage as specified in
the NRC license, or transports that material on public highways. Thus the requirement
to properly package the radioactive material applies from the point at which it left CGS
Owner Controlled Area and the fact that part of the journey was not on public highways
is not a basis to reduce the exposure time.
6. The likelihood the licensees recovery actions would successfully mitigate the
performance deficiency.
N/A
7. Additional Qualitative Circumstances for Management Consideration
- Guidance in RIS 2013-04 and NUREG 1608
- Vogtle precedent
- Programmatic aspects of finding - inadequate surveys, inadequate
inventory/labelling of items in SFP, incorrect manifest, failure of QA program to
ensure compliance with 10 CFR 61, failure to meet QA requirement of 49 CFR
173.475(a) to ensure packaging proper for the contents.
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SUNSI Review: ADAMS: Non-Publicly Available Non-Sensitive Keyword: NRC-002
By: LCC Yes No Publicly Available Sensitive
OFFICE SHP:PSB2 HP:PSB2 DNMS C:DRP/A ACES RC
NAME LCarsonII NGreene BTharakan JGroom MHay KFuller
SIGNATURE /RA/ /RA/ /RA/ /RA/ /RA/ /RA/
DATE 3/23/2017 3/23/2017 3/23/2017 3/30/2017 3/30/2017 3/27/2017
OFFICE C:PSB2 D:DRS
NAME HGepford AVegel
SIGNATURE /RA/ /RA/
DATE 3/31/2017 4/10/2017