ML19259A024
| ML19259A024 | |
| Person / Time | |
|---|---|
| Site: | 07003103 |
| Issue date: | 09/11/2019 |
| From: | Cowne S Louisiana Energy Services |
| To: | Document Control Desk, Office of Nuclear Material Safety and Safeguards |
| References | |
| 132253, 54101, LES-19-134-NRC | |
| Download: ML19259A024 (10) | |
Text
SEP 1 1 2019 LES-19-134-NRC Attn: Document Control Desk Director Office of Nuclear Material Safety and Safeguards U. S. Nuclear Regulatory Commission Washington, DC 20555-0001
Subject:
References:
Louisiana Energy Services, LLC License Number: SNM-201 O NRC Docket Number: 70-3103 60 Day Written Supplement for Event Notification 54101 USA The National Enrichment Facility
- 1. Letter from S Cowne to NMSS providing the 60 day written follow-up report for Event Notification 54101, dated 7/25/2019 (LES-19-109-NRC)
On June 4, 2019 Louisiana Energy Services, LLC dba URENCO USA (UUSA), submitted Event Notification 54101 to the NRC Operations Center in accordance with 10 CFR 70.74(a). On July 25, 2019, UUSA provided Reference 1, the 60 day written follow-up report required by 10 CFR 70.74(b).
Reference 1 stated that UUSA would provide the Apparent Cause Evaluation (ACE) following management review and approval. UUSA herewith provides the approved ACE as Enclosure 1.
UUSA has also revised the information provided, in Reference 1, to comply with 10 CFR 70.50(c)(2). This revision was performed as a result of the ACE completion. The revised information is in Enclosure 2.
Also note that Reference 1 incorrectly referenced EN 53892 in the
Subject:
. The event number that should have been referenced is EN 54101. UUSA requests that the NRC correct any internal references to the incorrect event number as needed.
If you have any questions, please contact Rick Medina, Acting Licensing and Performance Assessment Manager, at 575-394-5846.
Respectfully, n Cowne uclear Officer and Compliance Manager
Enclosures:
- 1. ACE for Event Report 132253
- 2. Written Follow-up Report I
Lou111lena Energy Services, U.C UUSA I PO Box 17891 Eunice I New MBXJCO I 88231 I USA T: +1 (575) 394 4648 I W: WWW uusa urenco.com
LES-19-134-NRC cc:
Karl Sturzebecher, Project Manager - UUSA U.S. Nuclear Regulatory Commission Karl.Sturzebecher@NRC.gov Jacob Zimmerman, Branch Chief Fuel Facility Licensing U.S. Nuclear Regulatory Commission Office of Nuclear Material Safety and Safeguards Jacob.Zimmemian@NRC.gov Robert Williams, Branch Chief Projects Branch 1 U.S. Nuclear Regulatory Commission Robert.Williams@nrc.gov
LES-19-134-NRC ENCLOSURE 1 ACE for Event Report 132253
Procedure
Title:
Apparent Cause Evaluation Guidelines CA-3-1000-02 F-1 Apparent Cause Evaluation Apparent Cause Evaluation ER Number: 132253 Event Date: 06/01/2019 Evaluator: Kevin S/avings Problem Statement CA-3-1 000-02 Rev. 9 Level 3 - Information Use Page 1 of 5 During the 1 LS1 Recovery, 1001-471-1A12, 1 MP6 Isolation was found open. During the connect procedure, this valve should have been ensured closed. This was the first connect following the annual IROFS10 surveillance which leaves this valve open.
Event Narrative On 06/01/2019 the annual IROFS10 surveillance was completed for 1 LS1. MA-3-2470-01, Step 9.1.1.c leaves the 471-1A 12 open following a soap bubble test (CAMR-2).
On 06/01/2019, 1 LS1 was being connected following the annual IROFS10 surveillance. The individual performing the autoclave connect is an experienced operator and was using OP 0470-01, Attachment 1 to connect autoclave 1LS1. Contrary to Step 3.5, first bullet, 471-1A12, 1 MP6 Isolation was not ensured closed.
On 06/04/2019, 1 LS1 was being recovered per OP-3-0470-01 Attachment 10 following a trip experienced during a station brownout. Step 3.16 first bullet ensures 471-1A 12, 1 MP6 Isolation valve closed. At this time it was determined that the 471-1A12 was left open following maintenance on 1 LS1 and was not ensured closed during the autoclave connect.
471-1A12 is an isolation boundary for IROFS10 and failing to ensure this valve closed during the connect sequence, allowed for the autoclave to be placed in operation without ensuring IROFS10 integrity. The resulted in a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> report to the NRG.
A review of approved procedures reveals the requirement to position the 471-1A12 in the closed position every time the autoclave is connected. The apparent cause of this event is complacency when performing a routine evolution. Furthermore discussions with numerous operators reveal that it is common practice to visually look at the valve when doing system lineups and not actually place their hands on the valve to verify position (CAMR-1 ). This practice when combined with complacency from performing the same routines frequently supports making this type of mistake. Additionally, it has been identified there are numerous IROFS related valves verifications that are not flagged as critical steps in the autoclave procedure alone (CAMR-3).
In summary, there was one apparent cause and several contributing factors in this event. The operators will receive coaching on the dangers of complacency when doing routine evolutions (CA-1 ). The planned corrective actions that will strengthen the robustness of the IROFS10
Procedure
Title:
Apparent Cause Evaluation Guidelines CA-3-1 000-02 CA-3-1000-02 F-1 Rev.9 Apparent Cause Evaluation Level 3 - Information Use Page 2 of 5 boundaries (CAMR-4), retrain operators in the preferred method of performing valve verifications (CAMR-1) and procedural enhancements to minimize the probability of recurrence (CAMR-2, CAMR-3, CAMP-4, CAMR-5, CAMR-6, CAMR-7 and CAMR-8).
A review of ReAct and the Operations HPE data base do not reveal any other times that this has occurred, therefore this is a one-time event.
Cause(s) and Corrective Action(s)
Actions Assigned Cause Corrective Action Impact Due Date Level Group Apparent Cause -
Coach Operators on the CA-1 Complete Shift "Complacency due to dangers of becoming Operations infrequent operation of complacent in routine valve" operations AC145236 through AC145241 Contributing Cause -
Provide training to all CAMR-1 Complete Shift "Improper verification of operators to include Operations valve positions by use physical verification of of visual verification vs components in the field AC145236 hands on verification."
and not using visual through indication as sole AC145241 method.
Contributing Cause -
Revise procedure to CAMR-2 9/20/19 Maintenance "MA-3-2470-01 leaves close XA 12 following AC145244 valves out of normal soap bubble test (Step position."
9.1.1.d)
Contributing Cause -
Revise all Operations CAMR-3 9/20/19 Operations "Steps that ensure Procedures to identify Support Integrity of IROFS 10 IROFS related steps as AC145236 and 28 In OP-3-0470-01 critical steps and not flagged as critical commitment steps. Also steps and commitment separate these steps steps."
from the system valve lineups to allow importance to be placed on them.
Contributing Cause -
Place configuration CAMR-4 9/20/19 Operations "Valves that are not control locks on 471-Work usually operated are the XA11, 471-XA12 and Control IROFS10 established 471XA14 in the closed AC145235
Procedure
Title:
Apparent Cause Evaluation Guidelines CA-3-1000-02 CA-3-1000-02 F-1 Rev. 9 Apparent Cause Evaluation Level 3 - lnfom,ation Use Page 3 of 5 boundary."
position Contributing Cause -
Revise all Chemistry CAMR-5 11/21/19 Chemistry "Steps that ensure Procedures to identify AC145979 Integrity of IROFS not IROFS related steps as flagged as critical steps critical steps and and commlbnent steps." commitment steps. Also separate these steps from the system valve lineups to allow importance to be placed on them.
Contributing Cause -
Revise all Logistics CAMR-6 11/21/19 Logistics "Steps that ensure Procedures to identify AC145980 Integrity of IROFS 10 IROFS related steps as and 28 In OP-3-0470-01 critical steps and not flagged as critical commitment steps. Also steps and commitment separate these steps steps."
from the system valve lineups to allow importance to be placed on them.
Contributing Cause -
Revise all Deco and CAMR-7 11/21/19 Deco &
"Steps that ensure Recycling Procedures to Recycling integrity of IROFS 10 identify IROFS related AC145981 and 28 in OP-3-0470-01 steps as critical steps not flagged as critical and commitment steps.
steps and commitment Also separate these steps."
steps from the system valve lineups to allow importance to be placed on them.
Contributing Cause -
Revise AD-3-1000-01 to CAMR-8 11/15/19 Operations "Steps that ensure require steps that Support integrity of IROFS 10 establish IROFS AC145977 and 28 in OP-3-0470-01 boundaries or implement not flagged as critical the IROFS actions be steps and commitment flagged as commitment steps."
steps and critical steps.
Contributing Cause -
UUSA Training perfom, CA-5 9/20/19 Operations "Not all personnel are a training needs analysis Support aware of the impact to detem,ine adequacy AC145246 their day to day jobs of training for mav have on the safety Maintenance and
Procedure
Title:
Apparent Cause Evaluation Guidelines CA-3-1000-02 CA-3-1000-02 F-1 Rev. 9 Level 3 - Information Use Apparent Cause Evaluation *.
Page 4 of 5 functions of IROFS."
Operations personnel for tasks _that can impact IROFS boundaries Contributing Cause -
Revise all Maintenance CA-6 9/20/19 Maintenance "Steps that IROFS Procedures to identify AC145245 boundaries are not IROFS related steps as flagged as critical steps critical steps and and commitment steps."
commitment steps. Also separate these steps from the system valve lineups to allow importance to be placed on them.
Contributing Cause -
UUSA Training perform CA-7 11/21/19 Operations "Not all personnel are a training needs analysis Support aware of the impact to determine adequacy AC145980 their day to day Jobs of training personnel may have on the safety outside the Operations functions of IROFS.
11 and Maintenance departments for tasks that can impact IROFS boundaries
Procedure
Title:
Apparent Cause Evaluation Guidelines CA-3-1000-02 CA-3-1000-02 F-1 Rev. 9 Apparent Cause Evaluatlon Level 3 - Information Use Page 5 of 5 Extent of Condition A review of standard evolutions that can impact IROFS boundaries falls mainly within Operations and Maintenance. Actions has been created to evaluate all Operations, Maintenance, Chemistry, Logistics and Deco/Recycling Procedures for steps that can have an impact of IROFS or their safety function to be flagged as critical steps and have commitment flagged to increase awareness and ensure compliance (CAMR-3 and CA-6).
An additional actions have been created for the UUSA Training Department to perform a training needs analysis to determine if additional training should be implemented to raise awareness when dealing with IROFS and IROFS support equipment boundaries (CA-5 and CA-7).
Attachments Include any additional documents that would not be readily available to a future reader of the report. This may include graphs, charts, photos, etc
LES-19-134-NRC ENCL0SURE2 Written Follow-up Report
LES-19-134-NRC Written Follow-up Report I.
Applicable information required by 10 CFR 70.50(c)(2)
- a.
The probable cause of the event, including all factors that contributed to the event and the manufacturer and model number (if applicable) of any equipment that failed or malfunctions is provided below:
- i.
The investigation determined that the apparent cause was complacency due to infrequent operation of the 1001-471-1A12 isolation valve. The contributing causes were;
- 1. Improper verification of valve positions by use of visual verification -vs-hands on verification.
- 2. MA-3-2470-01, Autoclave Leak Check Surveillance IROFS10, leaves the valves out of their normal position
- 3. Steps that ensure integrity of IROFS10 and 28 in OP-3-0470-01 are not flagged as critical steps and commitment steps
- 4. Valves that are not usually operated makeup the IROFS10 established boundary
- 5. Steps that ensure integrity of IROFS are not flagged as critical steps and commitment steps
- 6. Not all personnel are aware of the impact their day to day jobs may have on the safety function of IROFS
- b.
Corrective actions taken or planned to prevent occurrence of similar or identical events in the future and the results of any evaluations or assessments are:
- i.
The operators will receive coaching on the dangers of complacency when doing routine evolutions. The planned corrective actions that will strengthen the robustness of the IROFS10 boundaries include retraining the operators in the preferred method of performing valve verifications and procedural enhancements to minimize the probability of recurrence.
- c. UUSA is subject to Subpart H of 10 CFR 70; therefore, a discussion of whether the condition was identified and evaluated in the Integrated Safety Analysis (ISA) is provided below:
- i.
The IROFS was identified in the UUSA ISA as a safety control to mitigate the consequences of a release of UF6 within the autoclave. The ISA evaluated accident sequences that could result in consequences to the workers and public.
The valve was determined to be needed to mitigate the adverse consequences to workers and public.